BULLETIN OF THE NEW YORK ACADEM1Y OF MEDICINE
VOL. 54, No. 6
JUNE 1978
THE ROLE OF THE PRIMARY PHYSICIAN IN THE CARE OF ELDERLY PATIENTS: PREPARATION FOR THE FUTURE* IRVING S. WRIGHT, M.D. Emeritus Professor of Clinical Medicine Cornell University Medical College Chairman, Section on Geriatric Medicine The New York Academy of Medicine New York, New York
Ishall use the term "primary physician" for the physician who may or may not first see a patient in a particular illness, but who assumes the responsibility for the patient's chief and continuing care and medical guidance. He takes full responsibility for the diagnostic and treatment regimen when these are within his capabilities or guides the patient to the correct specialists or facilities when needed. Any specialists who are consulted report to him, and he advises the patient as to the wisest course to take when all aspects of the patient's health are weighed carefully. Unfortunately, the term "primary" also has been used to indicate the first physician to see the patient. He may turn out to be the long-term primary *Presented as part of a Symposium on Geriatric Medicine held by the Section on Geriatric Medicine of the New York Academy of Medicine and the American Geriatrics Society at the Academy June 8, 1977.
Vol. 54, No. 6. June 1978
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I. S. WRIGHT .S.WIH
physician, but the first physician to see a patient under many circumstances may be a matter of chance, and this physician may be totally unsuited, either by temperament or specialty, to assume such a role. In 1968, when I wrote about this role of the primary physician as a keystone of medical care, my views were criticized by some physicians who believed that such a need did not exist. However, with the passage of time the need for a highly competent central or primary physician to guide the medical care of the individual patient has become widely recognized. Recently, The Bulletin of the American College of Physicians published official statements by the American College of Physicians, the American Society of Internal Medicine, the American Board of Internal Medicine, and the Association of Professors of Medicine confirming this position and presenting the respective conclusions of these important organizations on this matter.2 They agree that well-trained internists are especially qualified for this function. However, a well-trained family physician with a broad medical background, a good relation with his patient, and an understanding of his medical and family history also may serve well in this capacity. With these prestigious organizations now behind this position, the primary physician (by whatever name he ultimately may be called) will, it is hoped, be accepted as the central agent of sound medical care. Such a physician is a requisite for optimal care in private practice, group practice, clinic, or medical center, whether outpatient or inpatient. This physician will reduce duplication of unnecessary tests and counteract the unfortunate depersonalization that is common in both private practice and large medical centers today. Some patients are referred from one specialist or testing laboratory to another, with no physician to whom they can turn for detailed, personal advice. Too often, on subsequent visits patients see a physician new to them, who either has to review their entire personal and family history (which may take hours) to advise them intelligently or who, for lack of time, must act on a snap judgment which may not represent the best solution to the problem. This essay will focus on the role of the primary physician in the care of the elderly or geriatric patients.
QUALIFICATIONS FOR THE CARE OF THE ELDERLY Unless the physician assuming this role has consideration, patience, and compassion, he may fail to provide optimal care to elderly patients. As McDermott has emphasized, a complete physician must exercise Bull. N.Y. Acad. Med.
PRIMARY PHYSICIAN
-~~~~~~~RMR
PHSCA
547 4
samaritanism as well as technical proficiency.3 A half century of experience with private and institutional medical care has led me to conclude that elderly patients (60 years of age or older) require different attitudes and approaches by physicians, nurses, and support staff from those needed for the care of patients in childhood, adolescence, early adulthood, or even middle age. As people become. older they often develop multiple diseases which require multiple medications, become more sensitive to favorable and unfavorable comments or acts by others, react more strongly to the implications of favorable or unfavorable medical information, become more easily depressed or frightened by medical problems-especially institutional confinement-whether acute or long-term, and as a result of this tend to lose their will to live. Experienced clinicians know -that these factors may affect the outcome of an illness or operative procedure. Younger patients generally are more optimistic and less easily depressed by indifference or inconsiderate acts by medical personnel at any level: physician, orderly, or practical nurse. Under adverse circumstances the young also are less likely to give up the struggle for life and recovery. Even when facilities are excellent, clean, and antiseptic and the food satisfactory (as in many Scandinavian hospitals), elderly patients complain about and resent depersonalization by the staff. SOCIOLOGICAL ASPECTS
In civilizations which still function largely as they have in past centuries, the aged ill are rejected by their own accepted standards. Old, sick Eskimos leave the igloo and wander into the arctic weather to die by freezing. The Bakhtiari, in their constant migrations over the vast mountains'of Persia, reach the great, wild Bazuft River, the crossing of which is a major yearly test; only the strong animals or men, survive, while the old stay behind to die. We do not like to think of treating our elderly in this way, yet many feel rejected by their families and, if institutionalized, by those who are supposed to care for them. Social change, along with the abandonment of multigenerational family dwellings, has forced the elderly into new patterns of life. They no longer entertain the status of the patriarch or matriarch, looked to for wisdom or even to fulfill the useful and instructive function of caring for the young. (Even among the second and third generation of westernized Chinese, the old tradition of esteemed paternal respect is being lost.) Many of the elderly, if they are still strong and healthy, and especially if Vol. 54, No. 6, June 1978
54854
I. S. WRIGHT
I.
