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Showing posts from January, 2012

The Aging Homeless: Geriatrics on the Streets

The demographic picture of the homeless has shifted markedly over the last 20 years, with a marked increase in the average age of homeless persons. Currently, nearly 1/3 of the homeless are over the age 0f 50.
A remarkable study paints a concerning portrait of the struggles faced by the aging homeless. It was led by Geriatrician Rebecca Brown who conducted the study while a Geriatrics Fellow at Harvard Medical School. Dr. Brown is currently our colleague in the UCSF Geriatrics Division. The senior author was Harvard Senior Life Geriatrician, Dr. Susan Mitchell. The study was published in the Journal Of General Internal Medicine.
This study examined prevalence of Geriatric Syndromes in the homeless elders. Geriatrics syndromes are problems affecting daily functioning and independence that typically occur in seniors. This includes basic activities of daily living like the ability to get dressed and cognitive functioning. The study showed strikingly high rates of "Geriatr…

The Dangers of Rote Medicine

***Warning: the below blog includes the direct Emergency Room documentation of an attempt to resuscitate a patient who died***

I understand the value that routine and standard procedure can have in medicine. For example, Quality and Safety endeavors often turn to checklists and protocols to ensure that patients receive a standard of care and that errors are not made. The same goes for the way providers document in medical records. We often follow a set format, such as SOAP for Subjective-0bjective-Assessment-Plan with progress notes. But a recent experience reading the account of how one of our Housecalls patients died left me wondering if compassion and reflection have been squeezed out by rote medicine.

We recently enrolled a 97yo woman with dementia into our Housecall program. This woman had no surrogate decision maker although she had a devoted caregiver and community case manager. Conservatorship application was submitted but had not materialized and because her goals of care ha…

GOP Candidates on Advance Directives

We have learned a lot of lessons in Hospice and Palliative Care about how political discourse can impact our field and the care we give to individuals with serious illnesses.  You only have to go back to January of 2011 to see how the hysteria around death panels led to the removal of legislation that would have reimbursed physicians for advance care planning discussions.

As the GOP primaries continue to heat up, it will be important for us as a field to continue to pay attention to the rhetoric used on the campaign trail and discussed on nationally telavised debates.  One interesting yet brief exchange took place between in Tampa, Florida on January 23, 2012 between Newt Gingrich, Ron Paul, Rick Santorum, and Adam Smith of The Tampa Bay Times. This transcript was provided by the Chicago Tribune (and a big thank you to the reader who emailed me this exchange):

SMITH: Thank you. Senator Santorum, in 2005, Florida was in the middle of a huge national debate over Terri Schiavo, whether…

The MMSE Saga: An Assault of the Values of the Academic Profession

The MMSE saga has attracted great attention here on GeriPal and elsewhere since the breakthrough NEJM article of Newman and Feldman.
As readers Eric Widera's previous posts (here and here) know, the MMSE was one of the most widely used tests in medicine. It was a brief, easy to use screen to identify older persons with cognitive impairment. A generation of students learned to assess using cognitive function with the MMSE, and the MMSE was reproduced in textbooks worldwide.

But after allowing widespread use of the MMSE for decades, the developers enforced their copyright. The MMSE disappeared. A tool that was used to improve the care of older patients became unavailable. Medical progress went into reverse. Patient care suffered. We directly saw this negative impact on patient care at our VA hospital. The MMSE, which was available to all clinicians via our electronic medical record, disappeared. It became much much harder to offer cognitive testing to our patients.

Even worse, whe…

The Third Annual Hastings Center Cunniff-Dixon Physician Award

The 2012 recipients of the third annual Hastings Center Cunniff-Dixon Physician Awards were just recently announced. I was honored to be one of the recipients of this award last year, but am humbled by this year’s awardees. Richard Payne said it best in the Hastings Center press release: "This year's winners emerged from an exceptionally strong field of nominees and serve as models of competent, caring, compassionate doctoring."

