Vol. XXIV,No. 11 Printed in U.S.A.
JOURNAL OF THE AMERICAN GERIATRICS SOCIETY Copyright 0 1976 by the American Geriatrics Society
Physicians’ Attitudes Toward the I11 Aged and Nursing Homes* DULCY B. MILLER, MS,AM**, REGINA LOWENSTEIN, AM? and RICKY WINSTON, BS White Plains and New York, NY ABSTRACT: A survey of physicians in private practice (exclusive of pediatricians) was conducted in a medium sized suburban city in the New York metropolitan area, to determine whether physicians’ attitudes toward the ill aged and nursing homes were predictors of the quality of medical care available to area nursing home patients. Questionnaires were circulated t o 302 practitioners. Of the 28 percent who responded, 32 percent were psychiatrists, 15 percent primary care physicians and 8 percent orthopedists. Physicians felt competent t o manage the ill aged, although 50 percent had had no significant degree of exposure t o geriatric medicine in their medical education, and 70 percent of the primary care group had had none. Primary care and older physicians were more likely to treat patients in nursing homes. Almost 40 percent viewed the nursing home as a place t o die. Although 85 percent stated that physicians should be involved in the nursing home placement process, only 21 percent believed that they continued to be in charge of their patients after placement. The findings demonstrate generalized medical disinterest in the care of ill aged patients in institutions. The persons responsible for awarding government grants and those involved in planning medical school curricula should pay more attention t o the needs of the chronically ill aged. Prior to 1965, nursing homes were basically nursing oriented institutions. Following the passage and implementation of Medicare legislation, nursing homes became medically oriented facilities with the Conditions of Participation of Medicare mandating the availability of such things as laboratory and x-ray diagnostic procedures. Obviously, medical facilities require medical leadership to function. The quality of care in long-term institutions is directly related to the competence and volitional interest of physicians in the care of the ill aged in nursing homes. Thus, it was postulated that a study of physi-
cians’ attitudes toward the aged and nursing homes in the White Plains, New York community might serve to forecast the quality of medical care available to patients in nursing homes in that area. White Plains, county seat of Westchester, has a population of 50,000 and is in a n activity area of 250,000. It is the site of two general hospitals, a rehabilitation hospital and the psychiatric division of a New York City medical school, as well as the headquarters of numerous national and international corporations. REVIEW OF THE LITERATURE
* Presented a t the 33rd Annual Meeting of the American Geriatrics Society, Shamrock Hilton Hotel, Houston, Texas, April 21-23, 1976. ** Adjunct Instructor in Public Health (Health Administration), Columbia University School of Public Health, New York, NY. Address for correspondence: Dulcy B. Miller, MS, AM, Administrative Director, White Plains Center for Nursing Care, 220 West Post Road, White Plains, NY 10606. A copy of the survey questionnaire may be obtained upon request. t Associate Professor of Public Health, Columbia University School of Public Health and Center for Community Health Systems, New York, NY.
Over 15 years ago the American Medical Association acknowledged that the quality of care in long-term institutions was directly related to the quality of medical care practiced therein (1). A 1965 study by Kramer and Johnson (2) of 118 Illinois nursing homes showed that 50 percent of the patients did not undergo admission and annual physical examinations. Discharge orders were noted in only 50 percent of the medical records of discharged patients. Seventy-one per-
498
Nouem ber 19 76
PHYSICIANS’ ATTITUDES TOWARD THE ILL AGED
cent of the administrators interviewed believed that physicians had no understanding of the psychologic needs of the patients. A 1972 study of nurse-physician communication in a nursing home setting (3) demonstrated generalized physician disinterest in the care of the ill aged. Reluctance on the part of the covering physicians to care for the institutionalized aged in the absence of their colleagues often resulted in a refusal to sign death certificates. Nurses felt attending physicians did not assist in the development of definitive plans for the care of their ill aged patients. M. B. Miller (4) noted that physicians can be influenced by their own feelings toward the aged, perhaps related to personal parental relationships or their own perceptions about living and dying when they become ill and aged, or by the feelings of the patient’s family. D. B. Miller ( 5 ) suggested the advantages of a closed medical staff. Under such circumstances, medical care is likely to be superior, as physicians are selected on the basis of proven interest and competence in geriatric medicine. Is there a sufficient number of interested physicians to form the medical staffs of nursing homes? Although physicians need a hospital affiliation in order to practice, they can easily survive without a nursing home affiliation. Charles Edwards (61, Assistant Secretary for Health, Department of Health, Education, and Welfare, stated that a lack of professional involvement by physicians was a deterrent to greater utilization of long-term care institutions. He emphasized the need for more physician involvement in the care of nursing home patients. Solon and Greenwalt (7) showed that 14 percent of the active physicians of the community under study were affiliated with nursing homes and that the amount of their time spent in the nursing home was positively associated with the level of nursing care. The authors stressed the need to develop methods and criteria for assuring quality of care in nursing homes. Freeman (8) queried 76 medical schools regarding the training provided students in geriatrics. Only 34 percent of the returns by the interns and residents noted some training in geriatrics. Geriatric training was considered essential by 20 percent, useful by 62 percent, and unnecessary by 18 percent. Spence et a1 (9) studied the general medical prejudice toward old patients in a medical school environment, showing that freshmen and seniors shared society’s conceptions and misconceptions
concerning the aged. Seniors were not involved in the socialized concept and continued their original medical prejudice against old patients; three years of medical school did not mitigate this attitude. In a specific question regarding the choice of care for young or old, the prejudice toward the aged was dramatically apparent in the responses that favored the young. Colombotos (10) noted that younger physicians more than older ones stressed the “science” rather than the ‘?art”of medicine and tended to be interested in medicine as “work of special interest” rather than a way of “helping people.” This emphasis on the scientific rather than the humanistic approach to medicine may be reflected in the attitudes of younger physicians toward caring for the ill aged. Cherkasky (11) commented that the view of chronic disease held by the public and even by some physicians is colored by misconceptions, e.g., that chronic disease is indolent, not much can be done for the chronically ill, and not as much or as high-quality medical care is needed for the chronically ill as for the acutely ill. The title of a recent publication of the Moss Committee, the Senate Subcommittee on Long Term Care, speaks for itself - “Doctors in Nursing Homes: The Shunned Responsibility” (12). In the Moss Report the reasons for physician absence from nursing homes were described as complicated and included: a shortage of physicians with fewer general practitioners and more specialization, the medical schools’ low priority for aging, Medicare and Medicaid red tape and low reimbursement, the lack of back-up staff in nursing homes, the belief that nursing homes are unpleasant places to visit, and the lack of incentives for time and travel to nursing homes. All of the foregoing contribute to poor care for longterm patients. Solon (13) stated that patients whose medical profile calls for continuing medical management typically languish in nursing homes with relatively little medical attention. The common pattern documented in past nursing-home studies is that of crisis medical care rather than continuing management. Attending physicians enter nursing homes in response to emergency calls, despite the stated need for frequent visits by experienced clinicians to deal with continuing medical problems. Solon noted that an overlay of attitudes toward the aging and chronically ill gives physicians the impulse to stay away from nursing homes. Miller and Elliott (14) found that the primary
