So now I'm a death pit doctor?

I hate headlines like this so I’ll say it again, If an engineer builds a one winged airplane that doesn’t fly, why blame the pilot and flight crew? Our society has underresourced NH’s and responds with surveys and fines. And blame.

https://www.nytimes.com/2020/04/17/us/coronavirus-nursing-homes.html

If you want to blame NH’s, blame society for rampant ageism that allowed NH’s to be so resource poor for decades and prefer older disabled adults to be out of sight out of mind.

If you’re a doctor, blame medicine for spending money on medications and procedures that only hurt older adults. Blame US medical schools that produce less than 100 gertiatricians out of 25,000 graduates each year. Blame the lack of primary care.

Blame hospitals for getting mad at NH’s who send pts and blame NH’s when we don’t. Blame the disparity of resources between hospitals and NH’s when the virus could care less.

Blame our govt for not providing testing which makes NH’s fly blind. “Assume your whole building is infected” has been said to so many medical directors pleading for tests.

Blame @CMSGov for doing nothing but surveying and fining NH’s during this pandemic (see Kirkland).

Who is rushing to volunteer in NH’s like the hospitals in NYC? Who is coordinating meals from restaurants for NH workers? If it isn’t you, well then....

For those of us who have pleaded for change for decades, who have been so content to work without recognition, to choose to be where no one wants to be, being blamed adds to the absolute agony of this pandemic.

Every time I see a new patient in the NH I ask them how they feel about it. It’s never positive. They feel discouraged. They would rather be home. Families feel like they failed in some way. They wish they had more resources. No one has a life goal of living in a NH.

But then I look at them and say, if you had a choice you wouldn’t be here but guess what, I chose to be here to be with you and so did everyone who works here. You are not alone. We love doing our best for you and you don’t have to go through this alone.

I was the only medical student in my class who did a nursing home elective. I was the only resident in my program who did a nursing home elective. Geriatrics is the second lowest paying specialty (still well paid all things considered). But despite everything I wouldn’t change it

I stand in a gap between the medical sub specialists to one side and the proceduralists to the other. I’m outside the academic ivory towers. But I never wonder if I am making a difference.

This is awesome! Way to go Dr. Heimlich

I love this story.  Dr. Heimlich, at 96, used his namesake maneuver for the first time to save a life!  Just goes to show that old people still matter a lot!

Caregiving school scholarship

For my many caregivers who are also in school, you can click on this link to apply for a $1500 scholarship.  Only 3 awarded nationally but it is wonderful to see this.

What are the biggest risk factors for dementia?

Recently I came across this article on Nature Reviews which is a very good authoritative journal.  (article is not free).  It lists MODIFIABLE risk factors for Alzheimer's.  Guess what ranks highest?  Diabetes increases risk by 46%, hypertension by 61%, obesity by 60%, depression by 65%, smoking by 59%, low education by 59%.  But the highest risk for dementia was physical inactivity which raises the risk by 82%!!!!!!!

Therefore-WALK!

An encouraging note from your geriatrician.

ps these are relative risks.  So if your baseline risk of developing dementia is 10%, then physical inactivity will increase the risk to 18%

pps the biggest risk factor for dementia is age.  By far.  This is not easily modifiable ;)

A geriatrician's view of the SPRINT study

This is all I have for now.

Should I get a PSA?

The decision to screen for prostate cancer seem so obvious.  For men, it is the most common cancer, and the second leading cause of cancer death.  For year, it was assumed that every man after the age of 50 would get a Prostate Specific Antigen blood test (aka PSA) every 1-2 years.  Ideally this would lead to a decrease in cancer deaths.  Unfortunately this has not turned out to be the case.

The US Preventive Services Task Force is a body that is funded by us (taxpayers) to look into health issues with objectivity (they're not physicians/drug companies who will profit off of treatment or even advocacy groups that are wired to make their issue the most important in public discourse or health insurance companies who are looking to save money).  You can see their most recent statement here.

