Thursday, July 2, 2015

ABIM Discontinues Requirement for Maintaining Underlying Board Certification



American Board of Internal Medicine (ABIM) has had a lot of, well, lets just say difficult press this year. There is one piece of news though that came out yesterday that should send a smile to any internal medicine physician practicing in the specialty of Hospice and Palliative Medicine and should resolve the debate that Alex Smith talked about one year ago in this GeriPal piece.  What happened? ABIM announced that it will discontinue the requirement for maintaining underlying board certification (sorry Alex, I know you already paid)!

What does all this mean?  

This means you will not have to take the re-certifying exam in Internal Medicine just so you can remain certified in Hospice and Palliative Medicine.  While there are still some good reasons to re-certify in ones primary specialty like Internal Medicine (as summed in Alex's article), there are plenty of reasons not to.  Just the cost alone is reason to celebrate as Maintenance of Certification (MOC) program fees for Internal Medicine is $1,940 on top of the $2,560 you have to pay for Hospice and Palliative Medicine.

Who should we thank?

Given the hardships that ABIM has been under of late, I for one will be sending a quick thank you to the ABIM and its CEO, Richard Barron.  I'd also like to acknowledge the work that the American Academy of Hospice and Palliative Medicine (AAHPM) staff and physician leaders (like Tara Friedman and Holly Yang) who have worked hard to advocate for this change and other workforce issues.

What about Family Medicine?

Sorry folks.  One must maintain their primary certification by the ABFM to maintain certification in Hospice and Palliative Medicine (or any CAQ like Geriatrics for that matter.)  Word on the street is that this is unlikely to change.

by: Eric Widera (@ewidera)
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Monday, June 29, 2015

A Master of Science Program in Palliative Care?

We’re in trouble.  There just aren’t enough specialists in palliative care to palliate all the suffering out there.  One estimate of provider need is over 5,000 full time employees, which could require up to 18,000 trained providers depending on the proportion of time providers devote to the practice of palliative medicine.

One important strategy to address this problem, as highlighted by the recent IOM report Dying in America is to improve the skills of all providers in the practice of “primary” palliative care. 

Historically, some physicians have turned towards palliative medicine and hospice later in their careers – perhaps out of a desire to broaden the meaning they find in their work. However, board eligibility in Hospice and Palliative Medicine now requires fellowship training.  While this is a wonderful thing for establishing the legitimacy of the field, a potential externality is further threatening the workforce supply.  Not only are there a limited number of Palliative Medicine fellowships, it is very difficult for many mid-career clinicians to obtain training without a major disruption of their lives, such as leaving their practice and/or moving. Currently there are 300-350 palliative medicine fellows in training each year; there are a limited number of opportunities for specialty training for nurse practitioners and no programs we are aware of for physician assistants.

Amos Bailey, MD, a well-known leader in the field of Palliative Medicine and a new colleague of mine at the University of Colorado has a pretty innovative idea.  He has set up a task force to prepare an application to the Board of Regents to offer a new degree program: Master of Science in Palliative Care.  This would be an inter-professional executive Masters that would be provided predominantly online (with three separate one-week on-campus intensives).  This program will be designed for the clinicians (physicians and advance practice providers) who are already working and need or desire more training in Palliative Care.  

As part of this effort, we need to gauge potential interest in such a Masters Program.  Dr. Bailey has prepared a brief (2-3 minute) survey to explore potential demand among physicians and advanced practice providers who might be interested in such a program.  [Click here for a link to the survey]

What do you think of this idea? Personally, I’m pretty sold on the idea.  Currently, the need is so great that I have no worry that such a program would undermine my board certification in Hospice and Palliative Medicine although I can see that being a concern.  We would love to hear thoughts.  Also, any help you can provide in identifying potential participants in the program to respond to our survey would be greatly appreciated. 

by: Dan Matlock, MD, MPH
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Wednesday, June 24, 2015

A better way to care for frail patients: Independence at Home

Last week the Centers for Medicare and Medicaid Services (CMS) released a report that I think will change how geriatric palliative care will be delivered in the United States.

What is the report?
 CMS released the results from the first performance year of the Independence at Home Demonstration.  The Independence at Home Demonstration  is modeled on the Home Based Primary Care program from the Department of Veterans Affairs (VA) which brings comprehensive, longitudinal, interdisciplinary primary care into the home setting for patients with complex, chronic, disabling disease.  HPBC has been shown to improve access to care and reduce hospitalizations while also reducing total cost to both the VA and to Medicare.  Patients of HBPC report high satisfaction with access and continuity of care.  Would such care have similar results if offered to a general Medicare patient population who are not veterans??

What were the results of the first performance year of Independence at Home (IAH)?
According to CMS' analysis, all 17 participating practices improved quality in at least three of six quality domains.  Medicare beneficiaries participating in IAH had fewer readmissions within 30 days.  They had less inpatient and emergency department utilization for diabetes, high blood pressure, asthma, pneumonia, or urinary tract infection.

Independence at Home participation resulted in over $25 million in savings in the first performance year.  Given just over 8,400  Medicare beneficiaries enrolled, IAH led to an average of $3,070 savings per participating beneficiary.

Why is this important?

I recently helped care for a frail, older couple.  I took care of one patient, and a colleague cared for the partner.  'Can't you convince them to move to a nursing home,' I was asked. 'They are barely safe at home and it is getting harder and harder for them to come to the clinic.'  As my patient and I discussed the stable but complicated medical situation, the difficulties of  bathing, along with the challenges of 1950's split-level home design, my patient ended our conversation ended as she always has: 'I just want us to be together in our home of fifty years.'*

How do we make care at home viable when being at home is the fundamental goal of the patient?

The move to a nursing home would certainly be a lot easier to implement, but it is not what the patient wants.  Hospice certainly has been a key for helping people stay in home, but what do you do when the 6 month prognosis is not met?

Independence at Home is a model of care that would give my patient exactly what is wanted:  Primary care delivered in the home setting.  It is care that she deserves and given the potential total cost savings, paying for a home based primary care program seems like a wise investment.

What next?

The Independence at Home is still a demonstration.  To become an option for my patient, more time is needed to show the full value of the program.  If the IAH continues to perform like its first year, like the Home Based Primary Care program has for years, then it should become a Medicare Benefit.