499
VOl. XXIV
MILLER, LOWENSTEIN AND WINSTON
admission diagnosis for 100 patients consecutively admitted to a nursing home was inaccurate or noninformative in 64 percent, and the secondary diagnoses were lacking or inaccurate in 84 percent, revealing a significant state of unpreparedness on the part of some physicians caring for the chronically ill aged. The authors concluded that the lack of identification of patients’ needs through diagnosis would result, perforce, in inadequate or inappropriate treatment programs for nursing home patients. Even in the 1957 study by Solon et a1 (19, the younger patients in a nursing home were seen by attending physicians significantly more frequently than the older patients. Haughton (16) noted no difficulty in attracting well trained physicians to nursing-home medical programs when there was a professional milieu and a minimum of bureaucratic red tape. In a demonstration project in which a general hospital provided medical care to a nursing home, the hospital resident (whose primary concern was his own education) responded to the stimulation of a professionally oriented program in the nursing home setting. According to Reiff (17), when a young person dies, the physician and family wish to know what happened and what could have been done to prevent it; often the postmortem examination is an important tool in learning the precise cause of death and the pre-existing morbidity. However, when an older person dies, the professionals and family are indifferent to finding out what happened; they accept death as caused by “old age,” with little interest in the mechanism that brought it about. Reiff cited the example of an outbreak of salmonellosis in Baltimore nursing homes which involved 107 of 140 patients; when the initial symptoms and early deaths occurred, too little attention was paid to the precise diagnosis and the cause of death. Further, in studying mortality in a geriatric center and hospital, mainutrition and infection related to debility were the two most important underlying causes causes that are often preventable and treatable. A recent popular publication by Lawrence Galton (18) noted that physicians deny health, productivity and independence to the elderly when they accept stereotypes that old persons must be sick, senile and complaining. He characterized physicians’ attitudes toward the aged as condescending and tolerant, and stated that these attitudes can be changed on an individual level without tackling all the social roots. He suggested the use of aggressive medical and surgical therapy
500
for reversible disorders, since it is better to try too hard than not at all. MATERIAL AND METHODS A questionnaire was designed to elicit information from the 302 physicians in private practice in the White Plains area, exclusive of 60 pediatricians. From the total of 302 area physicians, 151 were randomly listed for telephone interviews. As the response was not satisfactory, the initial and follow-up questionnaires were then sent by mail, with greater success. A total of 31 questions divided into 6 categories was designed to determine: 1)demographic data about the physicians and their practices not available in the New York State Medical Society Directory, 2) physicians’ general attitudes toward the ill aged, 3) physicians’ assessments of their training and their care of the aged, 4) physicians’ attitudes toward treating older people as compared to younger people, 5) physicians’ perceptions of nursing homes and nursing home patients, and 6) physicians’ attitudes regarding life and death for the ill aged. Demographic questions answered in the Medical Directory of New York State (19) were not repeated in the brief telephone interviews. Of the 151 candidates, 26 completed the telephone questionnaire. Contact was sought with all possible respondents until it was definitely ascertained that they would or could not participate. Since only 9 percent of the 302 area physicians proposed for the study completed the telephone questionnaire, the remaining 151 physicians received initial and follow-up questionnaires by mail. The mail survey proved to be more successful, scoring a completion rate of 40 percent as compared to only 17 percent for the telephone survey, or a total response rate of 28 percent. This increased response rate was perhaps attributable to the anonymity of the process, or to the fact that the physicians could complete the questionnaire at their leisure, or to the more official quality of printed matter in comparison to an unannounced telephone call. FINDINGS Demographic information on physicians and their practices
This information was derived from an official listing of the specialities of the 302 physicians considered for the questionnaire. Psychiatrists comprised 24 percent of the 302 physicians in the
November 1976
PHYSICIANS ATTITUDES TOWARD THE ILL AGED
White Plains area, general practitioners and internists together comprised 21 percent, obstetricians and gynecologists 8 percent, and surgeons 7 percent. The largest group (33 percent) represented those who graduated from medical school between 1951 and 1960; 24 percent represented graduates between 1941 and 1950; and 17 percent represented a combination of graduates from 1961 to 1970 and 1931 to 1940. Of the 87 physicians who responded to the questionnaire, 32 percent were psychiatrists, 5 percent general practitioners, 10 percent internists, and 8 percent orthopedists. Less than 12 percent of the general practitioners in the area responded to the survey, whereas 32 percent of the internists responded, as did 40 percent of the psychiatrists and 78 percent of the orthopedists. No pattern relating to the age of the respondents was noted. About 30 percent graduated from medical school in the decade 1951-1960, representing 26 percent of those graduates in the area; 24 percent were 1931-1940 graduates, representing 42 percent of that group; 20 percent were 1941-1950 graduates, representing 24 percent of the total group; and 17 percent were the 19611970 graduates, representing 30 percent of that group. After analysis of the data, physicians’ responses were divided according to two age categories - pre-World War I1 and post-World War 11, subsequently noted as “younger” and “older” groups. As psychiatrists comprised such a large proportion of the respondents, their responses were examined separately, as were those of primary care physicians (internists and general practitioners). Age 75 was used as the “dividing line” for old age instead of the usual age 65, as the average age of nursing home patients is about 80, and most of these patients represent the 75-85 age group. Fifty percent of the respondent psychiatrists did not care for patients over 75. Less than 25 percent of the younger physicians but 97 percent of the older physicians cared for patients 75 years and older. Perhaps the patients of the older physicians have been coming to them for long periods, and both physicians and patients have aged together. Half of the older physicians had patients in nursing homes as compared to 38 percent of the younger physicians.
Physicians’ general attitudes toward old age Seventy-nine percent of the respondents did not feel that those over 75 were severely disabled,
and 92 percent did not feel that they were mentally incompetent. However, 7 percent of the psychiatrists believed that persons over 75 were mentally incompetent.
Physicians’ training and ability to care for the elderly In a question designed to elicit significant exposure to geriatric medicine during their medical education, over half of the respondents reported that there had been none. Psychiatrists reported the most exposure (61 percent) but they cared for relatively few aged patients; 75 percent indicated that they would accept patients over 75 in their practice. Ninety-one percent of the physicians did feel competent to manage patients over 75. Of the psychiatrists, 61 percent reported significant geriatric medical education, but only 82 percent felt competent to manage ill elderly patients.
