What an unlikely place to find a frontier of medicine, this small doctors' office just off the main elevators of a community hospital in Northeast Washington. Nothing about it commands attention. Not its technology, which is nonexistent. Not its pace, which is incremental. Not its patients, the more reliable of whom show up with ailments written on note paper.
A sign beside the office door lists three names: Kathy S. Brenneman MD. Eleanor S. Stewart MD. Kris E. Kuhn MD.
And after each name, the same line: Geriatric Medicine.
In 1999, this is indeed the uncharted frontier, the outer boundary of a century in which leapfrogging medical advances extended life expectancy by decades. The next century will begin with record numbers of men and women surviving into their eighties, nineties and beyond. By 2040, their ranks will more than triple.
Yet longevity has exposed a sobering fault line. For the first time, chronic disease and disability accompany many through their final years. Such afflictions play poorly in a system geared toward cure more than maintenance, toward intervention over comfort. Failing a seismic shift, billions of dollars could be wasted on misdirected care and lives diminished unnecessarily or prematurely.
"It's the biggest health issue of our time," says Daniel Perry, executive director of the Alliance for Aging Research.
With increasing urgency, the alliance's concerns have been echoed by others. The Institute of Medicine, an arm of the National Academy of Sciences, has focused on geriatric training in and beyond medical school. Last year, a hearing on Capitol Hill warned that there are far too few physicians qualified to treat the geriatric problems soon to arrive in their waiting rooms.
"Too often," John Murphy, a professor at Brown University medical school, told the Senate Special Committee on Aging, "illnesses in older people are misdiagnosed, overlooked or dismissed as the normal process of aging, simply because health care professionals are not trained to recognize how diseases and drugs affect older people."
The cost? For starters, an estimated $20 billion a year in hospital stays for complications from the plethora of medications that elderly patients may be given. Some estimates peg a hip fracture at more than $40,000 for medical and long-term care. Incontinence carries a high price, too; undetected or poorly treated -- which frequently is the case, Murphy noted -- it causes other problems that land people in nursing homes.
"This can translate into needless suffering and unnecessary costs to Medicare from inappropriate hospitalizations, multiple visits to specialists who may order conflicting regimens of treatment and needless nursing home admissions," he testified.
A month in the company of physicians who treat only the elderly -- which is the mission of the geriatricians in Suite 104 of Providence Hospital -- reveals the challenges that will confront more and more doctors. The complexity of diagnoses demands the detective skills of Sherlock Holmes. The labyrinth of emotions requires the compassion of Mother Teresa. At times, the most compassionate care is to help someone let go.
The terrain already is daunting.
It is the 72-year-old man with congestive heart failure, hypertension, diabetes and kidney problems, who returns to Kuhn 21 pounds heavier than he was last month. Slouched in the wheelchair that ferried him from car to examining room, he offers little response to her questions and seems short of breath even while sitting.
Several floors up in a hospital bed, it is the 83-year-old woman with the vacant stare, inaudible whispers and thin feeding tube out a nostril. Her husband waits in the hallway, where the word "Alzheimer's" soon will explain months of confusion and agitation. "There's a man out there to see you," Stewart pushes gently. "Who is that man?"
And across the parking lot at Carroll Manor, the nursing home where each doctor makes rounds, it is the 87-year-old woman who fell 10 days ago and immediately ceased walking. X-rays gave her a clean bill of health, which is why Brenneman is standing cheerfully before her, trying to maneuver around her dementia and coax her back onto house-slippered feet.
There's no debating that other fields enjoy a better image. Surgery is glamorous, radiology lucrative, and pediatrics? Who doesn't love babies? Geriatrics suffers badly by comparison. Dead-end medicine, some say. Doctors Brenneman, Stewart and Kuhn disagree.
"It's really seeing over and over again people whose problems and complaints are simply discarded because they're old, because they're sick, and in a way, they've been given up on," Stewart says.
"Seeing that kind of patient, and then really being able to make a difference, a measurable difference, a difference you can see in how well they function, how long they stay independent, how good they feel. . . ." She takes a breath. "I don't know. That appeals to me."
At times, it all comes down to chicken soup.
"Do you still have friends around you?" Kuhn inquires. "People who can bring you chicken noodle soup?"
The question is directed at an 86-year-old white-haired grandmother, who has arrived with a daughter-in-law. Despite her long and not unimportant medical history (heart, lungs, thyroid, bones), the only thing that matters this instant is the jagged shard of pain cutting through Amelia Sheridan's right side. She is crippled by day, sleepless by night. And because she lives by herself in Florida -- ostensibly she is visiting until she gets better -- going home is a real concern.
