people who need people

Contrast this somewhat grim peek ahead at future geriatric care with

the oddly optimistic governmental opinion that the problems of medicine

will be solved by ever-better technology. Medical care for Mrs. E and the

other patients that I have introduced here will not be enhanced by better

software, office websites, or paperless electronic records. These patients

are, as Barbra Streisand sang, people who need people

Perhaps the most critically important individual in the doctor’s office is

the one who sits at the front desk and answers the telephone. She, or perhaps

he, is the portal of entry. She must not impose a barrier to the patient

with MCI. A warm greeting, in a somewhat daughterly yet respectful tone,

creates an air of calm and defuses what otherwise would be a confrontational

challenge for a mildly cognitively impaired old man. Contrast such

an introduction to the blunt, detached salutation, “I need to see your insurance

card” that makes me cringe when I am the patient at the window

in another doctor’s waiting room.

It is disgraceful that common courtesy and polite, respectful communication

are skills in need of honing, but that is the current sad state of

affairs. Medical office staff, doctors included, will need an adult education

crash course in medical etiquette (Kahn 2008, 1988), something akin

to taking an accelerated Berlitz course to become bilingual, if they are to

communicate effectively with the elderly who are cognitively impaired.

The staccato text-message style of modern interpersonal exchange won’t

fly with elderly patients who are a bubble off.

Change is hard. It is even more imposing for the patient who suffers

from MCI. The maintenance of a routine eliminates a barrier and makes

for a more user-friendly medical offi ce. This means that a stable, preferably

long-term group of employees is essential to the provision of effective

geriatric care. The bond formed between a fragile old woman with MCI

and a cheerful, responsive receptionist well may be stronger than the relationship

between physician and patient. How do we reduce employee

turnover? Aside from the obvious solution of competitive salaries and generous

benefi ts, we need to fi nd employees who are right for the job in the

fi rst place. It is the exceptionally even-tempered individual who can deal

with thousands of calls and visits annually from patients who are a little

irritable, suspicious, or disinhibited. Perhaps applicants for medical office

jobs should undergo pre-employment psychological screening to determine

if they possess the right temperament for working with patients with

MCI. Not everybody is cut out for this line of work. At the same time, we

need a national awareness campaign to teach all Americans to recognize

and understand the behavior patterns of MCI, just as we all ought to know

the warning signs of a heart attack or how to use an automated external

defbrillator (AED). We must become dementia ready.

Paperwork is another barrier for the cognitively impaired older patient.

On entering the office for a first visit, a nervous woman is handed a clipboard,

a pen on a string, and a formidable stack of forms as a required task

to be completed before she may be granted access to the great and powerful

Oz, the doctor. While the gauntlet of insurance forms and signature

pages may be a minor bureaucratic annoyance to the younger and more

functional individual, it is an embarrassing impediment that heightens

frustration, anxiety, and irritability for the older person who is just on the

margin of normal recall and mathematical and language skills. Such patients

are challenged at once by this cognitive stress test before they even

have had a chance to shake hands with the doctor.

Many older, slightly confused and forgetful patients must face this challenge

alone. The lucky ones have a son, a daughter, or other family member

who accompanies them and helps to navigate the paper trail of Medicare

cards, explanation of benefits forms, insurance releases, and health history

intake forms listing medications, surgeries, allergies, plus family data that

even the cognitively unimpaired would have trouble generating extemporaneously.

The ordeal in the waiting room, however, is not over until

the elderly woman with MCI has reached the summit of the highest peak

among piles of paperwork—the HIPAA form.

The Health Insurance Portability and Accountability Act of 1996 is legislation

that allows individuals the freedom to move from job to job without

risking the loss of health insurance coverage. Tacked onto the bill was

a provision to maintain the privacy of personal health information in a

new era of supercomputing information technology and massive, faceless

managed care corporations. It was designed to protect the little guy. Yet,

in the case of a patient who is just a bubble off, HIPAA exemplifies the law

of unintended consequences.

If a patient is competent, like you and me, he may sign the HIPAA form,

designating those family members or friends with whom the doctor may

share clinical information from the medical record. Conversely, by omitting

the name of a loved one, a patient specifically can block access to information

by one or more family members who are currently out of favor

with him. Few families function absolutely harmoniously, and the HIPAA

form offers subtle clues about family dynamics.

In the event that the patient is incompetent and unable to complete the

HIPAA form due to severe dementia,5 a family member must do so by

proxy. But what of the elderly patient with MCI who is not demented but

who is not making sound, rational decisions either? She may be in the

midst of an argument with her daughter over a trivial family matter. When

she arrives at the doctor’s office, it occurs to her, at the moment, to delete

her daughter’s name from the HIPAA form, thus registering her dissatisfaction

with her adult child. That will show her! A week later, when the

old woman has a massive stroke and is suddenly near death, I am left with

her daughter on the phone and, in my hand, a recently revised HIPAA

form that says in big block letters “Do not discuss my health with my daughter.”

What am I to do?6

HIPAA, as a means