The clinic was in a dilapidated old building, yet the entryway retained a worn grandeur. Tapering, semicircular walls extended like welcoming arms, and a half-moon of sidewalk stretched to the quiet side street.
That’s where I first saw her, standing at the curb with her cane propped on her walker, squinting toward the nearby boulevard. The woman was clearly well into her 80s, with a confident demeanor and with clothes and hair that revealed an attention to appearance. She had a cellphone in one hand and seemed to be waiting for a ride.
I had been heading into the clinic for a 4:30 p.m. appointment, and when I came back out, night had fallen. But for her tan winter coat and bright scarf, I might have missed her leaning against the clinic’s curved wall. She still held the cellphone, but now her shoulders were slumped and her hair disheveled by the cold evening breeze.
I hesitated. On one side of town, my elderly mother needed computer help. On the other, our dog needed a walk, dinner had to be cooked and several hours of patient notes and work e-mails required my attention.
I asked this woman whether she was okay. She looked at the ground, lips pursed, and shook her head. “No,” she said. “My ride didn’t come, and I have this thing on my phone that calls a cab, but it sends them to my apartment. I don’t know how to get them here, and I can’t reach my friend.”
She showed me her phone. The battery was now dead. I called for a taxi with my phone. She was tired and cold by then and suddenly seemed frail.
We chatted as we waited. She owned a small business downtown — or she had. She was in the process of retiring, having been unable to do much work in recent months because of illnesses. She’d been hospitalized twice in the past year, she said. Nothing catastrophic, yet somehow after the second stay things had never quite gotten back to normal.
The geriatrician in me noted that she had some trouble hearing, even more difficulty seeing, arthritic fingers and a gait that favored her right side. But her brain was sharp, and she had a terrific sense of humor.
Finally, the cab arrived. The driver watched as I helped her off the curb — a slow process because of her cold-stiffened joints, the walker and our bags — and then he sped away. I stared, dumbfounded, and pulled out my phone to call the company and complain.
“It happens all the time,” the woman said. Just then, a taxi from another company turned the corner. He slowed down for my outstretched hand, but when he saw my companion he, too, screeched off into the night.
It didn’t take a rocket scientist — or even a geriatrician — to figure out why taxis didn’t want to pick up this elderly woman. Doctors and medical practices often invoke the same reasoning: The old move too slowly, making efficiency impossible. And more often than not, there are complications.
“I’ll give you a ride,” I said, having refrained from making the offer until then at least in part because of that uniquely American quandary: What if something happens to her and her relatives sue?
Her face lit up. “Oh, no,” she said. “I couldn’t let you do that.”
It took almost as long to maneuver her into my front seat as it did to get across town. She directed me to an apartment complex on a steep slope. She lived near the top, up flights of steep, poorly lit steps.
I phoned my mother to reschedule and called home to say I’d be late. Getting up the steps was slow going. Along the way, I learned that the woman had been to the podiatrist that afternoon because she could no longer cut her own toenails. I told her I was a geriatrician and discovered that she got all her medical care except podiatry at my medical institution. I knew her primary-care doctor and several of her specialists.
As I wrote in an e-mail to my general internist colleague the next morning, getting the elderly woman “out of my car and up the forty-nine stairs to her apartment took nearly an hour because of her grave debility. She is very weak, has audible bone-on-bone arthritis in all major joints, frequent spasms in her left hip, minimal clearance of her right foot and could not move her left foot; I basically had to hoist her.” I had no idea how she ever made it up the steps unassisted and couldn’t imagine how long it might take when she did.
During the slow climb, she told me a bit about herself: several romances but no children; most of her friends were also old and ill, so she didn’t see them that much; she had lived in the same apartment since the early 1970s, loved it, and would never live anywhere else. She also said she had a blood cancer that hopefully was cured, asthma, some kind of heart problem and both glaucoma and macular degeneration. After a recent hospitalization for pneumonia, she had been sent to a local nursing home and said she would rather die than go there again.
I helped her settle into her apartment, and before I left asked the woman if I could contact her doctor and look at her medical records, with an eye toward making some recommendations to help improve her function and well-being. She agreed.
When I logged into her electronic record the next morning, it showed how sometimes, despite best efforts, our health-care system undermines both patients and clinicians.
The elderly woman had made 30 visits to our medical center in the previous year. This included nine ophthalmology appointments, five radiology studies, four appointments with her lung doctor, four visits to the incontinence clinic, three appointments with her cancer doctor, two emergency department visits and one appointment each with her cardiologist, a nurse in the oncology clinic and her primary-care doctor. She was taking 17 medications prescribed by at least five physicians.
The notes in the woman’s chart revealed clinicians providing thorough, evidence-based evaluation and treatment of the issue or organ system in which they specialized. The notes made it clear her doctors and nurses knew their patient, seemed to care about her and were applying all of their considerable expertise on her behalf. Unfortunately, their expertise didn’t include any of the skills that would have addressed what were clearly her most pressing needs.