S.WIH
both spouses are alive, can live fairly well on their own, depending in large measure on the amount of their income above Social Security benefits. Frequently these people are faced with several severe psychological readjustments within a year to two after the death of a spouse or relative. Besides the personal loss, they often experience sudden reductions in income and living standards, relocation from a long-time home, and chronic illness. When one spouse dies, the life pattern changes for the survivor, and, with confusion and depression, functional as well as organic disease becomes more difficult to handle. In addition, in large cities normal exercise often is curtailed for the elderly. They avoid healthy walks because they are afraid of being targets for muggers. Their money is easy to take and under our system of justice, with its excessive leniency for youthful offenders, the risk of penalty to the offenders is almost nil. For example, one of my patients, an elderly woman who suffers with atherosclerotic heart disease, has been mugged and seriously beaten three times in what was formerly a safe and respectable neighborhood. Her assailants are still free. The loss of social role and prestigious identity which is so commonly seen in retirees, especially those forced out of their jobs by mandatory retirement, is another major cause of stress in our work-oriented society. These various events occurring within a few years are met by a variety of reactions. For many, the subconscious reaction is to develop hypochondriasis (which was studied by Busse).4 Frequent visits to the physician's office seem to be the main motivation in the lives of some of these people. The primary physician should be alert to this syndrome. He can deal with many patients by explaining the reason for the multiple nonorganic aches and pains, but he may refer some for psychiatric care. These patients often will not accept psychiatric help, and the primary physician must handle the problem. While many of these may be regarded as social problems, the primary physician of such patients must expect to be used as advisor, counselor, and friend as well as physician. As more geriatric nurse-practitoners are trained, they may play an increasingly inportant role by working closely with the primary physician. However, the physician frequently is the most authoritative individual to whom an elderly patient can turn for intelligent help. He is asked to select appropriate specialists for a wide range of illnesses and injuries, to arrange admission to hospitals or nursing homes, or to arrange transfer to a suitable retirement community. Aged widows or Bull. N.Y. Acad. Med.
PRIMARY PHYSICIAN
-~~~~~~~PIMR
HSCA
549 4
widowers frequently are without living relatives, and the primary physician may be called upon to resolve the problems of a confused and failing mind. He may have to mobilize help in the form of legal, pastoral, and social services in order to arrange for patients to be admitted to appropriate long-term facilities where geriatric nursing is being slowly developed to a higher level of excellence. FUNCTIONS OF SPECIALISTS The medical profession rapidly is being divided into those who provide guidance and a large measure of medical care and those who provide highly technical skills but have little to do with the continuing care of patients. The latter group includes: computer experts, biochemists, radiologists, ultrasound and scanning experts, and various surgical specialists who operate but provide only immediate postoperative care. These physicians contribute their technical skills to a degree never before possible and save many lives. Their relation with the patient, however, is only temporary, and patients frequently do not know or remember their names. Primary physicians must assume a key role in evaluating the indications for such procedures, bearing in mind that these should not be judged exclusively on whether they will extend life but also on whether they can improve the quality of life. For example, reconstructive surgery on the arteries of the leg, neck, or heart in correctly selected patients may vastly improve the quality of life, yet it may be difficult to demonstrate that the patient's life has been prolonged. THE GENERATION GAP WITH YOUNG PHYSICIANS
It is particularly difficult for young physicians at the student or housestaff level to bridge the generation gap and understand the attitudes and apprehensions of elderly patients. This may be attributable in part to the fact that most American medical schools fail to provide orientation in the special problems of geriatrics. It also is related to the age-old difficulties in communication between successive generations which was noted in the dialogues of Socrates and Plato (400 B.C.),* in which they comment upon the love of Greek youth for luxury, their bad manners, their contempt for authority, their disrespect for their elders, their love of chatter in prefer*Plato: Republic, Shorey, P., translator. Book VIII, 562e and 563e, Bollingen Series LXXI.
