Wednesday, August 27, 2014

Debate: should palliative medicine physicians be required to certify in their primary specialty?

Cool picture of Kingfisher from Wikimedia Commons - has nothing to do with the post.
by: Alex Smith, @AlexSmithMD

It's been 10 years since I became certified in Internal Medicine, and that means it's time for me to re-certify.  My clinical practice is small, as I'm mostly a researcher.  The entire focus of my clinical practice is palliative care.  I used to attend on the wards, but I don't anymore.

Can I just say how much I hate studying for the boards...again?  MKSAP again?  Really?  Why am I reading about some obscure disease that I have no interest in remembering as a palliative medicine physician?

Hospice and Palliative Medicine is one of the few sub-specialties to require board ongoing maintenance of certification in the clinician's primary area of specialization - be it internal medicine, family medicine, pediatrics, radiation-oncology - whatever it may be (medicine subspecialties count - you could be certified in Oncology and Palliative Medicine, without maintaining your internal medicine certification).  Cardiologists, gastroenterologists, oncologists, you-name-it-"ologist" are not required to maintain certification in their primary area of specialization.  Same goes for Geriatricians - they're not required to maintain primary board certification either.  You can be a geriatrician and never re-take the internal medicine or family medicine boards again in your life.

Some people are starting to question if palliative medicine physicians be required to maintain certification as well.  Maybe we should only be required to maintain certification in hospice and palliative medicine.

Seeming tangent: A recent article in the New York Times decried social media as stifling debate.  We surround ourselves in our online worlds with like minded people, contributing to the polarization of America.

Therefore, in the spirit of promoting debate in social media, I will now debate myself about requiring palliative medicine physicians to maintain certification in their primary specialty.  I will enumerate points, as my brother (a debater) might do on debate cards.

Palliative medicine physicians should be required to certify in their primary specialty

1. Requiring primary specialty certification is less politically threatening to specialty boards and societies.  Palliative medicine is not "stealing" their business.  Without this requirement, many people would abandon certification in their primary specialty.  This might jeopardize these important relationships and support from our specialty societies.  Palliative medicine becomes a competing specialty, from their perspective, rather than a sub-specialty.

2. Palliative medicine doctors have to be grounded in a specialty.  Palliative medicine is unique in that people come to the profession from so many diverse specialty backgrounds - in fact palliative medicine set a record for the number of sponsoring boards when it went up for accreditation.

3. We are better doctors with our specialty certification.  Grudging admission - some parts of studying for the boards have been refreshing.  There are things I feel happy re-learning that may be important to the care of my patients.  I read a MKSAP question about osteonecrosis of the hip yesterday, and was reminded of patient with a cancer who had been on long term steroids and developed hip pain.  Without the broad differential, we would have assumed it was due to metastatic disease and never considered osteonecrosis.

Palliative medicine physicians should not be required to certify in their primary specialty

1. Specialty certification is not useful clinically.  For those of us who only practice palliative medicine, there is little need for learning the vast majority of stuff required for core specialty certification.

2. Taking the time to re-certify, including board prep and maintenance of certification, comes at a cost.  There is a limited amount of space in our brains.  As I'm stuffing internal medicine knowledge back in my brain, I worry that I may be excreting important palliative care knowledge.  (This may not be true - I may be excreting unimportant fantasy basketball knowledge).  In any case, time spent studying for core certification is time not spent learning and practicing palliative medicine.

3. It also comes at a monetary cost.  Board certification is expensive!  I just dropped several Benjamin Franklins on board prep material alone.  Total cost is easily over a thousand, and that money comes out of my salary, not grant funding.  In 5 years, I'll be paying and going through the studying again for palliative medicine.  More people might certify in palliative medicine if they didn't have to ALSO maintain certification in their primary specialty.

4. Palliative medicine is its own specialty.  We are as deserving of being a stand alone specialty in our own right as any other field (oncology, geriatrics, etc).  Why should we be held to a different standard?  It demeans the field.

If I was not required to maintain certification in my primary area of internal medicine, would I do it?  I'm not sure, though I think the answer would be no.  It's just not worth it to me to go through the process.

What do you think? What would you do if not maintaining your certification was an option?  
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Tuesday, August 12, 2014

What books inspired you to go into #geriatrics or #palliative care?



by: Alex Smith @AlexSmithMD

I just read a wonderful categorization of books about aging on Lousie Aronson's blog.  She categorizes books about aging into five types: informational, memoirs, wellness and longevity books, general non-fiction, and literary works.  My favorite category are the wellness and longevity books, you know the ones, about how if you eat enough "blueberries and kale" you will not "have to age or die."  Louise graciously declines to state the names of such books, only noting that the authors initials are often followed by the letters "M" and "D".  To that I would simply add that the author's name often contains the letters "O" and "z". 

In any case, I have been planning for some time to start a thread about books that inspired us to go into the fields of geriatrics, gerontology, palliative, hospice, and end-of-life care. 

Was there a particular book that pushed you along on your path to your current profession?  Please list books that inspired you in the comments!

I know there were several for me.  In medical school, a formative stage in thinking about what I wanted to do with my life, I read these two books:
  • A Midwife through the Dying Process: Stories of Healing and Hard Choices at the End of Life, by Timothy Quill.  Tim Quill presents 9 poignant stories of caring for patients who are dying, their families.  He delves deeply into ethical issues that arise in the patient-physician relationship when patients are near death, including physician assisted suicide. 
  • Dying Well: Peace and Possibilities at the End of Life, by Ira Byock.  Also based on stories of caring for dying patients, Ira Byock moves more seamlessly into the emotional/spiritual realm than other physician authors.  My favorite is chapter seven, where he describes a prescription for dying patients to say to loved-ones (I've used it for loved-ones to say to dying patients as well):
    1. I forgive you
    2. Please forgive me
    3. Thank you
    4. I love you
    5. Goodbye
These books are long form narratives that tell several stories in one coherent collection. Contemporary  micro-forms of these narratives use Facebook, blogs, and twitter.  Perhaps the next generation will recall being inspired by posts and tweets, rather than books. 

In that vein, and on the topic of goodbyes, I'll close with this Facebook post from a physician friend, Kevin Yee, reprinted with permission:

As a primary care physician you often know when you are seeing your patient for the last time before they die.

You don't say good bye because you do not want them to feel as if you've stopped being there for them after such a long journey.

And as you walk out of the exam room you gently lay your heart aside, just as you have hundreds of times before, and see your next patient.