Attitudes toward treating older versus younger patients About 87 percent of the physicians would agree to accept new older patients; slightly more of the older physicians (6 percent) than the younger would, and 75 percent of the psychiatrists would. (This has not been the experience in the nursing home setting in the White Plains area. It is very difficult to recruit physicians to care for new patients who are in nursing homes.) A quarter of the respondents did not find treating patients over 75 as challenging as treating younger patients. Almost 40 percent of the respondent psychiatrists did not find geropsychiatry challenging, even though many of the ill aged might benefit from psychiatric treatment, Over 50 percent of the respondents felt that younger patients can receive better quality medical care than can the elderly. More of the younger than the older physicians believed that the young population had better care. When physicians answered the question whether they try harder for patients under 50 or over 75, 38 percent stated that they put forth “equal” efforts in each category. About 50 percent of the older doctors reported they treated younger and older patients equally; 26 percent reported that 50-year-olds received better care; but only 3 percent reported that the over-75 group received better care. Less than a third of the younger physicians found the treatment for both age groups equal, but 43 percent designated the under-50 group as receiving
501
MILLER. LOWENSTEIN AND WINSTON
better care and only 2 percent named the over-75 group. A quarter of the psychiatrists reported that they treated both age groups equally, but 39 percent felt that they tried harder for the under50 group, and none indicated trying harder for those over 75. Twice as many physicians stressed survival for under-50 patients as for 75+ patients. In a question concerning priority for emergency treatment of a hospital patient aged 25 versus one aged 75, 40 percent of the physicians did not respond, 45 percent indicated that they would treat the 25-year-old first, and 14 percent selected the 75-year-old. Twice as many older physicians, almost five times as many younger physicians, and twice as many psychiatrists selected the 25-year-old patient.
Physicians’ perceptions of nursing homes and nursing home patients When asked if they try harder for the elderly in their offices versus the elderly in a nursing home setting, 39 percent of the respondents reported equal treatment in both settings; 28 percent selected their office; and only 1 percent selected the nursing home as the preferred setting. In response to questions asking physicians if they found mentally incompetent and incontinent old patients offensive, 15 percent indicated that incontinent old patients were offensive to treat. However, only 9 percent had this attitude toward incompetent aged patients. It was noteworthy that more than twice as many of the older physicians, who are more likely to care for elderly patients than are younger physicians, found the mentally incompetent elderly difficult to treat; possibly this was attributable to physician identification with their aging parents or with their own aging. In contrast, only half as many of the older physicians found mentally incompetent young persons offensive to treat. About 38 percent of all respondents viewed the nursing home as a place for old people to die. For those who worked in nursing home settings, even a greater percentage of physicians believed this. Although 85 percent of the respondents felt the physician should be involved in the process of placing the ill aged person in a nursing home, it was startling to learn that the physicians did not feel really in charge of the patients’ care thereafter. Respondents considered the nurses to be in charge in 33 percent of the cases, administration personnel in 23 percent, and attending physicians in only 21 percent. This was most apparent with
502
Vol. XXIV
the younger physicians, 43 percent of whom named the nurses, and only 15 percent the physicians. A vacuum definitely exists relative to responsibility for care of the patients. Younger physicians and psychiatrists questioned the adequacy of one medical visit per month for nursing home patients, yet neither group cared for many such patients. In several instances, physicians indicated that once-amonth visits were too frequent; indeed, one government physician stated one visit per year was sufficient. Over half of all respondents would not consider participating in a nursing-home utilization review committee. About half of the respondents believed that elderly patients in nursing homes could have rewarding sexual experiences. Considerably more young (58 percent) than older physicians (41 percent) made this statement. In fact, 15 percent of the older physicians stated that such activity should be discouraged.
Attitudes of physicians toward life and death for the ill aged In a query as to whether physicians believed in heroic medicine for severely physically disabled elderly patients, 67 percent did not, and 71 percent did not believe in it for aged mentally incompetent patients. The definition of heroic medicine may vary from physician to physician, but clearly the intellectually impaired patient is less favored. When the physicians were asked if they would want to live if they were old and severely physically disabled, 43 percent indicated that they would not, and 67 percent would not wish to live if they were old and mentally incompetent. Over three times as many would rather live if they were old and severely physically handicapped than if they were mentally incompetent. Only 10 percent of the respondents would want to live if they were old and mentally incompetent. When asked if they would want to live if they were young and severely physically disabled, the figure rose to 61 percent whereas only 37 percent wanted to live if they were old and physically disabled. Nearly half would not want to live if they were young and mentally incompetent. Of the older physicians, 67 percent would not want to live if they were old and mentally incompetent as compared to only 47 percent if they were young and mentally incompetent. Of the psychiatrists, four times as many would want to live if they were young and mentally incompetent than if
November 1976
PHYSICIANS ATTITUDES TOWARD THE ILL AGED
they were old and mentally incompetent. It appears that mental incompetence of the aged was the most abhorrent category of all to the respondents, yet this represents a major problem of the aged in nursing homes. Euthanasia, the process associated with premature death, was favored by 25 percent for the severely physically disabled aged; about 7 percent more of the older physicians than the younger ones were in favor of euthanasia. Only 18 percent of the physicians believed in euthanasia for the mentally incompetent, with twice as many of the older physicians than the younger ones favoring this process. Primary care physicians
In the category of primary care physicians were 13 internists and general practitioners; they warrant specific mention and accounted for 15 percent of the study group. It should be emphasized that primary care physicians have the most contact with the elderly in the nursing home setting, and 92 percent cared for nursing home patients. Although 69 percent of the primary care physicians reported no significant training in geriatrics, they all felt competent to care for the aged despite the fact that only 15 percent evinced a real interest in geriatrics. Indeed, 46 percent did not find geriatric medicine challenging and 69 percent believed that the quality of medical care for the young patient is better than that for the older patient. Although over half of the primary care physicians said they treated old and young equally, 31 percent admitted putting forth greater effort for the young, and none affirmed that they tried harder for the elderly. Five times as many primary care physicians were as dedicated to survival for the under-50 age group as for the 75+ group. Primary care physicians represented the largest proportion of doctors (54 percent) who would treat the young hospital patient before the older one on an emergency basis. No primary care physicians considered the nursing home as the preferred treatment site. Almost half of them viewed the nursing home as a place to die. Although all doctors affirmed their role in the placement of persons into the nursing home setting, 46 percent of the primary care physicians considered themselves remaining in charge of the patient, whereas 31 percent believed that the administrative staff took over after placement, and 15 percent believed that to be true for the nursing staff. This lack of alloca-