For now Congress needs to authorize an extension of the demonstration project. With better quality outcomes and at a lower cost, how could Congress possibly fail to act?

by: Paul Tatum (@doctatum)

* The patient case is an amalgamation of events, and not reflective of one patient

Image from http://www.clker.com/clipart-home-love.html
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Friday, June 19, 2015

Flags of Grief



by: Genevieve Flagello, LMSW, ASW

I am a social worker two years into my career, currently working with veterans on an inpatient hospice unit. My clients range in their generational experience of war, from the Gulf to WWII. My work with these veterans is intense, yet rewarding, and every day they teach me a little more about life. Recently, I returned to my office from an extended trip and was informed that a veteran I had worked with closely had died.

This is not uncommon. I mean, I work in HOSPICE. All of my clients, veterans, will at some point die while in my care. It’s the nature of the work. I assumed that many of my clients would be gone upon my return. I had not been back to work for more than a few hours before this particular client had died. In the flurry of the day, I didn’t get a chance to see him or say goodbye.

After a veteran dies on the hospice unit, the nurses clean him/her up, put him/her on a gurney, cover the body with a symbolic flag and silently process to the morgue. The body then remains in the morgue until the mortuary comes to pick them up. Anyone is allowed to join in the procession from the veteran’s room to the morgue. This is particularly helpful for families who are grieving the loss of their loved one as it facilitates closure and begins the healing process.

Though moving and helpful, something has been missing from our ritual. Another staff member, a veteran himself, has been reorganizing the process so that when a veteran dies anywhere in our facility, the veteran is draped in an AMERICAN FLAG, followed by the procession. This might not seem like much of a change to an onlooker, but to me, it made a world of difference.

The veteran’s flag is clean and simple. It has a red border and a blue star in the center. Half the time, no one really knows what it represents. Sometimes one can fail to realize that it is, in fact, a flag and not a decorative sheet. It does not carry antiquity in its fibers or require much by way of ceremony or procedure. In contrast, the American flag is vibrant and recognizable. It’s threads are woven in honor and stained in sacrifice. It has been destroyed, defiled and then raised up in celebration. It carries the history of a nation in its fabric and commands reverence. The type of reverence that derives from the unspeakable loss that comes with laying down one’s life for a country, and a people, that you love.

As I saw the bright reds, blues and spangled stars pass my office, I shot up and joined the procession for my client. There were no family members present…only a few medical team members and me. This happens often, as many of the veterans who come to this hospice unit have no close friends or family to speak of. In the end, the medical staff becomes like family to these veterans. I was comforted by the fact that at least he had us. I fell in line behind the nursing assistant and placed my hand on the gurney. I felt the cloth of the flag under my skin and whispered a soft prayer for my patient. I told him what an honor it was to work with him and I thanked him for teaching me.

There are long standing protocols to tucking and folding the American flag away. Once we arrived at the morgue, another nurse and I were singled out to receive an on the ground training to the procedure this symbolic emblem requires. I imagined the uniformed men and women I had seen do this before. I saw their crisp, white gloves gripping the flag tightly, folding her with their deft fingers and overwhelming sense of duty.

I tried to embody these memories, but my fingers were not so deft and nothing about my outfit that day was crisp. As I bent the flag into its neat, triangular pattern, under the watchful, silent gaze of my colleagues, I began to feel something. Tears began to well up in my eyes and I was confused. Who was I crying for? Was I crying for my patient who just died or for all of my patients? Was I remembering when a flag was folded for my grandfather? Was I filled with an unfamiliar sense of patriotism that was so strong that it was causing me to cry? Honestly, I’m not really sure.

I have worked with over 170 veterans during my time in hospice. I find that I carry these 170 veterans with me every day. Mostly, I carry their stories. Stories of brutality and horror, of hope and survival. Stories about falling in love and the birth of children. Stories of paranoia and fear, of betrayal and heartache, of resiliency and redemption. Sometimes the weight of these stories aches within me, but I know I am a better person for having heard them. These stories teach me that heroism exists and that the world is still worth fighting for. People are still worth fighting for. I hold these stories deep within me and I grieve for the loss of those that have told them.

After the procession was over, I took to the rose garden outside the hospital. I sat on a bench and looked up at the sky. I saw how blue it was and I felt the sun on my face. I listened to my own heart beating and for just a second realized what a miracle it is to be alive. In that moment, the stories and grief stood still. I sat, and I was thankful.

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Thursday, June 18, 2015

Top 10 Reasons Eric Widera is the Best Fellowship Director Ever

10.      Like President Obama, he keeps his wardrobe streamlined so he can focus on what’s important.
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9.      He shares the dark chocolate in the fellows’ candy bowl.
8.      His door is always open for career advice, teaching, venting, and laughing.
7.      He rules the Geriatrics and Palliative Care Twittersphere. At AGS, we realized he is the closest we’ll ever get to meeting a celebrity.
6.      He only made us do the #Thickenedliquidchallenge once.
5.      He creates an upbeat environment through witty banter with his office doppelganger, @AlexSmithMD.

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4.      He actively seeks out our feedback to continuously improve the fellowship.
3.      There’s an app for that: he shares his “GeriPal Depot,” the most extensive, organized collection of Geriatrics and Palliative Care PowerPoints and articles in the world.
2.      He allows us the autonomy to shape our own learning.
1.      He is a master communicator, clinician, and educator and inspires us to achieve his level of expertise.
Thank you, @EWidera, for an amazing year.  We are honored to have begun our careers with you!

The 2014-15 Clinical Geriatrics Fellows (from left to right)

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Claire Larson (@ClaireLarsonMD)
Allen Tong (@AKTongMD)
Daphne Lo (@Daphne_LoMD)
Stephanie Rogers (@SERogersMD)


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Monday, June 15, 2015

When to Stop Medications in Advanced Dementia


by: Claire Larson

Throughout medical training, we devote extensive time learning when to start medications. We memorize the pharmacology, indications for use, side effects, and sentinel trials showing their efficacy. Yet, not until my fellowship training in Geriatrics, did I learn another key part of medication prescribing: when to stop.

We’ve all seen it: patients with lists of 10, 20 or more medications, to which we are always adding and never subtracting. Most were added with good intentions and defined indications, but over time, like the medications themselves, the indications expire.

The case of one of my home visit patients stands out: a 65 year-old man with very advanced early onset Alzheimer’s disease. Bedbound, nonverbal, and aspirating, when I became his primary care provider, he was still taking donepezil and memantine, which he had taken for the last 10 years. When I discussed his care with his neurologists, they were reluctant for these medications to be stopped for fear of him worsening, despite recognizing that there was no evidence to support continued benefit.