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Friday, August 8, 2014

Surgical decision-making for elders: GeriBoards, prehab, and other great ideas

by: Alex Smith, @alexsmithMD

A while back people realized that outcomes of surgery in older people were probably better than previously believed. This led to a widespread perception that we were being ageist by not being aggressive enough in offering surgery to older adults.  We started operating on more older adults. We identified new ways to operate on increasingly elderly and frail patients.  If you look into geriatric surgery now, you will mostly find a bunch of stuff about how to optimize surgery for elders.  (Example - I was recently asked to review the orthopedic surgeon society's new guidelines on management of hip fracture.  It was all about this surgical approach or that approach, this screw or that piece of hardware, with almost nothing about the decision to have surgery or not.)

However, there is a new group of physicians researchers who are concerned that the pendulum has swung too far.  They are concerned that we are performing too many surgeries on high risk older adults.  These surgeries too frequently result in poor outcomes that older adults care about, like death or loss of functional ability.  And too often, these surgeries take place with too little thought and deliberation by the referring physician and surgeon about the decision to have surgery or not. 

This post identifies some of the superstars in this new group and summarizes some of their great ideas about how to address this issue:
  1. Emily Finlayson is a colorectal surgeon at UCSF who has published a number of studies calling into question the thoughtfulness of surgical decision making for nursing home residents.  Mortality for major abdominal surgery is far higher for nursing home residents than non-nursing home residents and functional status declines markedly following surgery for nursing home patients treated with surgery for colon cancer.  Emily is designing a new "prehab" clinic for frail older adults undergoing elective surgery.  This prehab clinic will include a Comprehensive Geriatrics Assessment and goals of care discussion by a geriatrician, with triggers for referral to palliative care. 
  2. Gretchen Schwarze is a vascular surgeon at the University of Wisconsin who has described two fascinating phenomena in surgery: (1) "buy in", or the unspoken pact that surgeon's feel they have made with patients to not deviate from an all out push to recover from surgery in the first 30 days post-op, including a refusal to listen to patient or family demands to stop life-support; and (2) problems with the "fix it" metaphor for surgical decision making.  Gretchen posted about fix it on GeriPal.  She also described a novel approach to surgical decision making using the "best case" and "worst case" scenario, including a visual of the surgeon's best guess of where the patient will end up on that spectrum.
  3. Mark Neuman is an anesthesiologist at the University of Pennsylvania who is the only anesthesiologist I know interested in health services research and geriatrics.  Fascinating!  We should have more.  He published the terrific piece on hip fracture in nursing home residents Eric wrote about for GeriPal last month.  Mark was also senior author of this awesome perspective for NEJM about a radical redesign of surgical decision making for high risk elders (first author Laurent Glance, MD, U Rochester).  My favorite idea from this perspective: GeriBoards.  We have multidisciplinary tumor boards for patients with cancer, including the surgeon, oncologist, and other care provders. Doesn't it seem logical that we should have multidisciplinary geriatric surgery boards?  The primary care doctor or geriatrician, who has a long relationship with the patient, can weigh in on the big picture, the anesthesiologist can weigh in about the risks from their perspective, and PT/OT can weigh in about the realistic potential for recovery of function.  They can deliberate together and follow the patient as a team.  Yes!  We should be doing that.
  4. Zara Cooper is a trauma surgeon certified in palliative medicine at the Brigham and Women's Hospital in Boston focused on decision making for older adults and seriously ill patients with life threatening surgical conditions.  Zara is working with Rachelle Bernacki, Susan Block, and Atul Gawande to develop a structured "check list" based approach to surgical decision making for high risk patients. 
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Wednesday, August 6, 2014

Potpourri from clinical work VII

by: Alex Smith, @alexsmithMD

The following are some reflections from being on service recently.  Not enough time to develop these into full posts.  If these issues tickle you, please respond in the comments!  To see previous potpourri's from clinical work follow the links to I, II, III, IV, V, and VI.
  1. David Reuben wrote a terrific perspective describing "The Hospital Dependent Patient."  These are patients who, usually elderly, who have chronic illness exacerbations that frequently land them in the hospital.  In the hospital they have a high quality of life, when surrounded by nurses and treatments that can only be delivered in the hospital.  I cared for one such patient.  He had frequent episodes of low blood pressure following dialysis, landing in him in the hospital over and over again.  He also had early dementia.  He could remember enough to think that he should be in dialysis most days, even when it wasn't his usual day.  Normally tired and sleepy, in the dialysis unit of our hospital, he came alive, talking animatedly with his "community" of care providers.  In goals of care discussions, this patient was clear that he enjoyed his quality of life and had no issues with returning repeatedly to the hospital for care.  As Dr. Reuben points out in his perspective, hospital-dependent patients are a product of our medical progress.  We have yet to grapple as a society with how to provide care for this increasing population of patients.  Nor have we addressed in a mature way the ethical issues around setting limits - if any - around what care our system should support and can afford for Hospital Dependent Patients.
  2. Cough is a tough symptom to treat sometimes.  I had a patients with cough and dyspnea on exertion due to idiopathic pulmonary fibrosis.  He did not believe that the opioids were helping him.  The pulmonary team suggested gabapentin, but my read of the literature is there is only case report level evidence.  The patient died before we could try alternatives.  What have you used for chronic opioid refractory cough?
  3. We had a patient who we communicated with just fine in his room.  No issues.  Then we had a family meeting.  Big room, lots of providers, including the medical team and 3 consulting teams.  We get about 1/3 of the way into the meeting and the patient says, "I can't hear what your saying."  Turns out he had hearing loss and we had no idea!  Brings home to me the importance of this issue.  In the room, alone, with the door closed, and 3 feet away from the patient's head, communication may be just fine.  But in a large family meeting, you may find a completely different experience.  Should we be screening for hearing loss in all of our patients over the age of, say, 75?  How should we screen?  Do you have ready access to pocket talkers for patients who have hearing loss?
  4. We cared for a man who experienced a hip fracture in the nursing home the other day.  His geriatrician care providers and surrogate decided that, as his pain needs were minimal, and he was in his 90s with dementia, they would not persue surgery.  Several months later we saw him and he was able to walk short distances to the bathroom, but did not try to venture out to the front desk as he did before the fracture.  Hindsight is 20/20, but it seems they made the right choice.  Other people's experience with non-operative managment of hip fracture?  Eric wrote about outcomes of hip fracture among nursing home residents last month.
  5. One patient requested that we start each mornings visit to his room with a joke.  What fun!  I told him some from my 6 year old son, like:
    1. "What's your favorite jam?" "Peach" "What's your least favorite jam?" "Grape" "But what about a traffic jam?"
    2. "Why is a nose not 12 inches long?" "Because then it would be a foot"
    3. This one is from Darth Vader's twitter feed (you follow him, right?) "How did Luke Skywalker stub his toe on the planet Endor?" "Ewoked into a tree."
    4. This one is from our team psychologist, "How do you make seven an even number?" "Take out the S"
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Tuesday, July 29, 2014

A Letter to My Geriatric Patients



I would like to send my deepest thanks to every one of you for teaching me so much during my Internal Medicine residency. With every lesson, you touched my heart.

