Thursday, September 29, 2011

Too Little Care? Too Much Care?

I wanted to get this community's thoughts on a recent article that made some headlines (see ABC news and New York Times for example).

In the Sept 26 issue of Archives of Internal Medicine, Brenda Sirovich and colleagues from Dartmouth report a survey of primary care physicians, where they found that PCP felt they were providing too much care more often than too little care.

First, I want to concede the point that the ideal answer is that we need to individualize decisions and that even if most patients are getting "too much" care, there will be some patients who would benefit from getting more care.

Focusing on averages and a population perspective, I've become interested in this topic since I felt a slight tension between younger and older geriatricians about the care for older adults. It seems that in a previous generation of geriatricians, the primary concern about the care of older adults was that we were not providing enough care. For me, this is highlighted by the coining of the term "ageism" by Dr Robert Butler in the late 60's. The subtext seemed to me that older patients were being denied appropriate services even though they may benefit because they were old. Thus, a dominant theme was elders getting "Too Little" care.

Since then, it feels like a much more dominant theme in geriatrics is how elders are getting "Too Much" care. From studies focusing on poor outcomes associated with surgeries in elders to foley catheterization to medications to avoid, it feels like more geriatricians believe that too much care is being provided than too little. The studies that focus on undertreatment of elders seems to come more from subspecialists (e.g. oncologists showing that elders are being undertreated for cancers) than geriatricians.

Do folks think that geriatrics as a field has shifted from fighting to ensure that elders get appropriate care to fighting to prevent harmful care?

My sense (completely unsupported by any data) is that this has happened. Further, I think much of this reflects a shift in US medicine, where more and more interventions being done. Thus, ideal care for the older patient has not changed in intensity over the past 40 years. However, the standard of care has shifted, so that 40 years ago, the standard of care may have been slightly less aggressive than ideal and now the standard is more aggressive than ideal.

6 comments:

Nancy Lundebjerg said...

Alex, I am not sure that this is a generational divide for geriatricians. Rather, it's that geriatricians are fighting the same battle -- what's best for patients -- but on a new battlefield created by the convergence of two evolutionary streams --- progress in medicine and changes in how it is practiced. Seems to me like geriatricians got it then and they get it now.

ken covinsky said...

A big part of the art of Geriatric Medicine is right sizing care. Sometimes this means it is the Geriatricians role to point out that their 85 year old is not too old for a knee replacement. Sometimes it means pointing out that a screening colonoscopy in a frail 80 year old is much more likely to harm than benefit the patient.

I definitely agree with Sei that the relative emphasis in Geriatrics has shifted, and this shift seems large.

The field has become increasingly concerned about the harmful effects of too much care. I agree with Nancy that much of this reflects a response to changes in how medicine is practiced.

On the other hand I do suspect a component of this reflects changes in the culture of our field. In particular, changing attitudes may be at least partially related to the profound influence of Palliative Medicine on the practice of Geriatric Medicine. Palliative Medicine has taught us that the care our patients need is not always found in more diagnostic tests and procedures.

I suspect the Geriatrics culture shift may be very different in the United States than in other countries. The risk of harmful care and procedures is probably much lower in nations with better functioning health systems. In these countries, perhaps Geriatricians put more emphasis on making sure older patients are not excluded from care.

Andrea Allen said...

I agree with Ken that Palliative Medicine has had a beneficial effect. Perhaps in the US we will actually right-size care once we truly establish each patient's goals prior to advising about diagnostics and treatment.

Christine Butler, APRN, BC-PCM said...

I believe that my father conceptualized ageism as a broad based description of society's marginalization and prejudice toward older people.
In his own life he tended toward minimal medical interventions but favored lifestyle choices to maximize health. I agree that Dr. Butler would promote individualized goals of care, just as he did when friends asked his advice or in discussions with his patients and families.

Mike Steinman said...

The challenge for our field is in being able to hold these seemingly contradictory ideas at the same time. Patients are both receiving too much care AND too little care - for example, many patients are taking drugs that are unnecessary, but are not taking other drugs that might help them. Our patients lose out when we become overly focused on undertreatment or overtreatment.

sei said...

Ms Butler,

Thank you for clarifying your father's views. To highlight the possible shift in biases within the field of Geriatrics, I over-simplified the original conception of ageism.

Your comment refocusing on ageism as a broader social marginalization of elders reminds me of how the concept is just as relevant today as it was when first developed.