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Showing posts from February, 2013

Larry Feigenbaum: Geriatrics Pioneer

The Bay Area Geriatrics Community recently lost one of our greatest friends, innovators, and pioneers with the passing of Dr. Larry Feigenbaum.   Decades before almost anyone else, Larry saw how how our health system was failing to meet the needs of older patients coping with frailty and disability.   So much of what is happening in San Francisco to improve the care of older persons can be traced to Larry's vision.

In 1978, Larry established the first fellowship in Geriatric Medicine in the western United States at Mount Zion Hospital in San Francisco, a premier community hospital and teaching affiliate of UCSF.  He was so far ahead of his time.  It would be another 20 years before UCSF even had a Division of Geriatric Division.   I wonder if our current fellows realize that the opportunity they have to learn Geriatric Medicine has its roots in Larry's vision.

Larry also saw the need to integrate social services with medical care.  He played a crucial role in the establishme…

Patient-centeredness is the Intuitive Grasping of Health care Quality

Improving the health outcomes of older adults with multiple chronic morbidities has been my calling as a physician. During residency, my colleagues were interested in difficult, rare, or novel cases. In contrast, I was attracted to the lingering, multiple everyday conditions that older adults faced. I was also struck by the fact that providing all the recommended screening and treatments for each of their conditions often did more harm than good. It became immediately clear to me that my role as a clinician was to partner with my patients. In the end, it was the patient and her family that had to identify health and life goals, prioritize which of those goals were most important, and then work with clinicians to find treatments that best aligned with one’s goals and values. From this perspective, “non-adherence is a dysfunctional concept.” The quintessential signs of poor quality of care for multimorbid older adults, e.g., polypharmacy, overutilization, adverse events, often result f…

Palliative Care and Chronic Pain: Time for a Rethink?

There is a revolution in palliative care.  No longer just for those with advanced and often-incurable illness, individuals receiving palliative care may have a prognosis of years if not decades.  We are starting to see this revolution occur all around us with the development of outpatient clinics that integrate palliative care at the time of a diagnosis of serious illness.

With any revolution though, things are never as easy as they first seem to be. One area that becomes increasingly more complicated is the question of how best to treat pain that also may persist for years, if not decades, in those who have a serious illness or who are survivors of that illness.  An excellent case example of this comes from a paper recently written by Jessica Merlin, Julie Childers and Robert Arnold.
Ms L is a 52-year-old woman with a history of a malignant glioma and bipolar disorder. She underwent resection, adjuvant chemotherapy, and radiation therapy for her tumor 6 months ago. She had a complet…

Opportunities to Educate the Public, National Public Radio (NPR), and Even Ourselves about Hospice and Palliative Care

I was completely thrilled this morning to see that NPR had a blog post covering the Choosing Wisely initiative.

The NPR blog explains how the American Board of Internal Medicine partnered with other organizations such as the American Academy of Hospice and Palliative Medicine (AAHPM) and the American Geriatrics Society (AGS) to warn against tests, procedures and treatments “that often do patients no good.”

As I read through the NPR blog I was even more excited to see that many of the recommendations highlighted were regarding Geriatric and Hospice and Palliative Medicine.

Later this afternoon I started thinking about one of the recommendations that NPR listed:
Don't hold back on providing hospice care to relieve pain and distress just because a seriously ill patient is getting treatment aimed at alleviating disease
I thought this statement was a little confusing. The Medicare Hospice Benefit does not currently allow patients on hospice to seek curative treatment for their te…

Five Things Physicians and Patients Should Question in Palliative Care and Geriatrics

The American Academy of Hospice and Palliative Medicine (AAHPM) and the American Geriatrics Society have partnered up the American Board of Internal Medicine (ABIM) Foundation in producing two lists of  “Five Things Physicians and Patients Should Question."  These lists just published today provide targeted, evidence-based recommendations to help physicians and patients have conversations about making wise choices about their care in order to avoid interventions that provide little to no benefit.

AAHPM’s Choosing Wisely list of 5 Five Things Physicians and Patients Should Question are the following:
Don’t recommend percutaneous feeding tubes in patients with advanced dementia; instead, offer oral assisted feeding.Don’t delay palliative care for a patient with serious illness who has physical, psychological, social or spiritual distress because they are pursuing disease-directed treatment.Don’t leave an implantable cardioverter-defibrillator (ICD) activated when it is inconsisten…

What is your patient's PPD status?