I have been an internal medicine resident the last two years and each day you accepted me into the most vulnerable period of your life. I have been there as you face a scary new cancer diagnosis, when you realize your independence may be lost forever, and when your mind has felt shaky and unstable. I have been there as you navigate the trials of watching your child, your life partner, your sibling or loved one as they face death. I have been there even as you approach the end of your life. In those most challenging times, I marveled at the strength of your generation and the tenacity to overcome the unimaginable.

With my sincerest gratitude, I also extend to your generation several apologies. I am sorry I spend more time looking at a computer screen than looking at you. I am sorry my time on the wards is not spent at your bedside but instead in a workroom lined with computer screens. I am sorry for sometimes using medical language you cannot understand and for asking the nurses to repeatedly poke and prod you for blood work. I am sorry for not speaking loud enough for you to hear me and too loud when I assume you have hearing loss. I am sorry that I prescribe you medications you cannot afford. I am sorry that I have taken away your independence and with it, your small pleasures like driving and shopping for food. I am sorry that when trying to treat you with the "gold standard" I instead make you feel worse. I am sorry that my shirts and pants are not always ironed. I am sorry if I at times seem skeptical in miracles of faith. I am sorry that I do not ask you what you really want but I hope you know that through it all, I always have your best interest at heart.

Finally, I am sorry for never saying “thank you” enough during the precious time we have together face-to-face. They call you the Greatest Generation and it truly is an honor to not only meet you but to be a part of your lives. Thank you for making such an impact on mine.

Sincerely,

A Deeply Indebted Resident

by: Megan Rau (@meganismyname)
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Friday, July 25, 2014

Preparing for the hospice and palliative medicine board certification exam



What do the following three things have in common:
  • The Paris Air Show
  • The World Table Tennis Championships 
  • The Hospice and Palliative Medicine Certification Exam

They all happen once every two years! And guess what, this is the year for the Hospice and Palliative Medicine certification exam. Two things to consider to get prepared for the test:

1.  Whether you are preparing to take the hospice and palliative medicine subspecialty board exam or just want to get up to date with the field, then considering joining us at AAHPM’s Intensive Board Review Course. The organizers have created a fast-paced, intensive review of best clinical practices when caring for seriously ill patients and their families.

2. Practice with Blogs to Boards! This is a series of posts from both GeriPal and Pallimed to get physician readers ready for the hospice and palliative medicine boards. We created these for the 2012 exam where every week GeriPal and Pallimed alternated publishing a new question, as well as a discussion of possible answers to the question. We then posted all the 41 questions via the link here.  

by: Eric Widera (@ewidera)
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Wednesday, July 23, 2014

Life and Death After Hip Fractures in Older Nursing Home Residents


Any who has had a loved one who sustains a hip fracture knows that these are life changing if not life-limiting events in the lives of older adults. A recently published article in JAMA Internal Medicine gives further credence to this, as well as giving us evidence to guide our prognostic estimates when caring for someone who sustains a hip fractures in a nursing home setting.

The study by Neuman and colleagues looked at survival and functional outcomes after hip fracture in 60,111 long-term nursing home residents who were hospitalized with an acute hip fracture between July 1, 2005, and June 30, 2009. The primary outcome was death from any cause within 180 days of hospital admission. They also looked at functional outcomes that were based on self-performance for 7 ADLs as recorded in the last available Minimal Data Set (MDS) assessment within 180 days after the index admission.

What Were the Results?

The median survival time after fracture was 377 days (the interquartile range was 70-1002 days).

Six months after hip fracture:

  • 1 out of every 3 (36%) nursing home residents died
  • 1 out of every 2 (46%) male nursing home residents died.
  • Half (54%) of those who were not totally dependent in locomotion prior to the hip fracture had either died or developed new total dependence in locomotion


At one year after hip fracture:

  • One out of two (47%) nursing home residents died
  • Of those who were not totally dependent in locomotion at baseline, 60% either died or experienced new total dependence in locomotion


Nonoperative fracture management, male sex, increasing age, white race, high levels of comorbidity, advanced cognitive impairment, non-femoral neck fracture location, and increasing baseline ADL dependence were all associated with worse survival after hip fracture.

Take Home Points

First, a new diagnosis of hip fracture in a nursing home resident carries with it a worse 6-month prognosis than most newly diagnosed metastatic cancers, with 1 out of every 3 nursing home residents dying within 6 months (for a good read, check out Fred Ko's and Sean Morrison's excellent editorial on the need for palliative care for these individuals).

Second, even if a resident was completely independent in getting around the nursing home, 6 months after a fracture they still had nearly a 50/50 chance of either being dead or being totally dependent on the nursing staff for getting around. However, a more optimistic way to think about it is that these individuals still had a one in three chance of returning to their baseline independent function after a fracture in a nursing home setting.

Third, while the dependence on locomotion is important, there are limitations to this outcome, including that not everyone who is "totally dependent" one week will be "totally dependent" the next week. Why? Well to address this we need to go back to the methods (I know, I’m doing this out of order)

A Finer Point: Why Totally Dependent May Not Mean What You Think It Means

Death is an easier thing to measure than someone's ability to perform activities of daily living (ADL).  You know when someone has died, but when is someone independent or dependent in ADLs?  In nursing homes, each ADL has a specific and standardized meaning that may be different than we may use it in our own practice. The main functional outcome of the study, locomotion on the nursing home unit, is described in MDS as: “how the resident moves from place to place in the room or hall using whatever device is appropriate or needed.” The device can be a thing like a wheelchair, walker, cane, feet, prothesis, or scooter. So if the nursing home resident did the activity completely on their own without cueing or supervision, then they are described as “independent”. If they need just some oversight or cueing then they are described as needing “supervision”. More help than that is “limited assistance” where the staff do some of the activity, and more help than that is “extensive assistance” where the staff do most of the activity. Lastly, complete dependence is where staff do all of the activity for the nursing home resident.

The other important thing to know is that functional status in this study is based on self-performance as observed across all nursing shifts over a 7-day period. So a resident is independent in an ADL if the resident is able to perform that activity “without help or oversight or requiring help or oversight only 1 or 2 times over 7 days”.  The same thing goes with total dependence, the resident needs to require staff to do all of the ADL for all 7 days to be described as dependent.

Why is all of this important? Although these definitions are standardized, a nursing home resident’s self-performance can change shift-to-shift, day-to-day, and week-to-week based on things like their mood, an acute illness, or even just their relationship to their nurse. So one week you may be “dependent” and another week you may be “limited assistance.” This is likely why in the study we saw a very small group of individuals who were completely dependent prior to the fracture, but after the hip fracture they improved to being completely independent in locomotion.

by: Eric Widera (@ewidera)
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Tuesday, July 22, 2014

Hospice patients should have access to physical therpay to improve function



by: Alex Smith, @alexsmithMD

I'm going to acknowledge up front that this is a rant. 

