Friday, December 20, 2013

Aging and the Art of Losing -

This is often how the story emerges: the cold, metal scale in the geriatrics clinic betraying a tightly held secret. "You've lost another four pounds," I say to my patient, an 85-year-old woman who layers multiple shirts against the season's chill and peels them off to reveal skin that hangs on her stooped frame. She wears an oxygen cannula and is mildly short of breath after this exertion. With some taps of the keyboard, I note a 22-pound weight loss in the past two years.

The true tally of her losses is more significant. First there was her husband, who died unexpectedly in the emergency room one winter day. She still will turn and expect to find him sitting in the chair beside her. Another loss was the home they shared. Her children moved her to a senior apartment building so she could be nearer to them. A fall resulted in a fractured pelvis, so that now she slowly negotiates a wheeled walker through the shrinking sphere of her life. It has all been an adjustment. She does not feel like eating when she is alone.

"The art of losing isn't hard to master," writes Elizabeth Bishop in her poem "One Art." "So many things seem filled with the intent to be lost."

In my third year as a geriatrician, a doctor who specializes in the care of older adults, I find these words are often in my mind as I listen to the stories of my patients. I've learned from them that aging is an emotional experience as much as a physical one. Doctors and nurses caring for the growing numbers of elderly need to recognize this.

I take histories from patients well versed in the art of losing: The widower who tries, unsuccessfully, to recreate his wife's pork chops, and instead sustains himself with whiskey and cigarettes in front of a flickering late-night TV. The Air Force veteran with swollen legs who can no longer walk to the bathroom and smells faintly of urine, swearing he would rather take a gun to his head than move to a nursing home.

Sometimes the metal scale is a cruel accomplice, uncovering lapses that can no longer be ignored. One woman, a wisp over 100 pounds and disoriented about time and place, has put plastic storage dishes in the oven and served raw hamburger to her husband. Both of them are shedding pounds, alarming their daughter, who accompanies them from the waiting room and gently, tearfully mentions the slips. Within the year, the husband will be dead and their children will have boxed up the contents of the three-story home where they lived for more than half a century.

One reason I chose geriatrics is that it offers the chance to help older adults have an excellent quality of life, in spite of disability and illness. And for sure, many of my patients continue to lead vibrant, joyous lives in their 80s and 90s — volunteering, traveling, remarrying, spending time with family. One is 97 and takes classes in memoir-writing, music and the Supreme Court. Another, 93, sings in his church choir, bowls in a league and dances the shag at the American Legion.

Still, I know there are some calamities I cannot fix, tragedies so ordinary and yet so singular: A patient, down nine pounds in the past year, who hits her face on the curb when she trips on the way to the store. Her daughter flies in from across the country and finds the refrigerator empty. The older woman misplaces the car keys, accuses the daughter of stealing, grows suspicious that people have been breaking into her house.

When I administer a short test of her memory and executive function, the ability to plan and organize behavior, she becomes flustered and annoyed. She looks at her daughter imploringly, but continues out of politeness. Young enough to be her grandchild, it feels cruel to ask her such ridiculous questions, but I know it is a necessary part of my assessment. I feel crueler still when she is unable to complete the task, and later, when I have to say, "You should not drive anymore."

I can only begin to imagine what it is like for her, and for other patients who lose spouses, confidants, homes brimming with memories. Mobility, independence, dignity. Their minds. Their identities. This is what I'm learning: Although I can't fix everything, I can ease suffering, and offer hope, understanding and dignity.

My patient's daughter has been taking notes in a spiral-bound notebook throughout the visit. I wonder if she will show them to her mother later, as proof of my conclusions and recommendations. When we are finished, the daughter returns the notebook to her tote bag, gathers their belongings – their role reversal an act of love that signifies how much has been lost. They walk down the hall away from here, the old woman taking small, cautious steps, heading out into the waning sunlight.

Ariel Green is a geriatric medicine fellow at the Johns Hopkins University School of Medicine in Baltimore.

Tackling a Racial Gap in Breast Cancer Survival -

MEMPHIS — After her doctor told her two months ago that she had breast cancer, Debrah Reid, a 58-year-old dance teacher, drove straight to a funeral home. She began planning a burial with the funeral director and his wife, even requesting a pink coffin.

Sensing something was amiss, the funeral director, Edmund Ford, paused. "Who is this for?" he asked. Ms. Reid replied quietly, "It's for me."

Aghast, Mr. Ford's wife, Myrna, quickly put a stop to the purchase. "Get on out of here," she said, urging Ms. Reid to return to her doctor and seek treatment. Despondent, Ms. Reid instead headed to her church to talk to her pastor.

"I was just going to sit down and die," she says.

Like many other African-American women in Memphis and around the country, Ms. Reid learned about her breast cancer after it had already reached an advanced stage, making it difficult to treat and reducing her odds of survival. Her story reflects one of the most troubling disparities in American health care. Despite 20 years of pink ribbon awareness campaigns and numerous advances in medical treatment that have sharply improved survival rates for women with breast cancer in the United States, the vast majority of those gains have largely bypassed black women.

