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Dr. James Pacala

Dr. James Pacala
University of Minnesota Medical School

Our country is experiencing a national health care crisis as fewer nurses and doctors choose to specialize in geriatric care. This shortage will increase dramatically as 76 million Baby Boomers become elders. At the University of Minnesota an innovative program sensitizes future doctors to the special needs of the elderly. They call it the Aging Game. Harry Wiland visited with Dr. James Pacala.

Dr. Pacala (addressing medical students): The idea of the aging game is to give you some insight into what it is like to grow old with disability, and we're going to be asking all of you to role-play this morning. I want you to start imagining yourself as an old person. Don't think about some abstract old person. Think about you as an old person. What are you going to be like when you are old?

Why is this exercise important?

Well, it's important because the students, when they become doctors, are going to be taking care of older people who are disabled. And it's important for them in terms of understanding the perspective of an older person who has accumulated some disabilities - what that experience is like.  There was a situation of a hospital administrator who wanted to find out about how his hospital is working so he faked an illness and checked in as a patient.  And he found out a lot about what it was like to be a patient in his hospital and that helped him make some changes for his hospital to provide better care.  It's the same idea here.  We need to give the students - remind them - exactly what this predicament is like. And I think that the impact of experiential learning can really be quite profound.

How are we doing as a nation in this age game of caregiving?

You can help them, you can really help them.  But, you can't cure them.

Mixed.  We don't really have a national plan on how we're going to be able to care for everybody and the burden of disability that we are going to be faced with in the next few decades.  For every person in a nursing home or an institution there are two people in the community who are equally disabled.  And as those numbers of disabled people grow I'm not sure that we've really figured out what we are going to do about it.  We need to have a better approach.

Yet, geriatricians are leaving the field

Yeah, I don't get it.  There are less schools teaching it. I don't get that.  You would think that market forces would work.  At our institution we've tried for about ten years very assiduously to recruit students and residents into geriatrics and we've been more successful than many other schools in doing so and yet we still struggle every single year. 

I think it has to do with a couple of things, number one, geriatrics is never viewed as an exciting field by most students going into it.  When they think of becoming a doctor they're inundated with lots of mass media messages about what that means.  So you think of the television programs that are on today, there aren't any television programs about a geriatrition who deals with caregiver issues and chronic disease.  That is just not exciting. 

And there is a comparative lack of role modeling in medical school and in residency, I think about taking care of old patients.  I think old patients in medical school and in residency are generally thought of as -- these are the people that are making your job difficult, these are the people that are making your day longer. 

Medical students and residents are very, very busy and they have a lot of work to do, and they have lots of information to learn and when they have patients with multiple disabilities, multiple medical problems -- what we call "six chart syndrome" -- the patient that comes in that's got five or six chronic illnesses, that are on ten or twelve medications and they have been admitted to the hospital a lot and they have six charts.  That's a lot of work for a medical student or a resident and immediately an association between having to do all this extra work and old people comes together and I think that's a big problem. 

What we call "six chart syndrome" -- the patient that comes in that's got five or six chronic illnesses

So we have to start exposing medical students, first of all to more positive situations in which older people are viewed in a more realistic light.  Now, you'd say well, the aging game is just doing exactly the opposite.  In a way the aging game does do the opposite because it portrays aging as an experience of disability, but that's why we try to balance with an interview at the end with somebody who's coping very well with disability. 

Why, if everybody is leaving the field, why are you still in it?  What do you get out of it?

I like the challenge of taking care of older people. This is a very challenging field that has tremendous rewards that aren't measured the way rewards in other fields are measured.  You don't cure a patient in geriatrics, you can't because they have chronic illnesses.  If they didn't have chronic illnesses and you could fix whatever it was then you would cure them.  But, you can't cure them, so you have to learn to readjust your goals of care. 

You can help them, you can really help them.  But, you can't cure them.  And I think we focus sometimes in education on the goal of cure rather than help, so that's one thing. 

I like the challenge.  I like the idea of having to manage lots of different chronic illnesses.  Having to use all that medical stuff that they teach in medical school and that you really focus on.  All that anatomy, physiology, pathology and everything.  But at the same time if you forget about the caregiver, the payment system - which is incredibly complex - and if you don't understand the system, you're not going to be able to take care of your patients properly.  If you don't understand the continuum of care across different venues from home care to long term care, acute care, step-down care, all these different, then you're not going to do a good job.  And if you don't understand something just about the psychosocial aspects of aging, which have a much more profound influence on health than psychosocial aspects have in younger patients.  I think throwing all those together is a fun challenge and I enjoy that. 

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Aging Game

An aging game participant is helped onto the toilet, then left there



Pills

Many pills to swallow

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