One of the skilled nursing facilities I work with has a hospice unit.  We occasionally have patients on the hospice unit who might benefit from physical therapy.  The physical therapists that see patients in the skilled nursing facility say they will talk with the patient about their goals, and if their goals are to maintain their current level of functioning, they will work with the patient.  If the goals are to improve their physical function, they cannot offer that type of support.

This seems ridiculous!

If someone has pain, we don't say, "we will keep your level of pain where it is, but we can't  help you if you want to improve."

If someone has social or spiritual issues, we don't say, "we want to maintain your current level of distress, but can't help you if you want to be less distressed."

Why is this happening?  It may be that a part of the problem has to do with resource allocation.  The physical therapists don't have the resources, nor are they reimbursed for their time the same way, for seeing hospice patients as for patients cared for under the Medicare Skilled Nursing Facility benefit, a comparatively high payment.

Another part - and this may be related - is that we don't prioritize functional improvement as much as symptom/social/spiritual improvement for hospice patients.  I gues the idea is that hospice patients will inexorably decline functionally and die.  It's as if physical therapy to improve funciton has been lumped in with life-sustaining treatments.  When did that happen?  Did I miss a meeting?

Granted, most patients on hospice will have an inexorable decline in physical function - something we've written about both on the blog and in journals.  And many hospice patients do not have the ability or motivation to participate in physical therapy to the extent needed to recover function.  Wanting extensive physical therapy to recover function, when there is no possibility of recovery, is often a red flag that goals of care and prognosis need to be discussed in more depth.

But to me hospice, at it's core, is about making each day as good as it can be, for the time that remains.  Being as indepent as possible is an important part of quality of life for many people.  And for a very small number of people in hospice, there is a potential for recovery of some function. 

I have a patient now who might benefit.  He's been delirious in the hospital, but is pulling out of it.  He might benefit from physical therapy to recover some of the additional disability he acquired from lying in bed in the hospital confused for days on end.  Though his family is starting to discuss hospice, they want him to have the best opportunity to improve funcitonally.  I think they're going to say no to hospice.  And that's unfortunate.  Our system should be flexible enough to accomodate him.

OK, I'm done ranting.  Maybe your hospice is different?  Or maybe you want to rant too?  Let's hear it.
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Monday, July 21, 2014

Never Stop Dancing: Breaking Stereotypes of Disability in Older Adults One Step at a Time



We have written a lot about disability in older adults here on GeriPal.  Here are just a couple of examples:
If I had to sum these posts up in a couple words, it would be that successful aging does not equal aging without disability.   If I had to sum these posts in a video, it would be this:



by: Eric Widera (@ewidera)

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Friday, July 18, 2014

Financial Capacity, Alzheimer’s, and the sale of the LA Clippers


More than 5 million Americans currently have Alzheimer disease. One of them happens to be Donald Sterling. There are a lot of directions we can go on a post about this now infamous man and this devastating disease, but the one I would like to highlight is the role that a physician’s determination of financial capacity played in a multibillion dollar sale of a professional sports team.

On May 29, 2014, Sterling was removed as co-trustee of the Sterling Family Trust, which owns the LA Clippers. This removal was based on the certification of two licensed physicians that Mr. Sterling was incapable of carrying out the duties as a Trustee of the trust because of his dementia. Shortly thereafter, his wife, now the sole Trustee of the trust, sold the Clippers to ex-Microsoft CEO Steve Ballmer. Sterling has since claimed that his subsequent revocation of the trust June 9 prevents his wife from completing the Clippers sale, although that appears to be an issue that will be decided by a judge (for a great summary of the facts and the legal aspects of the case, read this USA today piece).

The removal of Sterling as the co-trustee, and therefore the sale of the Clippers, was dependent on the physicians’ assessment of Sterling’s financial capacity. The family Trust allowed for him to be removed if his regular attending, or two other licensed physicians, certified in writing that he was incapacitated. We know, based on the limited court records that the two physicians certified incapacity based on his level of impairment in attention, information processing, short term memory, and ability to modulate mood, as well as risk of making errors in judgment.

So was it right that Sterling was removed as co-trustee? Based on the wording of the trust, the answer seems to be fairly clear. Yes. This also makes sense based on what we know about Alzheimers and financial capacity (see here for a JAMA paper on financial capacity). We also know based on research over the last decade is that the ability to manage finances is one of the first functional activities to decline in Alzheimer disease. Even before the onset of dementia, patients with mild cognitive impairment (MCI) begin to have impairments in complex financial tasks. Once diagnosed with mild dementia, emerging global impairments of both complex financial skills develop, which often rapidly worsen.

What about Sterling’s ability to revoke the trust? Maybe. His ability to revoke the trust (in California, anyway) is likely based on his capacity to make a will, which is a lower threshold than the capacity to be a fiduciary (his role as a trustee).   We know from court records that Sterling appears to have a mild dementia with MMSE of 23/30, but one that is notable for poor performance on executive function tasks like Trails B.  He may very well then be able to revoke the trust, but not have the capacity to be a trustee based on the wording of the trust.

by: Eric Widera (@ewidera)

Trails B



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Tuesday, July 8, 2014

Just "Fix-it"


by: Gretchen Schwarze (Vascular Surgeon)

She seemed awfully angry and at the very least dubious that I couldn’t do more for her father. After 7 hours of surgery trying to salvage her father’s leg, I tried patiently to explain that this new (third) bypass we had just successfully completed was unlikely to provide her dad with a long-term solution. Ultimately, he would lose the leg, if we were lucky he’d have it for another year or two. Accounting for the “unlucky” side of the coin was even more depressing; immediate wound or graft infection, a postoperative heart attack from the liter of blood I had just lost or early graft failure which few surgeons would attempt to reverse given the tenuous nature of the graft to begin with. I didn’t have the heart to mention these things too, she was already upset.

It’s conversations like these that make me feel like there is something intrinsically wrong with the way we conceptualize modern medicine, and by “we” I mean both doctors and patients. I worry that a much deeper issue - a larger social construct - plays a role in decision-making and influences treatment choices because it obscures the limits and boundaries of what health care can provide.

I chose to become a surgeon largely because I couldn’t stand the inadequate feeling that I had while managing chronic illnesses like COPD (emphysema) and diabetes. My ego loved the idea of taking a patient with a problem that was fatal if left untreated (like appendicitis) to the operating room and just fixing it.

