Providers by any other name

Guilty, guilty, guilty.

That was my reaction after reading Dr. Danielle Ofri’s take at the New York Times Well blog yesterday on the use of the word “provider” to refer to people in health care.

Dr. Ofri dislikes the term intensely:

Every time I hear it – and it comes only from administrators, never patients – I cringe. To me it always elicits a vision of the hospital staff as working at Burger King, all of us wearing those paper hats as someone barks: “Two burgers, three Cokes, two statins and a colonoscopy on the side.”

“Provider” is a corporate and impersonal way to describe a relationship that, at its heart, is deeply personal, Dr. Ofri writes. “The ‘consumers’ who fall ill are human beings, and the ‘providers’ to whom they turn for care are human beings also. The ‘transactions’ between them are so much more than packets of ‘health care’.”

I suppose this is as good a time as any to confess I’ve used the p-word – used it more than once, in fact.

It’s not that I don’t know any better. I’ve been aware for quite some time that many people in health care don’t really like to be called providers. I deploy the word rather gingerly, and have increasingly taken to calling them something more specific – doctors, for instance, or nurses, or clinicians.

Frankly, it’s hard to know what the right word should be. Once upon a time it was pretty safe to use the term “doctor” to refer to those who provide (sorry!) care. This is no longer a given; many of those engaged in patient care these days are nurses, nurse practitioners, physician assistants, medical assistants and… you get the picture. (For that matter, “doctor” and “physician” aren’t interchangeable either, but I digress.)

“Clinician” seems a little closer to the mark, and it has the merit of distinguishing those in health care who are engaged in the actual care of patients from those who aren’t. But it’s a catch-all term, not particularly descriptive and somewhat lacking in personal warmth and fuzziness.

Similar minefields lurk in terms such as “health care professional,” “mid-level professional,” “allied health professional,” “health care worker” and the like. They’re lengthy, cumbersome and stilted. It can be inaccurate to call everyone who works in health care a “professional,” because many of those who toil behind the scenes in disciplines such as medical records management and central distribution aren’t professionally licensed, even though their work is just as essential. On a more politically correct note, many allieds don’t like being called mid-level because of the hierarchy this implies.

Don’t even get me started on the varying levels of “health care organizations.” Hospitals, medical clinics, outpatient surgery centers, community health centers, public health agencies – each occupies a special place in the ecosystem and can’t easily be lumped into generic vagueness.

And if you really want to get technical, shouldn’t we consider health insurance, pharmaceutical companies and medical device manufacturers as part of the “health care system” as well?

What’s a writer supposed to do? It’s a constant challenge: trying to be accurate and descriptive yet not allow oneself to become bogged down in multiple syllables.

Language does matter. There’s a case to be made for the importance of being aware of cost, quality and medical necessity – for behaving as a consumer of health care, not solely as a patient. But I view myself first and foremost as a patient, and I’m not sure I like it when patients are urged to “shop around” for good care as if they were kicking the tires at a used-car lot. There’s a relationship aspect to health care that goes beyond pure consumerism and that needs to be recognized and valued.

If we’re debating about the language, perhaps it’s because everyone’s role is shifting to a greater degree than at any other point in history. Patients have more information and are being asked to take more responsibility, as well they should. The people who care for patients are being pulled in more directions than ever before. We don’t know what to call ourselves anymore, and reasonable alternatives don’t seem to have been created yet.

So here’s the deal: When I use the term “providers,” it isn’t because I think of them as burger-makers at a fast food restaurant. It’s generally because the word is short, to the point and encompasses the range of individuals and organizations I’m writing about. As far as I’m concerned, my doctor and nurse are still my doctor and nurse and I’m still their patient. Sometimes I’m a consumer, but only when consumer behavior is what’s called for.

If anyone has suggestions for new terminology other than “provider,” I’m all ears.

Photo: Wikimedia Commons

Good riddance to all that

I heart New York – more specifically, the fifth annual Good Riddance Day in Times Square, when people can discard all the negative baggage of 2011 that they’d prefer not to carry into the new year.

