The Geriatrician

Do I need an Implantable cardioverter-defibrillator (ICD)?

2011-11-08T09:20:00.000-05:00

What is an Implantable cardioverter-defibrillator anyway? Can I get it shut off? These are the type of questions I get. (BTW I tend to blog in spurts).

So here is the context: A 92 year old male patient of mine with metastatic melanoma, end stage (class 3, stage d) heart failure, recent fall with (a minor) hip fracture came to see me in the office. He had just had an ICD placed in July. This guy's main complaints were: he wants ear wax out so he can hear, he wants to stop urinating at night, he wants to sleep better at night, he wanted to be less short of breath, and stay at home with his wife. He had been hospitalized 5 times in 4 months for CHF and Oncology decided that his melanoma was only treatable with chemotherapy.

Question: What good is an ICD for this guy? This guy wants to avoid surgeries, being debilitated, lingering in pain and ICU's. He does not want aggressive care. If he could choose a way to die, he would like to die peacefully in his sleep. He wants to die in the hospital to avoid stressing out his family but does not want to end up in the ICU.

So what does an ICD do? Well just as a person is about to die peacefully in their sleep, or about to faint, lose consciousness and die painlessly, a large electrical shock wakes them up painfully and restarts their heart. Well for me, I would love that because I have no desire to die in my sleep. But for an older patient that is looking at dying from cancer vs heart failure vs consequences of immobility vs dying peacefully in his sleep, it's easy to see why he picked dying in his sleep painlessly, without being short of breath as his preferred way of dying. BUT an ICD is designed to prevent that specific way of dying.

The other thing to note is that the ICD often has false electrical shocks (of which this guy has had one), does not prevent death in all circumstances (asystole or when the heart stops altogether) and if you were to calculate a NNT (number needed to treat) it would likely be in the teens to 20's somewhere. In other words, it does not help the majority of people, and in those it helps, it likely delays death by months instead of preventing it altogether (kinda obvious but needs to be stated anyway), and it works by preventing what is likely the most peaceful way of dying.

Again, if you are a 45 year old person with a passion for life, a tolerance for medical procedures, then go for it. If you are looking at several ways of dying from various medical problems, many of which would cause suffering, then one needs to carefully consider not having an ICD placed which is designed to prevent the most peaceful way of dying I can think of.

Communicating to physicians goals of care

2011-08-02T10:27:00.001-04:00

Goals of care worksheet.

In geriatrics, there are so many issues to consider before deciding what is best for a patient. Nothing is more important than the goals that a patient defines for himself. While the effectiveness of treatments change as a person ages, and social situations and other medical problems can affect what is best, achieving a patient's goals should be the primary aim of a medical plan. The goals may vary based on what type of medical interventions a patient can tolerate, whether they want to live longer vs more comfortably.

The link is to a worksheet that I wrote that I hope will help people communicate goals to their physicians. The concern is that physicians can look at an older person and make two really wrong assumptions: that a older person is too old for certain interventions or that they should be treated like a 45 year old. Neither is right. A person should receive a treatment that is appropriate and that largely depends on what they want and their goals.

Edit:
Two things missing that have been suggested: spiritual beliefs and some sort of question about where a person, ideally, would like to spend their last days.

So what does it mean to "be a doctor."

2011-07-03T07:59:00.003-04:00

Edit:Please read the first part too!

Continuing with my last post on some non geriatric thoughts, the author of the NYtimes commentary told a medical student that if she wanted to be a doctor, she should just "be a doctor" implying that caring about a family life may not be compatible with being a doctor. Or at least her image of being a doctor. So it got me thinking, how would this author define "being a doctor?" I think her commentary raises more questions than answer.

My main question is what is the metric of a "being a doctor." How does one know that he is "a doctor."
1. Is it the number of hours per week? Is it 20, 30, 40, 60, 80, 120? Clearly for the author, 20 is not being a real doctor. But how does she draw the line?

2. Is it how many nights per week one takes call? She thinks you have to risk some interruption. How much is enough? Once a week, every night or something inbetween?

3. How many patients per hour does it take to be a real doctor? Apparently in her opinion, you have to see as many as men do. But why is that the metric? Is it 4 patients per hour or 12?

4. Other questions: Does a real doctor have to teach? Do research? Publish? Go to conferences?

At what point does caring about your personal life make you cease being a real doctor? Does she set no limits at all? If she does, how does she define herself as being a real doctor?

5. How many years should a real doctor work? In a medical school setting, we've all met docs in their 80's who have no desire to retire. Is that what real doctors do? (WWRDD-what would real doctor do?). Is it wrong for someone in their thirties decide to be doctor if their careers are shorter? How about in their 40's or 50's even?

6. How much vacation can a doctor take? As you can see, the questions become one of bravado: I work harder than you, that makes me more of a real doctor? Which specialties are real doctors? If you are a pathologist and never take call, are you a real doctor?

At the end of the day, I think the crux of the matter is that if by putting your personal life first, and by doing so you practice medicine in such a way to put patients at risk of bad outcomes, or you don't even care about the quality of medicine you are practicing as long as it fits your lifestyle, then you need to consider stopping the practice of medicine. That's unfair to patients. But if you take your job seriously, make sure your patient are well taken care of, your patients are satisfied and you practice good quality medicine, then you are "a doctor."

Being a physician isn't easy.

2011-06-17T22:04:00.004-04:00

Here's an article from the NYtimes.

While this doesn't have much to do with geriatrics, I thought I'd weigh in. The premise of this article is that since medical school and residency are subsidized by the states and the federal gov't through Medicare, there is a social obligation for physicians to serve the greater good and put the good of society above individual goals such as family and lifestyle. This is especially true in primary care specialties. And since women are the dominant subgroup of physicians who work part time, women ought to be ashamed of themselves for being so selfish. So says the anesthesiologist who clearly didn't care to meet the primary care needs in the country herself despite her subsidized education. For the sake of brevity, I'll make my points in a list:

1. It is not the job of women medical students to shoulder the burden of the primary care shortage in the US. Physicians should not have to (and I would argue can not) make up for major shifts in specialty choice driven by economics, public policy, the health insurance landscape and specialists like anesthesiologists.

2. Medical school is no more subsidized than any other public school education. Going to a public school is a benefit by working people paying taxes (of which doctors will pay a lot). No one expects those who go to public universities to enter public service in other fields and expecting that in medicine makes no sense. Why not ask it of lawyers? Or MBA types?

3. While residency is subsidized by the government through medicare, I would argue that the residents themselves subsidize their own education by taking a low salary while working long hours and sacrificing much in their personal lives. While the government does subsidize graduate medical education, they also set the rules that resident physicians (who are licensed physicians) can not bill for their services. So the subsidy is really just another way of paying a salary that is justly earned. If the subsidy goes away, then resident physicians ought to be able to bill for their services.

4. Part time women physicians bring incredible balance, perspective, talents to the physician work force that would not be there otherwise. If it was mandated that all physicians had to serve full time for 10 years after residency, I would think that the percent of women physicians would drop and medicine would be far worse off because of that.

5. It is too easy to look at physicians who work less than you and criticize their lack of dedication. As someone who worked as a solo doc, on call 24/7, seeing my patients 7 days a week in the hospital, I could be critical of a shift working anesthesiologist who hands off patients to other docs. How dare she think that transitioning patients between docs is good care? Where is her dedication? Doctors have to quit trying to guess each other's motives and just judge the quality of medicine that is practiced.