Turns out there were a lot of other things I liked about surgery that mattered more so when I chose to become a vascular surgeon I fully understood that I was committing to a career of palliative surgery. Of course there are some exceptions – the 65 year old man with an abdominal aortic aneurysm for example – but for most patients I am merely rearranging the deck chairs on the Titanic. I know I don’t have the solution for PVD – it’s a systemic problem and by the time a patient sees me, he has a lot of it. My job is to take out what I can or go around it, but I am certainly not fixing it.

In 1991 Joanne Lynn and David DeGrazia wrote a brilliant paper about the “Fix-it Model” of medical decision making. (An Outcomes Model of Medical Decision Making, Theoretical Medicine) In it, they posit that contemporary attitudes about medicine subscribe to a mental model whereby disease is defined by a deviation from normalcy and the role of health care is to provide an intervention that “fixes” or returns the patient to normalcy.

Although most medical decisions do not fit this model, it’s hard to deny its influence on both patients and physicians. Consider the vast use of coronary stents in settings outside acute myocardial infarction (Rothberg, Circ Cardiovasc Qual Outcomes, 2013) or the widely-viewed animated video parody “Orthopedia vs Anesthesia” with the infamous line “I have a fracture, I need to fix it.” While the need to repair a bone in a 97 year-old woman in asystole is preposterous, the video is funny precisely because it rings true.

Lynn and DeGrazia expose the hazards of this mental model for decision making particularly for patients with chronic illness and for interventions which have limited/no potential to return the patient to normalcy. Surprisingly few have recognized and championed their concerns. Notable exceptions include William Silverman in his observations about the care of extremely low birth weight babies (Fumes from the Spleen, Pediatric and Perinatal Epidemiology, 1996 and Medical Decisions: An Appeal for Reasonableness, Pediatrics, 1996) and Mark Neuman (Surgeons’ Decisions and the Financial and Human Costs of Medical Care, NEJM, 2010) in his New England Journal commentary about the video parody. Both point out that the “fix-it model” promotes medical decisions that are explicitly permissive of intervention and that the model neglects a broader range of outcomes that are important to patients. As Neuman notes, “It’s as if, on some level, a decision making process has been passed over, and an inevitable operative course, however absurd, [has been] set in motion, not by the patient, but by the fractured bone itself.” (p. 2383)

Recently, my research group has also examined the “fix-it model.” Over two years we listened to and analyzed nearly 80 conversations between surgeons and patients before high risk operations. Although we were looking to hear discussions about the potential use of life-supporting interventions postoperatively, we were surprised to find that surgeons routinely used language consistent with the fix-it model. Many actually used the words “fix-it” and those who didn’t, used words that certainly suggested something was broken and could be fixed. (“And I Think That We Can Fix It”: Mental Models Used in High Risk Surgical Decision Making, Ann Surg, 2014) They described disease as something that was leaking, blocked or damaged and proposed interventions that would plug or patch, repair or remove the problem.

While surgeons used this imagery to explain the patient’s disease and the operation under consideration, they later transitioned to a more deliberative stance. In a few instances, the only reason cited to pursue surgery was to “fix” the problem and these conversations lacked any deliberation or reason to pursue surgery apart from having the problem “fixed.” However, in most cases, the surgeons explicitly challenged the fix-it model as they deliberated in front of the patient about whether to pursue surgery – they noted that perhaps the problem was too broken to fix, or not broken enough to fix, or that maybe what was broken wasn’t actually the source of the patient’s symptoms. They also noted that while they could “fix” the patient’s presenting problem, the patient would not or might not return to normal after surgery due to complications, imperfect outcomes and the impact of surgery on the patient’s baseline health.

And this brings me back to my patient’s daughter. It seems only natural to me that we (surgeons and non-surgeons) use the “fix-it model” to describe both illness and treatment; it’s a good way to explain complex medical information succinctly (something that we believe promotes trust). But like all mental models, fix-it oversimplifies the situation, particularly for older frail patients with multiple chronic illnesses, where there is a broad range of possible outcomes and prolonging life for as long as possible isn’t necessarily the most important goal. Assuming that physicians with good communication skills transition to a deliberative phase that attempts to dispel the fix it model (as I’m sure it would be easy to find physicians who are not good at this), even in the best circumstances are patients able to make this shift after we have defined their disease as an abnormality that can be fixed? When you tell someone that there is no cure, or that additional interventions are burdensome and unlikely to achieve their desired goal, are you fighting a Sisyphean battle that was lost long ago in this deep conception of what health care is supposed to do? I don’t know, but the anger and disappointment in the daughter’s voice makes me think we are up against a firmly entrenched obstacle that will take a lot of work to overcome.
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Thursday, July 3, 2014

Informed consent in social media research



I’m simultaneously a behavioral researcher, an ethicist, and a hopeless Facebook addict, so I’ve been thinking a lot about last week’s controversial study (Kramer et al, PNAS 2014) in which researchers manipulated the emotional content of 689,003 Facebook users’ News Feeds. In summary, users who saw fewer of their friends’ posts expressing negative emotions went on to express more positive and fewer negative emotions in their own posts, while users who saw fewer posts expressing positive emotions went on to express more negative and fewer positive emotions in their posts.

This provides evidence for “emotional contagion” through online social networks—that we feel better when exposed to other people’s positive emotions, and worse when exposed to negative emotions. This finding isn’t obvious, since some have suggested that seeing other people’s positive posts might make us feel worse if our own lives seem duller or sadder in comparison.

The journal and authors clearly did not anticipate a wave of online criticism condemning the study as unethical. (Full disclosure: one of the authors is also a researcher at UCSF, though I don’t think I’ve ever met her.) In particular, the authors claimed that participants agreed to Facebook’s Data Use Policy when they created their Facebook accounts, and this constituted informed consent to research. Looking at the Common Rule governing research on human subjects, it’s clear that the requirements of informed consent (including a description of the purposes of the research, expected duration, risks/benefits, compensation for harms...) are not met just because subjects click “Agree” to this sort of blanket terms of use. There are exceptions to these requirements, and some people have suggested that the research could have qualified for a waiver of informed consent if the researchers had applied for one. I'm not so sure about that argument, and in any case the researchers hadn’t.

While the online discussion about this study has been fascinating, I think there are a few points that haven’t received as much attention as I think they deserve:

1. This controversy is taking place against a backdrop of more critical scrutiny of informed consent among ethicists. While bioethicists in general have traditionally advocated strong informed consent requirements in the name of participant protection and self-determination, in recent years there has been an opposite trend emphasizing that such requirements are burdensome and may inhibit important research. Last year we saw a controversy over a neonatal ICU clinical trial, in which many experts criticized regulators’ strict interpretations of informed consent. More recently, some prominent figures have suggested that informed consent requirements in medical research should be relaxed, particularly for “big data” studies made possible by electronic medical records and coordinated health systems. Much like with the Facebook study, these researchers and ethicists believe that new technologies hold promise for new ways of conducting research to promote health, and worry that these possibilities may be closed off by our existing ethical frameworks.