More ...

Sunday, December 15, 2013

Solving the Shortage in Primary Care Doctors -

Again and again, we hear that the country has too few doctors, particularly for primary care. And Obamacare is supposed to make the shortage much worse in the coming years as more Americans become insured and try to shoehorn themselves into already crowded medical offices.

But why, exactly, are doctors in such short supply?

I had always assumed the culprit was medical school enrollment. But when I looked into those numbers, I found that they are actually increasing noticeably. Thanks to the opening of new medical schools and expanded admissions at existing ones, enrollment is projected to rise by 30 percent between 2002 and 2017, according to the Association of American Medical Colleges. That's in addition, mind you, to the swelling number of med students studying abroad, with the goal of eventually practicing in the United States.

It turns out that the real bottleneck is at the post-med-school step: residencies, those supervised, intensive, hazing-like, on-the-job training programs that doctors are required to go through before they can practice on their own.

There has been little growth in residency slots; they totaled 113,000 in 2011-12, from 96,000 a decade earlier. Exactly why residencies have not increased faster is a subject of great debate in the health care industry.

Hospitals, doctors and med students usually give the same explanation: Congress is too stingy.

After all Congress, through Medicare, subsidizes the vast majority of residency slots, at $10.1 billion annually, or an average of $112,642 per resident per year. Congress froze the number of subsidized positions in 1997, and hospitals argue that the best way to train more doctors is for Congress to open the spigot and fund more jobs.

Obviously Washington is not keen on doling out more money for anything right now, especially not for Medicare. But there's a bigger problem with that argument: It's not clear that hospitals actually need taxpayer money to pay for more residents, because those residents might actually be turning a profit for those hospitals right now. It's hard to know, though, because hospital accounting is so opaque.

Residents definitely impose a lot of costs, besides the salaries they earn. Those salaries are fairly low — about $50,000 to $65,000 a yearjust slightly more than hospital janitors on an hourly basis. The enormous number of hours they work — about 80 hours a week — is crucial in these calculations. Their 80 hours may not be as productive as 80 hours spent by their supervisors would be, but they're still providing some valuable services during that time, said Uwe E. Reinhardt, a health economist at Princeton and contributor to The Times's Economix blog. Relative to other personnel alternatives, like hiring more nurse practitioners or physician assistants, residents provide relatively cheap, skilled labor.

Costs are only part of the story. "Hospitals don't like to acknowledge that there's anything other than a cost part of the equation," said Gail Wilensky, a health economist who is a co-chairwoman of the Institute of Medicine'sCommittee on Governance and Financing of Graduate Medical Education.

Dr. Wilensky says that most likely, hospitals lose money on residents in the first year, when the doctors just out of med school waste a lot of time and money on unnecessary tests and treatments. But residents' value goes up rapidly because the learning curve is steep, while their salary increases are not.

In fact, one data point that suggests hospitals are currently making a lot of money on the more seasoned residents is the quantum leap in compensation on the day doctors convert their status from trainee to attending physician, under a new job contract. How can a doctor be worth paying only $60,000 on Friday and then at least twice that on Monday? Does the doctor's marginal revenue product — that is, how profitable the doctor is for the employer — actually surge that much?

We don't know exactly how profitable individual residents are for hospitals because the hospitals can't or won't do the complicated accounting to figure it out, at least not publicly. But we can guess, at least, where hospitals believe they make the most money, based on how they've allocated their residency slots (both those Medicare subsidizes, and the 17,000 additional jobs that health care organizations have managed to create through other funding in the last decade).

There's another problem. The types of residencies with the most growth are not necessarily the ones that are most critical for the country's public health needs. They're more often in the lucrative specialties that America's fee-for-service billing system rewards. Think anesthesiology and neurology, and not primary care or pediatrics, where hospitals are more likely to lose money for many years in training a resident because of America's crazy payment system.

"Under our current system, despite the fact that they're getting huge amounts of federal money, there is no requirement that hospitals bring on residents in any kind of work-force-accountable way," said Dr. Fitzhugh Mullan, a physician and health policy professor at George Washington University. "So they're doing what businesses do, by bringing in residents that are most valuable to them."

In other words, hospitals are behaving rationally according to the incentives set up by law. Which brings us back to what Congress can do to help shape the health care work force. Merely funneling more taxpayer money to the doctor training system, as hospitals and med schools hope is done, is not likely to solve the problem. The money needs to be directed in a more deliberate, intelligent way.

There are, of course, other ways to reorganize the health system to alleviate the primary-care doctor shortage. Lawmakers might allow nurse practitioners, pharmacists and other nondoctor clinicians to provide more services, for example. But reshaping the physician work force through targeted subsidies for residents might be a good first step.