Princeton, N.J., Princeton University Press, 1971, p.791.
Vol. 54, No. 6, June 1978
550
550
I.S. WRIGHT
ence to exercise, their tyrannization of their teachers, and their gobbling of food. Of course, there are exceptional young physicians who understand this problem and handle it well. Interestingly, after residency training those who elect to become primary physicians-usually internists or family physicians-tend to go through a metamorphosis; gradually they become less brusque and hurried and more attentive, understanding, and sympathetic with their elderly patients. Regrettably, this growth sometimes requires many years. EFFECT OF SOCIALIZATION
As countries have moved toward socialized medicine, the care provided by primary physicians too frequently has been replaced by impersonal treatment, and numbers become more important than individuals. If a general practitioner must see 59 to 100 patients a day it becomes almost impossible to obtain a good history, perform an acceptable physical examination, and develop a sympathetic and close relation with elderly patients. When it is recognized that the patient has become seriously ill, he is admitted to a hospital and his family physician loses contact. There the patient is confronted with a new health-care team whose members know little or nothing of his background, in a strange and often frightening new environment. This situation is difficult for the elderly unless there is interest in their problems as a result of special geriatric services such as those so well developed under the leadership of Sir Ferguson Anderson of Glasgow. TRAINING IN GERIATRICS AND THANATOLOGY
Geriatrics and its companion study, thanatology (the study of problems related to dying and death), should become established subjects in medical school curricula. As Robert Butler, director of the new National Institute of Aging in Bethesda, Md., has emphasized, our medical schools have been negligent in preparing young physicians to understand and provide for this major health problem.- For example, in 1970 a survey revealed that of 99 medical schools 50 did not mention geriatrics in their catalogues, and only 32 of 114 schools offered electives in this subject. These figures symbolize the lack of constructive programming in our medical curricula. Since 1970 some progress has taken place. A few more schools now have elective courses, but fewer than 10 have any course on geriatrics or Bull. N.Y. Acad. Med.
PRIMARY PHYSICIAN
PRIMARY
PHYSICIAN
551
thanatology included in the regular curriculum, although all physicians could profit from such courses as early as the first year of their medical training. As yet we are not prepared to satisfy the special health needs of the very people whom we have helped to live longer in greater numbers than ever before. We must prepare for the demographic change taking place in our population. In 1900 4% of the population of the United States was 65 years or older. Today it is approaching I 1%, and in a few years, unless there is an overwhelming catastrophe, this figure will approach 18 to 20%. How members of this group and their multiple diseases will be cared for already is our most formidable health problem; it seems to be beyond solution unless we involve more young, trained medical problem-solvers. These problems are not going to be solved by political maneuvering, cost accounting, or computers-either alone -or in combination-although these may help to analyze and clarify the needs. The provision of care must come from health personnel in the field. Informed and sincerely interested physicians, researchers in the process of aging and its accompanying diseases, nurses, social workers, and all allied health personnel will have to join hands and prepare to meet this critical problem. It is already late as we begin to enter this new era. SPECIAL PROBLEMS WITH MEDICATIONS
Many physicians have little concept of pain and the need for adequate dosages of analgesic or narcotic drugs to give patients relief. Seeing patients suffering needlessly while physicians belittle their pain has led me to suggest that what some physicians need to complete their medical education is a serious and painful illness. Then their attitude toward these patients would change and they would be better doctors. For the elderly the need for medication frequently is greater than that of the young and strong, but the dosage required or the tolerance for specific drugs may be less. Chronic arthritis, for example, adds to the pains of acute illness. The tendency of physicians and nurses to limit medication which may control the excruciating pain of terminal illness often is unjustified; the problem of addiction is irrelevant here. Reassurance, which may reduce the need for narcotics after an operation, also can be an important contribution of the primary physician, especially if he sees the patient before and after an operation. The elderly may not react to single drugs or combinations in the same Vol. 54, No. 6, June 1978
552
I. S. WRIGHT