2. What’s “research”? One irony of this controversy is that Facebook manipulates users’ News Feeds all the time—they don’t show you everything that your friends post, but use a filter that they’re always tweaking “in the interest of showing viewers the content they will find most relevant and engaging.” (In other words: so that you’ll keep coming back and they can show you ads.) These tech firms take a relentlessly empirical approach to everything. Google once ran 41 experiments to figure out which shade of blue made users more likely to click on ads.

These activities aren’t categorized as research falling under the Common Rule, as typically construed, because they’re not designed to develop or contribute to generalizable knowledge. So, e.g., if Facebook had a purely internal purpose for figuring out how to manipulate users’ emotions by adjusting the News Feed filter, this controversy wouldn’t have arisen. What opens them up to ethical criticism here is that they tried to answer a more general scientific question and published their findings in PNAS.

As others have pointed out, this division creates weird disincentives. Experiments on Facebook users to improve Facebook’s own processes and make more money don’t receive this level of scrutiny, but experiments to answer general questions (and that are publicized in scientific journals) do. But the risks to subjects are probably greater in the first case, since Facebook will keep those studies and findings proprietary, and the social benefits are smaller.

3. Social media and technology are creeping us out. I agree with the critics of the study that it didn’t meet existing requirements for informed consent in research; however, I don’t think that’s why people have responded to the story as they have. As in most cases, "the scandal isn’t what’s illegal, but what’s legal." In other words, what many of us really want to know is: what other experiments are Facebook/Google/Apple/Amazon/Samsung running on me that they’re not required to tell me about?

Like many people, I have complicated and ambivalent feelings about my dependence on these technology giants. As a researcher, I think that these feelings are a defining feature of our modern lives, and would be worthy topics for further empirical study. In a sense, the broad outcry over this study is an illustration of why such research is so important, though I worry it will have the unintended result of making future academic-industry collaborations in this space less likely.

by: Winston Chiong
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Wednesday, July 2, 2014

Practice Change Leaders for Aging & Health: Jedi Training for Geriatric Professionals



This is your big opportunity!  The C-Suite is giving you 10 minutes to make a business case for your new service line to improve the health and delivery of care for older adults at your institution.  Wow, I've watched Shark Tank on TV and I'm already sweating...(and I wake up from my dream).  But more seriously, one morning before a project presentation, my 6-year old son, now a big fan of Star Wars, shouted out to me with his best Yoda voice, "Use the force, Dad!".  As I begin the transition to mid-career in medicine, I got inspired to seek further Jedi training to grow and cultivate leadership skills.  I have been fortunate to be part of the Practice Change Leaders (PCL) for Aging and Health program for 2014.

The Practice Change Leaders is a national program to develop, support, and expand organizational leaders who are committed to achieving transformative improvements in care for older adults.  The program, founded by Dr. Eric Coleman, is jointly supported by the John A. Hartford Foundation and Atlantic Philanthropies.  This is a 1-year journey where participants complete a project at their institution aimed at improving care for older adults.  The project becomes the vehicle for the hands-on learning of critical leadership skills.  With the support of national Senior Leaders who provide mentoring, Practice Change Leaders engage in self-directed learning acquisition and content expertise to become more effective leaders.

The best part of the experience so far is the shared pod learning with great feedback from Senior Leaders for your project and skill-building seminars from national leaders.  How do you foster cultural change and a sense of urgency at your institution?  How do you get more consumer engagement in your project?  Last month in Chicago, at one of the 3 highly interactive national meetings, my peers and I had an amazing opportunity to give a business case presentation of our project to an expert panel (think of a wise, supportive Jedi Council).

As geriatricians, we are aware of innovative approaches to enhance the health and function of older adults, yet often the greatest challenge is effective leadership to successfully implement evidence-based, best practices.  But how do you become a change agent at your institution?  I did not go to business school or take any formal leadership courses.  I identified with Julie Thai's recent geripal post on the Geriatrician Syndrome, defined "a pathologically modest view of self in the context of one's role as a physician caring for older adults; cardinal features include: inability to accept praise and downplaying the significance of one's role in medicine".  Most geriatricians I know are not comfortable about promoting their work and talking about themselves.

As I reflect and look ahead, my passion and clinical interest is improving advance care planning and the quality of conversations in the outpatient setting to ensure patient wishes are explored, expressed, and honored.  I am still a Jedi in training, but I highly recommend the PCL program for any geriatric healthcare professional interested in furthering their career satisfaction and dreams, learning how to implement clinical programs, and being an active participant of the national movement toward improving care for older adults.

To learn more about the Practice Change Leaders for Aging and Health program, please visit www.changeleaders.org.  From the website you may request an application (due August 27, 2014) and attend one of several informational calls to ask specific questions (you are welcome to join the calls anonymously).  Please check your "geriatrician syndrome" at the door to come in and join us!

by: Steve Lai (@SteveLaiMD)

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Monday, June 30, 2014

After Pronouncing

The following post is adapted from something I read at the San Francisco Veterans Affairs Geriatrics, Palliative, and Extended Care memorial service.  The case has been anonymized to protect confidentiality. 
- Alex Smith @AlexSmithMD

Many of the veterans we care for are fortunate to have family and friends with them during their last days. Some of you are here today.

Some veterans have no family or friends. Over the years, these veterans have either pulled away, or been pushed away, from their loved ones. Let us take a moment to remember the these veterans.

Last year I was asked to come and pronounce that a veteran had died in our hospice unit. I had just taken over for another attending physician and had not met this veteran while he was alive.

“Did he have any friends or family?” I asked. “No,” said our social worker, “we contacted everyone we could reach. We’ve tried for weeks. None of them would come. They are too angry.”

I went in the room. He appeared to be at peace. I conducted my examination. Then it seemed as if there should be more to do, some way to remember him, and acknowledge who he was as a person.

Who would grieve for him? It was obvious that his life had been difficult. He had been homeless. His face bore the ravages of his time on the streets.

Every person, if you go back far enough, was loved, at least by someone in their life. Even if they are not loved now. Before the anger and the arguments and the illness. Before the isolation.

Hopefully, if you go back far enough, a mother held this person, then a child, in her arms and loved him.

I held that thought of this veteran being loved by his mother in my head, as I thought of this poem, by Joan Siegel, about a dying mother.  About the love between a mother and her child.  About how we hold on to memories of our loved ones, take them with us, and leave a part of ourselves behind.

