In a recent essay in The Washington Post, geriatrician and author Jerald Winakur described the recent hospital experience of his 91-year-old mother. You won’t be surprised to learn it was a nightmare: Poor pain management, overworked staff, insufficient training, little communication among physicians and no communication between his mom and the waves of medical professionals who treated her each day.
She survived her two-month hospital stay but, Winakur suggests, only because he and his brother were constantly at her side.
Dr. Winakur, a geriatrician, is part of a mini-industry: Physicians who write first-person memoirs about caring for their own aging parents. In 2008, he published Memory Lessons, a terrific book that described the decline and death of his father.
Last year, the prolific Atul Gawande published Being Mortal, a best-seller about how medicine often fails patients at the end of life. Like Winakur, Dr. Gawande describes how the death of his father opened his eyes to the ways modern medicine fails aging patients. While the book is important, I could not help wondering what took him so long. How could Gawande spend two decades doing surgery in big US hospitals and not notice how poorly older patients, and dying patients of any age, are treated.
A few docs see this sooner. Dr. Pauline Chen described her epiphany in her 2008 book Final Exam. But Chen, also a surgeon, didn’t need the death of a parent to see how disconnected the medical system is from its aging patients. She figured it out as a young resident.
I often have the chance to meet with hospital executives, staff, residents, and medical students. And I see few Pauline Chens. Young physicians with the passion and compassion to care for aging and dying patients (Note: they are not interchangeable) are precious—and rare.
I see more Atul Gawandes– highly-skilled docs who are so focused on medical science or technique that they pay little attention to the needs and desires of their patients. Only when their own parents suffer directly from failures of our health care system is the problem burned into their minds, and maybe even their hearts.
Physicians like to think of themselves as dispassionate scientists, which is a big part of the problem. But like the rest of us, they are not immune to a tragedy that hits close to home. And make no mistake, what happened to Winakur’s mother was a tragedy.
But why are so many medical professionals still so bad at caring for older patients? Here are a few reasons:
Young docs don’t know older people. Many grew up far from grandparents, and lived with fellow students or in young, trendy neighborhoods after graduation. Because they’ve had little life experience with older people, it is no surprise they don’t know how to talk with them. Some of the best docs and nurses I know helped care for aging relatives or neighbors as kids. It makes a difference.
They are not trained. No med school would ever let a student loose in an operating room without training. Yet, most do nothing to prepare graduates to have difficult conversations with older patients. It gets worse in residency. One attending physician put it like this: “I walk into a patient’s room followed by 10 eager residents. We all hover over the patient. They want to impress me and their peers, and they know the way to do it is to give fast, shorthand answers to my questions. They have no incentive to take the time to ask the patient how she feels or to explain things in lay language. We teach bad habits and shouldn’t be surprised that they learn them well.”
There are no financial incentives. According to the just-published Medscape physician compensation report, the average orthopedic surgeon was paid nearly $450,000 last year. The average family practice physician makes half that. Medicare pays an orthopedic surgeon an average of about $6,000 for hip replacement. A family practice doc gets about $60 for a routine office visit. Is it any wonder that the default treatment for a hip fracture is surgery?
Hyper-specialization: Medical complexity, status, and that money all drive docs to highly-technical specialties. They are great at treating your heart disease, your cancer, your arthritis, and your diabetes. They are not so good at caring for you.
Hospitals don’t focus on older patients. Except for women giving birth and their newborns, hospitals are full of older patients. And the facilities obsess over how to improve patient satisfaction ratings, in part because Medicare partially bases compensation on those scores. Yet, they don’t redesign their practices and culture to respond to the needs of those patients. Here’s a nice consumer perspective on this from my friend Anne Tumlinson
It is sometimes the small things that matter: An aide who takes the time to wash the hair of a 70-something patient who has been in a hospital bed for a week. And sometimes it is big things: An emergency room doctor who gets a palliative care consult, and not an orthopedic consult, for an 85-year-old with dementia and heart failure.
Winakur, Gawande, and Chen keep writing. Consultants keep consulting. The Baby Boomers keep aging. And the medical system still doesn’t get it.