6. I would argue that having a healthy private family life is good for professional life.

7. Notice that there is no critique of the quality of part time physicians. If patients want a full time physician then they can select one. If they are satisfied with a part time physician, then where is the harm?

8. Students already graduate with $150,000 debt (average) which grows during residency. This is the reason that out of 20-25,000 medical students, only 90 choose geriatrics. Saying that medicals students are not appreciative of their subsidized education is incredibly insensitive to students who choose not to be anesthesiologist who make 3-4 times what a geriatrician makes ($100,000 to 150,000).

9. The shortage of doctors in this country is a problem of public policy, medical education, not women physician who choose to work part time. Why are women to be blamed for this instead of the men?

10. How is working full time her only metric of what it means to be a good doctor? She has defined it so that she meets the definition and other women don't. But what is she doing to correct the primary care shortage, health care discrepancies, deal with the underserved? No offense to my anesthesiology colleagues, but when I used to round in the hospital seven days a week, go to my office afterwards for a full day of clinic five days a week, go to football games on Friday nights, work in the ER one shift a week, do 200-300 physicals at the elementary and high school once a semester, teach about smoking to 4th graders, do home visits during lunch, attend deliveries at night, see my nursing home patients once a month, work as a medical director of a nursing home and hospice, teach PA students in my office, I felt more like a doctor than the anesthesiologist who worked half my hours but was still "full time." Yet somehow this anesthesiologist sees herself as enough of an ideal doctor to look down on others. Sigh...... I won't even mention some of my doctor friends who are working in rural third world countries. My work pales in comparison to their dedication.

At the end of the day, being a doctor isn't easy. The training asks for enough sacrifices on its own. It's too easy for a doc to criticize anyone working less than them as being lazy and anyone working harder than them as being a workaholic. I knew a doc who said his patients came before his wife. She would get hospitalized for overdoses a couple times a year but he felt if you didn't put your patients first, you weren't a real doctor. I knew another doc who felt if your office wasn't your house (i.e. work downstairs, live upstairs), you weren't a real doctor. This crazy machismo competition has got to end. At the end, if we practice good quality medicine, we should be proud whether it is a little bit or a lot. Just doing that is hard enough.

so much for brevity

Should I start dialysis? Should I stop dialysis?

2011-06-15T08:20:00.000-04:00

Over the last week, this issue has come up three times. One of my office patients who's chronic kidney disease (CKD) is at stage 4-5 (1 being least severe, 5 being the worst) decided not to proceed with dialysis. One patient in the NH decided to stop dialysis and another in the NH (nursing home) had not been on dialysis ever. All had stage 5 CKD. In all three situations, after a very careful family discussion, the decision was made against pursuing dialysis. Obviously, this is a big decision.

So what does dialysis do and why do people need it? The short version is that dialysis takes over the functions of failing kidneys: getting rid of excess potassium, excess fluid and general toxins.

What is involved in starting dialysis? First you need access because it is a blood filter machine. So either a port placed in the chest that sticks out, an artificial graft placed in the arm or a modification to the bodies own vessels called a fistula in the arm. Then usually, three times a week one would go to a dialysis center for 3-4 hours to get the blood filtered. More is involved than this, but this is the short version.

What happens if you are on dialysis? Well it can be very tiring, there can be complications such as nausea, bleeding, infection, clotting of the graft/fistula/port. It is almost always lifetime unless someone gets a kidney transplant.

What happens if you don't do dialysis? Well this is what is interesting. Many people do just fine. Even with the most severe cases of CKD. It depends, if someone is initiating dialysis because they have had recurrent episodes of being fluid overloaded, having a high potassium or being confused then they will not do so well without dialysis. But if a patient is stable and is just being told to do dialysis to be safe, we're learning that older patients may do okay without dialysis for years.

Discussion:
Without any question, dialysis is a life saving measure. It can extend life in most people. In some who have complications, it can shorten life just like any other medical procedure that goes wrong. It has been studied that older adults who initiate dialysis tend to decline in function over time. Not necessarily more rapidly or less rapidly than those who do not do dialysis, but needing dialysis is a sign of frailty that starting dialysis will not reverse. In other words, dialysis will not help somebody gain function that they have lost. It will not get someone back to how they were before even if that is 3 months before. (Generally speaking). There is more and more discussion among physicians and older adults about not starting dialysis and using watchful waiting in the meantime. For those who do not need dialysis, it is certainly an option to just watch it, knowing that there is some risk involved in doing so.

Here's a good article to read.

A guide to making health decisons

2011-06-12T21:50:00.000-04:00

For the average patient, navigating the health care system can be daunting, intimidating, and frustrating. For those who are caregivers of older patients, you add feelings of intense guilt, burden and regret sometimes. And for those who are unexpected decision makes, it can be overwhelming. Full code or no code? Which nursing home? How to manage finances? Which medications? What would my loved one want? etc.

I plan on writing a guide for health care decision-makers/caregivers to help navigate a variety of contexts: the office visit, hospital, nursing home, hospice as well as specific decisions such as: is this the right diagnosis; should I start/stop a medication; is a surgery necessary, feeding tubes, code status.

I will tell a story of a patient of mine. I have a young 50+ year old female who went into the hospital for a wound. She has no dementia, lives independently with a caregiver. She makes her own decisions. Other than being mostly a quadriplegic, she is healthy. Somehow, while in the hospital, her surgeon told her that her albumin was low, she was malnourished and unless she got a PEG tube, her wound would never heal. She eats normally, has no swallowing problems and is a very compliant/adherent patient who has great understanding of her health issues. Against her gut feeling, she let them put it in and came to my nursing home for rehab. I was very surprised to see her with a PEG tube because she definitely does not need it. As she told me the story I had a sinking feeling that I should have intervened. Unfortunately I did not know that she was asked to make this decision. Two problems with story, 1 medical, 1 relational-

The medical objection is to the surgeon's assumption that a low albumin reflects malnutrition causing a wound which can be corrected by PEG tube feeds better than oral feeds. First, the patient is not malnourished. Albumin has nothing to do with nutrition. There is no reason to think that a can of Boost via PEG three times a day is any better than a can of boost ingested orally.

The relational objection is that the surgeon did not take the time to explain to the patient to her level of satisfaction why the PEG was necessary. The truth is that he would not have been able to do so because it wasn't necessary but no attempt was made.

So what is the patient supposed to do? Gut feeling was that this was an unnecessary procedure, but how is she going to disagree with her surgeon? First, she could have involved her primary care doctor (me) and asked the surgeon to call me. She could have insisted on a consult with a GI doctor. She could have picked a doctor who cared about answering questions and making sure that decisions were made collaboratively.

When it is a caregiver making decisions, I think the dynamics can be even more complicated. Does the physician involve both the caregiver and the patient in a collaborative relationship? How does the caregiver balance risk vs benefit? What happens if the patient gave unclear instructions?

I hope to give somewhat of a guide with questions caregivers should ask in different settings, answers to listen for and statements to make that will communicate wishes clearly to physicians. I'll give it a go!

I really dislike medical billing

2011-06-10T12:52:00.000-04:00

I have to confess, I have been sent to collections once. It happened after my wife was in a motor vehicle accident. She went to the hospital by ambulance to get checked out because she had some back and neck pain. Afterwards, we got bills from the ambulance, ER physician, hospital, radiologist and lab (all separate). Somehow I lost track of one and a year later, I got a notice from a collections agency. Out of the 5 entities, 4 got the insurance info I had presented at registration in the ER but one did not. sigh.....

