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william coch, md

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For over 30 years, Dr. Coch has been a gerontologist and general practitioner in Andover, N.Y., a rural community with a large elderly population in Alleghany County. Through his many years of service and frequent home visits, he has come to know his patients and their families very well. Here, he discusses what the goals should be in treating the "old-old," what it means to die a "good death," and why community and family involvement is key to the quality of care for many elderly. This is an edited transcript of an interview conducted on Feb. 9, 2006.

How long ago did you come to this area? What brought you here?

I came in 1975, after I finished an internship in Vermont. I came here partially to get out of the academic medicine, which was just grueling, and it was partially to put in two years of service for the National Health Service Corps [NHSC]. ...

This is Allegheny County. It's the size of Rhode Island, has a 50,000 population, which is the same as it had 100 years ago. When I came, there were five or six doctors. They were both physicians and surgeons. They delivered babies, gave anesthesia, everything. The National Health Service Corps tried to recruit doctors to these needed areas. They could get loan forgiveness and that sort of thing. This project was relatively successful. I think five people stayed that were recruited, ultimately, and some have finished their careers and retired. ...

[Since you've been here, have you noticed any changes in the area?]

I've been here 30 years. It was primarily an agricultural economy when I came. The big industries were logging, oil and farming. I had lots of dairy-farmer patients, and I bet I don't have 10 anymore. The small family farm has died off. The area has not grown. The hospital is one of the biggest employers. Many of the young people leave because there are no jobs, so we have a very high population of elderly. …

How does that impact what you see and how it is to grow old here?

Even though I just told you that young people leave, it seems like everybody here has a family. It's rare that we have somebody dumped in the hospital. ... It's also rare that people will give up and want to put somebody in the nursing home at the first sign of trouble. Most people will go through a long period of trying to take care of them in their own home or actually in the family home, or even extended families.

We still have lots of three-generation households, four-generation households. ... That's one thing that we certainly get here, is this sense of generations and how important that is, as far as health care goes. If you don't have family, you're in big trouble when you get old, because you'll have to depend on institutionalized care, which is OK, but it's not as good as family care. ...

... Is growing old easier in a community like this?

“[M]any people don't want to live forever when they're old. In fact, that's their fear. ... They would give up a certain amount of years at the end to have a good death”

I don't know. In some ways I think it's more difficult. We don't have the services that are available. ... It gets a lot harder in some ways to keep your independence here, so you're much more dependent on families and neighbors. ...

What difference do you see that family makes?

Having a family really drives everything, from the care that they receive -- the actual physical, day-to-day care -- to the care that they receive from professionals. Having somebody there as your advocate improves the care that you get, no question about it. And I think it really gives people a reason to be better. ... It's really what their life is about, often, at the end of life, when their career is gone. It's what's important to them. …

I think people who don't have family are more likely to be in the nursing home; and that if you have good family support, you can stay out of the nursing home longer or stay out of it entirely. I have many patients that if we put them in a nursing home -- and this isn't to say anything bad about nursing homes -- [but] even [at] the best nursing homes they would get bedsores; they would be unhappy and probably die much more quickly. I don't think there's any question about that.

Sometimes, though, people come to nursing homes after families have done their best to keep them at home, but the family can no longer provide all of the care needed, right?

... I would say that a lot of times [it's a matter] where people have given up -- basic caregiver burnout or whatever you call it -- and [the family member] winds up in the hospital because they get sick …. They go to the nursing home for a short period of time and then go home again. We see that a lot. Then family members are able to cope for a while longer with health aides and a visiting nurse, [but] then often they burn out again. They go through the cycle again, and then some people just reach the end of their rope, and they've had it, and they don't even want to try again, but I would say that's the exception.

Do you help families make the decision on the nursing home? Is it tough?

It is. Sometimes they turn to me. But I usually try and take that one step ahead and tell them that it's time to do that. I think sometimes that's better because it's not their decision; it's kind of doctor's orders. ... I try and explain it like, if you had appendicitis, you'd go to a surgeon because that's who you need, and for some people, nursing home care is just what they need.