Talk about catharsis.

According to the WNYC News Blog, people lined up Wednesday for their turn with the shredder, the Dumpster and the sledgehammer. One woman got rid of the ugly metal and Styrofoam brace she was forced to wear after breaking her wrist. Others took revenge on exes. Then there’s the dad who unloaded the plastic sick bucket he bought when his 10-year-old son was diagnosed with leukemia last year.

His son is now healthy, Rick Santoriella told WNYC-WQXR News. “So I’m going to smash this thing and we’re going to say good riddance to children’s blood cancer and leukemia.”

I have my own list of health-related pet peeves I want to consign to the Dumpster before bidding adieu to 2011.

In no particular order of importance:

- The constant equating of screening with prevention. They are not the same thing.

- Efforts to repeal the Accountable Care Act. Millions of young adults now have access to health coverage under their parents’ plan, health insurance exchanges are being created, the Medicare prescription drug coverage donut hole is gradually being eliminated, millions of dollars have been pumped into the National Health Service Corps to bring clinicians to rural and underserved communities… and we want to undo all of this?

- The continuing assault on Medicare and Medicaid. Concerns about the rising cost are well founded, but at whose expense? Among the unintended consequences of ratcheting down provider payments: More clinicians may simply stop seeing these patients.

- New restrictions imposed on access to information contained in the National Practitioner Data Bank, which tracks how state medical boards oversee problem doctors. The direction should be toward more transparency and accountability, not less.

- The scale in the doctor’s office. Unless there’s a specific medical reason to weigh the patient, no one needs to know.

- The word “veggie.” OK, I know this is petty. But it’s hard to have a serious conversation about nutrition in the U.S. when we use language that’s better suited to a children’s cartoon. Say it: “vegetables.”

That’s my list. Into the shredder with all of them! 2012 is a new year.

Readers, what would you send to the Dumpster?

Photo: Wikimedia Commons

Social media use: the new risk factor?

Doctors already query patients about whether they drink, use tobacco or are up to date on their immunizations. Should they also be asking about the patient’s use of the social media?

The question was raised on Twitter recently by Jamie Rauscher, a consultant and strategist on digital communication for health care organizations. Then it was picked up by Dr. Elaine Schattner of the Medical Lessons blog, who reflected on the world of social media and why physicians should or shouldn’t blog or tweet.

Dr. Schattner writes that blogging, for her, is both liberating and fun: “As I’m no longer practicing, this wide-open world of shared facts, some questionable, and new ideas keeps me alert and, maybe, in-touch.”

Might this not be the case for patients as well? Rauscher joined the discussion, noting that when physicians don’t spend much time online, they can be unaware of what their patients are encountering, especially sources of information that are less than reliable.

And she makes an important point: Doctors “cannot help patients find credible resources unless they understand what patients are doing online.”

She writes:

I don’t mention my social media activity to my physicians because no one asks me and there isn’t a logical time to broach the topic during an exam. Perhaps doctors should start including questions about patients’ online activity, including social media use, in the questionnaires they give patients. This could provide an opening to discuss the topic.

I can think of many reasons why screening for this could help improve patient care. For one thing, it would identify where the patient gets most of his or her information and could help clinicians more effectively tailor their patient education. For another, it’s an opportunity to assess what the patient knows and to address misinformation or provide information that’s more detailed and in-depth.

But there’s the practical perspective to consider too. People’s online habits have a way of shaping their entire daily routine. When the National Sleep Foundation conducted a survey earlier this year, it found that the increasing use of technology is starting to interfere with a good night’s sleep. Six in 10 of the respondents said they spent time on their computer before bedtime and many of them reported lower-quality sleep and feeling drowsy during the daytime.

I’ve personally learned that the sedentary aspect of Facebook, Twitter, blog reading and online discussion can seriously interfere with the need for more physical activity.

It can be hard for doctors to offer helpful, appropriate counseling about insomnia or weight gain if they don’t take the patient’s online habits into account.

