Middle of the Road

Too much money to qualify for Medicaid, not enough money to qualify without it.

Looking, searching for a facility, a place to live until you die.

The fancy place says no. You can’t prove your monetary worth, can’t prove you will give them a check every month… until… eternity.

The modest place says no. You will cost them too much. You have too many needs. And you can’t prove you will give them a check every month…

            Until you have no more money to give and the Government

                                                                                                    Takes

                                                                                                               Over.

So you wait. Without a home to go to. Without a place to live. Moving between rooms and buildings, between facilities and hospitals.

            Until you are broke

                                    Or you die

                                                Whichever comes first.

When the best medicine is less medicine

            A majority of our medical education is devoted to the rote memorization of medical facts and than later to the practical application of that knowledge. As an internist this commonly involves the use of various medicines for treatment of ailments. However we must always be vigilant of when stopping medicine may be the best approach.

            I recently established care with a 87 year old woman who had recently moved to the area to be closer to her daughter.  By outward appearance she was a healthy highly functioning individual. After a brief discussion she handed me her medication list, which included 18 different medications and vitamins, many of which are scheduled three times a day or four times a day. After a brief discussion it became apparent the woman was under a tremendous amount of distress from the expense of the medications and difficulty of keeping medications straight. Additionally on review of systems she voiced many complaints that could easily be related to several of her medications.

            Although to any practitioner it was very clear that the patient needed to have some of the medications stopped this discussion can be much harder than expected. After getting push back from the patient and her daughter on stopping any medications we were able to stop only one medication at that visit with the plan to follow-up next month and evaluate if she noticed any changes.

-- Andrew Illif

Discrepancy between percentage of time Residents spend in the hospital training and percentage of time patients spend in the hospital

I have been thinking about the discrepancy between percentage of time Internal Medicine Residents spend in the hospital training and percentage of time our patients spend in the hospital.

My patient with the most hospitalizations this year is Mrs S. She has had 8 hospitalizations adding up to about 1016 hours in the hospital. She is definitely an extreme outlier in terms of frequent hospitalizations and yet she has spent 88% of her time OUT of the hospital.  This is in contrast to the resident who has spent 75% of his training IN the hospital this year (approximately 2304 hours in the hospital and 768 hours training in the outpatient setting). His inpatient learning is intense and he is well equipped to take care of the very sick patients in that setting.  But our patients (with rare exceptions) spend proportionately very little time in the hospital.

Would patients get better care if residents had more exposure to the patients’ out of hospital environments? Here are a couple of examples where knowledge of the patient’s environments would probably decrease unnecessary interventions and cost.

We couldn’t seem to keep Mrs B out of the hospital. She had repeated asthma exacerbations and was hospitalized 11 times in one year. Each time, she was treated appropriately and sent home but the scenario repeated about every month.  When we thoughtfully reviewed her home setting, we discovered her twenty-something year old grandkids would come over and smoke in her house. After having them stop smoking in her house, the next year she was not hospitalized once!

When doing a home assessment, I found Mr G compliant with all of his meds but the only food he had in the kitchen was some neck bones stewing. He said he couldn’t afford more food because his medications were so expensive. We realized that he really didn’t need all of the meds he had been prescribed and others could be switched to less expensive formulations.

Then there was the lady with advanced dementia who during an admission for urosepsis, was deemed to have a high aspiration risk and ended up with a feeding tube. In retrospect, she was always in bed in the hospital and attempts at feeding were made when she was in this suboptimal position. When I visited her at home after the hospitalization, she was up in her chair bright eyed and smiling after finishing a whole breakfast of ooey-gooey pancakes and maple syrup. Instead of making a decision about tube feeding in the hospital while sick, it would have been preferable to have her go back to her own environment to assess.

Have you ever seen a home set up like a nursing home? We just saw one today—the daughter has a bedroom set up PERFECTLY with a bed, supplies, shelving unit and pictures on the wall but free of clutter. As we watched her, we saw that she has trained herself to be as good as any practical nurse I’ve ever seen. The patient has been very stable so she doesn’t qualify for hospice care though we are still giving her palliative/hospice-like care.

While financial incentives push us to teach in the hospital, I but I think residents could be better doctors by exposing them to where the patient spends most of their time and helping them to consider this when they are in the hospital.  