way as younger individuals. For example, barbiturates can produce unexpected confusion or dizziness in the elderly and this may cause falls with serious results. They also may produce excitement rather than relaxation and then must be discontinued. The elderly may require a lower dosage of digitalis or quinidine, and most require digitalis only five days each week. Blood levels of digitalis now are being measured widely, and this may be helpful, but this is not always the case with the elderly. With these and other drugs careful clinical observations are still most important in guiding the physician. The elderly also are particularly subject to adverse interactions between drugs because their liver and kidneys may no longer be fully effective in handling and eliminating toxic products. All of this knowledge is part of the responsibility of the primary physician. Who else can be expected to record these idiosyncracies? Certainly not the otolaryngologist, radiologist, or surgeon-and it cannot be expected of a physician who sees the patient for 15 to 20 minutes in a clinic, yet the patient's life may rest on just such information. ROLE OF ALLIED HEALTH PERSONNEL
Allied health personnel may be trained to take blood-pressure readings, blood samples, electrocardiograms, and so forth (although, unless they are trained carefully and checked constantly, the error ratio may be high), but for important decisions these findings should be evaluated in the light of all other factors in the patient's health and environment. Treating multiple diseases in elderly patients can pose a difficult challenge to the best-trained physician, and should not be relegated to technicians with one or two years training in the simplest aspects of health care. Clinical practitioners, trained nurses, social workers, or other health-service personnel may carry out certain of these functions. THE TEAM APPROACH
In some medical centers efforts are made to have all important decisions made by a team. As many as six or eight different health disciplines are considered essential. While theoretically this may seem ideal in some respects, it proves impractical in the care of most patients. The team cannot always be assembled when a critical decision must be made, differences of opinion slow up or even stultify the making of decisions, and this practice is enormously expensive and wasteful of health-personnel Bull. N.Y. Acad. Med.
PRIMARY PHYSICIAN
PRIMARY
PHYSICIAN
553
553
resources. Frequently, the patient's problems do not involve the disciplines of several members of the group who might be occupied more productively elsewhere. The primary physician should use representatives of various disciplines freely as needed. Staff and visiting nurses, hospital administrators, social workers, physiotherapists, rehabilitation teams, and representatives of various specialties should all be called upon to contribute appropriate advice. However, the primary physician should take responsibility for making the final decision. Attempts to diffuse this responsibility for making complicated decisions results in overlapping and confusing patterns of treatment to the detriment of the patient. Team effort should aim at broader and more effective use of the available health manpower in a given institution or area, and meetings should be efficient to minimize use of the participants' valuable time. This broad planning should always include primary physicians as the keystone to optimal medical care.
SUMMARY The role of primary physicians in caring for the elderly is just beginning to emerge and be clarified. It is complicated and demanding. Until recently, the health professions have not recognized the enormity of geriatric care in terms of numbers. The care of the elderly requires a broad knowledge of medicine mixed with extraordinary patience and compassion. The simultaneous presence in a single individual of multiple diseases requiring various medications calls for judgment based on years of medical training and experience. Such decisions should not be delegated to allied health personnel, although they may be most helpful in carrying out a program of treatment. Geriatrics should be part of the curriculum of every medical school. Medical students also should participate in programs, discussion groups, and clinical experiences in thanatology. The two subjects may well be coordinated within the same curriculum module. Preferably, students should be taught the importance of these fields in the first or second year of medical school. For best results, a team headed by a physician experienced in geriatric medicine should assume responsibility for this and should obtain the cooperation of the other faculty members, since many disciplines may be involved. This study should fit into the department of medicine or family practice if the head of that department is sympathetic and will support it. It does not seem advisable to develop geriatrics as a Vol. 54, No. 6, June 1978
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limited specialty with a certification board. This discipline involves all physicians who deal with adults and constitutes a major health challenge for the foreseeable future. REFERENCES 1. Wright, I. S.: The case for the primary /06:135, 1977. physician. Cornell Univ. Med. School 4. Busse, E. W.: Hypochondriasis in the Alumni Assoc. Quart. 32:7, 1968. elderly: A reaction to social stress. J. Am. 2. Federated Council for Internal Medicine: Geriat. Soc. 24:145, 1976. Bull. Am. Coll. Phys. 7:10, 1976. 5. Butler, R.: Geriatric medicine, the imper3. McDermott, W.: Evaluating the physiatives. N.Y. State J. Med. 77:1470-72, cian and his technology. Daedalus 1977.