I recently led a journal club where we reviewed, “Use of Medications of Questionable Benefit in Advanced Dementia.”1 This cross-sectional study examined medication use by nursing home residents with advanced dementia. Medications of questionable benefit were defined as “never appropriate” medications as determined by the consensus of a group of Geriatricians.2

Over half of nursing home residents with advanced dementia (53.9%) received at least one medication of questionable benefit. The most commonly prescribed were cholinesterase inhibitors (36.4%) and memantine hydrochloride (25.2%). Continuing these medications does not increase survival or alter the course of advanced disease, can cause side effects, and contributes to increased health care costs.3

So why are so many patients with advanced dementia still taking medications of questionable benefit?

While stopping a medication may seem straightforward, as clinicians we know that stopping a medication is frequently more difficult than starting one. We often lack the knowledge and evidence to help us know when to discontinue medications.

Next, stopping medications involves discussing the balance of risks and benefits with patients and their families, and probably hardest, explaining that the disease has advanced beyond the point where the medication is helpful. For the families of my patients with dementia, stopping donepezil or memantine is most difficult, for this is often closely tied to their hope that the medication will cease or significantly slow the progressive course of the disease.

As clinicians we also may be uncomfortable taking away medications, as we are trained to always “do” something. But stopping these medications does not mean we stop caring for the patient, we simply shift our focus.

For my patient, a focus on careful hand-feeding and skin care, quality time spent with his family, and continued enjoyment of music and time outdoors was more important and helpful than any medication. Learning and studying when to stop medications, can help us start taking better care of our patients.


References

  1. Tjia J, Briesacher BA, Peterson D, Liu Q, Andrade SE, Mitchell SL. Use of medications of questionable benefit in advanced dementia. JAMA Intern Med. 2014;174(11):1763-1771. 
  2. Holmes HM, Sachs GA, Shega JW, Hougham GW, Cox Hayley D, Dale W. Integrating palliative medicine into the care of persons with advanced dementia: identifying appropriate medication use. J Am Geriatr Soc. 2008;56(7):1306-1311. 
  3. Buckley, JS and Salpeter, SR. A Risk-Benefit Assessment of Dementia Medications: Systematic Review of the Evidence. Drugs Aging. 2015 May 5. [Epub ahead of print]
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Thursday, June 11, 2015

Copyright claims a well-validated cognitive test




A new meta-analysis of brief cognitive tests appeared in JAMA Internal Medicine this week, and I was asked to opine on its significance. Cognitive testing is an important and complex topic already, but this had an unusual but sadly unsurprising twist.

Brief cognitive tests, like the Mini-Cog or MoCA, are relatively simple but powerful tools that can be used in almost any clinical setting as a screening tests for cognitive impairment or dementia. A surgeon might use one at a pre-op visit because cognitive impairment increases the risk of post-op delirium. Or a primary care provider might use one to see if cognitive impairment contributed to a patient's recent falls. For a provider who sees geriatric patients, they are as important as a pocket talker!

The meta-analysis asks if there is any well-validated alternative to the Mini Mental State Exam (MMSE). Readers of this blog probably recall why many providers are looking for alternatives to the MMSE - since 2001 it has come under strict copyright enforcement, creating barriers to its ready clinical use. And in 2006, a promising new alternative, the Sweet 16 test, vanished in a haze of copyright controversy, demonstrating that copyright enforcement of the MMSE is adding new barriers to dementia research as well. Many providers have switched to the MoCA or other yet-surviving tests, but the unfortunate reality is that no test had been as widely studied and validated as the MMSE. Where do alternative tests stand now?

Fortunately, the authors found an even dozen potential alternatives with enough studies in the literature to perform meta-analyses, and several were at least as good as the MMSE at detecting dementia or cognitive impairment. We can add the Mini-Cog, MoCA, and ACE-R to our quivers as well validated cognitive screening tools.

Er, actually, scratch the ACE-R. In trying to learn more about it for my commentary I discovered that it has followed the Sweet 16 into oblivion. It had been validated in 12 studies in 12 different countries around the world - work all now wasted.

Now, maybe the ACE-R's Australian authors should have known better. The test includes all of the questions on the MMSE, interspersed among many others that address the MMSE's deficiencies in executive function and sensitivity for mild impairments. But the ACE-R was published in 2000 (and was probably created years before that), back in the "benign neglect" days of the MMSE's copyright. And isn't this how medical research is supposed to work anyway? Iteratively improving on prior work? Building on best practices? Standing on shoulders? Isn't that how the MMSE itself came into existence? Isn't the purpose of copyright to promote the advancement of art and science?

Which test is next? Is the MoCA or SLUMS safe? Have other tests already quietly been disappeared? Would any bright young researcher risk their career making a better cognitive test? Should governments be content with research dollars being wasted? Does copyrighting a medical procedure even make sense? What can we do?

By: John Newman (@GeriSciDoc)

[It was surprisingly hard to find an open access shooting-gallery duck. The beautiful duck above is from the public domain collection at openclipart.org, created by PrinterKiller. With my hand-crafted red and white additions, I hereby designate the modified image as public domain as well.]
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Thursday, June 4, 2015

What should we call the physician-assisted act of intentionally killing oneself near the end of life



By: Eric Widera (@ewidera)

It was a big day in California today. The California Senate passed SB 128 which would permit a doctor to provide a terminally ill patient a lethal dose of a drug with the explicit intention that the terminally ill patient make take this drug to shorten his or her life.

So here is the problem that I have when trying to put my head around this issue and write about this for GeriPal. It all starts with what to call it when a physician prescribes a lethal dose of a drug for a terminally ill patient with the intent that the patient may choose to self-administer this drug to bring about his or her death. For obvious reasons, it would be hard to say this over and over again in a paragraph (as I just did), so what should we call it when we right or talk about it?