Bree Johnston, a true believer in geriatrics and palliative care, contributor to GeriPal, and erstwhile colleague at UCSF, recently returned to give grand rounds.  She said that while in Scotland, she had the opportunity to observe geriatrics and palliative care teams.  Bree previously posted many of her observations on the blog here and here.

One thing I want to highlight about her experience was the contrast in what clinicians considered vital information about patient's approaching the end of life in the UK.  Their PPD status.  What, you say, do they have severe outbreaks of tuberculosis among the dying?

No, PPD stands for Preferred Place of Death.  They actually ask patients about their preferred place of death as part of the advance care planning process, document it, and make a big deal about trying to get the patient to that setting as death approaches.

This is remarkable!  In the US the subject often comes up in the research literature, as in something like, "Most …

Gearing Up for the AAHPM Annual Meeting

This is the first in a series of posts focused on the upcoming American Academy of Hospice and Palliative Medicine’s (AAHPM) Annual Assembly in New Orleans.    

The AAHPM annual meeting serves as a venue for health professionals from diverse disciplines to gather together and learn from each other.  A particular challenge with such a broad audience is that it requires the participation of all disciplines as educators in workshops and symposiums to create a truly effective educational experience for all conference attendees.

Shaida Talebreza, MD, from the University of Utah School of Medicine, has put together a pre-conference workshop aiming to amplify the voice of  early career professionals from all health disciplines at future local, regional and national meetings by sharpening their skills in abstract writing and effective presentation preparation.

This is shaping up to be a fun and interactive workshop involving large-group educational sessions and hands-on small-group sessions…

More Tales of Medical Excess: Cancer Screening and the Dangers of Check Box Medicine

A distressing study recently published in the Journal of General Internal Medicine once again demonstrates the remarkable proclivity of the US Health System to subject patients to excessive and harmful testing.
The investigators, led by Dr. David Haggstrom of Indiana University, asked primary care physicians if they would consider colon cancer screening for different types of patients, using patient vignettes.While colon cancer screening is clearly indicated in many patients, in patients with very limited life expectancy, it is much more likely to cause harm than benefit.
Haggstrom included in their vignettes the prototype of a patient who should not receive colon cancer screening:A patient with incurable lung cancer.Looking for a new early stage cancer in a person who already has advanced cancer is absurd.Only bad things can come of this.At a minimum, you are subjecting the patient to the cost and hassle of a test that has zero chance of helping them.At its worst, you are subjecting…

Sport - A Poem on Frailty

An extremely pleasant 89 year old patient of mine has recently been struggling with functional decline.She has developed some new swelling in her ankles and has not been able to get around like she used to.  She is still active and at her most recent visit, she brought in a poem that she wrote with her poetry group. She was flattered that I wanted to post her poem but she did not want me to say anything else about her.The fact that she participates in a poetry group should tell you a lot about the type of thoughtful person she is.
Sport Not jumping broad nor high
Not running fast nor straight
My only sport is reading fate
In dramas now and late 
My body’s strength
Is measured by painful pressure
on delicate vessels a high systolic measure 
Oedipus gave us edema in ankles
While all humans
sport their pulses and crankles 
sport can be used as ridicule
by those who lack the tool
of coordination

There is a tension between respecting frailty and preventing frailty.  One of the recurrent themes of thi…

“A History of the Present Illness”, a New Book by Dr. Louise Aronson

It’s here, it’s here!

Dr. Louise Aronson, a geriatrician here in our division at UCSF, just released her book A History of thePresent Illness last week. It is a series of short stories, many connected by characters like a small gleaming thread through the text. They feature all manner of people—patients, physicians, mothers, children, writers, dog walkers—living their lives in the pocketed landscape of San Francisco. As the title might suggest, illness touches everyone, but the stories are far from uniform or predictable. And lucky us, we could absorb some of the behind the scenes magic when Dr. Aronson read this week from her work at a small event we held in her honor.

Now that it’s in our hands, the pre-release buzz in the air has turned into effusiveness about the communal verdict: it’s stunning. It’s what you hope a book will be: engaging in a can’t-put-it-down way, an effortless read with natural breaks (hey, we’re busy doctors), deeply affecting, and thought-provoking with …