Bull. N.Y. Acad. Med.
VOL. 54, No. 6
JUNE 1978
THE ROLE OF THE PRIMARY PHYSICIAN IN THE CARE OF ELDERLY PATIENTS: PREPARATION FOR THE FUTURE* IRVING S. WRIGHT, M.D. Emeritus Professor of Clinical Medicine Cornell University Medical College Chairman, Section on Geriatric Medicine The New York Academy of Medicine New York, New York
Ishall use the term "primary physician" for the physician who may or may not first see a patient in a particular illness, but who assumes the responsibility for the patient's chief and continuing care and medical guidance. He takes full responsibility for the diagnostic and treatment regimen when these are within his capabilities or guides the patient to the correct specialists or facilities when needed. Any specialists who are consulted report to him, and he advises the patient as to the wisest course to take when all aspects of the patient's health are weighed carefully. Unfortunately, the term "primary" also has been used to indicate the first physician to see the patient. He may turn out to be the long-term primary *Presented as part of a Symposium on Geriatric Medicine held by the Section on Geriatric Medicine of the New York Academy of Medicine and the American Geriatrics Society at the Academy June 8, 1977.
Vol. 54, No. 6. June 1978
54654
I. S. WRIGHT .S.WIH
physician, but the first physician to see a patient under many circumstances may be a matter of chance, and this physician may be totally unsuited, either by temperament or specialty, to assume such a role. In 1968, when I wrote about this role of the primary physician as a keystone of medical care, my views were criticized by some physicians who believed that such a need did not exist. However, with the passage of time the need for a highly competent central or primary physician to guide the medical care of the individual patient has become widely recognized. Recently, The Bulletin of the American College of Physicians published official statements by the American College of Physicians, the American Society of Internal Medicine, the American Board of Internal Medicine, and the Association of Professors of Medicine confirming this position and presenting the respective conclusions of these important organizations on this matter.2 They agree that well-trained internists are especially qualified for this function. However, a well-trained family physician with a broad medical background, a good relation with his patient, and an understanding of his medical and family history also may serve well in this capacity. With these prestigious organizations now behind this position, the primary physician (by whatever name he ultimately may be called) will, it is hoped, be accepted as the central agent of sound medical care. Such a physician is a requisite for optimal care in private practice, group practice, clinic, or medical center, whether outpatient or inpatient. This physician will reduce duplication of unnecessary tests and counteract the unfortunate depersonalization that is common in both private practice and large medical centers today. Some patients are referred from one specialist or testing laboratory to another, with no physician to whom they can turn for detailed, personal advice. Too often, on subsequent visits patients see a physician new to them, who either has to review their entire personal and family history (which may take hours) to advise them intelligently or who, for lack of time, must act on a snap judgment which may not represent the best solution to the problem. This essay will focus on the role of the primary physician in the care of the elderly or geriatric patients.
QUALIFICATIONS FOR THE CARE OF THE ELDERLY Unless the physician assuming this role has consideration, patience, and compassion, he may fail to provide optimal care to elderly patients. As McDermott has emphasized, a complete physician must exercise Bull. N.Y. Acad. Med.
