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what needs to change

photo of kass

Chairman, President's Council on Bioethics 2002-2005

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One of the really large and worrisome pieces of the problem of long-term care is the lack of physicians who can provide continuous and comprehensive care for the elderly and who [have known] them for some time. We need very much to encourage the development of geriatric physicians and nurses who will be there for the longer haul. One should not romanticize. This is very, very difficult and demanding work, and you do not have the satisfactions of pediatricians, that their patients are going up and up and ever higher and ever better. These are people who are going down, medicine or no medicine. You are somehow presiding -- one hopes compassionately and gracefully -- over the end of a life, keeping company with it, doing what one can.

But ... we can begin to change the incentives such that we could get better long-term care from the medical profession. The reimbursement schemes, which are now tied to acute-patient visits, could be changed so that people would be compensated if and only if, in fact, they gave continuous care for the same patients over a longer period [of time]. There are programs that are experimenting with this.

We could learn something from the hospice movement, which is admittedly only an end-of-life system, but they have somehow learned how to keep company with the dying without thinking that removing them from life is somehow their mission. They have learned what it means to say, "The time has come," and yet to be humanly present, up close and intimate.

There are some worrisome things, however. We now have, as a routine matter in hospitals, do-not-resuscitate orders written into the charts. You're required now by law, when you enter a hospital, to fill out these kinds of forms. That's a way of expressing our preferences not to have our lives unduly extended should a sudden heart attack fall upon us. The net effect of it is, however, if you write a do-not-resuscitate order in the chart, the interns and residents say, "Second-class patient, not one to be done everything for. Not only in terms of the heroic measures, but that's a person who's on his way out; we'll cut corners a little bit." ... Psychologically, people begin to cut corners.

So this, too, is tricky. You want a profession that knows the patients; that is, gives continuous and long-term care, that's on the one hand willing to accept the limitations of such a life, but is not going to do it in a bureaucratic and procedural way.

The good doctors will let the patient know: "Whatever happens, I'm here for the long haul. I've been here before. I will be at your side. I will get you through this, come what may." It's not a crucial part of the training of young house officers. They learn it, if they learn it at all, from the old-time physicians who are their mentors and role models. I don't know whether it's being taught sufficiently. I doubt it.

The doctors who know how to keep company with the dying are harder and harder to find. The culture is, after all, primarily in the business of rescue. We still basically think, and the culture generally teaches, that today's death is a failure of today's medicine, curable by tomorrow's. It's very, very difficult to acquire just the right sense that leads you to understand that if you stick around long enough, you're going to lose all your patients, unless they lose you first.

photo of muller

Dean of medical education, Mt. Sinai Hospital, New York City

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... The reality is that in medical schools, we don't train the students to provide continuity of care over the course of many, many years to people with chronic illnesses, whose most important need is probably communication and empathy. We don't train them to do that.

We train them to understand the basic sciences, cutting edge, lots and lots of procedures. We train them to diagnose, to fix things. And that's very exciting. You could even go so far as to say that we don't even attract the right kinds of people to medical school, because the people that we attract to medical school are already the ones that have that mind-set -- "I want to get my hands dirty; I want to fix things; I want to make a lot of money; I want the prestige" -- because that's how health care is defined. Maybe it's the social workers who we should be recruiting to medical school, or the nurses -- students with a different mind-set.

How are medical students responding to the idea of working with the elderly?

Traditionally in the residency training period, the exposure that we get to geriatrics patients as such, most of the people in the hospital who are sick are elderly, and people are coming in very, very sick, nowhere near their functional baseline. So the person who is going to the hairdresser once a week and going to the supermarket every other week and has pneumonia comes in unable to speak, unable to swallow, incontinent, just looking like a pile of old person, and not like a human being anymore. So who wants to do that? By the time you've barely gotten them better to the point where they can sit up in bed, out the door they go.

You never really see the peak. There's not much attraction there for someone who was taught in medical school to look for the exciting and the new and the interesting and the cutting edge and the science and the procedures. It all gets left way, way behind.

The medical students here at Sinai get a taste of Visiting Doctors [housecall program]. They get a month in the outpatient geriatric practice, so they get to see functional elderly people coming in to the doctor, representing themselves, advocating for a change in medication. That's a big deal. Just this year they started something called a Seniors as Mentors [SAM] program, where the students, from the minute they get to medical school, are paired up with a community-dwelling senior citizen. They kind of become buddies at first, just buddies, and then slowly advocate for their health care over the course of a year or two.

Those kinds of experiences, I think, will open their eyes, not just to geriatrics, but to the fact that most of the people who are going to need most of their care are going to be the elderly or the very elderly. And they could do that in general medicine, too. They can do it in cardiology, too, as long as they're aware that it's an important subset of their patients, and they can't just be treated like every 40-year-old on the street.

photo of farber

Geriatrician, Mt. Sinai Hospital, New York City

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… Lots of times we're called upon to manage end-of-life care issues and say: "I would not even offer to put your father on a breathing machine because he's dying. He'll die with or without that machine. You're just going to prolong his suffering and prolong the dying process by doing that."

It's hard for people to accept withholding care, discontinuing certain treatments. And it's hard for physicians in general, [because] our medical system is not built to do that. ...

A lot of time goes into trying to tell people what they are, what they can do, what they cannot do, what does the evidence show, and help people make a decision about, do they want to use that treatment for their loved one? ... Then you're left with people that don't have the support they need to make these major decisions, so the default is "do it." So you have all these people with all these interventions that could have been avoided.

I think that's where a lot of the savings financially could be. It's in the inappropriate use of these interventions.

photo of coch

General practitioner, Alleghany County, N.Y.

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…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. ...

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posted nov. 21, 2006

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