To My Daughter by Joan Siegel

When it comes time
let all the words be spoken
that must be
so that I may take your voice with me
for the next ten billion centuries
mine will be with you
like a packet of letters
handwritten over the years
to unfold anytime
read
hear me speak
in the voice that used to put you to bed
telling the story of all our days
fingered in the retelling
like pages of your books
the best parts dog-eared
pressed smooth by thumbprints
and the refrain of all our nights
as you slipped away
I loved you before dinosaurs 
Even before the stars 
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Wednesday, June 25, 2014

Snow and Lollipops: Reflections on caring for the dying while raising children



Over the past year of my palliative care fellowship, I have learned that the discoveries made by the dying are not always that unlike the discoveries of my newly growing children that somehow get lost to us who are hopefully somewhere in the middle. While I am far from a philosopher, it is with humility that I would like to briefly share 5 lessons I have learned from my three year-old son, Ezra, as a reflection of the many wonderful people whom I have been privileged to care for over the past year.

Lesson #1: Snow

“Snow” is a children’s book about the adventures of two little children on a snowy day. They throw snowballs, sled, ski, and build a snowman together. Then in the midst of their fun day, the sun comes out and their snowman starts to melt. Ezra, who has never seen snow, looked at me worriedly the first time he heard the story and asked, “Mommy, am I going to melt?” Even at three years of age he confronted impermanence. He slept in our bed that night, scared, and needing to be held by we who loved him, needing reassurance that he would not melt. We have all witnessed the impermanence of lives lived well, lives lived in regret, and lives shortened too soon. But in these moments of fear, wives have crawled into the husband’s hospital bed, sons have hugged their fathers tightly with dignity, and mothers have held hands with their daughters before their last breaths.

Lesson #2: Lollipops

One day after a long family hike, we gave Ezra a small lollipop. It was red like 3D glasses and seemed flimsy next to his joy. I asked him what it tasted like. He answered “red.” It did not taste like strawberries, cherries, or licorice. It simply tasted as he perceived “red” would taste. As I have grown as a physician, I have learned to appreciate that sometimes things just are. Pain may be pain. Not necessarily sharp, dull, aching, radiating or electric. Just as love can be love and healing healing indescribable and without question.

Lesson #3: Tantrums

Ezra has to eat his broccoli before pizza, share his favorite toys with his younger brother, and brush his teeth before bed. I do not let him sleep at the playground or stay up until 10 o’clock at night. He does not eat cookies for breakfast nor play games on the iPad. Any one of these or a long list of circumstances might lead to a tantrum. While it is hard to acknowledge in the midst of him crying and stomping, nearly all tantrums stem from the absolute amazingness of a world with pizza and technology and friends worth talking to for hours. Tantrums happen because life is good and yet is also filled with boundaries. While no patients have lain prone on the floor screaming in my office, the disappointment of a recurrent cancer or failed chemotherapy regimen is the grief of loving this life fully and facing our own human limitations.

Lesson #4: Easter egg hunts

We celebrated Easter with a small egg hunt. Plastic eggs filled with goodies were scattered throughout the park. While we were preventing his younger brother from running into the street, Ezra took the liberty of exploring the contents of each egg well after his chocolate quota had been reached. When we finally noticed, Ezra continued, saying “uh-oh, I opened another one” as he peeled off another chocolate wrapper and quickly popped it into his mouth. Over the past year, I have witnessed hope. Simple hope to eat one more chocolate as well as vast, inspiring hope for a cure, hope for reconciliation, hope to have years, months, or even minutes more to live even when being told no.

Lesson #5: I’ll miss you

Every night we read books together, sing 2 songs, then I tuck Ezra into bed, give him a kiss and say “I love you. I’ll miss you. Sleep well.” Because even after a difficult day, the time between good night and good morning starts to feel long and I miss the boys sleeping in the room beside me. I have seen many people die over this past year of fellowship and years of residency, but I remember most the big, large, deep love I have seen fill hospital rooms and homes. So on behalf of all of those who were lost this past year, I write with a full heart, to our loved ones who have gone before us “We love you. We miss you and sleep well.”

by: Laura Koehn (@lauraekoehn)

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Wednesday, June 18, 2014

Motivating Aging Friendly City Design with a Personal Touch



The WHO Global Network of Age-friendly Cities and Communities (GNAFCC) promotes the generation of knowledge on how to assess the age-friendliness of a city or community, and provides guidance on how to create age-friendly urban environments. All members of the Network share a commitment to creating physical and social urban environments that sustain age-friendly, healthy, livable communities for older adults.

Having the option to age independently within one’s community is a fast emerging global prerogative. Cities and communities can share experiences by joining the network directly or through sister organizing bodies such as the American Association for Retired Persons (AARP). They can access the global resources and approaches cities and communities are taking to define baseline measures for policy and practice and exchange results under commonly defined domains and categories.

Over the last two years, the City of Chicago in partnership with Northwestern University has conducted an assessment of the city’s age-friendliness in accordance with the terms and conditions of Mayor Rahm Emanuel’s membership in the World Health Organization’s Global Network of Age- Friendly Cities. Utilizing the World Health Organization’s Age Friendly protocols and resources, the Department of Family and Support Services (DFSS) has begun to build an evidence based profile of older Chicagoans using a range of methods and drawing on a variety of funding sources. Methods to date have included: focus groups with older adults using senior centers, an environmental scan of popularly cited age-friendly indicators for livable communities, q sort interviews with key stakeholders working with older adults in the community; a community wide survey for all older Chicagoans. If you work with older adults in the City of Chicago please friend the Age-Friendly Chicago Survey on Facebook here or send out the survey link (http://www.surveymonkey.com/s/ChicagoAgeFriendlySurvey).

by: Jay Bhatt DO MPH, Northwestern Feinberg School of Medicine &
Rebecca Johnson Ph.D, Northwestern Feinberg School of Medicine
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Thursday, June 12, 2014

World Elder Abuse Awareness Day (WEAAD) is June 15 – Take Action to Protect Older Persons



It is estimated that 5 million older Americans are abused, neglected and exploited each year yet only about one in five of those crimes are ever discovered. WEAAD was launched in 2006 to promote a better understanding of abuse and neglect of older persons and to highlight its significance as a public health and human rights issue.

Each year communities and organizations around the world plan activities and programs, both small and large, in an effort to make a difference in the lives of vulnerable elders. Consider taking a moment to visit the Administration for Community Living (a part of HHS) website on WEAAD, for a variety of tools, tips and resources you can use in support of efforts to raise awareness about the importance of preventing, identifying and responding to this often hidden problem (World Elder Abuse Day Tools).

by: Joan Abrams, MPA
Associate Director UCSF Northern California Geriatric Education Center
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Monday, June 9, 2014

Behavioral Symptoms of Dementia Should Be Treated WIth Behavioral Approaches



Persons with dementia often suffer from behavioral symptoms such as agitation and aggression.  For the caregiver, these symptoms can be very distressing.