PRIMARY PHYSICIAN
-~~~~~~~RMR
PHSCA
547 4
samaritanism as well as technical proficiency.3 A half century of experience with private and institutional medical care has led me to conclude that elderly patients (60 years of age or older) require different attitudes and approaches by physicians, nurses, and support staff from those needed for the care of patients in childhood, adolescence, early adulthood, or even middle age. As people become. older they often develop multiple diseases which require multiple medications, become more sensitive to favorable and unfavorable comments or acts by others, react more strongly to the implications of favorable or unfavorable medical information, become more easily depressed or frightened by medical problems-especially institutional confinement-whether acute or long-term, and as a result of this tend to lose their will to live. Experienced clinicians know -that these factors may affect the outcome of an illness or operative procedure. Younger patients generally are more optimistic and less easily depressed by indifference or inconsiderate acts by medical personnel at any level: physician, orderly, or practical nurse. Under adverse circumstances the young also are less likely to give up the struggle for life and recovery. Even when facilities are excellent, clean, and antiseptic and the food satisfactory (as in many Scandinavian hospitals), elderly patients complain about and resent depersonalization by the staff. SOCIOLOGICAL ASPECTS
In civilizations which still function largely as they have in past centuries, the aged ill are rejected by their own accepted standards. Old, sick Eskimos leave the igloo and wander into the arctic weather to die by freezing. The Bakhtiari, in their constant migrations over the vast mountains'of Persia, reach the great, wild Bazuft River, the crossing of which is a major yearly test; only the strong animals or men, survive, while the old stay behind to die. We do not like to think of treating our elderly in this way, yet many feel rejected by their families and, if institutionalized, by those who are supposed to care for them. Social change, along with the abandonment of multigenerational family dwellings, has forced the elderly into new patterns of life. They no longer entertain the status of the patriarch or matriarch, looked to for wisdom or even to fulfill the useful and instructive function of caring for the young. (Even among the second and third generation of westernized Chinese, the old tradition of esteemed paternal respect is being lost.) Many of the elderly, if they are still strong and healthy, and especially if Vol. 54, No. 6, June 1978
54854
I. S. WRIGHT
I.
S.WIH
both spouses are alive, can live fairly well on their own, depending in large measure on the amount of their income above Social Security benefits. Frequently these people are faced with several severe psychological readjustments within a year to two after the death of a spouse or relative. Besides the personal loss, they often experience sudden reductions in income and living standards, relocation from a long-time home, and chronic illness. When one spouse dies, the life pattern changes for the survivor, and, with confusion and depression, functional as well as organic disease becomes more difficult to handle. In addition, in large cities normal exercise often is curtailed for the elderly. They avoid healthy walks because they are afraid of being targets for muggers. Their money is easy to take and under our system of justice, with its excessive leniency for youthful offenders, the risk of penalty to the offenders is almost nil. For example, one of my patients, an elderly woman who suffers with atherosclerotic heart disease, has been mugged and seriously beaten three times in what was formerly a safe and respectable neighborhood. Her assailants are still free. The loss of social role and prestigious identity which is so commonly seen in retirees, especially those forced out of their jobs by mandatory retirement, is another major cause of stress in our work-oriented society. These various events occurring within a few years are met by a variety of reactions. For many, the subconscious reaction is to develop hypochondriasis (which was studied by Busse).4 Frequent visits to the physician's office seem to be the main motivation in the lives of some of these people. The primary physician should be alert to this syndrome. He can deal with many patients by explaining the reason for the multiple nonorganic aches and pains, but he may refer some for psychiatric care. These patients often will not accept psychiatric help, and the primary physician must handle the problem. While many of these may be regarded as social problems, the primary physician of such patients must expect to be used as advisor, counselor, and friend as well as physician. As more geriatric nurse-practitoners are trained, they may play an increasingly inportant role by working closely with the primary physician. However, the physician frequently is the most authoritative individual to whom an elderly patient can turn for intelligent help. He is asked to select appropriate specialists for a wide range of illnesses and injuries, to arrange admission to hospitals or nursing homes, or to arrange transfer to a suitable retirement community. Aged widows or Bull. N.Y. Acad. Med.