Here are the leading options:
  • Death with Dignity: I know what I’m about to say will be taken as a great offense to some who read this blog, but come on. This is just pandering. The term is vague and value laden that offers nothing to the debate over the topic except spin. It also makes it seem like this is the only road to go if you want dignity at death. 
  • Physician-aid in dying (PAD): I’m not loving this one either mainly because of a loss of specificity. Are we providing people aid that are dying by focusing on their comfort or are we aiding them to die by giving them medications with the intent to end their lives? Only the latter is correct but people may confuse the former with it 
  • Aid in Dying: I’m not even sure what to do with this one. Who is aiding who with what again
  • Physician Assisted Death (another PAD): I'll talk more about this below, but this makes it unclear if we are including euthanasia
  • Physician Assisted Suicide (PAS): this is probably the most specific term for the physician assisted act of killing oneself intentionally. However I do realize that many criticize this definition as suicide is linked with mental illness and lack of decision-making capacity (both of which may I add shouldn't be stigmatized either)

With all of this said, I feel the most technically correct phrase to use is Physician Assisted Suicide (sui: of oneself + caedere: kill).

Physician Assisted Death probably comes in at a close second for best term to use, although another worry is that it is vague enough that I don't know if it encompasses euthanasia and/or assisted suicide (this is also true of aid-in-dying as it doesn't state who is doing what to whom). For example, a recent NEJM article defined Physician Assisted Death as the administration of drugs with the explicit intention of shorting of life that both encompassed euthanasia or PAS. As I don't think most people would argue for endorsing euthanasia, I think specificity is important.

So with that said, I’d love to know what term you use and why. Take my poll and leave comments below.

What should the physician-assisted act of killing oneself intentionally near the end of life be called?

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Monday, June 1, 2015

International Celebration of Aging at University of Michigan Health System


A Kyrgyzstani elder watching the kids while parents are away. 
My exhibit entitled An International Celebration of Aging will be featured by Gifts of Art at the University of Michigan Health System (UMHS) in the Taubman Health Center South Lobby Gallery from June 15th to August 23rd, 2015. The UMHS Gifts of Art program is a multifaceted arts in healthcare program that presents changing art exhibits in nine galleries that are viewed by approximately 10,000 people a day. These galleries are some of the most widely visited indoor, non-museum exhibit spaces in Michigan. For more information, please visit: www.med.umich.edu/goa.

The exhibit features photos I’ve shot over the last 2 decades in my travels searching for positive views of people who thrived into old age. They feature images from Asia, Russia, Central Asia, South America, North America, and India, samples of which appear on this GeriPal post. They celebrate the universality of aging and the contribution of elders to societies around the world.  My photos have been published on over 50 covers of The Gerontologist, the flagship publication of the Gerontological Society of America. 

In the city of Benares in India an elderly woman gathers water from a public well for cooking.
On the banks of the Ganges an elderly man watches over the water buffalo.
Outside a Moscow cathedral a woman weaves delicate lace.
Elders celebrate the New Year on Okinawa with Hatsumode, or the first shrine visit.
High in the Peruvian Andes an elderly woman shows off her traditional dress.

At a 4th of July celebration, a Tuskegee Airman steals the show.  That is the Congressional Medal of Honor on his neck.
Aging is not a popular topic to look at, and few people embrace images that tweak insecurities about wrinkled skin and thoughts of mortality. I like to show elders who are not shy about being themselves and outwardly reflect their culture in an era where globalism is eroding many local traditions and costumes. I do this as an antidote to the ageism that permeates the mass media's imagery of growing old, which contributes to stereotypes and negativity. With my photos I hope to open a door to understanding aging as part of the life experience and build positive attitudes about growing old.

The exhibit opens on June 15, 2015 and I will be there with Caroline Vitale MD for a gallery walk-through on opening day sponsored by the UM Division of Geriatric and Palliative Medicine. Caroline is Director of the Geriatric Medicine Fellowship Program and Associate Professor of Internal Medicine. For further info please email me at jlevinemd@shcny.com



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Thursday, May 28, 2015

The house calls imperative and what you can do about it - right now.



A timely study came out in JAMA IM this week that highlights the need and potential demand for home-based delivery of health care in the US. The study, led by Katherine Ornstein, gave us the most reliable estimate to date of the homebound population in the United States.

The Study

The authors of this study used data from the National Health and Aging Trends Study (NHATS), a population-based survey of individuals 65 years and older living in the US and enrolled in Medicare. For this study, they included 7,603 community dwelling adults ages 65 years and older.

The problem with NHATS is there was no predefined measure of homebound status. So the authors created measures that accounted for the fact the homebound status is more than just disability and more than just receiving skilled home health care service benefits. These measures included data on (1) the frequency with which individuals leave home, (2) whether the individual had difficulty leaving the home, and (3) whether help was required to leave the home. The authors then categorized participants into the following groups:
  1. Homebound: never or rarely left the home.  They further broke this up into two sub-categories:
    • Completely homebound: never went out in the last month 
    • Mostly homebound: went out once a week or less 
  2. Semi-homebound: getting out of the home was difficult or they needed personal assistance to do so 
  3. Non-homebound: the rest of the cohort

The Results: there are more homebound adults than nursing home residents

What the authors found was noteworthy:
  • 6% or an estimated 2 million older Americans are homebound, meaning they rarely or never leave the home (to put this in perspective, there are 1.4 million nursing home residents in the US.) 
  • 1% of the population (an estimated 395 422 people) are completely homebound (never leaving the house in the last month) 
  • 6 million older adults (15% of the population) are at risk of becoming homebound because they only leave the home with another person, or have difficulty doing so alone. 
  • Those who were completely homebound had on average twice as many chronic conditions as those who were nonhomebound (4.9 vs 2.5) and were significantly more likely to be depressed or have possible or probable dementia 
  • Half of those who were completely homebound were hospitalized in the last year 
  • Only 12% of those who are completely homebound report that they received primary medical care services at home.

The Home Based Care Imperative and 

One can look at that last bullet point (12% of completely homebound older adults are getting primary medical care service in the home) from both a pessimistic or an optimistic point of view. The pessimistic view point would argue that for completely homebound adults we need far more home-based primary care as there is growing evidence that these services improve care for this population (for instance, home-based primary care (HBPC) in the Veterans Affairs system has been shown to lower hospital and nursing home use, 30-day hospital readmissions, and costs of care.)

The optimistic point of view is that this number is a great trend upward, as the number of homebound older adults getting primary medical care service at home was likely much smaller 10 years ago.  For instance, just between between 2000 and 2006, the number of physician house call visits to Medicare beneficiaries more than doubled.   I don't know what the numbers are now, but I'm bettering they are much higher.

What You Can Do to Make These Numbers Better

One way to continue the growth of home based care is to support demonstration projects under the Medicare Independence at Home Medical Practice Demonstration Improvement Act.  The bill to extend the demonstration project has passed the Senate but the House has not taken action yet.