So recently, my son was born. Of course he has no existing insurance until he gets added. The pediatrician and obstetrician who did the circumcision accidentally billed it under me and my insurance ID which promptly got rejected by the insurance company. In order to correct it, I called the insurance company and the biller for each physician. Not my mistake but my mess to clean up. I hate that.

The problem is that billing is a pain for physicians to. I have to keep track of medicare guidelines that care about how many review of systems I ask patients about. So instead of saying to a patient, is there anything that is bothering you? Anything else? (like a normal person may), I have to say, do you have any fevers, loss of appetite, diarrhea, burning when you pee, chest pain, shortness of breath (ideally 2 points from 10 organ systems). The person is obligated to say, no, no, no, no, no, I would have said something, no, no, no. All this to be compliant and not be accused of medicare fraud.

Somehow the billing system works for neither patients nor physicians. Nothing in health care reform every addresses that.

Red Yeast Rice

2011-06-07T08:02:00.000-04:00

I was asked recently about red yeast rice. This is what I wrote:
I do recommend Red Yeast Rice. It does lower cholesterol in small trials. Here's an example of one:

BACKGROUND: We examined the cholesterol-lowering effects of a proprietary Chinese red-yeast-rice supplement in an American population consuming a diet similar to the American Heart Association Step I diet using a double-blind, placebo-controlled, prospectively randomized 12-wk controlled trial at a university research center.

OBJECTIVE: We evaluated the lipid-lowering effects of this red-yeast-rice dietary supplement in US adults separate from effects of diet alone.DESIGN: Eighty-three healthy subjects (46 men and 37 women aged 34-78 y) with hyperlipidemia [total cholesterol, 5.28-8.74 mmol/L (204-338 mg/dL); LDL cholesterol, 3.31-7.16 mmol/L (128-277 mg/dL); triacylglycerol, 0.62-2.78 mmol/L (55-246 mg/dL); and HDL cholesterol 0.78-2.46 mmol/L (30-95 mg/dL)]who were not being treated with lipid-lowering drugs participated. Subjects were treated with red yeast rice (2.4 g/d) or placebo and instructed to consume a diet providing 30% of energy from fat,<10% from saturated fat, and<300 mg cholesterol daily. Main outcome measures were total cholesterol, total triacylglycerol, and HDL and LDL cholesterol measured at weeks 8, 9, 11, and 12.

RESULTS: Total cholesterol concentrations decreased significantly between baseline and 8 wk in the red-yeast-rice-treated group compared with the placebo-treated group [(x+/-SD) 6.57+/-0.93 mmol/L (254+/-36 mg/dL) to 5.38+/-0.80 mmol/L (208+/-31 mg/dL); P<0.001]. LDL cholesterol and total triacylglycerol were also reduced with the supplement. HDL cholesterol did not change significantly.

CONCLUSIONS: Red yeast rice significantly reduces total cholesterol, LDL cholesterol, and total triacylglycerol concentrations compared with placebo and provides a new, novel, food-based approach to lowering cholesterol in the general population.
(PMID 9989685)

So it works in populations. There are three questions
1. Does the lowering of cholesterol lead to lower heart attacks and strokes like statins? Zetia for example may possibly lower cholesterol without preventing heart attacks and strokes. So while it does lower cholesterol, in reality that isn't the goal.
2. How does one know that the red yeast rice obtained is of equal quality to that found in studies?
3. What are long term safety issues?

These are the same questions of any herbal/alternative/complementary supplement.

It's worth considering using Red Yeast Rice because not everyone tolerate statins. And it can be used with statins possibly (it does possibly work by blocking the same enzyme in the liver however).

Does Aricept work? yes/no/maybe so

2011-05-30T18:38:00.000-04:00

So this is my favorite picture from any study I've ever read on the treatment of dementia. This study is from Mass General's NIH funded Dementia/Memory center. Published in 2008 in the Alzheimer's Disease Associations journal, it is a publication of their longitudinal data. In academic terms, this is a retrospective historical cohort control study looking at three groups: Placebo, Aricept only and Aricept plus Namenda. (cohort=group of people) All prospective, placebo controlled trials that are of decent quality are less than 2 years in length, and all but about 4-5 are a year or less in length. So for this chronic disease, we have very little data about the benefits/harms of using the 4 FDA approved dementia meds long term. This study attempts to answer this question using the best data available.

So on to this study. This picture is from Mass General's decades long database of patient info. The top picture is the placebo group, the middle one is Aricept only and the last one is Aricept plus Namenda. What is being measured is cognition (Blessed Dementia Scale) where the higher the number the greater the impairment. The dark line going across each graph is the line of best fit or approximately the average of each group. The flatter the line, the more preserved the cognitive ability. Each little line with dots is an individual person.

The punch line from the study is that this is the longest cohort controlled data published to date (2008) and not only does it confirm a benefit to medications, but an increasing benefit over time. Let's look at this....

So does Aricept and Namenda work?

1. Yes: In this study you can see that the dark line in the bottom picture (Aricept+Namenda) is flatter than the dark line in the top picture (Placebo). This is consistent with almost every placebo controlled study. By the time you get to the end of the study, the group on treatment has an overall/average score that is better than the placebo group.

2. No (You'd never know part 1): If every patient achieved that average score for the population, you would likely never know the difference. If one person worsened by 6 points (out of 36) on placebo but another person worsened by 4 points, you'd be hard pressed to figure out who kept two of their points. While these results are statistically significant, clinically, very difficult to tell. This picture is also seen when looking at function (Activities of daily living) or any other measure of Alzheimer's. Average benefit is incredibly difficult to tell without looking through the magnifying glass of a researcher.

2. No (You'd never know part 2): But every patient does not achieve the average benefit. That should be clear from the chaos of the light lines connected by dots. There is an incredible variation of the course of dementia whether on treatment or off treatment. Patients improve, stabilize and decline whether they are on treatment or not. Trying to compare how a patient is doing compared on treatment to guessing how they would have done off off treatment to measure effectiveness for an individual patient is futile because you just never know. Regardless of group, you can see in this picture that for any specific individual patient, you can see a matching patient in another group. In other words, a stabilization of MMSE, a decline of only 1 point per year, an improvement of 1 point per year, an improvement in ADL's can all come out of any group.

3. Maybe so: So does it work? The answer is maybe. But you'd never know. It is clear these drugs have an effect in populations, that the response is incredibly variable. They may really work. For a very small proportion, they may work really really well and those improvements may be masked in groups of people. But it should be clear that the average person benefits little or not at all. So why do most people feel that these drugs do nothing? An incredibly variable response which is very very small leaves a lot of us thinking that these medications don't seem to be doing anything most of the time. It's just so hard to tell.

Conclusion
Would I take it if I started with mild dementia? Yes, if I were healthy, were on minimal medications, did not have to sacrifice anything to afford it and most importantly had zero side effects from the meds. Also, I'd want to have a decent quality of life (personally meaning that I could communicate and not be in a lot of pain)

Second conclusion: Be very wary of any treatment of dementia that says it works and publishes their average data between two groups of people. The skeptic in me would want to ask: 1. how would I know if it is working so I can stop it if it is not working? 2. What is the exact benefit and what proportion of people achieve that benefit.

What is the purpose of hospice?

