Senior Psychcare

I am an aging geriatrician, three and a half decades in the healthcare trenches now. As it happens, since almost all of my patients are covered by Medicare, I have worked in what amounts to a single payer health care program all these many years.

Despite the simple fact that my professional medical specialty - the primary care of the oldest and most susceptible among us - is the least remunerative of any specialty in adult medicine, we geriatricians constantly rate our job satisfaction higher than any other class of doctors. An economist or policy wonk or journalist might have a hard time understanding this state of affairs. Such a person might ponder the workaday life of a geriatrician and question how that doctor can stand to get up and go to work every day. Ministering to failing bodies and minds, giving low-tech awareness to everyday physical functions, and continuously dealing with patients and families in traumatic end-of-life scenarios? How can he or she possibly go on undertaking this for a professional lifetime?

Without a doubt, it is not only outsiders who are unable to imagine themselves practicing geriatric medicine. Less than 2% of medical residents show any interest in the primary care of our nation’s aging population. Thus, in this age of burgeoning need, the numbers of physicians specifically trained to care for the elderly will continue to decline.

From the "Mediscare" debates in Congress to the op-eds in the Washington Post, one could get the impression that this decrease might be a good thing for the ultimate economic well-being of our nation.

Rep. Paul Ryan of Wisconsin and his like-minded, mainly fellow-Republican colleagues want to change Medicare to a voucher system. This is supposed to empower beneficiaries to shop around for the very best deal they can get from contending private insurance plans.

Robert J. Samuelson hammers home the fiscal facts of our aging nation at every opportunity from his editorial position at the Washington Post."Medicare as we know it" is going to end, he wrote early during the debt-limit fight this summer. Late in that episode, in his July 28 column titled "Why are we in this debt fix? It’s the elderly, stupid," he wrote, "Older Americans do not intend to damage America, but as a group, that’s what they’re about." I am not a health care economist. I hold no diploma in public health or health law. I have never kept public office. I have expended my years thinking about differential diagnoses, counseling families, and doing my best for individual clients.

I am not discounting Rep. Ryan’s or Mr. Samuelson’s information collecting and reporting. It is self-evident to most Americans that as more of us age, as we live for a longer time, and as new health systems come along, medical treatment is going to get more costly. We realize that as a modern society, we will have to place a value judgment on what piece of our overall economy should be used on our health and wellbeing.

It should not have to be stated in this manner, but seemingly it does: None of this is the fault of the aging population! And here is where the controversy begins to get sticky, the slope slippery.

Recently I was talking about the case of one of my patients with two physicians I respect, one a research scientist, the other an internist. Ms. T., I related, had been my patient for more than 20 years. She had emphysema and acute asthma. She then had several strokes, became demented, and in her late 70s was placed in a long-term care facility.

Although disoriented and not able to communicate, she had been conscious and alert and generally pleasant, unless she was feverish with one of her frequent rounds of pneumonia or urinary tract infection.

I had done my best to treat her in the facility, but she almost always eventually required hospital admission. No amount of "end-of-life counseling" (unreimbursed then, as now, by the single payer program I work for) could convince her only child - a devout Catholic - to forgo extraordinary measures or enroll his mom in hospice care. Of course, she finally died, but not before she had had over twenty hospital stays under my care.

My colleagues, on hearing about this case, were appalled. The research scientist said the solution was simple: Separate the dollars in the public pie into pieces and give each elderly patient his or her share. If the individual wants to pay privately for the rest, fine. This from someone in a field where lab scientists toil to uncover"life-prolonging" chemotherapeutic agents that can cost $100, 000 to prolong one life maybe by 1 month.

The internist’s response was this: There are ways to cope with patients and families who are so demanding of assets. It is not unethical, I was reminded, to insist that the family locate another physician to take over the case. Of course, this begs the question of who might assume such a case. And if such a person were found, wouldn’t he or she undoubtedly accede to the family’s wishes anyway, since it was the family that vetted the new doctor?

In my career, I have cared for 1000's of people. I have been engaged with many families in difficult, often wrenching scenarios. Yes, there have been a few individuals in these last years who dismissed me - or vice versa - from the case. But very few.

My position is that of an advocate for my patient and his or her family - an advocate with practical experience and compassion who will help guide these people through the often complicated, infuriating, and terrifying periods of acute illness, decline, and demise. I run interference for them in opposition to insurance providers, hospital directors, ward nurses and aides, device providers, and even my (ordinarily) well-intentioned colleague who blithely plans to slip in that "new" knee or to poison that cancer into submission.

As it has turned out, even on the exceptional occasion when I see a patient through twenty hospital admissions before I get her to the other side, I am a"cost-effective service provider," compared with the hospitalists and procedure-oriented professionals I come upon.

Rep. Ryan, columnist Samuelson, and even some of my colleagues may judge me harshly in view of the fiscal difficulties that are attributable to our aging citizenry. Those naysayers may say that I and other doctors who practice in a related manner are the source of the trouble, we who dare to question one-size-fits-all algorithms.

But then they will call my office and ask if I might be able to fit in a new patient: their mother or their father or perhaps even themselves. And I will say: "Of course I can." Because I enjoy what I do.