So now is the time to go to the AGS's Health in Aging Advocacy Center (click here), where you can take 5 minutes to contact your Representative and ask that he or she support this important legislation aimed at continued testing of new approaches for treating these patients in their homes.

by: Eric Widera (@ewidera)


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Tuesday, May 26, 2015

New guidelines address conflicts over "potentially inappropriate" treatment in the ICU



By: Laura Petrillo, @lpetrillz

Summary

Decisions about life-sustaining treatment in the intensive care unit are among the most ethically fraught decisions in medicine, and disagreements between clinicians and families are not uncommon. To provide guidance to clinicians, the American Thoracic Society (ATS) collaborated with the American Association of Critical Care Nurses and other critical care societies to create a policy statement on "Responding to Requests for Potentially Inappropriate Treatment in the Intensive Care Unit," to be published on June 1st in the American Journal of Respiratory and Critical Care Medicine.

Proponents of palliative care will be glad to see that the guidelines recommend an emphasis on good communication in the ICU and early, expert consultation from palliative care or ethics services to prevent conflict. There has been increasing appreciation of the value of palliative care in intensive care, and efforts like IPAL-ICU are making strides to facilitate the collaboration of ICU and palliative care teams. But there is still a long way to go, and the ATS's endorsement of early palliative care in the ICU is most welcome.

When conflicts arise despite proactive communication, the guidelines recommend using specific language to categorize the family request that led to the dispute. The authors use the term "potentially inappropriate treatment" to acknowledge that in some scenarios, the treatment that a family requests may have some physiologic benefit, but the clinician disagrees with the worth of that benefit or the means justified to achieve it. This is a move toward transparency about the competing value judgments inherent in these decisions, in contrast to the past when clinicians had sole power to deem a treatment "futile" if it could not bring about an outcome that the clinician considered meaningful. The authors resurrect the idea of futility, but narrow the definition to apply only to treatments with absolutely no chance of bringing about a physiologic effect, like providing CPR to a corpse with rigor mortis.

The guidelines go on to propose a multi-step process for resolving intractable conflicts that ensures fairness and justice for patients and families. The steps again emphasize good communication and transparency. The authors suggest review by a multidisciplinary committee, and providing families with the opportunity for extramural appeal and transfer if the committee ultimately upholds the clinician's stance on the request.

Finally, the guidelines take a bold step to urge clinicians to lead the way in advocating for policies and legislation about when life-sustaining treatment should be used. The authors suggest that clinicians partner with patients and other "key stakeholders" to create rules that guide how ICU beds should be allocated when scarce, for example, and whether to ever provide intensive care to patients with advanced dementia or in a persistent vegetative state.

Discussion

At first blush, the ATS guidelines appear to strike a cautious balance of patient autonomy, exercised by families as surrogates, and clinician judgement of best interest. The press release for the article quotes one of the authors, Douglas White, MD, as saying, "Clinicians should neither simply acquiesce to treatment requests that they believe are not in a patient's best interest, nor should they unilaterally refuse to provide treatment."

But on closer inspection, the guidelines take a firm stance on which requests are open to debate. The guidelines assert that clinicians can refuse to provide treatment with no physiologic benefit, and can refuse requests for "legally proscribed" treatments, such as providing ongoing life support to a patient diagnosed as brain dead, in a state where brain death is recognized. This may seem obvious, but there has been an erosion of previously clear lines since the tragic and widely publicized case of Jahi McMath, the 13-year-old patient with anoxic brain injury who was kept on mechanical ventilation at her family's request despite a diagnosis of brain death in California.

In addition, the guidelines suggest that when time is so limited as not to permit the recommended conflict-resolution process, clinicians can refuse to provide treatments that they feel certain are "outside of the bounds of accepted practice," leaving room for interpretation. There is also a loophole in states, like Maryland, with statutes that give clinicians the right to refuse to provide "medically ineffective treatment," with the example of a clinician refusing to provide CPR in a metastatic cancer patient with multi-organ system failure.

There is considerable variation in what clinicians believe is within the realm of "accepted practice" when it comes to the provision of resuscitation and life-sustaining treatment. The recommendation that we examine these situations systematically to arrive at public policy about when to offer these treatments is completely reasonable and just, but bound to fan political flames and fear of rationing, given that even legal endorsement of advance care planning met with hysterical fear of "death panels".  Even the idea that clinicians can raise an objection to "potentially inappropriate" treatments on an ethical basis, and consider distributive justice in the context of a decision about a single patient, is itself somewhat radical and counter to current practice.

On a more basic level, I wonder whether the question posed by the authors, "how to respond to family requests for potentially inappropriate treatment" truly captures the issue in question in ICU conflicts.  How often do families bring their loved ones to the hospital and ask for vasopressors or mechanical ventilation by name? Much more often, clinicians provide life-sustaining treatment in an emergency by default, or out of uncertainty, and the conflict arises about when to discontinue it. Or resuscitation is offered even in situations with low likelihood of benefit, and then clinicians are disappointed when patients or families choose it. Can families be faulted for opting for more aggressive care when the healthcare system itself presents such ambivalence about the "appropriateness" of these interventions?  The idea of creating boundaries as a society would be ideal, but if the process will be hamstrung by politics, perhaps clinicians should agree on boundaries among themselves that can be applied fairly and consistently. Or the use of trials of treatment could be more uniformly applied, so that families expect that once treatments are initiated, there will be periodic review of whether those treatments are meeting the patient's goals.

Another idea that merits mention is the presentation of an alternative, so that families do not feel that the options are life-sustaining treatment or nothing. In a different guideline, published last year in the same journal, the ATS presented its "Choosing Wisely" list for critical care medicine. In it, the ATS again endorsed the idea of palliative care in the ICU with its recommendation, "Do not continue life support for patients at high risk for death or severely impaired functional recovery without offering patients and their families the alternative of care focused entirely on comfort," and the additional comment, "Even among patients pursuing life-sustaining therapy, initiating palliative care simultaneously with ongoing disease-focused therapy may be beneficial."

There is still much work to be done to establish the boundaries of "appropriate treatment" for critically ill patients, but the ATS guidelines present a great starting point for discussion and attempt to find routes to transparency and fairness in an ethically murky area.


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Sunday, May 24, 2015

Decision aids in serious illness: dissemination strategy, anyone?