2011-05-16T07:46:00.002-04:00

Whether or not to be on hospice can be an incredibly emotional, gut wrenching, contentious decision. This is something I'll discuss with patients on a weekly basis whether in my office, nursing home, or hospital. In surveys of some populations, the vast majority of people with a hypothetical terminal illness would want palliative (or comfort) oriented care but in the same survey would reject hospice services which aims to provide that type of care. Why? Somehow, hospice services are seen as something negative. People fear that hospice means that everyone has given up, they will be left to die alone, they are being told they have less than 6 months to live, that they are being abandoned.

Having been a hospice director (but no longer at my current job) and working with dozens of hospice agencies (both for profit and not for profit), I know there is a lot of confusion as to what hospice is supposed to be.

There are several types of patients that sign on to hospice and you will note very different goals.
1. The patient who is actively dying. This patient has less than a week to live. Has already started the dying process of multi-organ failure, low blood pressure, low heart rate, coma, kidney failure, cessation of eating/drinking etc. Hospice is used to help make the dying process comfortable. Possibly at home.
2. The patient who is sick and tired of doctors/therapeutic interventions such as ICU's, intubation, ER visits and wants to be left alone. This patient wants to have quality of life maximized without invasive procedures.
3. The patient who has a very short life expectancy (i.e. < 6 months) who still wants to live as long as possible but has some patient preferred limits (i.e. no intubation) and/or doctor limits (chemotherapy/dialysis is no longer effective as an option). The difference between the last two is that the last patient may still want options that the doctors are no longer offering. The limits on care options are due to the severity of the illness, not the patient's preferences. One contentious issue is ED visits/hospitalizations/Codes. Some patients may still want this even when it is ineffective. One very real example is that a true code in nursing home (where the patient is found without a pulse and not breathing) is 100% fatal situation. Yet it is not uncommon to find half of nursing home patients as full code. Hospice is an easy answer to patients #1 and #2, but can be very upsetting to those who are patient #3. Patients in the last category feel that options are being taken away that they still want (everything from blood draws to xrays, to ER visits, ICU care etc). Ideally, hospice could be flexible for patients in this last category, continuing to provide patient centered education while allowing the patient the dignity of directing their own care. However I find this is often not the case and why hospice has such a bad name. Often hospice nurses, in the name of improving quality of life, will dictate goals of care TO the patient, set limits on what options are considered available regardless of patient wishes and fail to let patients direct their own care. As the proportion of patients being referred to hospice reflects an increasing diversity of goals, this type of management will fail and offend many. (i.e. Palin's death panels). Hospice agencies used to dealing with patient #1 and #2 will need to increase flexibility to help those in category #3. So far many haven't. In this case, ideally the primary care physician will be able to ~~medicate~~ mediate between hospice and the patient, advocating for the patient and ensuring the patient gets the care that they want.

Being a solo doc

2011-04-04T08:52:00.000-04:00

Here's a fun article from the NYtimes. It made me think of the following.

Coming out of family medicine residency the last thing I ever thought I would do would be solo practice primary care. But since my wife matched for her residency at Geisinger, at 28, I ended up being a solo doc in a town of 950 about a half hour southwest of Wilkes Barre, PA. I never thought I'd love it as much as I did and I actually found the work easier. Instead of being on call for thousands of patients that were not mine, every patient that called at night I already knew. Knowing that they would reach me directly anytime and that they could see me the next day always, I found patients respected my time at night and I rarely got called. I also made sure I finished all my work each day so I wouldn't get called.

When patients showed up at the hospital, I already knew them. I didn't have to spend an hour getting a complete history and physical because I already knew them in the office. I rounded 7 days a week and always knew what was going on. When I took care of patients in the nursing home, I didn't have to wade through tons of medical records to find out what went wrong because I was the hospital doc too. I made home visits, went to the football games and went to deliveries. I didn't have to come in every morning spending time figuring out what happened over night or over the weekend because I had taken care of everything already.

Now I am at the University of Pennsylvania. When I'm on call, I get paged constantly. It takes me a lot longer to figure out what is going on. Patients are faceless on the other end of a phone line. When I'm not on call, I have to figure out what happened to all my patients. I'm only on call less however. Much less. My wife appreciates that. I do get weekends off.

I do miss taking care of patients that are all mine. I miss the relationships. Anonymous medicine is unlikely to produce higher quality medicine. There's no passing the buck when you're solo. You take care of things right the first time and you clean up your own mistakes. My salary was half to 1/3 of my ER buddies, derm, ophtho, anesthesiology, radiology friends. But my patients were better friends. (even on facebook!). The only thing I missed was having an opportunity to work with medical students and residents.

Solo practice is really enjoyable. It is sad to me to see that it is likely to go away.

I love being a geriatrician!

2011-02-08T12:50:00.000-05:00

What a great article!

Unfortunately despite the growing need for geriatrics in every way (patient care, cost effectiveness etc), fewer and fewer students go into geriatrics.

Out of 18,665 students who graduate each year from US medical schools, 90 go into geriatrics eventually.

Medical homes are not policies but persons.

2011-01-23T16:30:00.000-05:00

It's interesting for me to read about the policy push for medical homes on the state and federal level. As a previous solo practice primary care doctor in a town of 950, a lot of what is described feels a lot like what I was doing and many other physicians. At the end of the day, to me, the medical home is not something that can be written into existence by policy, it needs a physician who cares to BE the medical home for his patients. If the physician could care less about all the issues facing his patient and wanting to be involved, neither will his staff. The office policies and procedures will not be medical home friendly either. Some primary care physicians will always care about their patients on a deeper level, wanting to be involved in their care, others never will.

Before I ramble too much more, here's a very good article that describes the essence of a medical home.

Is it time for a nursing home?

2011-01-22T14:19:00.000-05:00

This has to be one of the most common questions I get from new patients in the office and something I discuss with every patient and family in the hospital. (the other being, do I have a memory problem).

While every case needs to be individualized, there's a fairly straight forward way of looking at a person's ability to function and the available options for living situations.

There are two broad things to look at: function and safety. The two overlap somewhat.

Looking at a person's function, I usually split it up into IADL's and ADL's. IADL's are instrumental activities of daily living and ADL's are activities of daily living. IADL's include: shopping, financial management, medical management, cooking, house keeping, laundry, driving/transportation, telephone use. ADL's include: bathing, dressing, feeding, grooming, ambulation, continence. For example someone does not need to be continent, but they need to be able to manage their own bowel/bladder habits to be considered independent. Someone does not need to be able to drive, but they need to be able to take a taxi by themselves.

Generally speaking, someone who has deficits in their IADL's will likely need some support from family members or hired help. This type of need is unskilled need (in a nursing sense). You can hire someone to meet these needs fairly easily: hire a house keeper, meals on wheels, laundry service, etc. Normally people with this type of need can stay at home and the necessary help can be hired. Family members can check in by phone or visit weekly. Another option is assisted living facilities (ALF). Currently this is the role that ALF's have. ALF's tend to be self pay and cost about $100-200/month.

Where things get more difficult for the patient is when there are deficits in ADL's. Some ADL's are more of a problem than others. Incontinence and being able to walk are very difficult. Not being able to walk usually means stairs are big barrier, so is bathing, and toileting. A person likely needs 24/7 help at this point. Incontinence, I find, is very tiring for the caregiver. At this point, care is skilled. A person needs to be careful how they help someone from a bed to a wheelchair so the person is not dropped or injured. Skin care requires some training for someone who is incontinent. At this stage, I always worry when there is one caregiver at home trying to handle things. Burnout is something I see almost every day. Fortunately there are a lot of options nowadays. First is intensive home services: hiring a home health aide 7-8 hours per day 7 days a week; LIFE/PACE program and nursing home. (PACE=Program for all inclusive care for the elderly). I have seen families handle this stage on their own successfully but the family has to be pretty committed and even then it is not without cost.