tion of responsibility means that no one is in charge, even though it is the attending physician’s role. Although heroic medicine (sometimes defined in the nursing home as assisted feeding by any means required to support life and the use of antibiotics for infections) was considered more appropriate for the physically disabled than for the mentally incompetent, 77 percent of the primary care physicians voiced opposition to these measures for the aged who are severely physically disabled. Only 10 percent of the primary care physicians would wish to live if they were old and intellectually impaired, and 92 percent would not favor heroic medicine for the mentally impaired. Twenty-five percent of the primary care doctors favored euthanasia for the aged who are severely physically handicapped, and 31 percent favored it for the mentally incompetent aged. DISCUSSION There are obvious limitations to this study because of the small number of physicians in the different specialities, the lack of clarity of such terms as heroic medicine, and the guarded or inaccurate responses in such areas as willingness to accept nursing home residents as new patients. There is need for further study in other settings. If the ill aged in nursing homes are to receive the quality of medical care received by the younger noninstitutional population of this country, changes in the attitudes and perceptions of physicians need to be effected. Ingrained positions can be altered by learning, earning and yearning. Learning is the most obvious. Miller (20) has written on the need to restructure medical education so that medical students will continue to be trained as diagnosticians as well as in the management and treatment of patients, to function not as solo practitioners but as leaders of the clinical team. Academic exposure in medical school, however, is not sufficient. Spence et a1 (9) noted bias regarding geriatric medicine on the part of firstyear medical students, and this was unaltered by the senior year. Perhaps medical schools could be encouraged to develop clerkships in long-term care facilities, thereby revealing to medical students at a younger and possibly more receptive age the problems they will encounter in their future practices or medical careers, whatever the setting. However, the medical school faculty should join the students in the nursing homes in order to effect a more constructive attitude to-
503
VOl. XXIV
MILLER, LOWENSTEIN AND WINSTON
ward treating the ill aged in long-term care facilities. A positive interest in aging on the part of students can be reflective of the attitudes of their professors. Students generally cannot “go it alone.” Internships and residencies in nursing homes for primary care physicians would serve to increase familiarity with the problems of the chronically ill aged. Familiarity tends to develop sympathy and an understanding of the potential help available for geriatric patients through dynamic medical leadership. Earning also plays an important role in attitudes of physicians in their treatment of the ill aged. If physicians are not reimbursed at the same level for the care of patients in nursing homes as for the care of patients in hospitals, they will continue to perceive the needs of nursing home residents as less important. The present fee schedule for nursing home visits allowable by Medicare encourages second-class care. Yearning relates to the low esteem in which aged patients and nursing homes are held by the medical profession. Physicians are proud of, and need hospital affiliations in order to function. In contrast, they do not seem to need nursing home affiliations and these do nothing to enhance their position in the medical community. Indeed, physicians associated with nursing homes are looked upon with suspicion by their colleagues. This can be changed with the assistance of organizations such as the Joint Commission on Accreditation of Hospitals. Data could include the quality of the hospital-nursing home relationship and the resultant continuity and discontinuity of care as part of the hospital accreditation process. Currently the nursing home survey is distinct from the hospital survey, but hospital accreditation should be dependent upon proper interrelationships between the hospitals and the nursing homes to which patients are discharged. If hospitals required members of their medical staffs to serve on the medical staffs of nursing homes with which they enjoy transfer agreements, improvements would ensue in nursing home medical care. The use of the same utilization review committee by affiliated hospitals and nursing homes would help to ensure continuity of care and would directly expose hospital physicians to the problems of nursing home patients. During their survey process, government regulatory agencies, instead of holding the nursing home responsible for the quality of medical care practiced therein, could properly attribute poor medical care to the responsible attending physi-
504
cians and could encourage appropriate medical societies to concentrate on improving medical care in the nursing home. The American Medical Association, rather than disbanding its committee on aging, should properly focus attention on the care and treatment of the elderly instead of merely on administrative programs for nursing home medical directors. Professional Standard Review Organizations could ensure that patients seeking admission to a nursing home receive a medical, nursing and psychosocial evaluation with a comprehensive and regularly re-assessed care plan designed to maximize their functional status. The attention of persons responsible for awarding government grants and of those involved in planning medical school curricula should be directed to the needs of the chronically ill aged. Once physicians learn enough, earn enough and yearn enough to be appointed to a nursing home medical staff, the quality of medical care in nursing homes will be elevated and will reflect such interest. REFERENCES 1. American Medical Association, American Nursing Home Association, American Hospital Association: Guides for Medical Care in Nursing Homes and Related Facilities, June 1960. 2. Kramer CH and Johnson GF: The problems of physician responsibility, Prof Nursing Home 7: 54, 1965. 3. Miller D, Brimingion J , Keller D et al: Nurse-physician communication in a nursing home setting, Gerontologist 12: 225, 1972. 4. Miller ME: Therapeutic decision making and institutional advocacy in caring for the ill aged, J Am Geriatrics SOC20: 585, 1972. 5. Miller D, Keller D and Woodruff S: Evaluation of a n open and closed medical staff in a nursing home setting, Gerontologist 14: 158, 1974. 6. American Nursing Home Association: Dr. Edwards discusses nursing home needs with ANHA representatives, ANHA Weekly Notes 3: 2, 1974. 7. Solon JA and Greenwalt LF: Physician participation in nursing homes, Medical Care 12: 486, 1974. 8. Freeman J T Medical school education in geriatrics, in Medical and Clinical Aspects of Aging, ed. by HT Blumenthal. New York, Columbia University Press, 1962, p 605. 9. Spence DL, Feigenbaum EM, Fitzgerald F e t al: Medical student attitudes toward the geriatric patient, J Am Geriatrics SOC 1 6 976, 1968. 10. Colombotos J: Physicians’ responses to changes in health care: some projections, Inquiry 8: 20, 1971. 11. Cherkasky M: Patient services in chronic disease, Public Health Rep 73: 978, 1958. 12. Subcommittee on Long Term Care of the Special Committee on Aging, US Senate: Doctors in Nursing Homes: The Shunned Responsibility. Washington, DC, US Govt Printing Office, 1975, p 319. 13. Solon JA: Nursing homes and medical care, in Medical Care: Social Organization Aspects, ed. by L De Groot. Springfield, Illinois, Charles C Thomas, Publisher, 1966, p 194.
November 1976
PHYSICIANS ATTITUDES TOWARD THE ILL AGED
14. Miller MB and Elliott DF: Errors and omissions in diagnostic records on admission of patients to a nursing home, J Am Geriatrics SOC24: 108, 1976. 15. Solon JA et al: Nursing Homes; Their Patients and Their Care. Washington, DC, US Govt Printing Office, 1957, p 21. 16. Haughton JA: Organization of medical services in a private nursing home: three new approaches, New England J Med 272: 996, 1965.
17. Reiff T: We’re doing a third rate job for the aged, Prism 1: 23 (Dec) 1973. 18. Galton L: Don’t Give Up On An Aging Parent. New York, Crown Publishers, 1975. 19. New York State Medical Society: Medical Directory of New York State. Lake Success, NY, 1974. 20. Miller MB: Restructuring medical education for management of the chronically ill aged, J Am Geriatrics SOC 22: 501, 1974.