Then there are the emotional minefields of bullying and harassment, which prompted the American Academy of Pediatrics to issue guidelines earlier this year for pediatricians to be on the lookout for online trouble among kids.

Many of these issues are already being debated in the medical world: Should doctors be on Facebook? How should they interact online with patients and the public? What’s ethical and what isn’t?

Although there’s a growing consensus that health care organizations need to join the online conversation (for an example, check out the Mayo Clinic Center for Social Media), whether to routinely screen patients regarding their social media habits is a different issue altogether – and at least as far as I can tell, one that apparently hasn’t gotten much attention.

What do readers think? Should doctors ask patients more often about their use of the social media? Would it lead to better patient care?

Photo: Wikimedia Commons

‘This is where I belong’

Nine months of hands-on clinical training, seeing patients and working with physician mentors at Affiliated Community Medical Centers reinforced the desire of Sarah Eisenschenk, now a fourth-year medical student at the University of Minnesota, to become a rural primary care doctor.

“I guess I found out that this is where I belong!” she concludes in an essay posted this past summer on the Discover ACMC blog.

When you get right down to it, all health care ultimately is local – and you can’t have a good local health system when the right people aren’t in place.

Much has been written about the supply of physicians in the U.S.: how there aren’t enough of them, how specialties such as primary care and geriatrics are in short supply, and the geographic imbalances that leave some urban areas with a surfeit of physicians while rural and/or remote communities go begging.

As someone who lives in rural Minnesota, I’m keenly aware of how much it takes for local providers to attract and retain qualified doctors. They’ve notched up several successes in the past couple of years, but they can’t ever really stop recruiting because they know that a departure or a retirement, or a decision to expand a service – cardiology, for instance – could change the whole situation.

We don’t seem to be alone. The Association of American Medical Colleges projected last year that the national shortage of physicians could reach 62,900 doctors by 2015 (that’s just three years away) and 91,500 by 2020.

I was therefore taken aback when I recently came across some reports suggesting the doctor shortage isn’t as bad as it’s made out to be. According to data released by the Association of American Medical Colleges, there were 258.7 active physicians for every 100,000 Americans last year. More than six in 10 physicians settle in the state where they received their medical education, the report found.

This month the Colorado Health Institute issued a report on the state’s health care workforce and the impact of adding the uninsured to the health insurance rolls when this provision of the Affordable Care Act takes effect in 2014. The report’s conclusion: There’ll be a need for more health care providers but it won’t be as dramatic as many anticipated.

Here’s a final piece of data: First-time applications to medical school reached an all-time high this year, according to the Association of American Medical Colleges. Medical students are increasingly diverse, and the majority start their training with some previous exposure to clinical experiences.

While all of this sounds positive, the picture becomes more complex when you start studying the details.

The Colorado Health Institute report, for instance, is careful to point out that rural areas are, and will continue to be, short of doctors. Nor did the report take into account the impact of an aging population or the increasing trend among physicians to specialize rather than go into primary care.

The situation also varies considerably from state to state (click here to see an interactive map put together by American Medical News). Some states do very well at retaining physicians after they complete their training at one of the state’s medical schools. Alaska, California and Montana manage to keep 60 percent or more of their medical school graduates in the state. New Hampshire is the worst, exporting all but 28.3 percent of its graduates. The Upper Midwest is somewhere in the middle; of the 17,516 medical graduates whose training was in Minnesota, 7,735 – or 44.2 percent – remained in Minnesota to practice medicine.

Dig deeper and you’ll find that although Minnesota has 269.6 active physicians for every 100,000 residents, a figure that puts it among the best 15 states in the U.S., the number of active primary care physicians is 103.8 per 100,000. Moreover, 22 percent of all physicians in Minnesota are over the age of 60 and presumably beginning to think about retiring.

It’s not a time to get complacent, which is why I’ve found it encouraging to read the many physician stories posted at the ACMC blog. One of the most recent comes from Dr. Michelle Cilek of ACMC-Redwood Falls, who describes the rewards of being a family doctor in a smaller town where she can practice quality medicine yet still have time to garden, sew and attend her children’s soccer games. “Redwood Falls is a great community; my practice is busy and I am able to get to know my patients on a more personal level because I see them at church, my children’s activities and more,” she writes.