Hiring home aides for most people is prohibitively expensive and difficult. If someone is near poverty level, then Medicaid or the local Area Agency on Aging can sometimes pay for services. Sometimes family members get paid for services through waiver programs. The LIFE/PACE program is like an adult day care program on steroids. It involves signing over a person's medicare insurance to the specific LIFE/PACE program. It is open 5 days a week typically. Staff come to the house, help a person get ready, transport the person to the program. Once there, anything available in a Nursing home is available at LIFE/PACE including physicians, physical therapy, nutritionist, pharmacists, nursing, nurse aides etc. Finally the other option is nursing homes which can provide total care for long term needs.

In addition to function, the other big issues to deal with is safety/psychiatric issues. A person who wanders or has such severe psychiatric problems that even though they are capable of their ADL's and most of their IADL's, they're not safe to live alone. People who wander outside the house and get lost, or people who are physically/verbally aggressive/abusive to those around them almost always need placement.

One other way I think about it is also function based. If a person is safe (they have not gotten lost, no fires or water problems in their house) and their weight is stable, things may be okay or good enough. Not ideal, but not an emergency situation either.

In any case, I find starting with the ADL's/IADL's a good way to start looking at a situation and then customizing it from there.

"Death Panels"

2010-12-27T21:49:00.000-05:00

I read this yesterday. It's interesting to see how alarmed people can be when they think that the government is going to get involved in end of life decisions for patients. Conservatives worry that it is a way to "kill grandma." Economists hope that it will help save money be decreasing the costs of excessive care at the end of life (which only serves to make conservatives worry more). Some proponents of physician assisted suicide may even see it as the beginning of legalization of PAS. But from my perspective, none of those views are correct.

I spend half of my time in nursing homes and half of my time in the office. I also spend 10 weeks a year doing inpatient medicine in the hospital where I supervise residents and medical students. I probably spend about 2-5 hours per week talking to patients about end of life issues, mostly without being reimbursed.

End of life issues are tricky. It goes far beyond whether someone wants to be full code (CPR, intubation) or DNR/DNI. Most people I know are inbetween: do CPR/intubation if there is some chance of recovery but not if it causes permanent impairment (which is a medical impossibility to know). But even more than that, patients have ideas about everything from how often they want blood tests, to whether they want to continue mammograms to chemotherapy, major surgery, nursing home placement and how often to see a specialist. What I tell patients when I ask them about their goals of care is that every patient has different desires, goals, values and limits and there is no way I can tell what a patient wants by looking at them. So instead of guessing how aggressive a patient wants me to be in pursuing therapeutic care, I ask them what they want. That's it. I ask some further questions to clarify issues ("You don't want dialysis because...? What is your impression of chemotherapy?"). Currently, this type of conversation is not reimbursable (i.e. I don't get paid for it).

So what happens if this type of care is not reimbursed? Physicians often don't engage in this type of conversation. What happens when physicians don't engage in this type of conversation? Physicians guess what the patients want and often guess wrong. Sometimes physicians assume the person wants aggressive care and the patient ends up suffering through invasive procedures. Sometimes the physician assumes that patient would not want to tolerate anything and the patient is denied treatment options without their knowledge.

So from my perspective, what would be the result of reimbursing physicians for talking to patients about end of life issues? Patients would more precisely get the level of care that they want. What's wrong with that?

Now in all honesty, when it comes to most people, most people get more interventions done on them than they want and end up having to suffer more than they want to because they get talked into procedures/treatments or even yet physicians just do them without any meaningful consent. While more end of life discussions may lead to less aggressive care, increase use of hospice and cost savings, to me that is not the main goal or benefit. I would frame the benefit in terms of helping to increase the autonomy of patients be giving patients a greater voice in their end of life decisions rather than this being an intervention what would limit autonomy or coerce/impose patients to do things they don't want to do.

Here's a good commentary.

Medicare fee fix

2010-12-15T21:42:00.001-05:00

As you may have heard, every year Medicare has to "fix" the medicare physician fee reimbursement to avoid having physicians get a pay cut. Every year we hear physicians voice concerns that if Medicare cuts physician fees by 25% or more, no physician will take Medicare patients anymore or that physicians will go bankrupt taking care of Medicare patients. Medicare patients and advocacy groups voice concern that doctors will limit their access. Deficit hawks argue that passing the "fix" will only make Medicare insolvent faster and/or increase the already alarming federal deficit.

Geriatricians are in a somewhat in a unique position among physicians in that our reimbursement is much more dependent on public health insurances than others. For example my patients are predominantly (>90%) Medicare and Medicaid (most nursing home patients have Medicaid). Without any question, a physician fee cut would hurt geriatricians more than any other specialty. Geriatricians are already the second lowest paying specialty next to pediatrics.

A little bit of math....If a geriatrician's net revenue is $300,000 and overhead is $150,000 and the physician is 100% dependent on Medicare and there is a 25% cut then while the net revenue will decrease by 25% ($75,000), if the overhead remains the same, income will be cut by 50% ($150,000 to $75,000). Now if a nephrologist has net revenues of $500,000 and an income of $250,000 and have 30% of their revenue come from Medicare, they would have a salary cut of $37,000 or 15% of income. Their salary would decrease from $250,000 to $213,000.
While a 15% cut in income is no small cut, it is hardly career ending when the starting salary is so high.

So what is my conclusion? A medicare cut would be devastating for the field of geriatrics which already has fewer and fewer new physicians each year (less than 250 in the country), while having a much smaller impact on other specialties. It would also affect primary care disproportionately as well. But part of me feels that the cuts ought to happen. The deficit can not be quickly wished away. The shortage of geriatricians and primary care doctors will just be prolonged and masked by the 1 year fixes. I would rather have the crises come to a head quickly and dealt with decisively rather than have 1 year fixes that prolong the financial disincentives that keep geriatrics to such a small field. In the long run, it is better to deal with the problem now, even if it is painful, rather than to drag it on slowly and painfully year after year.

My 2 cents.

Future hope

2010-07-25T15:47:00.001-04:00

Well, I've realized that blogging successfully means some serious time which I did not have over the last several months, but I'm hoping to get back into it. I love geriatrics and it's such a developing field.

In any case, I came across this article in the NY Times. There are over 70 medications under development. There are only 4 that are FDA approved today. It provides some hope that we will have some medications for geriatrics that will do more than just give minimal improvement on research studies. Ideally something that will allow a person to stand back and say, yeah I see the difference. One day......

I also read this in the NY Times about an elderly man who ended up having a pacemaker and the craziness that developed when it was time to shut it off. Unfortunately, without a geriatrician or a geriatrician perspective among the specialists, this is what can happen.

Osteoporosis

2009-10-30T10:24:00.001-04:00

One of the things I did last year was complete a project on Osteoporosis for a Master of Public Health degree. In the process I learned quite a bit. The statistics are sobering:

1 in 2 women will have a fracture after the age of 50
1 in 4 men will have a fracture after age 50.
Each year there are 300,000 hip fractures and 700,000 spine fractures from osteoporosis.

That's a lot of people! That's a lot of fractures!
It's also a lot of pain and a lot of people ending up in nursing homes from hip fractures.