An example decision aid in serious illness: Prepare, www.prepareforyourcare.org

by: Alex Smith, @AlexSmithMD

I was fortunate to be part of a really nice systematic review of decision aids for patients with serious illness by Adrian Austin (senior author Laura Hanson).  This manuscript was published online ahead of print in JAMA: Internal Medicine last week.

For this study, Austin reviewed nearly 10,000 titles to identify 38 rigorous studies that meet inclusion criteria.  Seventeen were randomized controlled trials.

I'm not going to summarize the article here - suffice it to say there are a number of very promising decision aids to help people with serious illness.  The article is self explanatory, and I highly recommend that people at a minimum look at the tables to see if there are decision aids you might like to incorporate into your practice. Note, you have to be a JAMA: Internal Medicine subscriber to read the article.

I'd like to pose a question, raised in part by James Tulsky in his terrific accompanying editorial.  James says:
Hospitals and health care systems must make the commitment to introduce such tools at the point of care to ensure that patients facing decisions have the resources they need when they need them. Most of the tools reviewed by Austin et al are free and could be disseminated relatively inexpensively.
Emailing with Laura Hanson and Rebecca Sudore after the paper was accepted, we were at a loss as to what the next steps should be for dissemination.  In many ways, we are at a similar point to where we were after conducting a systematic review of prognostic indices for older adults.  We decided (spurred by Lindsey Yourman) to put the prognostic indices in our review online - voila!  ePrognosis.

But these decision aid tools differ from prognostic indices in important respects. Several include booklets.  While many are free, others are proprietary videos that must be purchased.  A few do not appear to be publicly available at all.  These are not as amenable to a website compendium or toolkit, like ePrognosis.

The problem is that busy clinicians will not use these tools unless they are easily available.   Putting them in one place, or linking them somehow, makes a tremendous amount of sense.

So my question for you - does anyone have a dissemination strategy for decision aids in serious illness?

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Saturday, May 23, 2015

Insights into Geriatrics by Cartoonist Roz Chast


Roz Chast, a beloved and well known cartoonist for the New Yorker, has written a brilliant book that should be required reading for the geriatric curriculum. It is entitled “Can't we talk about something more PLEASANT,” and the title comes from her parents’ refusal to discuss their advancing years and the prospect of death. As I read it I literally saw my entire field flashing before my eyes. 

Known for her nervous looking pen and hilarious observations of urban life, she presents a starkly realistic portrayal of the last years in her parents’ lives and their progressive physical and mental deterioration. An only child, she takes on the responsibility of caring for them in their 90's as they face a trajectory of decline that is the bread-and-butter of any geriatrician. Through the artist's words and images, elder care is depicted in a way that is heartbreaking, funny, and quite accurate.


We observe Ms. Chast’s ailing parents through simple pen and ink and watercolor as they trundle through their last years, often in denial. The artist grapples with her feelings of guilt and anger as she takes charge of her parents’ finances and living situation, while deftly documenting the quirks of their personalities and the tenderness of their relationships. She fearlessly steps into their world of frailty and describes falls, social isolation, and cognitive changes, all while juggling her own family responsibilities. Her cartoon panels are peppered with personal photographs and the occasional flashback when we learn of her life as an overprotected, nerdy child with an overbearing mother.

Difficult and important challenges of geriatric caregiving are illustrated, including discussion of advance directives and driving after cataract surgery. Ms. Chast describes her shock at discovering the extent of her father’s cognitive deterioration, and does an outstanding job of presenting the anxiety and behavior changes that commonly occur in people with progressive dementia, as well as the stress and fatigue she experienced as a caregiver. When I read about her father getting lost in his apartment building and leaving the stove on, I was vividly reminded of events I have seen so many times with my patients.

The book realistically presents her interface with the healthcare system, including long waits in the emergency room, visits to the neurologist, and the transitions from assisted living to hospital to nursing home to hospice. On the way, she brushes nearly the entire gamut of geriatric syndromes including falls and fall related injuries, deconditioning due to hospitalization, depression, fecal incontinence, dysphagia, pressure ulcers, pain management, and progressive dependence in ADLs that often accompanies frailty. On the way she describes doctors who have no clue how to deal with frail elderly, and the difficulty of making choices regarding operative interventions in people of advanced age. Throughout her journey, Ms. Chast remains remarkably rational in evaluating her options and abiding by the choices of her parents.

At the very end when her dying mother enters hospice and becomes nonverbal, she presents a series of drawings that eliminate captions in a way that echoes her mother’s wordlessness. This series in particular brought back images from my years working as a nursing home physician.

The most important aspect of this book is the unflinching yet touching way her parents’ trajectory of decline is presented through simple drawings, and the very realistic observations and stream of consciousness that appear in the captions. This book can serve as a starting point for any student or family member interested in principles of geriatrics and the experience of growing old in America. Roz Chast is not a doctor, but with an accurate pen and sharp wit she combines art and medicine to create not just a memoir but a realistic portrayal of progressive frailty and death in a society and culture that usually ignores these issues.

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Friday, May 22, 2015

Outcomes of In-Hospital CPR in Patients Receiving Dialysis



We’ve talked a lot about the prognosis after receiving in-hospital CPR in this blog (here, here, and here to name a few). In a recent issue of JAMA Internal Medicine, Susan Wong and colleagues looked at what happens to individuals on maintenance dialysis when they receive in-hospital cardiopulmonary resuscitation (CPR).  The results are summarized in the infographic above, and discussed in a little more detail below.

The Study

The authors used data from the US Renal Data System (USRDS) registry that enrolls patients after the onset of end stage renal disease, identifying all patients 18 years or older without a prior kidney transplant who initiated maintenance dialysis from January 1, 2000, through December 31, 2010. Importantly, to be included in this study, these patients needed to be on dialysis for at least 90 days (thereby exluding the sickest of the sick). By linking Medicare claims, they determined who in this registry was hospitalized and who got in-hospital CPR (although they excluded ER CPR).

Outcomes of interest included incidence of in-hospital CPR, proportion of patients surviving to hospital discharge after their first inhospital CPR event, and post-discharge survival. Among those who died in the hospital, they also measured the proportion who received CPR during their terminal hospitalization.

What did they find?

Most of the key findings are in the infographic, but I'll just highlight a few here:
  • The vast majority of individuals on maintenance dialysis were hospitalized at least once during the follow-up period (81% of the cohort)
  • Of these individuals who were hospitalized, 6% underwent at least one episode of CPR while hospitalized with a trend toward higher rates of CPR in more recent years. 
  • The proportion of CPR recipients who survived to discharge has increased in from 2000 to 2011 (15.2% to 28%) but there was no substantial change in duration of post-discharge survival.
  • The median survival fromthe time of discharge was 5.0 months among those who survived to discharge.