Dr. Merlin Nelson, a neurologist, likes the challenge of the variety of patients he sees. Being a five-minute drive away from the clinic or hospital when he’s on call is a pretty good deal too. ACMC physicians in Granite Falls, Litchfield, Marshall and Willmar share their stories here, here, here and here.

To the average patient, what matters most is having a doctor quickly available when the need arises. Issues of supply and demand, of geographic distribution, specialty distribution, availability of training slots and even the increasing burden of medical training costs can seem rather remote and academic. But making all the pieces come together is much harder than it looks, and it’s all the more rewarding to see when this happens in your own backyard.

Illustration: “Doctor and doll,” Norman Rockwell, 1929

Health-ready for the holidays

Tinsel? Check. Cookies? Check. Prescription medication refills… um… check?

Like a lot of other people, I tend to get so fixated on the shopping, the baking and the Christmas cards that I don’t give much thought to other necessary preparations for the holidays – namely, the stuff that helps us stay in a healthy groove despite all the bustle and schedule disruptions of the holidays.

My inbox has been filling up in recent days with tips and advice from the experts, and this is a great time to share it.

Let’s start with the travelers. For them, U.S. HealthWorks offers these suggestions:

- Get adequate rest the night before, so you don’t start your day already feeling rundown.

- Carry pocket-sized tissues, hand sanitizer and saline nasal spray. Use hand sanitizer periodically after touching public surfaces and before eating, and try to avoid touching your face, mouth and nose with hands that might be contaminated.

- Drink plenty of water to stay well hydrated. If you’re going to be eating while traveling, eat wisely and avoid alcohol.

- Cramped seating and inactivity during long flights can put air travelers at increased risk of deep venous thrombosis, or a blood clot in the legs. To reduce the likelihood of this potentially life-threatening complication, it’s advisable to move around periodically. Wiggle your feet and toes, stretch your legs if there’s enough room to do so, and get up and walk around the cabin briefly every 20 to 30 minutes to restore your circulation.

- If you have chronic medical issues, check with a health provider about special travel precautions you might need to follow.

Here’s something for grandparents to heed when their grandchildren come for a visit during the holidays (or any other time of year, for that matter): Leaving your pills on a countertop might help you remember to take them each day but it also places them within easy reach of curious kids. In a study by the U.S. Consumer Product Safety Commission and the Poison Information Center at Children’s Hospital in Birmingham, Ala., one-third of accidental prescription drug-related poisonings among children involved a grandparent’s medication.

Many older adults don’t use child-resistant pill bottles or weekly pill minders, often because arthritis or poor vision makes them too difficult to open. When possible, grandparents should ask for child-resistant packaging and take the time to learn how to use it properly, experts suggest.

Because child-resistant is not the same as childproof, grandparents should also take the extra step of placing medications out of reach. This includes medications stored in grandma’s purse or in a suitcase. If these precautions make it harder to remember to take the medication, try setting an alarm instead as a reminder.

From the U.S. Centers for Disease Control and Prevention comes a list of 12 holiday health and safety tips, a la the familiar “Twelve Days of Christmas”, that applies to just about everyone. The folks at the CDC even were festive enough to come up with a song you can send to your friends and family in a holiday e-card.

The list includes advice such as washing your hands often, bundling up to stay warm, using seat belts, preparing food safely and observing the rules of fire safety.

Speaking of fire safety, here’s a startling video, courtesy of WDAY-TV in Fargo, N.D., demonstrating how quickly a Christmas tree can go up in flames. The lesson here: Don’t leave candles or fireplaces burning unattended, don’t use Christmas lights with frayed or damaged cords, and have an emergency plan to evacuate the house should the worst occur.