The awardees for the 2012 year are:

Senior Physician Award: 

Janet Bull, MD.  Janet is the chief medical director and principal investigator of Four Seasons, a nonprofit hospice and palliative care organization in North Carolina. She is a role model for many palliative care clinicians thanks to her work that combines both clinical practice, research, and local and national leadership in hospice and palliative care. 
Mid-Career Award: 

Michael Rabow, MD.  Mike is a professor of clinical medicine at the University of California San Francisco (U…

Eprognosis gets Half a Million Hits in the First Week

Eprognosis is barely a week old, and we've already had over 500,000 pageviews (150,000 unique visitors).  For perspective, GeriPal is about 3 years old, and in that time we've had 400,000 pageviews.  We've had loads of press, including 6 stories in the New York Times about prognosis and eprognosis (Stories by Paula Span here, here, here, here, and here.  Story by Pauline Chen in today's paper here.  For a more complete list of media stories, see the eprognosis "About" page here.  Unexpectedly, about a quarter of our hits have come from Turkey, due to this news story.)

All this attention prompted my six year old son to say, wistfully, "I remember before daddy was famous" --  as if our lives have changed dramatically, and the paparazzi are chasing us down!

But seriously...what does all this mean?

The central objectives of our scholarly work on this topic were to: (1) promote consideration of prognosis in clinical decision making for older adults - bec…

Prognostic Indices In Patient Care: Useful or Waste of Time?

Many clinical decisions in older persons are dependent on life expectancy. For example, as life expectancy declines, cancer screening is likely to do more harm than good. Also, persons who have limited life expectancy may want to plan, discuss their values, and consider palliative care approaches of care in addition to care focused on living as long as possible.

But can one actually predict life expectancy accurately in an individual patient? In an oustanding review of prognostic indices to predict life expectancy in older persons just published in JAMA, Dr. Lindsey Yourman suggests the glass may be more then half empty. Dr. Yourman is an internal medicine resident at Scripps Mercy Hospital in San Diego. Other authors include Alex Smith (senior author), Sei Lee, and Eric Widera of UCSF and Mara Schonberg of Beth Israel Hospital.

So what are the problems with prognostic indices? Well first, at least when applied to an individuals, they are of limited accuracy. For example, lets say yo…

Copyright and Access to Taxpayer Funded Research

This is the third post in a series on copyright in medicine. We started off the series with two posts. The first discussed the importance of a NEJM article advocating for the greater use of copyleft licenses in medicine. The second detailed the dubious copyright infringement claims by the authors and owners of the mini-mental state exam. This last post in the series is a call for help maintain a bare minimum of open access to taxpayer funded research.

A new Association of American Publishers (AAP) backed bill titled the “Research Works Act” is threatening the currnet National Institutes of Health (NIH) public access policy. The current NIH policy requires that all final peer-reviewed journal manuscripts that arise from NIH funds be submitted to PubMed Central upon acceptance for publication, and that these papers are accessible to the public on PubMed Central no later than 12 months after publication.

Despite an overly restrictive period of up to 12 months before making these work…

Should for-profit hospices be banned? Or are they victims of a witch hunt?

For-profit hospice has been in the news recently, and the press has not been favorable.  We have this from a recent lengthy article in the Washington Post:
"Hospice care, once chiefly a charitable cause, has become a growth industry, with $14 billion in revenue, 1,800 for-profit providers and a base of Medicare-covered patients that doubled to 1.1 million from 2000 to 2009. Compensation based on enrollment numbers, pay to nursing-home doctors who double as hospice medical directors, and gifts to the nursing facilities have helped fuel the boom, according to a study of 1,000 pages of court documents and interviews with more than 45 hospice employees, patients and family members." And from Wednesday's Kaiser Health News, we have:
"A national hospice company improperly cycled patients through nursing homes and hospice with a goal of making as much profit as possible from Medicare, according to a whistleblower lawsuit announced this week." All of this press on the h…