The Take Home

The results of this study are in line with other studies that suggest less people die in the hospital, but that doesn't mean that their long-term prognosis is any better.  In particular, Joan Teno's work shows that despite a decline in hospital deaths and an increase in hospice use, end of life for Medicare decedents increasingly includes ICU stays, short hospice stays, and multiple health care transitions.   This is particularly true to the dialysis population who undergo CPR.   We are better able to get them out of the hospital alive, but their survival after hospital discharge really has not improved, making them otherwise prognostically eligible for hospice.

by: Eric Widera (@ewidera)


Note: for more on the geriatric and palliative care needs of those with end-stage renal disease see these posts:


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Wednesday, May 20, 2015

Yes, There is a Medical App for That



At this years AGS Annual Meeting, Manuel Eskildsen, Alice Pomidor, Amit Shah, Niharika Suchak, and I led a session aimed teaching how to integrate mobile applications and other emerging technologies into clinical education and patient care.

As part of this session, we created a brief handout for attendees describing some of the apps and resources we use in our own teaching and clinical practice.  We thought it may also be helpful to share this with our GeriPal audience.  We also would love to hear from you on what apps you use in your teaching or clinical practice (please add to the comment section below the handout):
Yes, There’s an App for That: How to Integrate Mobile Applications and Other Emerging Technologies into Clinical Education and Patient Care Apps and Resources List
American Geriatrics Society 2015 Annual Meeting 
Manuel A. Eskildsen, MD, MPH; Alice Pomidor, MD; Amit Shah, MD; Niharika Suchak, MD; Eric Widera, MD 

Apps/Resources Mentioned by Dr. Eric Widera (Clinical Teaching and Patient Care) 
  1. Seeing the world as our patients do: 
    •  VisionSim:   Simulates visual problems (excellent for empathy exercises and teaching importance of addressing vision in comprehensive geriatric assessments) 
  2. Multimorbidity and Geriatric Principles: 
  3. Prognosticating
Apps/Resources Mentioned by Dr. Amit Shah (Massive, Flipped and Spaced Learning)
  1. Flipped Learning 
  2. Spaced Learning
  3. Massive Open and Online Courses and Degrees (MOOCs and MOODs)
Apps/Resources Mentioned by Dr. Alice Pomidor (Patient education mobile application resources)
  1. Socialwellth - “Prescriptive Digital Health”
  2. Health tap: top 10 in various categories, overall top 10
  3. ALZ--Alzheimer’s Association Pocketcard
    • Has clinical information, interactive assessment tools such as clock, educational materials that can be directly e-mailed to patients/caregivers. Free at App Store and Google play)
  4. MNA--Mini-Nutritional Assessment
    • Recommended by American Dietetic Association, Hartford, AMDA, European Society for Parenteral and Enteral Nutrition (ESPEN). Has supporting website at www.mna-elderly.com. Available in multiple languages. App is the short screening version and results can be e-mailed. Free at App Store only for iPhone. Sponsored by Nestle.
  5. webMD--#1 most used general health website with 12 billion page views per year (same group that does Medscape)

Apps/Resources Mentioned by Dr. Niharika Suchak (Mobile Apps in Medical Education)
  1. Epocrates (drug information, drug interactions, pill ID etc.)
  2. Pulm Tools for PORT score or pneumonia severity index calculator
  3. uCentral from Unbound medicine: (5 Minute Clinical Consult, MEDLINE search, calculators, textbooks, guidelines, systematic reviews, etc.)
  4. ePSS (USPSTF health maintenance recommendations by age groups) 
  5. Dynamed (a clinical reference tool for use at the 'point-of-care' with clinically-organized summaries)
  6. Pepid Clinical Rotation Companion (point-of-care reference, drug database, and decision support tool)
  7. Access Medicine (online medical resource with leading medical textbooks, videos, self-assessment, drug database, quick reference, and decision support tools)

Other notable apps not mentioned above that you might want to try:

A curated library for health professional who provide care for geriatrics patients which is updated: http://upmc.com/agingapplibrary. Maintained by Dr. Steven Handler and Dr. Nagib Manov

1. Mobile Apps for Clinical Teaching:
  • Eponyms (for fun!)
  • Agile Diagnosis
  • Diagnosaurus (large lists of differentials for chief complaints)
  • Visual Dx (online and app-- great derm reference)
  • Medical Calculators: QXMD, MedCalc, and Mediquation
  • Antibiotics: Sanford Antibiotic Guide, the Hopkins Antibiotic Guide, or the Antibiotic Advisor
  • Prognosis-Your Diagnosis (teaching preclinical/early clinical students)
  • Radiology 2.0 (cases and teaching)
  • Casefiles
  • Heart sounds teaching apps (many): Best: Littman, Blaufuss (great!), iMurmur
  • Teaching anatomy: Visual Anatomy and Netter’s

2. Mobile apps for clinical care
  • CDC Vaccination schedule
  • Hospice Apps: Vitas, Hospice by the Bay, etc
  • Medscape (full feature reference app) goes with webMD (patient level)
  • Dynamed (like Up To Date)
  • Skyscape (similar to Medscape)
  • Drug information apps:
  • Micromedex (most comprehensive drug information program)
  • Lexi-comp (great drug information app)
  • Epocrates #1 used/rated app by doctors for quick drug info, pill pictures, interactions

3. Mobile apps for patient use/patient education use:
  • UK’s NHS Health Apps Library: apps.nhs.uk (reviews apps for accuracy and posts them by topic for patients) 
  • DrawMD (great for patient education when you need clear anatomy pictures)
  • HealthTap overall top 10 for iOS (2014): 1) MyFitnessPal.Com 2)Weight Watchers 3) Lose It 4) White Nose Lite 5) First Aid (Red Cross) 6) Runkeeper 7) Stoke Riskometer 8) Emergency First Aid and Treatment guide 9) Instant Heart Rate 10) Fooducate 
  • Healthtap overall top 10 for Android (2014): 1)Weight Watchers 2) White Noise Lite 3) Lose It 4) First Aid (Red Cross) 5) Runkeeper 6) Emergency First Aid and Treatment guide 7) Instant Heart Rate 8) Fooducate 9) Glucose buddy 10) Pocket First Aid and CPR
  • Best Alternative Medicine App: About Herbs (Memorial Sloan Kettering)
  • Best Medication Apps: Meditation Oasis; Mindfulness Trainer
  • For General Medical Knowledge: webMD and Mayo Clinic apps
  • For Arthritis: ArthritisID
  • Hearing screening: UHear
  • Find cheaper medications and costs of medications by pharmacy: GoodRx and GoodRx.com
  • Pill reminders (many): 1) Drugs.com Pill reminder 2) RxmindMe 3) Pill Monitor 4) MedMinder

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Tuesday, May 19, 2015

Finding the Workforce to Care for an Aging Population

Returning from the American Geriatrics Society Annual Scientific Meeting, I am struck by the thought that the United States’ health care policy is functioning without a compass. We are at the beginning of a tremendous demographic change in this country, but are we adequately preparing US physicians to care for an aging population?