PRIMARY PHYSICIAN
-~~~~~~~PIMR
HSCA
549 4
widowers frequently are without living relatives, and the primary physician may be called upon to resolve the problems of a confused and failing mind. He may have to mobilize help in the form of legal, pastoral, and social services in order to arrange for patients to be admitted to appropriate long-term facilities where geriatric nursing is being slowly developed to a higher level of excellence. FUNCTIONS OF SPECIALISTS The medical profession rapidly is being divided into those who provide guidance and a large measure of medical care and those who provide highly technical skills but have little to do with the continuing care of patients. The latter group includes: computer experts, biochemists, radiologists, ultrasound and scanning experts, and various surgical specialists who operate but provide only immediate postoperative care. These physicians contribute their technical skills to a degree never before possible and save many lives. Their relation with the patient, however, is only temporary, and patients frequently do not know or remember their names. Primary physicians must assume a key role in evaluating the indications for such procedures, bearing in mind that these should not be judged exclusively on whether they will extend life but also on whether they can improve the quality of life. For example, reconstructive surgery on the arteries of the leg, neck, or heart in correctly selected patients may vastly improve the quality of life, yet it may be difficult to demonstrate that the patient's life has been prolonged. THE GENERATION GAP WITH YOUNG PHYSICIANS
It is particularly difficult for young physicians at the student or housestaff level to bridge the generation gap and understand the attitudes and apprehensions of elderly patients. This may be attributable in part to the fact that most American medical schools fail to provide orientation in the special problems of geriatrics. It also is related to the age-old difficulties in communication between successive generations which was noted in the dialogues of Socrates and Plato (400 B.C.),* in which they comment upon the love of Greek youth for luxury, their bad manners, their contempt for authority, their disrespect for their elders, their love of chatter in prefer*Plato: Republic, Shorey, P., translator. Book VIII, 562e and 563e, Bollingen Series LXXI.
Princeton, N.J., Princeton University Press, 1971, p.791.
Vol. 54, No. 6, June 1978
550
550
I.S. WRIGHT
ence to exercise, their tyrannization of their teachers, and their gobbling of food. Of course, there are exceptional young physicians who understand this problem and handle it well. Interestingly, after residency training those who elect to become primary physicians-usually internists or family physicians-tend to go through a metamorphosis; gradually they become less brusque and hurried and more attentive, understanding, and sympathetic with their elderly patients. Regrettably, this growth sometimes requires many years. EFFECT OF SOCIALIZATION
As countries have moved toward socialized medicine, the care provided by primary physicians too frequently has been replaced by impersonal treatment, and numbers become more important than individuals. If a general practitioner must see 59 to 100 patients a day it becomes almost impossible to obtain a good history, perform an acceptable physical examination, and develop a sympathetic and close relation with elderly patients. When it is recognized that the patient has become seriously ill, he is admitted to a hospital and his family physician loses contact. There the patient is confronted with a new health-care team whose members know little or nothing of his background, in a strange and often frightening new environment. This situation is difficult for the elderly unless there is interest in their problems as a result of special geriatric services such as those so well developed under the leadership of Sir Ferguson Anderson of Glasgow. TRAINING IN GERIATRICS AND THANATOLOGY
Geriatrics and its companion study, thanatology (the study of problems related to dying and death), should become established subjects in medical school curricula. As Robert Butler, director of the new National Institute of Aging in Bethesda, Md., has emphasized, our medical schools have been negligent in preparing young physicians to understand and provide for this major health problem.- For example, in 1970 a survey revealed that of 99 medical schools 50 did not mention geriatrics in their catalogues, and only 32 of 114 schools offered electives in this subject. These figures symbolize the lack of constructive programming in our medical curricula. Since 1970 some progress has taken place. A few more schools now have elective courses, but fewer than 10 have any course on geriatrics or Bull. N.Y. Acad. Med.