"I live alone," she says.
"Are you in a house where you have lived a long time?"
"Yes. Thirty years."
There is a pause. She is sitting on the examining table, looking down more than at Kuhn, and her chin is trembling.
Kuhn waits. "I was just wondering what the tears are about."
"Are you worrying about losing your house?" Not convincingly, Sheridan shakes her head no.
"I'm just a crybaby," she blurts out.
This is whole-body medicine, unlike most. It offers tissues when sadness spills over, and it understands the value of talking about little things. Gardening, for instance, which Kuhn discovers is a shared pastime.
The doctor does not keep her distance, rubbing Sheridan's back and listening at length to the daughter-in-law. Kuhn and her colleagues rarely interrupt during an exam. In contrast, one study concluded that doctors commonly cut off patients at 18 seconds -- the point at which some elderly men and women hardly have collected their thoughts.
Like Brenneman's and Stewart's days, Kuhn's rotate among office, hospital and nursing home. She crouches low beside bed rails to talk at eye level. A stethoscope rides on her left shoulder. Intensity animates her face.
Kuhn, 43, chanced into geriatrics during college, when she joined a group bent on improving nursing homes, and today she finds the perspective of older people more interesting than ever: "There's just a certain rapport that I feel, and a certain joy. . . . It just feels as natural to me as breathing."
Geriatricians hold no monopoly on empathy, of course. Nor are they the sole physicians qualified to care for those older than 65. Internists and family practitioners have amassed decades of on-the-job training, and the good ones look beyond the obvious.
The others do not. They discount aches, dismiss the chance that rehabilitation will do much good. What do you expect at your age? They treat the immediate -- the knee that lands twisted when the 80-year-old widow falls in her kitchen. Harder to fix, and more convenient to ignore within the constraints of a 10-minute appointment, is the problem that tripped her up in the first place.
"You have to give time, a lot more time," and by that Sister Carol Keehan also means the step-by-step written instructions some elderly patients need whenever their pills change; or the undressing assistance they may require for an exam; or the schedule that bends when Mrs. Smith shows up on the wrong day.
For Keehan, the ebullient Providence Hospital president and chief executive officer, it is "a gentle crusade." Medicare covers more than half of Providence's patients, and though its community includes healthy elderly, more are fragile and ailing.
Nancy Dickey, president of the American Medical Association, is optimistic that she and her colleagues will be ready for the advancing geriatric juggernaut. In her view, "medicine is extraordinarily responsive to the marketplace."
But hers seems a minority opinion. Medicine identified geriatrics as a defined field only in 1985. Both the Institute of Medicine and the Alliance for Aging Research say the nation is woefully short of the needed number of primary care physicians with geriatric training. Yet only 14 of the country's 127 medical schools require students to take a course on geriatrics.
"When you understand that every medical school has a required course in pediatrics . . . something is wrong with how we educate doctors," says Sen. Harry M. Reid (D-Nev.), of the committee on aging. "The problems in America are not healthy young kids."
Geriatric medicine is nothing if not surprise and ambiguity.
"It's easy to diagnose someone who's 40 years old with pneumonia," says Brenneman, who is 49. "They say, `I've got a fever, I'm coughing up yellow junk, and my chest hurts.' It doesn't take a rocket scientist to figure that diagnosis."
By contrast, in an elderly person, the only clues may be lethargy and confusion. Similarly, confusion can be the sole signal for anything from depression to dementia to infection. Brenneman, who was a nurse before she was a doctor, enjoys chasing the ambiguity, enjoys the entanglement with both patients and families. In medical school, others told her she was crazy to choose geriatrics. Old people come with so much baggage, her own adviser griped.
Pages of that baggage are hole-punched into thick binders awaiting her attention at Carroll Manor. She and her colleagues care for more than one-third of the nursing home's 240 residents -- assisted, they stress, by a team of nurses, aides, social workers and therapists. That means team paperwork, voluminous records ordered by Uncle Sam on each person.
One page is titled "Problem List," and for one patient, the inventory includes colon cancer, rheumatoid arthritis, mitral fibrillation, hypothyroidism, aortic stenosis, mild cognitive deficit and leg ulcer. Thirteen conditions in all. Thirteen balls for a doctor to juggle.
The goals are always: Maintain independence, maximize function. Brenneman believes absolutely that improvement always is possible, yet her creed carries a caveat of reality. "Improvement may mean a peaceful death."