Understanding the disease

How many times have you been at church or social functions and witnessed that “little old lady” that is running the show? From party planning to organizing the Christmas plays to cooking dinners for 30+ people, my grandmother has always been that person.  I often compared her to geriatric patients in my medicine clinic and thought, “how does she do it?”  No one in my very large family was prepared for the day when she suddenly was no longer able to juggle it all.

My grandmother had a very difficult 2013 that all started with her having back surgery.  She had undergone multiple back and other joint surgeries in the past and always seemed to be back on her feet within days (so everyone thought this time would be no different).  Unfortunately, following a very lengthy procedure, my grandmother woke up and really didn’t know anyone.  Her husband of 50 years, her 4 children, the multiple grandchildren, and even great grandchildren that she often babysat, were only intermittently recognized.  At first, I assumed (from 100s of miles away) that she just had hospital delirium.  I received calls almost daily from my very distraught mother asking “what is wrong with her?” and “is she going to get better?”  The longer my grandmother was hospitalized and as the confusion persisted, the less clear those answers became.  The decision was made to take her home after about 2 weeks as we all hoped that she would improve after being back home in her normal environment.  This unfortunately was not the case, she actually declined – screaming all night in pain, became incontinent of stool and urine, and completely exhausted my poor grandfather that was trying to take care of her.  There was no medical background in the family and this situation with my grandmother was not being handled well.  Some blamed my grandmother – they felt that she was “faking”.  Others blamed her pain medications (to the point that they essentially took all of them from her).  Everyone started to fight, cry, and many stopped visiting or communicating.  My grandfather on multiple nights took my grandmother to our local hospital because he did not know what to do with her.  The last night that he took her she was septic and transferred back to the original surgeon who did her surgery.  She was found to an abscess at the level of her new spinal hardware so AGAIN had to go back to surgery.  On one hand, everyone was relieved that maybe the infection was the problem all along and she would now to cured!! On the other hand, here she was going through ANOTHER surgery.  Following the surgery my grandmother’s memory did improve some, but she is certainly nowhere close to the person she was before this all started.  The more I talked with my mother about this case; there were subtle things that had been missed – like the fact that my grandmother had been forgetting places and names long before her initial surgery.  She likely did have some mild cognitive impairment that certainly did not help her in the recovery phase – especially with delirium (and superimposed infection).  My grandmother knows our family members now and is functioning quite well at home, but constantly has to be monitored and requires quite a bit of assistance. 

This story is just one example of the impact that cognitive impairment can have on someone and their family.  It is important to accept the process of aging and understand cognitive decline.  My family has learned a lot this year thanks to my grandmother, and finally has taken the initiative to start learning about cognitive impairment and dementia and how to prepare as things continue to change throughout both of my grandparent’s lives.  Educating family members and patients about what to expect is clearly important in the case above, and something that I have noticed to be emphasized often during my month on geriatrics.  

 -- Lindsey Prochaska

Tweaking the discharge process

During my inpatient months I had not thought much about where the patients end up after their stay.  I know many are going to SNFs and rehabs, but I mostly just imagined a hospital-like setting with a focus on rehab and PT instead of on medical issues.  However, during my first week of geriatrics I realized how vastly wrong my ideas had been.  The care of patients in SNFs seems to be a cross between a hospitalist and a PCP.  You get to see the patients several times, in their normal clothes I might add, over the course of several weeks and are able to build a relationship with them and see (most) improve and able to return home.  You also realize all the things that fall through the cracks on discharge.  The person has diarrhea? It's good to know they don't have C.diff, but it might also be helpful stopping that BID sennakot-s.  Oh, yea lets remove that rectal tube at some point as well.  They were taking Benalopril prior to admit, lets change them to lisinopril b/c it's formulary on discharge.  They are confused, but we don't know what the baseline is, so we cannot justify hospitalization, so lets get them someplace where someone can keep watching them instead of dc'ing home, it's in the best interest of the patient after all.  All of these issues, and so many more, seem kind of oxy-moron after discharge, but while you are getting paged every 5 minutes you lose focus on the fine-tuning.  Being responsible for the discharged patient made me so much more aware of my discharging process, and I wish I had had that experience from the beginning of my residency. 

 -- Kellie Wark

A change in perspective...

I’ve spent years in clinic putting patients on medications to lower cholesterol, lower blood pressure, and improve blood sugars in hopes of extending their life.  I’ve pushed for dozens of colonoscopies, mammograms, and stress tests in hopes to prevent disasters. 