Most residency education in the US is funded through Medicare. Given Medicare’s charge is primarily to care for adults over 65, you would think that Medicare would emphasize training physicians to meet the needs of an aging population. Yet the statement that sticks with me from AGS is this: “10,000 new beneficiaries enroll in Medicare every day, yet we lose 5 geriatricians every week.” Astounding!

Moreover, the additional trends in geriatric education actually point to less support for training physicians to care for older adults. The Reynolds Foundation, which has been a tremendous supporter, is a foundation designed to spend down its assets and will soon no longer be a source for innovative grants to improve delivery of care to older adults. Likewise, the main grant for training geriatrics clinician educators, the Geriatric Academic Career Award, will not be funded by the Health Research Services Administration this year. How will we create the clinicians that we need for our future without support for the educators who will teach them?

My wife would remind me that when you are lost (and our health care policy is lost in this regard) it is time to stop and ask for directions. Of course the modern equivalent for directions is the GPS map. I propose it is time for a new GPS, this one inspired by the National Service Corps. We need a National Geriatrics and Palliative Service Corps. It can be our new compass to provide the US the health care workforce we need to care for older adults.

(Note: I include palliative care with geriatrics here recognizing the distinction between the two, but in the knowledge that most palliative care patients are in fact part of the Medicare population and that palliative care workforce suffers from the same issues as geriatrics. You need both geriatrics and palliative care together to make a GPS for health care policy.)

The National GPS Corps should consist of three elements:
  1. To promote geriatric or palliative care training, all residents who complete a geriatric or palliative care fellowship shall have half of their student loan burden relieved through federal debt forgiveness or payment to private lenders. Crushing student debt is a key factor driving trainees to higher paid specialties and this will make geriatric and palliative care training more feasible. 
  2. To promote excellent geriatric and palliative care academicians, those who opt for a second year of additional academic or research training will have all subsequent student loans forgiven or paid. 
  3. To promote clinicians practicing in geriatrics and palliative care rather than further specialty training and to allow for appropriate geographic distribution across the country, those who only complete one year of fellowship will be eligible for further debt forgiveness after completion of a three or five year clinical commitment in a designated geriatrics/palliative care service area. 
In addition, we must create teachers who can train the workforce to meet our countries needs. As Congress works to create the National Geriatrics and Palliative Service Corps, the act should also fully fund both Geriatrics Academic Career Awards (GACAs) and Palliative Academic Career Awards (PACAs) to allow junior faculty to train to be master educators that lead educational efforts to reach all physicians in all specialties. The National Geriatrics and Palliative Service Corps will be an excellent complement to both the Geriatrics Education and Training Act and the Palliative Care and Hospice Education and Training Act or PCHETA (which must also pass and soon!)

With regards to geriatric and palliative care workforce, our health care policy is lost, but this is the GPS that can get us back on the path.

by: Paul Tatum

Disclaimer: This piece is the opinion of the author alone and does not represent the opinion of the American Geriatrics Society nor the American Academy of Hospice and Palliative Medicine.
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Monday, May 11, 2015

The AGS Annual Meeting Program Cover

I am thrilled that the AGS is using my images on the cover of their Annual Meeting program. The collection of photos is the result of years of travel across America photographing aging. The message in this design is that our country's aging population is vast and diverse. In my images I try to portray the inner strength of my subjects that has enabled a long life, and explore spiritual connectedness with the world and society. I also like to show the commonalities of growing old and how the elderly fit within our culture, and present a realistic and positive view of the human journey that most of us will experience.  

Aging is not a popular topic to look at, as most people would rather see flowers, dogs, parakeets, or cute kids. Few people embrace images that tweak insecurities about wrinkled skin and thoughts of mortality. Ageism permeates the mass media's imagery of growing old, which contributes to stereotypes and negativity. In my view, the lack of images of aging in mass media contributes to our culture's collective denial of the aging process and distortion of expectations. Indeed, a great number of images of aging on prime-time television are in commercials for erection medications and incontinence products.

However the phenomenon of aging is intertwined with the fabric of every human life, particularly for those who choose geriatrics as a specialty. The impact of the aging demographic on our society and healthcare system has yet to be measured, but we as geriatricians are acutely aware of its immense scope.  

In explaining my motivation to both practice geriatrics and photograph aging I would like to quote my mentor, Leslie S. Libow, who introduced me to the field in an article published in The Gerontologist in 1982:
"It is the humanism that excellent geriatrics represents, especially in dealing with the frail elderly and their families. Here we see clinicians committed to health care approaches that balance curing and caring, touch and technology. Basically, then, the emphasis is on life and fulfillment by patient and professional. The quality of the approach to the frail elderly is a key measure of our health system's compassion and competence, not merely for the elderly but for those of all ages." 
"Our work is pleasure, yet the outsider often wonders how we do it. Like so many of you, I enjoy older people. I like the art of medicine. I like the process of science. I am attracted to humanism and social-psychological dynamics. I favor the underdog. I enjoy a struggle and advocacy. Geriatrics and gerontology have satisfied those desires in me more than a person can hope for."

* * * * * * * * * * * * * * *

Reference for this post is: Libow LS. Geriatric Medicine and the Nursing Home: A Mechanism for Mutual Excellence. The Gerontologist 22 (2) 134-141; 1982.

Dr. Jeff Levine’s photography exhibit entitled “An International Celebration of Aging” will be at the University of Michigan Medical Center  in the Taubman Gallery from June to August, 2015 as part of their Gifts of Art program.


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