In any case, you would think that this is a big deal among patients and physicians but it continues to be a very silent epidemic.

For example, most women get a mammogram at least every 2 years (over 65%). Most women never get a bone density scan (DXA scan) more than once (less than 35% get a DXA scan more than once). Yet women are much more likely to get a fracture than breast cancer.

Even after a hip fracture, most patients never get put on calcium and vitamin D (only 35% do) and most patients never even get a prescription for a osteoporosis medication (less than 15%).

About half of people who are prescribed an osteoporosis medication stop in within the year and of the half who continue it, on average they take half their medication.

In other words, the take home message is that Osteoporosis is severely underdetected and undertreated. Probably no more than 5% of people in the United States with osteoporosis are taking their medication regularly to maximally prevent a fracture.

So what can you do?
1. Ask for a DXA scan to be detected
2. Read this website to calculate your own fracture risk.
3. Take calcium and vitamin D every day if you are older than 13.
4. Take a bisphosphonate like Actonel, Fosamax or Reclast.
5. Exercise and don't smoke.

On the 4th point, I actually do not care a whole lot which Bisphosphonate a person takes. People often ask me what medication is better than another and what type of calcium is ideal. I hope I've convinced you that that does not matter. It's better to take anything than nothing. I would take whatever is cheapest myself and what is covered on insurance. And for sure, I would take the generic over the brand because like I said I'm cheap. For those who are forgetful, Reclast which is a once yearly bisphosphonate is wonderful. I'd recommend it.

That's my 2 cents on Osteoporosis!

H1N1 and the regular Influenza virus

2009-10-07T09:24:00.001-04:00

I've gotten my flu vaccination, have you?

This year is a little confusing because there are two flu vaccines to get. The first one is the regular influenza vaccine that everyone older than 6 months should get yearly. Kids 6 months to 8 years old who are getting their first vaccine need two. The high risk targeted groups for this vaccine are 1. children 6 months to 4 years old

2. children 4-19 with chronic illness

3. all adults older than 50

4. pregnant women

5. nursing home residents

6. adults with chronic illnesses/compromised immune systems

7. adults who are in close contact with kids listed above

8. Health care workers.

The H1N1 vaccine recommendations are different. The CDC lists it in order of importance.

1. Kids 6 months to 24 months

2. Pregnant women

3. People who care for kids birth to 24 months

4. health care workers and emergency personnel

5. Anyone 6 months to 24 years old

6. Anyone 25-64 who are at increased risk for complications due to chronic illness.

The big differences between the two vaccines is that the H1N1 vaccine targets young people, not geriatric patients. If you have grand kids, should you get vaccinated? If you provide a significant amount of child care then yes, you should get both.

How effective are these vaccines? I'm not sure about the H1N1 vaccine, but for the flu virus it depends on the year. Sometimes the vaccine correctly predicts the version of the flu and sometimes it doesn't. Each year anywhere between 25-75% of the population gets the flu of varying severity. The flu vaccine can prevent the flu (when it is effective) about half the time. So you would need to vaccinate anywhere from 4-15 people approximately to prevent 1 case of the flu.

I do wonder if this means yearly vaccines with two flu vaccines. Maybe they can combine it one year. We'll see!

Diabetes and geriatrics

2009-09-05T12:57:00.000-04:00

Uh oh, I've been getting behind on my blogging. I still have to make this part of my routine. I see interesting things almost every day, and I've been thoroughly enjoying reading http://thealzheimerspouse.com/. It's a great blog and I've realized that folks will discuss tons of tough tough issues online with peers over talking to their physician (which is fine of course). But I think I will make this mandatory reading for the medical students, residents and fellows that I teach. One example was a forum post that asked when other spouses started sleeping in separate rooms because their spouse's dementia progressed to the point where they weren't recognized in the middle of the night. Not a question that I've ever been asked in the office.

In any case, we had an interesting journal club yesterday. An article in JAMA is one of a growing body of literature that simply debunks the idea that all people with diabetes need to have tight control of their sugars (defined as a HbA1C <6.5 or fasting sugars less than 100 and after meal sugars less than 140). In this article it states that having one low sugar episode (< 70) which is common in people trying to maintain tight control, can increase the risk of Dementia by about 2-3% per year. This adds up quickly. While the stats are somewhat debatable, I think it adds to other articles that came out last year showing that low sugars increase the risk of death in hospitalized patients. The known risks of low sugars includes death, dementia, falls, confusion, hospitalizations etc.

So to review, what's the benefit of lowering sugars? Is it worth the risks in elderly patients? The answer is surprising: while high sugars increases the risk for heart attacks and strokes, lowering sugars does not reverse the increased risk. So what does it do? It decreases the risk for complications like kidney failure, blindness and nerve damage to the feet. Those aren't small complications but it may take over 8-10 years of tight control to see those benefits. Many of my patients are not going to live that long. And even if patients do have 10 years ahead of them, is the small decrease in blindness worth the increased risk of hospitalizations, death, dementia and falls? I doubt it.

At least among geriatricians, there is a large resistance to putting people on multiple oral medications and complicated insulin regiments to achieve tight control that has little or no benefit for the majority of our patients but carries significant risks of serious medication side effects.

I think the challenging aspect of geriatrics is every patient has different goals. It's important to remember not all geriatric patients are the same. I saw an 80+ year old female the other day who wakes up at 6:00 am to do aerobic exercise at a local gym. I have 70+ year old patients with end stage dementia in a nursing home. Tight control of sugars may be reasonable for some patients, but for many it is not. It needs to be considered thoughtfully.

Am I that scary?

2009-08-14T07:50:00.000-04:00

I have not been following the Obama health care debate very closely, but a friend of mine on Facebook posted some questions so I looked up some info about Obama's health care plan. The first link in Google points to this CNN article. The second points to this article on Salon.com. It refers to comments by Sarah Palin regarding "death panels."

These articles point to a couple of fears that people have: the government is going to force people to have a primary care doctor and the government is going to force people to discuss end of life care.

What's amazing to me is that being a family doc, I am a primary care doc and as a geriatrician, I regularly have discussions with patients and/or families about end of life issues. I never thought that I was so scary!

All kidding aside, I'm such a believer in both primary care and clarification of end of life issues. I can't tell you how many times I've had a patient who's primary care doctor was a cardiologist who tried to manage their depression/overactive bladder/dementia and how badly that has gone. Or how many patients have ended up getting CPR and put on a ventilator when that is not what they had wanted. The purpose of having a primary care doc and having end of life care is to make sure that every patient has someone who is responsible to knowing them and their preferences. There's no reason that should be all that scary!

I'm not ready for hospice!

2009-08-07T10:50:00.001-04:00

This morning we had a discussion in the department about how to have the ideal hospice discussion. The author of this article was the presenter. It was an interesting thoughtful discussion based on the premise that doctors and patients often have a tough time communicating. One of the ideas that I really try to teach medical students is that the key to being a good doctor has to do with normal people skills.

The most important thing that I try to teach is that physicians don't need to know what to say, or how to have a conversation but how to listen (actively). In some ways, it is not all that different from being married. I don't need to do studies to research why my wife is angry at me, or figure out what has worked for most angry wives, I just need to ask her what's wrong and listen. Or if she's happy, what's right!