505
JOURNAL OF THE AMERICAN GERIATRICS SOCIETY Copyright 0 1976 by the American Geriatrics Society
Physicians’ Attitudes Toward the I11 Aged and Nursing Homes* DULCY B. MILLER, MS,AM**, REGINA LOWENSTEIN, AM? and RICKY WINSTON, BS White Plains and New York, NY ABSTRACT: A survey of physicians in private practice (exclusive of pediatricians) was conducted in a medium sized suburban city in the New York metropolitan area, to determine whether physicians’ attitudes toward the ill aged and nursing homes were predictors of the quality of medical care available to area nursing home patients. Questionnaires were circulated t o 302 practitioners. Of the 28 percent who responded, 32 percent were psychiatrists, 15 percent primary care physicians and 8 percent orthopedists. Physicians felt competent t o manage the ill aged, although 50 percent had had no significant degree of exposure t o geriatric medicine in their medical education, and 70 percent of the primary care group had had none. Primary care and older physicians were more likely to treat patients in nursing homes. Almost 40 percent viewed the nursing home as a place t o die. Although 85 percent stated that physicians should be involved in the nursing home placement process, only 21 percent believed that they continued to be in charge of their patients after placement. The findings demonstrate generalized medical disinterest in the care of ill aged patients in institutions. The persons responsible for awarding government grants and those involved in planning medical school curricula should pay more attention t o the needs of the chronically ill aged. Prior to 1965, nursing homes were basically nursing oriented institutions. Following the passage and implementation of Medicare legislation, nursing homes became medically oriented facilities with the Conditions of Participation of Medicare mandating the availability of such things as laboratory and x-ray diagnostic procedures. Obviously, medical facilities require medical leadership to function. The quality of care in long-term institutions is directly related to the competence and volitional interest of physicians in the care of the ill aged in nursing homes. Thus, it was postulated that a study of physi-
cians’ attitudes toward the aged and nursing homes in the White Plains, New York community might serve to forecast the quality of medical care available to patients in nursing homes in that area. White Plains, county seat of Westchester, has a population of 50,000 and is in a n activity area of 250,000. It is the site of two general hospitals, a rehabilitation hospital and the psychiatric division of a New York City medical school, as well as the headquarters of numerous national and international corporations. REVIEW OF THE LITERATURE
* Presented a t the 33rd Annual Meeting of the American Geriatrics Society, Shamrock Hilton Hotel, Houston, Texas, April 21-23, 1976. ** Adjunct Instructor in Public Health (Health Administration), Columbia University School of Public Health, New York, NY. Address for correspondence: Dulcy B. Miller, MS, AM, Administrative Director, White Plains Center for Nursing Care, 220 West Post Road, White Plains, NY 10606. A copy of the survey questionnaire may be obtained upon request. t Associate Professor of Public Health, Columbia University School of Public Health and Center for Community Health Systems, New York, NY.
Over 15 years ago the American Medical Association acknowledged that the quality of care in long-term institutions was directly related to the quality of medical care practiced therein (1). A 1965 study by Kramer and Johnson (2) of 118 Illinois nursing homes showed that 50 percent of the patients did not undergo admission and annual physical examinations. Discharge orders were noted in only 50 percent of the medical records of discharged patients. Seventy-one per-
498
Nouem ber 19 76
PHYSICIANS’ ATTITUDES TOWARD THE ILL AGED
cent of the administrators interviewed believed that physicians had no understanding of the psychologic needs of the patients. A 1972 study of nurse-physician communication in a nursing home setting (3) demonstrated generalized physician disinterest in the care of the ill aged. Reluctance on the part of the covering physicians to care for the institutionalized aged in the absence of their colleagues often resulted in a refusal to sign death certificates. Nurses felt attending physicians did not assist in the development of definitive plans for the care of their ill aged patients. M. B. Miller (4) noted that physicians can be influenced by their own feelings toward the aged, perhaps related to personal parental relationships or their own perceptions about living and dying when they become ill and aged, or by the feelings of the patient’s family. D. B. Miller ( 5 ) suggested the advantages of a closed medical staff. Under such circumstances, medical care is likely to be superior, as physicians are selected on the basis of proven interest and competence in geriatric medicine. Is there a sufficient number of interested physicians to form the medical staffs of nursing homes? Although physicians need a hospital affiliation in order to practice, they can easily survive without a nursing home affiliation. Charles Edwards (61, Assistant Secretary for Health, Department of Health, Education, and Welfare, stated that a lack of professional involvement by physicians was a deterrent to greater utilization of long-term care institutions. He emphasized the need for more physician involvement in the care of nursing home patients. Solon and Greenwalt (7) showed that 14 percent of the active physicians of the community under study were affiliated with nursing homes and that the amount of their time spent in the nursing home was positively associated with the level of nursing care. The authors stressed the need to develop methods and criteria for assuring quality of care in nursing homes. Freeman (8) queried 76 medical schools regarding the training provided students in geriatrics. Only 34 percent of the returns by the interns and residents noted some training in geriatrics. Geriatric training was considered essential by 20 percent, useful by 62 percent, and unnecessary by 18 percent. Spence et a1 (9) studied the general medical prejudice toward old patients in a medical school environment, showing that freshmen and seniors shared society’s conceptions and misconceptions
concerning the aged. Seniors were not involved in the socialized concept and continued their original medical prejudice against old patients; three years of medical school did not mitigate this attitude. In a specific question regarding the choice of care for young or old, the prejudice toward the aged was dramatically apparent in the responses that favored the young. Colombotos (10) noted that younger physicians more than older ones stressed the “science” rather than the ‘?art”of medicine and tended to be interested in medicine as “work of special interest” rather than a way of “helping people.” This emphasis on the scientific rather than the humanistic approach to medicine may be reflected in the attitudes of younger physicians toward caring for the ill aged. Cherkasky (11) commented that the view of chronic disease held by the public and even by some physicians is colored by misconceptions, e.g., that chronic disease is indolent, not much can be done for the chronically ill, and not as much or as high-quality medical care is needed for the chronically ill as for the acutely ill. The title of a recent publication of the Moss Committee, the Senate Subcommittee on Long Term Care, speaks for itself - “Doctors in Nursing Homes: The Shunned Responsibility” (12). In the Moss Report the reasons for physician absence from nursing homes were described as complicated and included: a shortage of physicians with fewer general practitioners and more specialization, the medical schools’ low priority for aging, Medicare and Medicaid red tape and low reimbursement, the lack of back-up staff in nursing homes, the belief that nursing homes are unpleasant places to visit, and the lack of incentives for time and travel to nursing homes. All of the foregoing contribute to poor care for longterm patients. Solon (13) stated that patients whose medical profile calls for continuing medical management typically languish in nursing homes with relatively little medical attention. The common pattern documented in past nursing-home studies is that of crisis medical care rather than continuing management. Attending physicians enter nursing homes in response to emergency calls, despite the stated need for frequent visits by experienced clinicians to deal with continuing medical problems. Solon noted that an overlay of attitudes toward the aging and chronically ill gives physicians the impulse to stay away from nursing homes. Miller and Elliott (14) found that the primary