There can be a fine line between obsessing about everything that might go wrong and enjoying the holidays with some preparation, moderation and common sense. But an extra helping of the latter can go a long way toward having a Christmas worth remembering in a way that’s good rather than bad.

Photo: Wikimedia Commons

Getting personal about the cost of care

Health care is very personal, and this includes the financial aspects of how we pay for care.

Costs of Care, a nonprofit organization dedicated to raising the level of awareness about medical decisions and how they affect what the patient pays, has announced the finalists in its second annual essay contest – and I can’t wait to read the entries.

There’s the story of Renee Lux, a patient from Connecticut who received an unnecessary CT scan for neck pain and ended up being branded with a pre-existing condition that caused her health insurance premiums to go up.

There’s Melody Chung of California, whose mother underwent a barrage of diagnostic tests for fleeting chest pain and was charged an unexpectedly high bill.

There’s Molly Kantor, a medical student in Massachusetts who helped treat heart failure on a $100 budget by avoiding an unnecessary hospital admission.

Winners of the essay contest will be announced in mid-January. Entries will appear on the Costs of Care blog throughout 2012.

This is the second year Costs of Care has sponsored the national essay contest. More than 100 entries were submitted from across the U.S. The distinguished panel of judges includes C. Everett Koop, former U.S. Surgeon General; Peter Orszag, former White House budget director; Jennifer Granholm, former governor of Michigan; women’s health advocate Dr. Susan Love; and Alan Garber, Harvard University provost and health economist.

In the intense, ongoing national conversation about the cost of health care, it’s easy for individual stories to become lost in a sea of statistics and arguments. The personal stories are a reminder that this issue is more than academic; it’s about real lives and real people. Watch this space for the announcement of the essay contest winners next month.

More respect for chickenpox, please

I was in grade school when I came down with chickenpox. I don’t remember much about it, other than being itchy and uncomfortable.

This was long before a chickenpox vaccine was developed. Back then, the majority of kids had the disease by the time they were in their teens. If a vaccine had been available, I suspect many parents would have gladly agreed to it in order to avoid the illness and misery.

It’s an entirely different ballgame now. Most younger adults have grown up with little or no firsthand experience of childhood diseases, such as measles, chickenpox and whooping cough, that once were common. There’s less trust in vaccines and more worries about vaccine safety.

When you put all these factors together, they can result in some questionable decision-making, of which so-called chickenpox parties are a prime example. In fact, health officials are so concerned about the pox-party trend that they’ve been speaking out; the latest warning came last week from the Minnesota Medical Association.

Chickenpox parties are nothing new. For those who don’t know, a chickenpox party involves bringing children together with a child who has the disease, in hopes the exposure will make everyone sick so they can get the disease over with and be naturally immunized for life. At one time, they were seen as somewhat of a convenience, allowing parents to plan for a child’s illness and to have their child contract the disease earlier in life, when chickenpox tends to be milder. But since the mid-1990s, when the chickenpox vaccine was introduced, another element has entered the discussion: fears about the vaccine and the belief that it’s safer for children to acquire natural immunity from the disease itself.

The chickenpox party is a controversial practice. Many people see it as unnecessarily risky. Others see nothing wrong with it.

What’s not exactly clear is why chickenpox doesn’t seem to inspire the same level of caution in many people as other infectious diseases do – influenza, for instance, or whooping cough.

A little background on chickenpox:

It’s caused by the varicella zoster virus, a member of the herpes virus family. There are records of it as far back as ancient Babylonian times. It was first formally identified by a 9th-century Persian scientist. Despite its name, it doesn’t have anything to do with chickens nor is it related to smallpox.

Modern-day Americans tend to regard it as a non-serious disease – and for the most part, it usually is. But this fact shouldn’t obscure the complications that can come with chickenpox. Teenagers and adults who get chickenpox can become severely ill. Complications include pneumonia, encephalitis and secondary bacterial infection of the soft tissues. The disease can be especially serious among women who are late in pregnancy or individuals who are immune-compromised. It’s worth noting that chickenpox, along with measles, smallpox and venereal disease, was among the diseases brought by early colonists to the Americas, decimating a native Indian population that had never been exposed and hence was defenseless.