Several notes hinted at what I saw as we had slowly climbed the steps to her apartment. They documented terrible arthritic pain, significant mobility issues and ongoing transportation problems. One physician commented that she “does not walk much in her own apartment but does utilize a walker. Often, however, she is semi chair bound.” Despite these important observations, none of the clinicians had evaluated her joints and gait, done a functional assessment, treated her pain or referred her to either a social worker or another clinician who might address these crucial needs.
Equally significant were the problems that no one mentioned. No physician commented on the number of doctors the woman had or visits she made, both of which might reasonably raise questions about fragmented care and the need for care coordination. Nor did any of her clinicians address her use of a very long list of medications, a situation associated with adverse drug reactions and bad outcomes including falls, hospitalization and death.
Finally, and particularly remarkable for a woman in her 80s with multiple medical problems and no immediate family, no one had documented her life priorities and goals of care, or who she would want to make medical decisions on her behalf if she were unable to do so herself.
After exchanging e-mails with her primary doctor, I called the woman. She wasn’t nearly as concerned about her medical care as I was. She liked her doctors and, as is the case with many people, seemed to take for granted that each body part required its own specialist. It also became clear that her medical visits served an important social purpose. When I mentioned that she could get her toenails trimmed by a home-visit podiatrist instead of making bimonthly trips to the clinic where we had met, she exclaimed, “But I’ve been going there for years. And they’re so nice to me!”
I gently asked whether she had ever considered moving to someplace on flatter terrain, without stairs, and closer to shops. Assisted living, if she could afford it, would provide those advantages plus cleaning services, meals and a built-in social network.
“The only way I’m leaving here,” she said, “is feet first.”
I didn’t press her. The apartment had been her home for decades, and anywhere she moved would be many times the cost of her 1970s-era, rent-controlled apartment. What she wanted most was someone who would help her maximize her health and function so she could continue in the life and home she had created for herself.
Before hanging up, I asked whether I could put her on the wait list for our geriatrics practice. A geriatrician would manage her diseases as her previous doctors had, but he or she also would begin by establishing her life and health priorities, address her function and transportation challenges, review her medications and appointments to see whether all were truly necessary, and be available by phone or to make home visits.
She was silent for a moment. Then she said, “That sounds too good to be true!”
I know most of the woman’s doctors. Each one is compassionate, smart and dedicated. Indeed, her diseases were largely under good control. Yet her health was declining, she was missing appointments and she was less and less able to care for herself and her apartment. Several of her clinicians recognized this, but none took action. This was not because of personal or professional failings. Their actions — and inaction — were the inevitable result of their medical training and our medical system’s sometimes myopic focus on medicine at the expense of health.
Medical education prioritizes the same specialties today as it did a century ago, when life expectancy in the United States hovered around 50 and when tuberculosis and childbirth were among the leading killers. People in their eighth, ninth and 10th decades are as dissimilar, physiologically and socially, from middle-aged adults as children are, yet while all medical students learn pediatrics and adult medicine, there are no universal requirements for geriatrics training. This makes no sense demographically or medically.
There are 48 times more octogenarians now than there were in the first half of the last century, and older patients are the age group most likely to be harmed by medical care.
At her first visit to the geriatrics practice, the woman made clear that arthritis and pain were her biggest problems, so she received steroid injections in her two most painful joints and a pain medication safe for older adults. Her specialists previously had noted that her blood pressure was quite high. It turned out she wasn’t taking several medications because she hadn’t been able to get to the pharmacy for them. The geriatrician arranged for home delivery from the pharmacy and also took her off several medications that at her age were no longer necessary or recommended.
The geriatrician also learned that on days when the woman couldn’t manage her stairs at all, getting to the medical center was outrageously costly: She had to pay taxi drivers $3 dollar per step to carry her first down and later back up the steps to her apartment. Since there were 49 steps, this meant $147 each way, not including the fare for the ride itself. Fortunately, from now on she wouldn’t need to visit the medical center as often, since the geriatrician and other caregivers could treat her incontinence, stable lung disease and other chronic conditions, and monitor her for cancer recurrence, during home visits. With the money she saved on transportation, she could hire more help at home.
Nearly three years later, the woman is looking forward to her 90th birthday. She is frailer than when I first met her, but she has remained out of the hospital, out of nursing homes and in her beloved apartment.
Those who argue that health care consists primarily of prescriptions and procedures, or treatment of body parts and diseases, have created a system that prioritizes medicine to the detriment of patient health. It’s time we took a broader view of health care, one that puts the well-being of patients first and trains and rewards clinicians who work with patients, caregivers, and other health professionals to achieve that goal.
Aronson is an associate professor of medicine at the University of California at San Francisco, where she directs the Northern California Geriatrics Education Center. This article was excerpted from the Narrative Matters section of the journal Health Affairs and can be read in full at http://content.healthaffairs.org/content/34/3/528.full.
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