So here's my list of things doctors should do when discussing something difficult like hospice:
1. Listen, don't talk
2. When the physician is talking, the goal should be to seek further clarification of what the patient (and/or family member) was saying
3. Figure out what the patient's goals are
4. Discuss goals of care all the time, not just when the physician has a goal for the patient
5. Emphasize that the physicians goal is to help the patient carry out his/her goals.
6. If you're not sure how a patient is going to react to something, be honest about that. i.e. I'd like to bring up the issue of hospice but I'm not sure how you're going to feel about that? Or how do you feel about discussing hospice?

The goal at the end of the day is to not cram anything down a patients throat in a manipulative fashion but empower the patient by helping them maintain autonomy and control. Communication can achieve either the former or the latter. Somehow in this day and age, with all the pressures (legal, financial etc.) that doctors face, listening has become a lost art.

Is surgery safe for older patients?

2009-08-06T14:12:00.000-04:00

Today I saw a patient for the first time. Because of a condition, she will require bilateral hip replacements. Cardiology cleared her for surgery and ortho believes it will significantly help the patient. The surgery, however, requires 2-4 weeks of bed rest afterwards for optimal healing. And orthopedics wants to do one hip at a time. In a frail elderly patient who is bed-bound (due to her hip problem), the issue is not the surgery itself, but the recovery. This is something often missed by nongeriatricians. One number that I always remember is that an elderly person who is on bed rest for four weeks will lose 50% of their muscle mass and 75% of their strength. Joint contractures (permanent stiffness of the joints) can occur in as little as a week in an elderly patient and sometimes as little as 24 hours. Bed rest can cause a loss of calcium, and nitrogen that may never recover and new onset diabetes after 8 weeks of bed rest. In someone who is already cognitively impaired, pyschosis is not uncommon or infections such as pneumonia and urinary tract infections.

I have not met with the family yet, but a surgery requiring prolonged bed rest may still be very risky even if the surgery itself is not terribly risky. One thing to remember though is that not all people who are 85 are the same. The best predictor of outcome after a surgery is how functional a person was before the surgery. But a frail cognitively impaired older adult is going to have a very though rehabilitation course after a prolonged period of bed rest.

In other news, I may not be able to continue this blog after all. I have to clear this with the legal folks of the University of Pennsylvania. We'll see what they have to say!

How do you pick a good doctor?

2009-08-01T20:32:00.000-04:00

My family and I just moved to Philadelphia where I will start work on Monday at the University of Pennsylvania. My brother in law and his pregnant wife just moved here this last week as well. Between the 4 adults, 2 kids, and one kid in utero, we're looking for primary care doctors (pediatric and adult), a specialist, and an OB. We're also picking benefits such as deciding between PPO insurance vs HMO insurance (which costs at least $300/month more than an HMO insurance). So we have some decisions to make.

The funny thing to me is that the dilemma in picking a good doctor on an individual level is the same dilemma that the federal government has (and all health payers) on a large scale level: how does one determine the quality of a health care provider and whether they are worth the cost?

Most people want to know if their doctor is a "good doctor." Sometimes people mean whether the doctor knows and practices up to date medicine. The problem with that is if you could truly tell if a doctor practiced up to date medicine, then you wouldn't need that doctor. I believe that it is nearly impossible for a non physician (and very difficult even for a physician), to be able to know if a doctor practices up to date medicine.

So what else is there to go by? Here's a list
1. You click with the doctor. Never underestimate the power of a good warm relationship with a physician. The physician will think harder, listen better and care more. You will be more open, more trusting and less fearful. It's a good thing.

2. The office staff is professional. My wife and I took our newborn to a doctor once. One of the worst experiences we ever had. The office staff would unlock the front door at 9:02 for a 9:00 appt. The phones were often not answered. And they were rude. A good doctor will care about the professionalism of his office staff.

3. The doctor is accessible. The Institute on Medicine defines quality medicine as what you need, when you need it and how you need it. If you can't easily get an appointment or talk to the nurse or even the doctor, either the doctor is too busy or has an adversarial relationship with patients. Not a good idea.

4. The doctor answers questions (and is not in a rush). This is the most important for me. A good doctor shouldn't be afraid to answer questions and sometimes say, "I don't know" or "I'll get back to you later." No doctor is omniscient, should not pretend to be omniscient and should be honest. Humility is a key trait. A doctor who takes the time to draw out questions and answers them to the satisfaction of the patient will go a long ways towards building trust. They won't make things up (fellow doctors have done that to me a lot which I hate).

5. The doctor seems to take your concerns as his concerns. This goes along with the last one but makes it more personal. I hate it when a doctor blows off a patients concerns and I see doctors do it all the time. Medicine is serious. There's no room for belittling the concerns of patients and families.

6. The doctor uses an electronic medical record with a disease registry (icing on the cake). For economic reasons and tech reasons, there are plenty of docs who are great but because of a lack of finances (some EMR systems cost hundreds of thousands of dollars), some great docs don't have this. But to take medicine to the next level, you want a doc who audits themselves. This can't be done (very easily) without a disease registry. You don't a want a doc who assumes they are a good doc, but measures themselves to find out reality.

The last note is that there is no such thing as quality by association. A partner of a good doc is not necessarily a good doc. I've noticed a lot of University of Pennsylvania advertisements now that I'm in Philly and starting work there on Monday. They want people to assume that any doc at Penn is an amazing doc. I've been around long enough and in enough places to know that that is wishful thinking.

Anyway, these is not meant to be a comprehensive list, but these are some of the things I'm looking for for my family.

Faculty listing

2009-07-19T21:04:00.000-04:00

On a personal note, I saw that I was offically added to the Penn Faculty listing in the Geriatric Division. If you want to check it out, it's here.

What is old?

2009-07-13T23:57:00.000-04:00

I still take care of young patients sometimes. Today I was chatting with a 27 year old patient and his twenty something year old wife. I was telling them that at least he's doing better than a 30 year old patient with the same problem but has much much more severe deficits. The nice wife looked at me and asked (seriously), is it because he is old? I couldn't help but laugh out loud.

hint: if you ever feel old, talk to a geriatrician. Virtually everyone seems young to us.

What makes a geriatrician different?

2009-07-05T14:10:00.001-04:00

In the United States, there are approximately 300 geriatric fellowship positions. Many of them go unfilled. In fact, less get filled every year. I heard that only about 200 positions are filled. From talking to one fellowship director, many fellows are just killing time until they get another fellowship that they really want like cardiology or heme-onc. Fewer medical students and residents express interest in primary care (1, 2, 3, 4), much less geriatrics. According to the Institute of Medicine's report (Retooling for an Aging America), there were just over 7,000 geriatricians in 2007 (not all of whom went through a fellowship). And at the American Geriatric Society meeting, I heard that most geriatricians are choosing not to recertify as geriatricians. My main point is that every year, there are fewer geriatricians, both new grads and practicing physicians, not more.

So the question is, does this matter? What makes a geriatrician different? Right now I'm working for a group practice of physicians as their hospitalist. There is one patient that I saw there that provides a good example.

An 85 year old female who came in with an intestinal infection, developed pneumonia, sepsis, respiratory failure, a urinary tract infection and renal failure and 45 days later she is still immobile, has a feeding tube and requires 5 L of oxygen. While all her specialists have written that they think she's getting better, no one has addressed her immobility. After 28 days of bedrest, a geriatric patient will have lost 50% of their muscle mass and 75% of their strength. Like an astronaut, she will have a component of low blood pressure whenever she tries to get upright (even in a wheel chair). This patient has been bed bound for 45 days. Geriatricians excel at not only coordinating complicated care, but also thinking about the patient as a whole with an eye towards geriatric syndromes. Things like delirium, pressure ulcers, deconditioning, malignant effects of bedrest are issues that are best prevented. Treatment is very very difficult. Would a geriatrician made a big difference in this lady's hospitalization? Maybe, but it definitely would have given her her best chance for getting out with the fewest complications.