I tell people all the time that they should never tell their children, "Don't ever put me in a nursing home," or vice versa: "Mom, we'll never put you in the nursing home." ... That's the wrong thing to say, ... because sometimes that's the best place for a person to be. It really is. Unless you have an overabundance of money and can hire shifts of two or three people to be there constantly, some people just need the environment of a nursing home.

Your influence with families, what's that like?

It took me a long time to really recognize the power of being a doctor and really how you can use that in a good way. I think in the past doctors were -- and probably still [are] -- accused of being paternalistic, but often what a person needs [is] somebody who knows them, who has an idea of who they are, of what their goals are, and all the other things that have impact on their illness, to tell them what to do, be that an individual or family. ...

Sometimes people are given too many choices. How is the average person to know whether they should do this treatment or that treatment? I think you can often phrase them in ways that people can understand, but sometimes people just need to be told, "Doctor's orders." ...

You're relieving them of responsibility and guilt?

You are. People feel terribly guilty about putting somebody in the nursing home: They let them down, and if they tried harder, this wouldn't happen.

Do you see an older and sicker population in nursing homes here?

There certainly are sicker patients in the nursing home, partially because they're the ones that get booted out of the hospital after your five-day stay, or minimum three-day stay, and continue treatment at the nursing home. That aspect of it has become much more intense. They can do ultrasounds, echocardiograms, X-rays, blood tests. For some things, I can get them done faster in the nursing home than I can in the hospital. There's no question that there's that group of patients that are sicker. ...

Half of the Medicare money is spent on people in the last six months of their life. So if you're spending all this money and they're dying anyway, I think you should refocus your treatment on what's going to be best for this person. What's going to make them and their family feel more comfortable? What's going to promote pain relief, function? Not necessarily doing more CAT scans, surgery, chemotherapy.

The real trick is to identify who is in that group that isn't going to live six months, because a big operation is appropriate for somebody who's going to really get better. ... I will tell patients that I think it's time to stop curative treatments, whether they go in hospice or not, and just focus on function and comfort.

I don't want to make a generalization, but many older people, if not most, recognize that they're not going to live forever and don't necessarily want to do it with the most aggressive treatment. They often do it because somebody tells them to do it. They don't know that there's another choice. I think if you rounded up 80-year-olds and asked them how they would like to die, it would be quickly. ... Most of them don't want to live forever. When you're young, you want to live forever, ... but many people don't want to live forever when they're old. In fact, that's their fear. ... They would give up a certain amount of years at the end to have a good death, one that doesn't necessarily wreck their estate, one that is comfortable, one that doesn't involve a lot of frustrating disappointments in medical facilities. ...

Are they not asked enough? Why is that so infrequent? ...

The fragmentation of medical care doesn't help. ... With experience and knowledge of a patient, you're more able to make those decisions. ... [But] physicians are like anybody else -- 20 percent move every year -- so those long-term relationships aren't there. ...

Your long-term relationship with patients impacts all kinds of decisions?

I think it does. Patients are just desperate to hear somebody sit down and look them in the eye -- somebody who's asked them about their children, about what they did in life -- and give them a recommendation, tell them why they're recommending that, tell them what other things they could do, and go from there. They're just desperate to have that, rather than just a quick visit and say, "Well, this is what you should do," and walk out, and let somebody else do it. ...

Is our health care system antithetical to what old people need?

Well, I don't know if the whole thing is antithetical. I think often acute care is great, ... but the system is focused on treatments, on diagnostic venues to find out what's wrong, and then you do one scan, and then another one's recommended, and before you know it, you're stuck with all these, all this information, and then you don't know what should we do about it or not.

