Patients were said to “die the Harvard death” when they underwent every
imaginable blood test, biopsy, scope, scan, or surgery before passing, leaving
behind a challenging case study worthy of publication in the New England
Journal of Medicine but ending in a tragically miserable and coldly
technological death.
As I look out on my packed office waiting room, I must admit that I
am skeptical. Many of the frail, demented octogenarians sitting out there
can barely negotiate the short path to the lavatory, let alone navigate a
complex, fractionated system of health care, no matter how much help
and support they may get from their medical home.
How am I to maintain
my burgeoning geriatric practice, with all of its stressful demands,
while at the same time assuming the new role of clinical information manager
and expert in health information technology?
During office hours in a
busy practice there is barely time for a doctor to make a phone call, grab a
bite to eat, or even to go to the bathroom. I am not exaggerating. At present,
the image of the doctor’s office is more like a crowded bus station than
a quiet, peaceful home.
What else is wrong with this model? It incorrectly presupposes that a
physician can be either a touchy-feely relational communicator or an Oz like,
imperious, non communicating, specialty wizard, out on the rim of
the wheel. Both images are wrong. To be a physician, regardless of specialty
or narrow focus of practice, is to be both technically competent and relational,
a communicator, a teacher, and a healer.
Even the high-tech superstar surgeon must be
able to sit down and talk with patient and family in order to serve them
well. Somehow, in the course of medical specialization as a form of subcontracting,
we have all forgotten our Hippocratic mission statement.
Without doubt, none of us is as sharp as we once were. A missed appointment,
a forgotten name, or a word that escapes us is a deficit easily
attributable to normal aging. “Benign forgetfulness of the elderly” was a
clinical term once popular among neurologists (Kral 1962, 257). It characterized
the nonmalignant type of mild memory impairment that does
not presage a dreaded diagnosis of Alzheimer’s disease (AD). More accurately,
I think, it labeled the forgetfulness that afflicted older neurologists.
The physician who cares daily for hoards of cognitively impaired patients
likely will suffer from similar frustration, exasperation, early burnout,
and compassion exhaustion. Instead of the strain of round-the-clock
comprehensive care of one individual at home, the primary care physician
will be subject to a slow erosion of morale and loss of a sense of professional
purpose from an endless procession of the elderly, many mildly
cognitively impaired or even frankly demented, each with a fifteen- to
thirty-minute appointment, but absent the tireless, loving devotion and
commitment of a member of the family. Geriatric medical care, under the
auspices of Medicare, is, after all, only a government job.
it is doubtful that
even an old woman who is as sharp as a tack can take her medications
exactly as prescribed. The cognitively impaired patient certainly won’t get
them right.
Some years ago, before hospitalists had assumed the care of hospitalized
patients, I was called in late at night to see an old man in the ICU who
was experiencing chest pain and shortness of breath. He was delirious
at the time, perhaps from medication or inadequate oxygen to his brain,
Several months later I received a scathing letter from the fellow, in response
to a submitted bill, stating in no uncertain terms that we had never
met that night. He articulately, but confusedly, wrote to the fraud division
at Medicare, accusing me of attempting to cheat that federal agency of
approximately $100 for services never rendered. Shortly thereafter, with
no official investigation of the patient’s medical chart, formal notice arrived
from the government that I indeed had committed Medicare fraud.
Although there was an option provided to request a hearing on the matter,
it was of course neither practical nor cost-effective to close my office for a
day to defend myself against the insulting accusation. I let it go, but perhaps
that was a mistake, as it still bothers me years later. Shortly after this
incident, however, I did permanently give up doing hospital work and
restricted my practice to the office, then the last bastion where a doctor
still had any control over his work environment. Hippocrates wrote nothing
in his physician’s oath about having to endure the abusive ranting of a
paranoid, cognitively impaired older patient. In the future, when primary
care is regarded by all as merely a job and not a calling, who will choose to
care for the coming wave of such patients?
Self-centeredness is an undesirable persona
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