Somehow, I hope to see the state of geriatrics take a turn. I hope to see more and more students choosing to go into geriatrics as a career. I think it is clear that there is a huge need for more professionals in this field who have a passion for making sure that older patients get the care they need and deserve.

Weighing options of treatment

2009-06-29T17:06:00.000-04:00

While I don't plan on writing daily updates until August, I figure that I want to get in the habit of writing thoughts down when they occur. Over the weekend I met a lady who is 73. She has severe osteoporosis but because she has bad side effects to oral bisphosphonates, she does not want to try even an intravenous bisphosphonate. Instead, she was trying an unproven combination of Evista and Calcitonin nasal spray. This lady is not one of my patients. She told me she has lots of medical people in her family and on their advice, she decided that the risks of using an IV bisphosphonate like Boniva or Reclast was not worth the benefits. It's not clear to me what she perceived the risks and benefits to be or how she came to that conclusion. She may be right, she may not be but it did make me reflect that how people make medical decisions is really really interesting.

The way physicians make decisions is they use studies to try to quantify the risks and benefits and if the benefits outweight the risks (and don't cost too much), then it's the right decision to try the treatment. If the risks outweigh the benefits, then it isn't. There isn't a lot of emotion in the decision. In the situation that there is no evidence, or poor evidence, then the situation is tricky.

The way I see it, which is limited I'm sure, patients make decisions quite a different way. Most patients don't have access to the studies, or have trouble making sense of the medical literature. There are several categories of decision making process that I see patients go through: some try to weigh risks and benefits as interpreted by their physician, some decide based on what they fear more (fracture or side effects), some by gut feeling, some by cost, some by what somebody famous says or by what family says. In other words, patients look to a different source of authority for decision making information.

What's challenging for the physician (and patient) is to bridge this gap. As I write about different issues, I hope to give the information needed to help any person make an educated decision regardless of decision making style. We'll see how it goes!

What is Axona?

2009-06-27T15:27:00.000-04:00

I hope to write some critiques of treatments that are in advertisements to give some perspective to claims. So one thing that I get is called Clinical Geriatrics. It's a subscription I get from my membership in the American Geriatric Society. This last issue there was a supplement (i.e. advertisement) about a new nutritional supplement called Axona that will help patients with Alzheimers.

So what is Axona?
Axona is essentially a variety of fatty acids (fats) that get metabolized to ketones. So what? Well the brain can use ketones as well as glucose in helping us think. Since the brain that has Alzheimer's has trouble using glucose, maybe supplying some ketones will provide more energy to the brain.

So does Axona work?
That depends on what the goals are. If the goal of an Alzheimer's patient or family is to keep the patient functional, out of a nursing home, engaged in hobbies and relationships then the answer is unknown. If the goal is to see a miniscule improvement on a research cognitive scale (ADAS-cog), then the answer is, according to the manufacturer's 1 study, yes. At 45 days there was a 1.91 point difference between the two groups (out of 70 points). By 90 days this improvement disappeared.

Conclusion
Axona may have an effect on cognition that a researcher may be able to detect, but I am doubtful that any family member or patient would notice. In any case, the benefit disappears by 90 days according to the manufacturer's own data. And according to the data, for every 8-9 patients treated, 1 will get a side effect (like diarrhea).

My conclusion is that this nutritional supplement is interesting, but not worth trying yet.

edit: As one comment points out, this medication/food supplement is a single triglyceride (>95%). But I think it is made from a variety of oils (palm oil and others) due to the warning on label regarding food allergies.

Edit (6/12/2011)
I realized that this is my most viewed post on my blog and I would like to update it a little. There are several things I would like to see studied/researched about any specific intervention for dementia before I get too excited about it: The intervention has to
1. Show a difference between placebo and treatment in long term studies (i.e. more than 6 months)
2. It has to show an effect in both research scales and clinically oriented outcomes
3. Clinical significance (as opposed to statistical significance) has to be defined separately from the study
4. The study has to be large enough to define subgroups (i.e. those who achieve the threshold of clinically significant change/improvement)
5. A Number Needed to Treat needs to be able to be calculated
6. Ideally a way to tell if the treatment is working or not working would be researched along with effectiveness
7. Discontinuation studies need to be done that are not simply open label studies in order to allow people to feel comfortable stopping a med that will likely not benefit the majority of subjects.

These seven criteria will allow a patient/physician to know what a medication is supposed to achieve and whether it is clinically meaningful, what percentage of people actually achieve it, when it is not working so it can be stopped and the risk involved of stopping it.

To be fair to Axona, no medication/treatment meets these criteria so it is hard for me to get excited about any pharmacological intervention. I'm not a fan of starting a medication without knowing if it is working, whether it is doing anything clinically meaningful, how likely someone is to get benefit, when to stop it and risks involved.

Introduction

2009-06-26T19:58:00.000-04:00

Blog entry #1

Geriatric Issues: A blog of questions and answers

After being a practicing physician for four years, I decided to go back to training to do a Geriatric Fellowship. I'm finishing my fellowship on Tuesday and after that I'm joining the University of Pennsylvania as a faculty in Geriatrics.

Geriatrics is something that has been on my heart since before starting medical school. I love the interaction with families and patients. Geriatrics is a field of change and transitions and one thing I find rewarding is helping patients and their families anticipate, adjust, and succeed in the transitions of getting older. In order to do this, one thing I have found myself doing very frequently is having family meetings, but the problem is that the more patients I get, the more family meetings I need to do and I end up having difficulty trying to communicate everything that I want to to patients and their families.

In many ways, I find that geriatrics is a lot like pediatrics-a lot of the transitions are predictable and if information can be given out in time, patients and families can plan for the future instead of waiting for crises moments like a hospitalization or a hip fracture. One of the purposes of this blog is to provide a forum to distribute good, accurate anticipatory guidance to patients and families to allow everyone access to the medical knowledge needed to make good decisions and to plan. The goal of this blog is to make sound medical information fully accessible to patients and their families to allow them to become as informed as a physician. In this day and age of Internet and the world wide web, I believe fully that nothing should stand between patients and medical information.

My second purpose behind this blog is to allow patients and families to ask me questions to challenge me. I find that patients often ask the best medical questions (usually something that begins with "why") and it pushes me to learn more, read, and be much more precise in my medical knowledge and practice.

I haven't done a blog like this before so this will be a work in progress. The format will be fairly straight forward-I will post entries and will come up with future topics from comments, emails, and things I'm learning from my practice. While there are many web sites to serve as resources on the Internet, I hope this blog takes on the flavor having geriatrician in your own family. I really hope to make this blog and my answers very interactive, personal and relevant to you. So, please feel free to ask questions and I hope you enjoy my blog!

About me:
I started my medical career at the University of Michigan where I received my B.S. in Biomedical Sciences in 1997. In 2000 I received my M.D. from the University of Michigan as well. From 2000-2003 I went to MacNeal Family Practice Residency Program-University of Chicago in Berwyn, IL and from 2004-2008 I worked as a solo practice physician in Shickshinny, PA. In July of 2008, I started my Geriatric Fellowship at the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson. Starting August 1, 2009, I'll be on faculty at the University of Pennsylvania.