Now, I’m in Geriatrics Clinic taking people off medications and forgoing screening because, well, it’ll probably be something else that kills them first.

I’ve spent the other part of my three years on the General Medicine inpatient teams and ICUs trying to cheat death, halt death, or revive persons from near death. 

Now I’m in a Geriatrics Clinic and it feels like I’m actively planning for someone to die.

…But before you think I’m morbid, let me explain

It all started on my first day in Geriatrics Clinic when I was shown a chart of life expectancies for elderly persons in America.  The concept was simple enough, using a person’s age, gender, and overall health to determine how long they were likely to live.  It took more than an instant to digest that even a rather healthy woman  in her 70s may only have less than 10 years to live on average.  It made me afraid to be in my 70s.

With this information, however, came a new sense of purpose and a new outlook on what I was doing in this clinic.  It was easy to feel as if we weren’t “being aggressive” enough or that we were “being passive” but what it really showed was how at all ages in Medicine, the focus always remains on the patient.  With every decision I’ve made for every patient, every day in the past several years, the common focus is doing the best to provide benefit with the lowest possible risk.  While it initially seemed different than what I had been doing on before, it was the exact same.

So as we sat there, taking medications off her list which were unlikely to provide her any further benefit, it felt liberating.  It was not as I felt earlier, a sign of defeat, but rather a celebration of a life lived to its best.  And as we continued to talk, it was just like my usual clinic, continuing with every visit to make sure that everything we are doing is focused on living a longer and better life.  

What a Wonderful World

“And I think to myself, what a wonderful world”, sang the volunteer to the group of elderly individuals encircling her.  As she continued to sing to the group, I found myself, pen resting on the table, listening and reflecting on the aging population around her.  I was on my second nursing home visit and the geriatrics rotation had taught me two great lessons, the elderly population is complex and the goals of treatment are often different.

Medicine’s complexity has always interested me, the chance to investigate someone’s history, their multitude of symptoms, analyze the collected laboratory data, and formulate a plan. The geriatric population amplifies this process due to their atypical presentations and innumerable psychosocial factors, all in the face of a population with differing goals of care.

As a patient ages, the recommendations for screening and treatment change. The evidence based medicine I have so devotedly learned has been broken on this rotation. Each patient requires an individualized plan based on their physical illness, psychosocial components, and their personal goals. For example, is it truly beneficial to pursue colorectal screening in a patient with a terminal illness? More than once, I have had the opportunity to expand my medical thought process.

This rotation not only taught me to enjoy another multifaceted aspect of medicine, but also provided me with a renewed perspective on life; what are the most significant aspects of life and how to define quality of life.  Watching the volunteer move throughout the crowd, I caught a glimpse of what my future might be like and reflected on what is most important. What a wonderful world it is indeed.

 -- Leanard Riley

Dementia, the bigger picture

My experience in geriatrics has enlightened me on multiple levels. I came to realize the importance of looking at the bigger picture with older patients. It’s not just about focusing on medical problems but also aspects of daily living that may impact overall health. I discovered I can get to know someone very quickly simply by asking questions pertaining to ADLs and IADLs. These are items we as residents often overlook while training in the inpatient setting as we focus quite a bit on the acute problem. I also came to recognize the huge impact dementia has on a patient and their family. In my eye, it is a medical condition that doesn't get enough credit as it truly should. From a physician’s perspective, I realized I should pay more attention to this disease process as it has a multifaceted impact on a patient. In my opinion, unless a person has a family member or friend with dementia, the general public otherwise views this condition as ‘something old people get.’ I hope to educate people that it is much more than that. To look at this from a broader perspective, actor Seth Rogen recently presented a statement to members of congress to encourage funding for research into Alzheimer’s dementia. Despite his witty yet moving speech about his personal experience with a family member suffering from the disease, his presentation was made to a poor showing of congressmen. I have had the opportunity to see various types of dementia in person. I would hope that as time goes on that this condition receives more recognition to the general public's eye about its impact on overall health and ultimately lead to early recognition and appropriate management. Looking back now that I have come to the end of my experience with geriatrics, I do wish I could have had this experience during my intern year. I feel like it would have changed my practice with older patients. Nevertheless, I will definitely carry over what I have learned to the rest of my residency and into my career.

- Arvind Satyanarayan