Consider the case of a daughter trying to take care of her mother.   Daughter is doing her best, and after a long day of work, comes home to take care of her Mom, and help with her activities of daily living.  While trying to help her mother bathe, Mom gets angry, swings her arm toward her daughter, and yells, "why do you always try to hurt me?"  The daughter loves her Mom, but stuff like this is often the breaking point that makes transfer to a nursing home necessary.  And it is not like Mom's agitation will be much better in the nursing home.  Often, the nursing home will treat Mom with an antipsychotic drug.  The drug will be marginally effective at best at improving the agitation, and will also increase the risk for stroke, heart attack, and death.

There has got to be a better way.

Well there is a better way. A MUST READ article recently published in the Journal of the American Geriatrics Society describes a pragmatic drug-free approach towards understanding and managing dementia behaviors.  The approach is grounded a skilled and careful analysis of the behavior.  The approach goes by the acronym DICE, and considers patient, caregiver, and environmental perspectives.

The 4 DICE components are:

Describe the Behavior:  In our bathing example, a careful description would reveal that Mom gets verbally and physically aggressive at bath time.  Mom seems uncomfortable, and says "it hurts."  The daughter wonders if Mom is doing this on purpose.  She thinks it is important that she give Mom a bath every day.

Investigate to identify possible causes of the behavior:  In our bathing example, one would discover that Mom has arthritis, but is not on any pain meds.  Moving Mom's arms and legs causes pain.  Further investigation reveals that when Mom gets angry, the daughter gets angry and uses harsh, confrontational language.  Daughter does not know that agitation and aggression are common in dementia.  There are no grab bars in the bath which contributes to Mom's fear.  The daughter notes that Mom took daily baths all her life, and she feels it is her responsibility to keep things as normal as possible for Mom

Create a Management Plan:  To continue our example, Mom might be prescribed acetaminophen an hour before bathing.  The daughter would learn that aggressive behaviors in dementia are not intentional.  She could be taught to respond in a calm voice, learn how gentle touches might reassure her mother, and avoid sudden movements.  A new normal routine could be established that may allow for bathing several times a week, and explore possibilities such as sponge baths.

Evaluate:  After these steps are tried, one can work with the daughter to see which steps are working, and make refinements as needed.

This is the kind of practical stuff that is not taught in medical school or residency.  Also, these are the types of high caring, time consuming interventions that may be hard to implement in most office practices.   Kind of a shame that there is much more profit in doing scans and procedures on dementia patients than on actually doing interventions such as DICE that will really help the patient and caregiver.  But a clinician that learns the DICE approach will gain a lot of satisfaction from making a big difference for their patients and those who care for them.

by: Ken Covinsky (@geri_doc)

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Friday, June 6, 2014

An antidote for our emotional distance

 
By: Laurel Coleman, MD

I have been pondering Danielle Ofri’s NY Times column, “The Silence of Doctors Around Alzheimer’s” for the past few weeks.

Dr. Ofri’s article raises some very good points, and this excerpt especially caught my attention:
“Most doctors are required to get recertification every 10 years, to undergo a battery of tests and training courses to keep us up to date and to identify shortfalls in our medical skills. We don’t, however, do any periodic checks on our inner selves, to uncover any lapses in our emotional core that might affect the care of our patients.  
Just because the diagnosis of dementia can be difficult and treatments frustratingly limited doesn’t mean we can shy away from this disease. We need to face down our own uneasiness, confront our own disconcerting reactions, so that we may be there in full for our patients, their families and, indeed, ourselves.”
Well-intended clinical pathways and algorithms that are designed to achieve good care do not address the “lapses in our emotional core.” How do we examine ourselves for these lapses, identify our own fears and denial, and equip ourselves to be present “in full?”

Of course, just taking a moment to realize how we feel when interacting with a person with dementia is the first step in changing how we behave and ultimately improving the quality of our care. Dr. Ofri’s article challenges us to think about the “how” and the “why” of any uneasiness that we might experience in this context.

I am reminded of the author Henry James’ challenge to be, “finely aware and richly responsible," and of being a person "on whom nothing is lost." He argues that literature and the arts are crucial to our moral development, and quite possibly an excellent antidote to the “lapses in our emotional core” that Dr. Ofri identifies.

Therefore, I think we should try to encounter Alzheimer’s Disease in a different way – outside the office or the hospital. Go to a play, read a book, or watch a movie. The arts reach us at our core, and they often invigorate and inspire us in a more lasting way than a professional article or lecture. Here are three specific suggestions that I have found helpful recently.

Try to see “The Genius of Marion,” an outstanding documentary film about a woman and her family as they come to terms with this illness in a way that honors her humanity. It will be on PBS stations, September 8th – or check for local showings on “Geniusofmarian.com”.

An excellent new book produced by Dr. Peggy Noel of MemoryCare in Asheville, NC includes 3 one-act plays about the experience of Alzheimer’s Disease. They were selected from a national competition and performed by local actors in Asheville for a standing room only audience. I left the performance with renewed energy and compassion for the patients and the caregivers that I see in my practice. “The Memory Care Plays” book provides the scripts so community groups can produce them locally – or you can just read them personally. “The MemoryCare Plays” is available on Amazon.

The gripping novel by Lisa Genova, “Still Alice” is being produced as a movie – soon to be released to theaters with Julianne Moore in the lead role. It is unique in that the narrative comes from the person with dementia – opening up a new perspective for us as physicians. What does it feel like to experience Alzheimer’s, to become unmoored from the intellectual skills and talents that we have so long cultivated?

If we are to be more “finely aware and richly responsible,” then we need to examine our inner self. We are faced with a difficult and incurable disease, but we can be better health care professionals when we engage dementia through the arts. Don’t shy away from Alzheimer’s Disease. Try the antidote, because your patients need you.

By: Laurel Coleman MD, @lmcmd
Augusta, Maine
Member, Alzheimer’s Advisory Council, HHS

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Thursday, June 5, 2014

House calls go Hollywood



Mindy Fain, Chief of Geriatrics at the University of Arizona, penned a fabulous Op-Ed in today's Los Angeles Times extolling the virtues of home care medicine to what is surely a wide new audience. Readers of GeriPal are probably familiar with how house calls can provide safe, effective care that is both cherished by patients and cost-saving to boot - but I hope visibility like this will help the message sink in with policymakers as well!

Coincidentally, I had the pleasure of meeting Dr. Fain this morning as we both arrived at a scientific workshop designed to engage geriatricians and basic scientists in a conversation about how to move recent advances in aging biology into the clinic. What a day! House calls to mouse models to clinical trials and back again. It is an exciting time to be a geriatrician!

by: John Newman
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