Before the chickenpox vaccine became available in the mid-1990s, there used to be 4 million cases of chickenpox in the U.S. each year, according to the U.S. Centers for Disease Control and Prevention. Chickenpox resulted in 10,500 to 13,000 hospitalizations each year and 100 to 150 deaths. Vaccination has lowered the number of hospitalizations by 71 percent and the number of deaths among children and teens younger than age 20 by 97 percent. Public health officials worry this trend might be reversed if growing numbers of parents decide to skip the chickenpox vaccine.

For what it’s worth, you can find pediatricians and nurses who don’t think it’s essential to vaccinate children against chickenpox. Based on early experience, the vaccine was about 85 percent effective at preventing the disease. Many states now recommend a second dose of vaccine, which has been found to boost its effectiveness to better than 95 percent. But there continues to be debate on how well the vaccine truly works or how long it stays effective. In view of the fact that the vaccine has been in use for less than two decades, it will take time for research to help answer these questions more definitively. In the meantime, there’s bound to be confusion and conflicting opinions.

No one can force parents to vaccinate their children. Health decisions are among the most personal decisions we make. When infectious disease is involved, however, there’s a case to be made for protecting the health of the whole community. Chickenpox is not always the mild, harmless disease that many people think it is, and deliberate exposure at a chickenpox party can have unplanned, unintended consequences. Chickenpox could use a little more respect.

Photo: Wikimedia Commons

The darker side of holiday spirits

At this time of year, warnings abound about overdoing the alcoholic holiday cheer. For the most part, it’s a lesson we know almost by heart.

What’s a little surprising are the myths that seem to persist – such as the one about drinking coffee to sober up, or that you aren’t really impaired unless you’re stumbling or slurring your speech.

Here’s a little myth-busting from the National Institute on Alcohol Abuse and Alcoholism:

- Myth: Alcohol doesn’t lead to impairment until after several drinks have been consumed. Reality: Alcohol’s effects begin quickly and can diminish critical decision-making and driving skills long before the physical signs of intoxication show up.

Drinking initially acts like a stimulant, causing the drinker to feel upbeat. But those first couple of drinks soon begin affecting inhibition and judgment. As more alcohol is consumed, reaction times become slower and behavior becomes less controlled. Continued drinking can lead to the slurred speech and loss of balance typically associated with being drunk. At even higher levels, alcohol acts as a depressant, causing people to become sleepy or pass out.

Myth: Once you stop drinking, the effects of alcohol go away. Reality: Alcohol continues to affect the body and brain long after the last drink has been downed. Even after someone stops drinking, the alcohol in their stomach and intestine continues to enter the bloodstream, impairing judgment and coordination for hours.

Myth: Drinking coffee will sober you up. Reality: Caffeine can help reduce drowsiness but it won’t do anything for the effects of alcohol on decision-making The only real cure is time while the body metabolizes the alcohol that’s been consumed and returns to normal.

From Narconon International comes this bit of myth-busting about wine:

Myth: You’re less likely to get drunk when you’re drinking wine. Reality: Alcohol is alcohol and it all holds the same potential for getting drunk, whether it’s poured from a bottle of fine wine, a bottle of single-malt whiskey or a can of beer. Serving sizes might vary but the alcohol content in each case is mostly the same – about six-tenths of an ounce of pure alcohol.

Here’s something that isn’t a myth: Alcohol-related traffic crashes increase during the holiday season. Statistics in fact suggest Americans are more likely to die in an alcohol-related holiday crash than at any other time of the year. About 40 percent of fatal crashes over the Christmas and New Year’s holidays involve at least one driver who has been drinking, according to statistics analyzed by the National Highway Traffic Safety Administration.

Many people enjoy a drink or two during the holidays but moderation is the key. Experts offer this advice: If you’re going to drink, pace yourself. Know what constitutes a standard drink and have no more than one per hour. Have “drink spacers” – make every other drink a nonalcoholic one.