She starts with the gray binders when she goes on rounds with doctors-in-training. One reads aloud the notes on a resident with Alzheimer's disease, a Cinderella who routinely is out of her room after midnight. "Who does it bother?" Brenneman replies, of no mind to order a sleeping pill. "Is it an issue for her or nursing?"
Modern medicine is largely responsible for this sort of setting, where about 1.5 million men and women live today. Demographers predict that three of every 10 baby boomers surviving to retirement will move into a nursing home at least once. Surveys show that death is more welcome a prospect.
But in this place, where halls may smell of urine and unintelligible cries chill the soul, Brenneman senses spontaneity and resilience. "Look at John's jewelry!" she exclaims as a resident wanders by, resplendent in loop after loop of gold. Her laugh is boisterous and frequent, and it magnifies her physical presence. Others in Washington medical circles consider her a natural leader. Her nine-page curriculum vitae shows that she holds three medical director posts.
For the next few hours, she will travel door to door. "Okay," she says, "let's go find our folks."
Sure, Sweet Victories
When true victories come, they are sure and sweet. They are stories like Richard Gillison, a federal worker who retired at 65 and then drove a cab until he turned 90. He was 98 when Stewart found cancer in his colon. Ignoring his age -- considering more his firm handshake and robust six-foot frame -- she sent him to surgery, where everything went just fine.
Except that in subsequent days, Gillison could not get out of bed. Too weak, said Stewart, who ordered a rehabilitation program. Too old, said his Medicare HMO, which expected him to go to a nursing home.
"This man walked into the hospital," Stewart remembers. "He had limited cancer. He tolerated the operation well. He should be able to walk out."
In the end, the doctor won, and last year, Stewart danced with Gillison at his 100th birthday bash. "I don't think Daddy would have done as well if he hadn't had Dr. Stewart," says a daughter, Barbara Derritt. Gillison talks about living "as long as Moses." Or perhaps it is Methuselah.
Stewart keeps the program from that party on her office wall, and it draws a feel-good smile on rough days. There have been a few this year. In February, her mother-in-law died of Alzheimer's disease. Her own mother now lives with her, and she has Alzheimer's, too. On that devastating road, the talents and capacities of a lifetime slowly are stolen -- taken in reverse order, like a movie being rewound to its beginning.
"Sometimes, your best reward is to help them die better," she says. That too few doctors do is a cruel paradox. First medicine writes off older patients, equating age with disease and decline. Then, at the end, it won't let them go.
She never expected to be at this intersection. In the early '60s, though Stewart excelled in high school science, she had no idea what a woman could do with that, and so she aspired to fame as a writer. It was an in-law, a female family practitioner, who prompted her second career.
Now, at 52, Stewart talks regularly about the end of life. In her white doctor's coat, she guides families as they grapple with wrenching human drama. She makes clear the complications -- and, ultimately, the futility.
"Give her a chance? Save her?" she presses one family. "But save her for what? A chance for what?"
Their mother lies dying, essentially comatose, with organ after organ shutting down. Limbs are contracted from disuse, and a leg has been amputated because of infections. Her feeding tube is failing. Still, her doctors are being told, treat her actively.
"How much are we going to do to her?" Stewart asks. "We're not going to do anything for her. . . . Really and truly, there's a point at which we need to stop and need to ask ourselves, `How many legs are we going to cut off?' "
New Lease on Life
In a month with the physicians of Suite 104, there is humor and humanity and the finality of death, which is not viewed here as failure. Geriatricians are, above all, closers.
And in between are stories like that of Amelia Sheridan, the self-described crybaby. She is recuperating from double surgeries -- for her back, because Kuhn persisted after one neurologist deemed the situation futile, and for her hip, because the relief Sheridan got from the first operation made her realize how much her deteriorated right hip had hurt for years. So, at 86, she replaced it.
She'll need rehabilitation at Carroll Manor, and Kuhn is nudging her toward assisted living after that. But with something of a new lease on life, Sheridan would rather think several steps ahead.
To Florida. To home.
CAPTION: Patient Alice Morgan, 71, gets reassurance from Eleanor Stewart, left, a doctor at Providence Hospital's geriatric office, and Morgan's sister, Vernese Boulware.
CAPTION: Kathy S. Brenneman, who treats the elderly, shares a laugh with Ruth Coleman at Carroll Manor nursing home.
CAPTION: Helen Nielson thinks about a question asked by Kris E. Kuhn, a geriatrics specialist whose rounds take her from her office to a hospital and a nursing home.
CAPTION: Making a house call, geriatrician Henry Wieman tests the flexibility of the fingers of Margaret C. Randall, 92.