499
VOl. XXIV
MILLER, LOWENSTEIN AND WINSTON
admission diagnosis for 100 patients consecutively admitted to a nursing home was inaccurate or noninformative in 64 percent, and the secondary diagnoses were lacking or inaccurate in 84 percent, revealing a significant state of unpreparedness on the part of some physicians caring for the chronically ill aged. The authors concluded that the lack of identification of patients’ needs through diagnosis would result, perforce, in inadequate or inappropriate treatment programs for nursing home patients. Even in the 1957 study by Solon et a1 (19, the younger patients in a nursing home were seen by attending physicians significantly more frequently than the older patients. Haughton (16) noted no difficulty in attracting well trained physicians to nursing-home medical programs when there was a professional milieu and a minimum of bureaucratic red tape. In a demonstration project in which a general hospital provided medical care to a nursing home, the hospital resident (whose primary concern was his own education) responded to the stimulation of a professionally oriented program in the nursing home setting. According to Reiff (17), when a young person dies, the physician and family wish to know what happened and what could have been done to prevent it; often the postmortem examination is an important tool in learning the precise cause of death and the pre-existing morbidity. However, when an older person dies, the professionals and family are indifferent to finding out what happened; they accept death as caused by “old age,” with little interest in the mechanism that brought it about. Reiff cited the example of an outbreak of salmonellosis in Baltimore nursing homes which involved 107 of 140 patients; when the initial symptoms and early deaths occurred, too little attention was paid to the precise diagnosis and the cause of death. Further, in studying mortality in a geriatric center and hospital, mainutrition and infection related to debility were the two most important underlying causes causes that are often preventable and treatable. A recent popular publication by Lawrence Galton (18) noted that physicians deny health, productivity and independence to the elderly when they accept stereotypes that old persons must be sick, senile and complaining. He characterized physicians’ attitudes toward the aged as condescending and tolerant, and stated that these attitudes can be changed on an individual level without tackling all the social roots. He suggested the use of aggressive medical and surgical therapy
500
for reversible disorders, since it is better to try too hard than not at all. MATERIAL AND METHODS A questionnaire was designed to elicit information from the 302 physicians in private practice in the White Plains area, exclusive of 60 pediatricians. From the total of 302 area physicians, 151 were randomly listed for telephone interviews. As the response was not satisfactory, the initial and follow-up questionnaires were then sent by mail, with greater success. A total of 31 questions divided into 6 categories was designed to determine: 1)demographic data about the physicians and their practices not available in the New York State Medical Society Directory, 2) physicians’ general attitudes toward the ill aged, 3) physicians’ assessments of their training and their care of the aged, 4) physicians’ attitudes toward treating older people as compared to younger people, 5) physicians’ perceptions of nursing homes and nursing home patients, and 6) physicians’ attitudes regarding life and death for the ill aged. Demographic questions answered in the Medical Directory of New York State (19) were not repeated in the brief telephone interviews. Of the 151 candidates, 26 completed the telephone questionnaire. Contact was sought with all possible respondents until it was definitely ascertained that they would or could not participate. Since only 9 percent of the 302 area physicians proposed for the study completed the telephone questionnaire, the remaining 151 physicians received initial and follow-up questionnaires by mail. The mail survey proved to be more successful, scoring a completion rate of 40 percent as compared to only 17 percent for the telephone survey, or a total response rate of 28 percent. This increased response rate was perhaps attributable to the anonymity of the process, or to the fact that the physicians could complete the questionnaire at their leisure, or to the more official quality of printed matter in comparison to an unannounced telephone call. FINDINGS Demographic information on physicians and their practices
This information was derived from an official listing of the specialities of the 302 physicians considered for the questionnaire. Psychiatrists comprised 24 percent of the 302 physicians in the
November 1976
PHYSICIANS ATTITUDES TOWARD THE ILL AGED
White Plains area, general practitioners and internists together comprised 21 percent, obstetricians and gynecologists 8 percent, and surgeons 7 percent. The largest group (33 percent) represented those who graduated from medical school between 1951 and 1960; 24 percent represented graduates between 1941 and 1950; and 17 percent represented a combination of graduates from 1961 to 1970 and 1931 to 1940. Of the 87 physicians who responded to the questionnaire, 32 percent were psychiatrists, 5 percent general practitioners, 10 percent internists, and 8 percent orthopedists. Less than 12 percent of the general practitioners in the area responded to the survey, whereas 32 percent of the internists responded, as did 40 percent of the psychiatrists and 78 percent of the orthopedists. No pattern relating to the age of the respondents was noted. About 30 percent graduated from medical school in the decade 1951-1960, representing 26 percent of those graduates in the area; 24 percent were 1931-1940 graduates, representing 42 percent of that group; 20 percent were 1941-1950 graduates, representing 24 percent of the total group; and 17 percent were the 19611970 graduates, representing 30 percent of that group. After analysis of the data, physicians’ responses were divided according to two age categories - pre-World War I1 and post-World War 11, subsequently noted as “younger” and “older” groups. As psychiatrists comprised such a large proportion of the respondents, their responses were examined separately, as were those of primary care physicians (internists and general practitioners). Age 75 was used as the “dividing line” for old age instead of the usual age 65, as the average age of nursing home patients is about 80, and most of these patients represent the 75-85 age group. Fifty percent of the respondent psychiatrists did not care for patients over 75. Less than 25 percent of the younger physicians but 97 percent of the older physicians cared for patients 75 years and older. Perhaps the patients of the older physicians have been coming to them for long periods, and both physicians and patients have aged together. Half of the older physicians had patients in nursing homes as compared to 38 percent of the younger physicians.
Physicians’ general attitudes toward old age Seventy-nine percent of the respondents did not feel that those over 75 were severely disabled,
and 92 percent did not feel that they were mentally incompetent. However, 7 percent of the psychiatrists believed that persons over 75 were mentally incompetent.
Physicians’ training and ability to care for the elderly In a question designed to elicit significant exposure to geriatric medicine during their medical education, over half of the respondents reported that there had been none. Psychiatrists reported the most exposure (61 percent) but they cared for relatively few aged patients; 75 percent indicated that they would accept patients over 75 in their practice. Ninety-one percent of the physicians did feel competent to manage patients over 75. Of the psychiatrists, 61 percent reported significant geriatric medical education, but only 82 percent felt competent to manage ill elderly patients.