Finally, have a plan to get home safely. The designated driver in the group should be the one who hasn’t been drinking, not the person at the party who drank the least.

For more information, check out the federal government’s Rethinking Drinking website.

Photo: Wikimedia Commons

The case for geriatricians

If ever there was a case to be made for the importance of gerontology as a medical specialty, it can be found at the GeriPal geriatrics and palliative care blog, where several recent entries focused on the special needs and dynamics surrounding health care for older adults.

One entry explored what’s known as “hospital disability syndrome,” or the downward spiral that can occur among older adults for whom a hospital stay might result in higher risk of falls, delirium, poor nutrition and functional decline.

Another entry raised important issues about the growing use of standard, one-size-fits-all indicators to measure quality of care. While rigorous control of blood pressure and blood sugar is beneficial for the majority of adults, it can result in more medication, a higher risk of side effects and a higher risk of harm for older patients, blogger Ken Covinsky wrote. “A key issue is that quality indicators almost always promote more medical intervention and more medical is not always better. This is especially the case for frail older persons, where the risk of treatments often exceeds the benefits.”

Finally, an entry titled “Too Much of a Good Thing” analyzed a recent study in the New England Journal of Medicine about emergency hospitalizations among older adults due to adverse drug events, and drew two conclusions: First, many of the older patients in the study got into trouble because they were receiving too much of a prescription medication – for instance, too much insulin. Second, many of the less obvious adverse drug events among the elderly, such as drug-induced delirium, can be difficult to recognize in the emergency room and indeed might not be identified at all.

Geriatrics is defined as “the branch of medicine concerned with the diagnosis, treatment and prevention of disease in older people and the problems specific to aging.”

It’s not a specialty that carries much allure. Doctors who specialize in geriatrics tend to earn some of the lowest salaries in medicine. Moreover, in America’s youth-obsessed culture, caring for aging patients with multiple health issues often holds little appeal.

It’s not surprising, then, that the U.S. health care system is woefully short of geriatricians, even as the number of older adults has been rising dramatically. According to the Geriatrics Workforce Policy Studies Center of the American
Geriatrics Society, only 86 students who graduated from medical schools in the U.S. in 2009 chose geriatrics as a specialty. That’s fewer than 1 percent of family medicine and internal medicine grads. And it’s not for lack of training slots, because about half of the fellowships available in gerontology were left unfilled.

The Geriatrics Workforce Policy Studies Center estimates there’s currently one geriatrician for every 2,620 Americans over the age of 75. By 2030, this ratio is projected to fall to one geriatrician per 3,798 older adults.

You could argue that we don’t really need specialists in geriatrics. Why can’t the care of aging adults be managed just as well by internists or family medicine physicians? There’s in fact a fair amount of debate on this point, helped along by confusion on the part of many patients and families about what, exactly, a geriatrician does.

To be sure, many internists and family medicine doctors are skilled and knowledgeable in caring for the elderly. And not everyone who’s old necessarily needs to have a geriatrician, particularly if they’re relatively healthy.

But let’s not underestimate what geriatricians bring to the table. In “The Way We Age Now,” a lengthy article that appeared in 2007 in The New Yorker, Dr. Atul Gawande takes readers into the world of aging, what it means in the medical sense to age, and what it takes to help older adults remain healthy and functional.

Gawande makes many important observations about care of the elderly, one of them being this: “Good medical care can influence which direction a person’s old age will take. Most of us in medicine, however, don’t know how to think about decline.”

And this: “People can’t stop the aging of their bodies and minds, but there are ways to make it more manageable, and to avert at least some of the worst effects.”

Although primary care doctors can certainly fulfill this role, it’s perhaps unrealistic to think they’ll be able to keep up with the new research being added almost daily to what we know about aging. Moreover, it takes both expertise and experience to understand the nuances surrounding geriatric health – to recognize, for instance, that when we talk about rigorous cut-off points for blood sugar levels, it can be harmful to older adults whose bodies don’t function the same way as younger adults and who have much more to lose from side effects such as dizziness leading to falls.

