I was forwarded an email containing the following article that I find so interesting as we prepare for the Silver Tsunami in Singapore...
Op-Ed Contributor
The Patients Doctors Don’t Know
By ROSANNE M. LEIPZIG
AS they do every July, hospitals across America are welcoming new interns,
fresh from medical school graduation. Given how much these trainees have
yet to learn, common wisdom holds that it’s not a good time of year to get
sick. This may be particularly true for older patients, because American
medical schools require no training in geriatric medicine.
Often even experienced doctors are unaware that 80-year-olds are not the
same as 50-year-olds. Pneumonia in a 50-year-old causes fever, cough and
difficulty breathing; an 80-year-old with the same illness may have none of
these symptoms, but just seem “not herself” confused and unsteady, unable
to get out of bed.
She may end up in a hospital, where a doctor prescribes a dose of
antibiotic that would be right for a woman in her 50s, but is twice as much
as an 80-year-old patient should get, and so she develops kidney failure,
and grows weaker and more confused. In her confusion, she pulls the tube
from her arm and the catheter from her bladder.
Instead of re-evaluating whether the tubes are needed, her doctor then asks
the nurses to tie her arms to the bed so she won’t hurt herself. This only
increases her agitation and keeps her bed-bound, causing her to lose muscle
and bone mass. Eventually, she recovers from the pneumonia and her mind is
clearer, so she’s considered ready for discharge but she is no longer the
woman she was before her illness. She’s more frail, and needs help with
walking, bathing and daily chores.
This shouldn’t happen. All medical students are required to have clinical
experiences in pediatrics and obstetrics, even though after they graduate
most will never treat a child or deliver a baby. Yet there is no
requirement for any clinical training in geriatrics, even though patients
65 and older account for 32 percent of the average doctor’s workload in
surgical care and 43 percent in medical specialty care, and they make up 48
percent of all inpatient hospital days. Medicare, the national health
insurance for people 65 and older, contributes more than $8 billion a year
to support residency training, yet it does not require that part of that
training focus on the unique health care needs of older adults.
Medicare beneficiaries receive care from doctors who may not have been
taught that heart attacks in octogenarians usually present without chest
pain, or that confusion can be due to bladder infections, heart attacks or
Benadryl. They do not routinely check for memory problems, or know which
community resources can help these patients manage their conditions.
They’re uncomfortable discussing goals of care, and recommend screening
tests and treatments to patients who are not going to live long enough to
reap the benefits.
I was part of a group of doctors and medical educators who recently
published in the journal Academic Medicine a set of minimum abilities that
every medical student should demonstrate before graduating and caring for
elderly patients. Nicknamed the “don’t kill Granny” list, it includes being
able to prescribe medicines, assess patients’ ability to care for
themselves, recognize atypical presentations of common diseases, prevent
falls, recognize the hazards of hospitalization and decide on treatments
based on elderly patients’ prognosis and their personal preferences.
The 2008 Institute of Medicine report “Retooling for an Aging America”
resolved that all licensed health care professionals should be required to
demonstrate such competence in the care of older adults. But this
resolution lacks teeth. Medical resident training programs that receive
Medicare money should be required to demonstrate that their trainees are
competent in geriatric care. Medicare should finance medical training in
nursing homes. And state licensing and medical specialty boards should
require demonstration of geriatric competence for licensing and
certification.
Basic geriatric knowledge is preventive medicine. Nurses, social workers,
pharmacists and other health care professionals should have it, too, in
order to improve care for older people. But until doctors get this basic
training, we can’t even begin to give 80-year-olds the care they need.
Rosanne M. Leipzig, a physician, is a professor at Mount Sinai School of
Medicine.
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