Attitudes toward treating older versus younger patients About 87 percent of the physicians would agree to accept new older patients; slightly more of the older physicians (6 percent) than the younger would, and 75 percent of the psychiatrists would. (This has not been the experience in the nursing home setting in the White Plains area. It is very difficult to recruit physicians to care for new patients who are in nursing homes.) A quarter of the respondents did not find treating patients over 75 as challenging as treating younger patients. Almost 40 percent of the respondent psychiatrists did not find geropsychiatry challenging, even though many of the ill aged might benefit from psychiatric treatment, Over 50 percent of the respondents felt that younger patients can receive better quality medical care than can the elderly. More of the younger than the older physicians believed that the young population had better care. When physicians answered the question whether they try harder for patients under 50 or over 75, 38 percent stated that they put forth “equal” efforts in each category. About 50 percent of the older doctors reported they treated younger and older patients equally; 26 percent reported that 50-year-olds received better care; but only 3 percent reported that the over-75 group received better care. Less than a third of the younger physicians found the treatment for both age groups equal, but 43 percent designated the under-50 group as receiving
501
MILLER. LOWENSTEIN AND WINSTON
better care and only 2 percent named the over-75 group. A quarter of the psychiatrists reported that they treated both age groups equally, but 39 percent felt that they tried harder for the under50 group, and none indicated trying harder for those over 75. Twice as many physicians stressed survival for under-50 patients as for 75+ patients. In a question concerning priority for emergency treatment of a hospital patient aged 25 versus one aged 75, 40 percent of the physicians did not respond, 45 percent indicated that they would treat the 25-year-old first, and 14 percent selected the 75-year-old. Twice as many older physicians, almost five times as many younger physicians, and twice as many psychiatrists selected the 25-year-old patient.
Physicians’ perceptions of nursing homes and nursing home patients When asked if they try harder for the elderly in their offices versus the elderly in a nursing home setting, 39 percent of the respondents reported equal treatment in both settings; 28 percent selected their office; and only 1 percent selected the nursing home as the preferred setting. In response to questions asking physicians if they found mentally incompetent and incontinent old patients offensive, 15 percent indicated that incontinent old patients were offensive to treat. However, only 9 percent had this attitude toward incompetent aged patients. It was noteworthy that more than twice as many of the older physicians, who are more likely to care for elderly patients than are younger physicians, found the mentally incompetent elderly difficult to treat; possibly this was attributable to physician identification with their aging parents or with their own aging. In contrast, only half as many of the older physicians found mentally incompetent young persons offensive to treat. About 38 percent of all respondents viewed the nursing home as a place for old people to die. For those who worked in nursing home settings, even a greater percentage of physicians believed this. Although 85 percent of the respondents felt the physician should be involved in the process of placing the ill aged person in a nursing home, it was startling to learn that the physicians did not feel really in charge of the patients’ care thereafter. Respondents considered the nurses to be in charge in 33 percent of the cases, administration personnel in 23 percent, and attending physicians in only 21 percent. This was most apparent with
502
Vol. XXIV
the younger physicians, 43 percent of whom named the nurses, and only 15 percent the physicians. A vacuum definitely exists relative to responsibility for care of the patients. Younger physicians and psychiatrists questioned the adequacy of one medical visit per month for nursing home patients, yet neither group cared for many such patients. In several instances, physicians indicated that once-amonth visits were too frequent; indeed, one government physician stated one visit per year was sufficient. Over half of all respondents would not consider participating in a nursing-home utilization review committee. About half of the respondents believed that elderly patients in nursing homes could have rewarding sexual experiences. Considerably more young (58 percent) than older physicians (41 percent) made this statement. In fact, 15 percent of the older physicians stated that such activity should be discouraged.
Attitudes of physicians toward life and death for the ill aged In a query as to whether physicians believed in heroic medicine for severely physically disabled elderly patients, 67 percent did not, and 71 percent did not believe in it for aged mentally incompetent patients. The definition of heroic medicine may vary from physician to physician, but clearly the intellectually impaired patient is less favored. When the physicians were asked if they would want to live if they were old and severely physically disabled, 43 percent indicated that they would not, and 67 percent would not wish to live if they were old and mentally incompetent. Over three times as many would rather live if they were old and severely physically handicapped than if they were mentally incompetent. Only 10 percent of the respondents would want to live if they were old and mentally incompetent. When asked if they would want to live if they were young and severely physically disabled, the figure rose to 61 percent whereas only 37 percent wanted to live if they were old and physically disabled. Nearly half would not want to live if they were young and mentally incompetent. Of the older physicians, 67 percent would not want to live if they were old and mentally incompetent as compared to only 47 percent if they were young and mentally incompetent. Of the psychiatrists, four times as many would want to live if they were young and mentally incompetent than if
November 1976
PHYSICIANS ATTITUDES TOWARD THE ILL AGED
they were old and mentally incompetent. It appears that mental incompetence of the aged was the most abhorrent category of all to the respondents, yet this represents a major problem of the aged in nursing homes. Euthanasia, the process associated with premature death, was favored by 25 percent for the severely physically disabled aged; about 7 percent more of the older physicians than the younger ones were in favor of euthanasia. Only 18 percent of the physicians believed in euthanasia for the mentally incompetent, with twice as many of the older physicians than the younger ones favoring this process. Primary care physicians
In the category of primary care physicians were 13 internists and general practitioners; they warrant specific mention and accounted for 15 percent of the study group. It should be emphasized that primary care physicians have the most contact with the elderly in the nursing home setting, and 92 percent cared for nursing home patients. Although 69 percent of the primary care physicians reported no significant training in geriatrics, they all felt competent to care for the aged despite the fact that only 15 percent evinced a real interest in geriatrics. Indeed, 46 percent did not find geriatric medicine challenging and 69 percent believed that the quality of medical care for the young patient is better than that for the older patient. Although over half of the primary care physicians said they treated old and young equally, 31 percent admitted putting forth greater effort for the young, and none affirmed that they tried harder for the elderly. Five times as many primary care physicians were as dedicated to survival for the under-50 age group as for the 75+ group. Primary care physicians represented the largest proportion of doctors (54 percent) who would treat the young hospital patient before the older one on an emergency basis. No primary care physicians considered the nursing home as the preferred treatment site. Almost half of them viewed the nursing home as a place to die. Although all doctors affirmed their role in the placement of persons into the nursing home setting, 46 percent of the primary care physicians considered themselves remaining in charge of the patient, whereas 31 percent believed that the administrative staff took over after placement, and 15 percent believed that to be true for the nursing staff. This lack of alloca-