If we can’t buy into geriatrics from the standpoint of enhancing the quality of life for older adults, maybe we’ll be swayed by the economics of what it’s likely to cost if we don’t become better at meeting the health needs that come with aging.

Photo: Wikimedia Commons

Health care’s new commodity

You’re at the doctor’s office and the nurse or medical assistant is assessing your vital signs. Weight, height, temperature, blood pressure, pulse – each is measured and silently written down.

What’s missing from this picture? The sharing of information, that’s what. Are the patient’s vital signs a matter for the clinician’s eyes only, or are they something that also should be shared with the patient? Because all too often, whether it’s in the exam room or at the hospital bedside, the information goes straight into the medical record while the patient is bypassed.

I’m not trying to single out the people who take vital signs or suggest that they’re deliberately withholding information from the patient. This just happens to be an example I’ve noticed of a pattern that seems ingrained in health care culture: the assumption that the information doesn’t really need to be shared unless the patient specifically asks for it.

Late last week I was drawn into an online debate at Mind the Gap, a doctor-patient communication blog hosted by Steve Wilkins.

Wilkins opened with a basic premise: that the fastest way to disempower, de-activate and disengage patients is a trip to the doctor’s office. He writes:

If you were to believe the admonitions of the NIH, AHRQ, hospitals, pharma and every WebMD lookalike, you would think that patients these days would be more involved in their visit… asking questions, sharing information and making decisions. But as most physicians will attest… most patients don’t have much to say in the exam room anyway. And the longer they have to wait before being seen, the less patients are likely to bring up the few questions they wanted to ask.

Predictably, the responses were divided into doctors-are-incredibly-pressured-and-doing-the-best-they-can vs. patients-feel-shut-out-and-are-sick-of-fighting-for-every-scrap-of-knowledge-about-their-health.

While there are numerous factors contributing to this less than optimal state of affairs, at least some of it seems to stem from a playing field that simply isn’t level when it comes to sharing information.

One of the commenters said she asks questions in the doctor’s office and asks for copies of her medical record. “I ACT LIKE an empowered patient,” she wrote.”But it’s only possible to BE an empowered patient when the doctor is an active part of the process. An empowered patient can ask questions. That doesn’t mean that the doctor will provide an answer. An empowered patient can request notes and test results. No guarantee that those will be provided either.”

There’s in fact a new commodity in health care these days: information. Clinicians have it; patients want it. And therein lies a constant source of misunderstanding, frustration and defensiveness on both sides.

Patients chafe at the hoops they’re often required to jump through in order to obtain their medical information. This isn’t just their perception. Among complaints alleging violation of the federal HIPAA law governing the privacy of patient health information, problems with access to the medical record consistently rank No. 3 on the list of the top five violations requiring investigation and corrective action.

For their part, clinicians are under intense pressure and often can’t spend the time they’d like to share information more fully with patients. A physician commenter at Mind the Gap wrote:

This is the reality of today’s primary care office visit. 15 minutes: 4 minutes used for data entry into the EMR (has to be completed by the time the patient leaves); 3 minutes for entering lab orders and referrals; 90 seconds for reviewing health maintenance needs that have no relation to the visit at hand; 60 seconds for prescription reconciliation; THEN the six active problems can be addressed. There is no time for communication for any type, much less patient-centered communication!

Yet if you look at the research, it suggests many patients leave the doctor’s office with an incomplete understanding of key information such as what their diagnosis is or why they need a particular medication.

It’s true that for some patients, this simply might be more information than they’re able to absorb. This can’t be assumed for all patients, though. And it’s hard to see how patients can help make the most of limited time with their doctor when the default strategy is to give them minimal information in the belief that they don’t need more or won’t know how to use it.

What to do? Ironically, there’s more health information available than ever before. Consumers can go online and research their diagnosis. They can connect with other patients. They can check out the quality of their local hospital. They can rate their doctor. But none of this means very much when patients still often struggle for access to some of the most important data of all – information about their own health.