Skip to main content


Showing posts from August, 2011

Hospital Medicine is Part of Primary Care

There has been a lot of policy discussions about the emergence of the hospitalist movement. A decade ago, when a patient was hospitalized, the doctor managing their care in the hospital was usually their primary care doctor. Increasingly, primary care doctors do not manage their patients in the hospital. Instead their care is managed by a breed of specialist known as a hospitalist. Many hospitalists limit their clinical practice to the hospital. It is been debated whether or not having hospital care managed by hospitalists is good for patients. Previous studies have shown that hospitalist management results in a shorter hospital stay. But studies of post hospitalization outcomes are sparse. A recent study , authored by Yong-Fang Kuo and Geriatrician James Goodwin from the Sealy Center on Aging at the University of Texas in Galveston, suggests the effects of hospitalists are mixed. The study has received extensive media attention, including an excellent review and discussion from

Should Clinicans Give Recommendations?

I was taught to give recommendations to seriously ill patients and family members facing tough choices.  This was probably best taught to me via the following analogy.  Let's say you go to Best Buy, and ask to buy a computer, and the store person says, "Do you want SDRAM or GDDDR5 Ram?  Do you want a Thunderbolt port or a Firewire port?  Do you want a dual core or a quad core processor?"  Unless you're a total computer geek, you're going to feel lost, and unable to make these decisions.  On the other hand, the store person could say, "What do you want to do with the computer?  Do you need it to be portable?  Are you going to use it for intensive graphics or gaming?  Based on your needs, I think the best option for you is..." Similarly, I was taught to elicit patient and family goals and preferences, and as the medical expert, offer a recommendation.  "Based on what you've told me about your mother - her preference not to live on machines - i

Graceful dying - all is not equal

My dog is dying. When he was diagnosed two months ago with brain lesions, we had an open, practical conversation with the veterinarian about quality of life, palliative symptom management and options for a gentle death, including euthanasia, when the time is right. Humans (with rare exceptions) are not offered these options. A news article in the Albuquerque Journal tells of Dorothy and Armond Rudolph, ages 90 and 93, who decided to choose their own time to die, peacefully and together, by declining food and fluids. The couple first consulted Compassion & Choices, a non-profit organization that focuses on improving people’s rights and choices at the end-of-life. They found out that they were within their legal, medical and ethical rights to fast, knowing they would likely die within ten days. Their assisted living facility responded by calling the police and emergency services, reporting that they were attempting suicide. Three days into their fast the couple received an e

Asian Cultural Taboo Impedes End-of-Life Care?

Last week, I started interviewing clinicians who care for frail elders at On Lok Lifeways as part of a study led by Dr. Alex Smith. (On Lok was one of the first sites to launch the Program of All-inclusive Care for the Elderly (PACE) for nursing home-eligible elders residing in the community). In talking with one of the practitioners, I was surprised to learn that almost all of the participants have an advance health care directive, especially as a majority of the participants served at On Lok are Asian. From personal experience, Asians don’t generally talk about the end of life because death is a cultural taboo. When my grandfather passed away last December, I flew to Vietnam to mourn with my family. In talking with my relatives, my grandfather’s death was never mentioned in explicit terms; instead, we talked about him as though he had gotten lost somewhere. In one of my previous posts , I realized I had (subconsciously) described death in my cultural terms. My exact

The (Ir)Relevance of Medical Research to Older Patients

Research studies often are conducted as if older patient's don't exist. Even when the disease being studied predominantly effects older persons, the study includes patients that bear little resemblence to the typical older patient. This makes providing the best care for older patients difficult because we have little evidence to inform best care practices. We have discussed several specific examples of this problem on GeriPal (see here , here , and here ). An important study in the Journal of General Internal Medicine shows these examples are not isolated incidents. Rather, the failure to make clinical research relevant to most older patients is a deeply embedded, pervasive, and systemic problem. Things really need to change. The investigators, led by Dr. Donna Zulman at the University of Michigan, reviewed over 100 studies of theraputic interventions for diseases that are common in older persons. They focused on studies published in the most widely read and influential med

Are Antidepressants Ineffective for the Treatment of Depression in Dementia?

Depression is the most common mood disorder in elderly individuals with Alzheimer disease, with prevalence rates somewhere between 15% to 57%. One major difficulty in dealing with this issue is the inherent difficulty in diagnosing depression in dementia, as evident in the huge prevalence range that I just cited. The other difficulty is figuring out how to treat it. Antidepressants so far have only showed mixed results in the few studies that have examined their efficacy in Alzheimers. Unfortunately, most of these studies have been either too small or too poor of quality to give much guidance. The Health Technology Assessment Study of the Use of Antidepressants for Depression in Dementia (HTA-SADD) significantly changes this landscape. This multicenter, double-blind, placebo-controlled trial is the largest study to date on this subject. The conclusions do not bode well for antidepressants, although they shouldn't take them off the table as treatment options. Before we

Social Determinants of Accelerated Aging

Do you: 1) Make less than £25,000 ($40,926) a year? 2) Rent your home? 3) Fail to eat your vegetables? If you answered yes to all three questions, your telomeres may be shortening at a faster rate than those who answered no (read: are less deprived). [Note: Telomeres are the ends of chromosomes that get depleted as we age]. At least that’s what a new study coming out of the Glasgow Center for Population Health is reporting. The Public Library of Science recently published the study’s findings, which established that there may be a scientific association between socioeconomic status and aging. The Glasgow study involved measuring telomere length in blood samples of 382 Glaswegians. For people with annual incomes lower than £25,000, telomeres showed an average 7.7% decrease in length over a 10-year period. Those with incomes greater than £25,000 showed only a 0.6% shortening in their telomeres in comparison. Moreover, poor diet was found to exacerbate telomere shorte

Matchless: Residents Left in the Lurch

Over the last two weeks I have had four different second year residents from several institutions ask me about when they should start thinking about applying for fellowships . Some of these residents were applying for palliative care positions, and some geriatrics positions. The answer I gave them unfortunately was the same: “If you are interested in a 2013 spot at UCSF, start getting your application together for an interview season that will likely start in the fall and end in the early winter.” The overwhelming response that I got was “ really?  I just finished internship. ” Although, I’m pretty sure a more verbose response was going on inside their head akin to “ are you &#!@% kidding me !” There was one response though that really caught me off guard and made me worry about what the lack of a match meant for the future of our fields.  The resident replied to my statement by saying: “but our residency director told us that we now don’t even have to worry about the