In the past, if a man wanted to get screened, I would caution them that even if the PSA is normal (<4 abnormal="" and="" cancer="" could="" f="" get="" ignore="" nbsp="" not="" psa="" should="" still="" symptoms.="" the="" they="" were="">4), they should not panic because most of the time, a PSA>4 does not represent cancer anyway.  Great test right?  If they could live with the fuzziness of the PSA test, willing to not panic with every test >4 then maybe it would be useful for them.  If it was high (>4), I would recheck it in a matter of months.  If it were high again, I would refer for biopsy and then we could stop and make a decision about how aggressive to treat AFTER the biopsy.  I have a cousin (not a physician) who advocated on a blog post that patients should decide if they want to pursue screening and how aggressive to treat but physicians should not decide ahead of time paternalistically.  I agree with this on face value but when looking at the data, it becomes much messier.  

So looking at the data
For every

1000 men who under go screening for 10 years,
5 will die from prostate cancer if not screened
At most 1 will have their death prevented by being screened

Harms are significant
100-120 men will get biopsies (1 will get hospitalized from complications)
110 men will get a diagnosis of prostate cancer (and the accompanying worry)
29 will develop erectile dysfunction due to treatment
18 will become incontinent (lose control of bladder function)

So the ration is for every 1 person helped by screening
100-120 men get a procedure they don't need
110 will get a diagnosis and worry
29 will get ED, 18 will get incontinence.

The problem with this is that for the 110 men diagnosed with prostate cancer, it is very difficult to hit the brakes and not pursue further treatment.  In some ways, the guys who know they won't do anything about it should not get screened in the first place.

So this is the dilemma of prostate cancer screening-it is an emotional dilemma with physical outcomes.  Most men, clearly would be better off without being screened.

Why see a geriatrician?

It's not just patients, but other physicians, who have trouble figuring out what I do and when I should do it.  Is it when a person turns 65?  Or when they develop problems with memory like dementia?

Here are a list of reasons
1.  The patient has multiple medical problems.
At some point managing multiple medical problems becomes an art in itself.  A typical patient might see a specialist for every one of their medical problems, with the inevitable increase in the complexity of managing them.  A geriatrician might take that patient, put it into a big picture and treat the big picture.

2.  The patient has functional decline.
Geriatricians know about mobility issues, health implications of falls and how to collaborate (not just refer) to physical therapists and rehab physicians.

3.  Age
This seems obvious but what geriatricians understand about aging is that it can modify the benefit and harms of what we do in medicine.  Understanding how age and future prognosis modifies risks/benefits is a geriatric skill.  Decisions like when to stop cancer screening or what is the ideal blood pressure or sugar target, the decision to treat or not treat a disease (like surgery for a back problem or blood thinners for an irregular heart beat) all have age as a consideration

4.  Geriatric syndromes
Geriatric syndromes are multi-organ.  Geriatricians specialize in multi organ stuff.  Falls, incontinence, memory loss, psych issues, polypharmacy, pain, wounds etc.

5.  Patients who have mixed palliative / therapeutic goals
Some patients want to pursue therapeutic/curative care for some of their medical problems and forgo aggressive treatment on others.  Some docs want pts to be all or none (full code or hospice).  Geriatrician (ideally) would be able to straddle the sometimes messy space between full therapeutic care and hospice.

6.  Pt's who transition between health systems
Geriatricians receive training in hospitals, offices, house calls, assisted living facilities, rehab facilities etc.  We know the pros/cons/limits of each and how to make things work.  Ideally these transitions are not stressful.

7.  Pts who need collaborative interdisciplinary care
A large part of what we do is working with other disciplines such as physical therapy, occupational therapy, speech therapy, nutritionists, wound care nurses, social workers, home health aides, medical supply companies, hospices.

8.  Caregiver support
This is something assessed (I feel) better by geriatricians than non geriatricians.  It's not just the patient we care about but also the support team (family and friends).