[The most recent example] is prostate cancer in older men. I mean, PSA [prostate-specific antigen] tests do identify prostate cancers earlier. The problem is, a man's risk of having prostate cancer is his age minus 5. So if you're 70, your chances of having prostate cancer are 65 percent right now. So you have a test; it's positive; and then you go through a series of treatments and diagnostics tests, which can be dangerous or unpleasant, where many of these cancers are what are called "unimportant" cancers. You don't need to do anything about them. You won't die of it, or it won't even bother you. ... [But] once you start, then it's hard to stop. It really is. It's like [being] on a ventilator. It's a lot easier not to put somebody on a ventilator than to stop it. It's a lot easier to not put a feeding tube in than to put it in and then take it out. ...

One of the best things I've done in my whole career happened recently, which involved a complex patient. She was elderly. She was perfectly healthy, and she had surgery for cancer, and then she had some postoperative treatments, and then she developed this mysterious abdominal problem. ...

It was clear to me that she was not going to get better, and I suggested to her family that what they ought to do, when they proposed [another] surgery, is don't have the surgery; bring her back down here and just visit with your family, and try and have some good time before she dies. Nobody would say so, but I thought she was going to die, and I certainly thought she was going to die if she had an operation.

Her family did bring her down, and she stayed here for a week. All the family came in, and it was some real meaningful time for the family. They switched from a "get better" mode to that "this is it" mode. I think that was all worthwhile.

Then I sort of got cold feet, too, and we did the operation, and she died a few days after the operation.

But I don't regret doing that. ... But I certainly wouldn't do that for everybody if I didn't know the family. It was sort of an outrageous thing to not do what the specialist recommends, ... but I think it was a good thing. It made no economic sense at all. Medicare will pay for an ambulance to go to a higher level of care, but they won't pay to go to a lower level of care, which [is what we were doing]. So the family had to come up, on the spot, with $2,000 to do it. ...

[Is providing medical care a bit of an art?]

Yeah. But all doctors will tell you that medicine is an applied science. When I went into medicine, I thought: "This is great. All you have to do is, they tell you this, this and this. You figure out what's wrong, and then you do that, and that's it." But in between there are so many variables, including the people who don't want to do this; they don't want to have that test; they don't want that treatment; they don't tell you things that are really wrong. The application of this wonderful science that we have is an art. ... It doesn't matter how good your treatment is; if the patient ... won't take it, then they don't get the treatment. ...

[Are there any disadvantages to having a close, long-term relationship with a patient?]

There are certain disadvantages of knowing somebody for a long time and having a long-term relationship with them. It's like with my own father: I didn't want to see that he was starting to get a little demented, and I do that with my patients, too. I'll say, "Oh, that's just them. They were always that way. They're just having a bad day," whereas another doctor might immediately see that there's a problem. ... I think I probably recognize it less early because I don't want to believe it's true.

What's the hardest thing for those growing old?

Giving up independence is the worst. It is what everybody fears. It's what I fear. ... Probably at least once a week, and sometimes every day, people say, "If I ever get like that, take me out behind the barn, because I don't want to live that way." ...

[What's the biggest change you've seen in your 30 years practicing medicine?]

Probably the biggest thing is the explosion in diagnostics, the ability to look in and see things with CAT scans and MRIs. Often, when you're transferring care to another physician, you spend more time talking about what the imaging shows than what the patient says or what the physical findings are. I wish there were more of a way to [not do] the unnecessary testing. I mean, how do you know what's an unnecessary test? I think most tests that are done wind up being negative. That is, you didn't need to do the test. That would probably be the biggest change.

People are certainly living longer, and I think many of them are living better, which is good; that we're able to treat a lot of conditions to make them feel better, function better. Sometimes we prolong their life, and sometimes we don't. As I said, that shouldn't necessarily be the number one goal in treating the elderly. ...

People are going to die. You have to be happy with limited success in what I do. It's not like maybe surgery or something like that, because no matter what I do, if I'm going to continue seeing this person, and I stay in business long enough, they're going to die. So my goal shouldn't be to keep them alive. Even if I can stave something off for two years, they're still going to get sick. So a measure of success often is [that there is] nothing happening. That's not very dramatic success, to have nothing happen. ...