tion of responsibility means that no one is in charge, even though it is the attending physician’s role. Although heroic medicine (sometimes defined in the nursing home as assisted feeding by any means required to support life and the use of antibiotics for infections) was considered more appropriate for the physically disabled than for the mentally incompetent, 77 percent of the primary care physicians voiced opposition to these measures for the aged who are severely physically disabled. Only 10 percent of the primary care physicians would wish to live if they were old and intellectually impaired, and 92 percent would not favor heroic medicine for the mentally impaired. Twenty-five percent of the primary care doctors favored euthanasia for the aged who are severely physically handicapped, and 31 percent favored it for the mentally incompetent aged. DISCUSSION There are obvious limitations to this study because of the small number of physicians in the different specialities, the lack of clarity of such terms as heroic medicine, and the guarded or inaccurate responses in such areas as willingness to accept nursing home residents as new patients. There is need for further study in other settings. If the ill aged in nursing homes are to receive the quality of medical care received by the younger noninstitutional population of this country, changes in the attitudes and perceptions of physicians need to be effected. Ingrained positions can be altered by learning, earning and yearning. Learning is the most obvious. Miller (20) has written on the need to restructure medical education so that medical students will continue to be trained as diagnosticians as well as in the management and treatment of patients, to function not as solo practitioners but as leaders of the clinical team. Academic exposure in medical school, however, is not sufficient. Spence et a1 (9) noted bias regarding geriatric medicine on the part of firstyear medical students, and this was unaltered by the senior year. Perhaps medical schools could be encouraged to develop clerkships in long-term care facilities, thereby revealing to medical students at a younger and possibly more receptive age the problems they will encounter in their future practices or medical careers, whatever the setting. However, the medical school faculty should join the students in the nursing homes in order to effect a more constructive attitude to-
503
VOl. XXIV
MILLER, LOWENSTEIN AND WINSTON
ward treating the ill aged in long-term care facilities. A positive interest in aging on the part of students can be reflective of the attitudes of their professors. Students generally cannot “go it alone.” Internships and residencies in nursing homes for primary care physicians would serve to increase familiarity with the problems of the chronically ill aged. Familiarity tends to develop sympathy and an understanding of the potential help available for geriatric patients through dynamic medical leadership. Earning also plays an important role in attitudes of physicians in their treatment of the ill aged. If physicians are not reimbursed at the same level for the care of patients in nursing homes as for the care of patients in hospitals, they will continue to perceive the needs of nursing home residents as less important. The present fee schedule for nursing home visits allowable by Medicare encourages second-class care. Yearning relates to the low esteem in which aged patients and nursing homes are held by the medical profession. Physicians are proud of, and need hospital affiliations in order to function. In contrast, they do not seem to need nursing home affiliations and these do nothing to enhance their position in the medical community. Indeed, physicians associated with nursing homes are looked upon with suspicion by their colleagues. This can be changed with the assistance of organizations such as the Joint Commission on Accreditation of Hospitals. Data could include the quality of the hospital-nursing home relationship and the resultant continuity and discontinuity of care as part of the hospital accreditation process. Currently the nursing home survey is distinct from the hospital survey, but hospital accreditation should be dependent upon proper interrelationships between the hospitals and the nursing homes to which patients are discharged. If hospitals required members of their medical staffs to serve on the medical staffs of nursing homes with which they enjoy transfer agreements, improvements would ensue in nursing home medical care. The use of the same utilization review committee by affiliated hospitals and nursing homes would help to ensure continuity of care and would directly expose hospital physicians to the problems of nursing home patients. During their survey process, government regulatory agencies, instead of holding the nursing home responsible for the quality of medical care practiced therein, could properly attribute poor medical care to the responsible attending physi-
504
cians and could encourage appropriate medical societies to concentrate on improving medical care in the nursing home. The American Medical Association, rather than disbanding its committee on aging, should properly focus attention on the care and treatment of the elderly instead of merely on administrative programs for nursing home medical directors. Professional Standard Review Organizations could ensure that patients seeking admission to a nursing home receive a medical, nursing and psychosocial evaluation with a comprehensive and regularly re-assessed care plan designed to maximize their functional status. The attention of persons responsible for awarding government grants and of those involved in planning medical school curricula should be directed to the needs of the chronically ill aged. Once physicians learn enough, earn enough and yearn enough to be appointed to a nursing home medical staff, the quality of medical care in nursing homes will be elevated and will reflect such interest. REFERENCES 1. American Medical Association, American Nursing Home Association, American Hospital Association: Guides for Medical Care in Nursing Homes and Related Facilities, June 1960. 2. Kramer CH and Johnson GF: The problems of physician responsibility, Prof Nursing Home 7: 54, 1965. 3. Miller D, Brimingion J , Keller D et al: Nurse-physician communication in a nursing home setting, Gerontologist 12: 225, 1972. 4. Miller ME: Therapeutic decision making and institutional advocacy in caring for the ill aged, J Am Geriatrics SOC20: 585, 1972. 5. Miller D, Keller D and Woodruff S: Evaluation of a n open and closed medical staff in a nursing home setting, Gerontologist 14: 158, 1974. 6. American Nursing Home Association: Dr. Edwards discusses nursing home needs with ANHA representatives, ANHA Weekly Notes 3: 2, 1974. 7. Solon JA and Greenwalt LF: Physician participation in nursing homes, Medical Care 12: 486, 1974. 8. Freeman J T Medical school education in geriatrics, in Medical and Clinical Aspects of Aging, ed. by HT Blumenthal. New York, Columbia University Press, 1962, p 605. 9. Spence DL, Feigenbaum EM, Fitzgerald F e t al: Medical student attitudes toward the geriatric patient, J Am Geriatrics SOC 1 6 976, 1968. 10. Colombotos J: Physicians’ responses to changes in health care: some projections, Inquiry 8: 20, 1971. 11. Cherkasky M: Patient services in chronic disease, Public Health Rep 73: 978, 1958. 12. Subcommittee on Long Term Care of the Special Committee on Aging, US Senate: Doctors in Nursing Homes: The Shunned Responsibility. Washington, DC, US Govt Printing Office, 1975, p 319. 13. Solon JA: Nursing homes and medical care, in Medical Care: Social Organization Aspects, ed. by L De Groot. Springfield, Illinois, Charles C Thomas, Publisher, 1966, p 194.
November 1976
PHYSICIANS ATTITUDES TOWARD THE ILL AGED
14. Miller MB and Elliott DF: Errors and omissions in diagnostic records on admission of patients to a nursing home, J Am Geriatrics SOC24: 108, 1976. 15. Solon JA et al: Nursing Homes; Their Patients and Their Care. Washington, DC, US Govt Printing Office, 1957, p 21. 16. Haughton JA: Organization of medical services in a private nursing home: three new approaches, New England J Med 272: 996, 1965.
17. Reiff T: We’re doing a third rate job for the aged, Prism 1: 23 (Dec) 1973. 18. Galton L: Don’t Give Up On An Aging Parent. New York, Crown Publishers, 1975. 19. New York State Medical Society: Medical Directory of New York State. Lake Success, NY, 1974. 20. Miller MB: Restructuring medical education for management of the chronically ill aged, J Am Geriatrics SOC 22: 501, 1974.
505