When I was a young doctor, I had this old farmer [as a patient]. He was great. He was a real character, ... but he had all these symptoms, and I put him on a medicine and then another medicine and another medicine. I thought I really had nailed it, ... and I said: "Howard, you look great. That last medicine must have really done it." And in front of the whole waiting room full of people, he said: "No, doc. I got rid of all those medicines, and I feel great now."

You're never going to win. Sooner or later, they're going to get sick and die if you stick with them long enough. That can't be a measure of your success. ...

When and why did you decide to do home visits?

I just always did them. Home visits are important to really understand a person. ... To go and see where they live and how they live is very useful practically. It builds this bond.

Then there are all these funny stories about how people say they're following a low-sodium diet, and you open their refrigerator and all you see is pickles and TV dinners and all that sort of stuff, food and salt shakers all over the place. ...

For some people, coming to the doctor's office means a $100 wheelchair [rental] -- more than I get paid for the visit, much more than I get paid, just to come. Or [maybe it means] one of their family members taking a half a day off. Around here, that's a big deal. ...

What's ahead for you?

I'd like to continue being a doctor for as long as I can. ... I'd like to be able to have more time that I don't practice. I haven't figured out how to do that yet and still maintain [that] kind of relationship with patients. ...

Do you imagine, if you retire, they'll find a young doctor to step in?

I don't think young doctors want to do what I do. Times are different. Medical students tend to go toward these things that are controllable lifestyle practices, where it's more 9:00 to 5:00, or 9:00 to 9:00 but you only do three days a week. I see that. My son's a new physician, and I'm not sure I want him to do what I do. ...

I see less and less of this, more shift work. But somehow we have to design our system so that even if somebody is doing shift work or something, that you can still make these relationships. ...

Did you sell your practice?

I couldn't sell it. It's worth nothing. I mean, the main asset is me.

So what did you do?

I transferred my practice to the hospital. I'm an employee of the hospital. I didn't want to do it, but the solo practice had just gotten to the point that it was overwhelming as far as the regulations that needed to be met. And you need to be a businessman, ... but I'm not a businessman. I don't enjoy it. It just requires a lot of tending. If I have a minute off, I want to go do something else.

Someday you may actually retire.

It's possible.

What will happen with your patients?

I worry about that terribly. ... Probably everybody thinks about retiring or doing something else, but I used to think to myself, "OK, I'm going to still be a doctor until this person dies, and then after that I can retire, because this person is really important." And then that happens, but by then, somebody else has taken their place.

I'll just have to have some humility. I'm replaceable. Everybody's replaceable. It's maybe more on a personal level. Practicing medicine -- I don't want to say it's addictive, but you get a lot of strokes from people. You can feel really bad, but most days you feel really good. How many times a day [are people told]: "Thanks, doc. Boy, that really helped me. It made a big difference to me"? How many people get that day in and day out? ...

Your views of your own aging? ...

I think my generation, and probably also me, are going to want to be more directive about their care. ... [They want] the ideal life: They call it squaring of the curve. That is, if you look at the quality of your life versus how many years you live, if it goes down each year, that's no good. So instead of being a curve, your quality is great up until about an hour before you die. I think my generation probably wants more of that. They want to live well up until they can't live.

Do you think boomers are prepared for being chronically ill for years?

I don't know. It certainly is one thing that I fear. To me, being unable to drive a car, to make music, to think clearly -- I don't want to have anything to do with it. A lot of what I am, and I think a lot of people, is what we do. And if you can't do anything, then ... what are you? ...

What does it mean to die a good death?

Well, you know it when you see it, I think. You certainly know a bad death when you see it. A really bad death is where you're actively being treated with blood tests and X-rays, with no attention paid to how you feel, right up to the end. That's a very bad death.

A good death, I think, is where you're in a physically comfortable place, where you don't have a lot of intrusion of outsiders, where your family can gather and be with you. They can sing if they want to; they can get in bed with you if they want to. You can have your dog there if you want to. You can have as much drugs as you need to relieve your symptoms. ... I think there is such a thing as a good death. ...

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posted nov. 21, 2006

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