PRIMARY PHYSICIAN
PRIMARY
PHYSICIAN
551
thanatology included in the regular curriculum, although all physicians could profit from such courses as early as the first year of their medical training. As yet we are not prepared to satisfy the special health needs of the very people whom we have helped to live longer in greater numbers than ever before. We must prepare for the demographic change taking place in our population. In 1900 4% of the population of the United States was 65 years or older. Today it is approaching I 1%, and in a few years, unless there is an overwhelming catastrophe, this figure will approach 18 to 20%. How members of this group and their multiple diseases will be cared for already is our most formidable health problem; it seems to be beyond solution unless we involve more young, trained medical problem-solvers. These problems are not going to be solved by political maneuvering, cost accounting, or computers-either alone -or in combination-although these may help to analyze and clarify the needs. The provision of care must come from health personnel in the field. Informed and sincerely interested physicians, researchers in the process of aging and its accompanying diseases, nurses, social workers, and all allied health personnel will have to join hands and prepare to meet this critical problem. It is already late as we begin to enter this new era. SPECIAL PROBLEMS WITH MEDICATIONS
Many physicians have little concept of pain and the need for adequate dosages of analgesic or narcotic drugs to give patients relief. Seeing patients suffering needlessly while physicians belittle their pain has led me to suggest that what some physicians need to complete their medical education is a serious and painful illness. Then their attitude toward these patients would change and they would be better doctors. For the elderly the need for medication frequently is greater than that of the young and strong, but the dosage required or the tolerance for specific drugs may be less. Chronic arthritis, for example, adds to the pains of acute illness. The tendency of physicians and nurses to limit medication which may control the excruciating pain of terminal illness often is unjustified; the problem of addiction is irrelevant here. Reassurance, which may reduce the need for narcotics after an operation, also can be an important contribution of the primary physician, especially if he sees the patient before and after an operation. The elderly may not react to single drugs or combinations in the same Vol. 54, No. 6, June 1978
552
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way as younger individuals. For example, barbiturates can produce unexpected confusion or dizziness in the elderly and this may cause falls with serious results. They also may produce excitement rather than relaxation and then must be discontinued. The elderly may require a lower dosage of digitalis or quinidine, and most require digitalis only five days each week. Blood levels of digitalis now are being measured widely, and this may be helpful, but this is not always the case with the elderly. With these and other drugs careful clinical observations are still most important in guiding the physician. The elderly also are particularly subject to adverse interactions between drugs because their liver and kidneys may no longer be fully effective in handling and eliminating toxic products. All of this knowledge is part of the responsibility of the primary physician. Who else can be expected to record these idiosyncracies? Certainly not the otolaryngologist, radiologist, or surgeon-and it cannot be expected of a physician who sees the patient for 15 to 20 minutes in a clinic, yet the patient's life may rest on just such information. ROLE OF ALLIED HEALTH PERSONNEL
Allied health personnel may be trained to take blood-pressure readings, blood samples, electrocardiograms, and so forth (although, unless they are trained carefully and checked constantly, the error ratio may be high), but for important decisions these findings should be evaluated in the light of all other factors in the patient's health and environment. Treating multiple diseases in elderly patients can pose a difficult challenge to the best-trained physician, and should not be relegated to technicians with one or two years training in the simplest aspects of health care. Clinical practitioners, trained nurses, social workers, or other health-service personnel may carry out certain of these functions. THE TEAM APPROACH
In some medical centers efforts are made to have all important decisions made by a team. As many as six or eight different health disciplines are considered essential. While theoretically this may seem ideal in some respects, it proves impractical in the care of most patients. The team cannot always be assembled when a critical decision must be made, differences of opinion slow up or even stultify the making of decisions, and this practice is enormously expensive and wasteful of health-personnel Bull. N.Y. Acad. Med.
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resources. Frequently, the patient's problems do not involve the disciplines of several members of the group who might be occupied more productively elsewhere. The primary physician should use representatives of various disciplines freely as needed. Staff and visiting nurses, hospital administrators, social workers, physiotherapists, rehabilitation teams, and representatives of various specialties should all be called upon to contribute appropriate advice. However, the primary physician should take responsibility for making the final decision. Attempts to diffuse this responsibility for making complicated decisions results in overlapping and confusing patterns of treatment to the detriment of the patient. Team effort should aim at broader and more effective use of the available health manpower in a given institution or area, and meetings should be efficient to minimize use of the participants' valuable time. This broad planning should always include primary physicians as the keystone to optimal medical care.
SUMMARY The role of primary physicians in caring for the elderly is just beginning to emerge and be clarified. It is complicated and demanding. Until recently, the health professions have not recognized the enormity of geriatric care in terms of numbers. The care of the elderly requires a broad knowledge of medicine mixed with extraordinary patience and compassion. The simultaneous presence in a single individual of multiple diseases requiring various medications calls for judgment based on years of medical training and experience. Such decisions should not be delegated to allied health personnel, although they may be most helpful in carrying out a program of treatment. Geriatrics should be part of the curriculum of every medical school. Medical students also should participate in programs, discussion groups, and clinical experiences in thanatology. The two subjects may well be coordinated within the same curriculum module. Preferably, students should be taught the importance of these fields in the first or second year of medical school. For best results, a team headed by a physician experienced in geriatric medicine should assume responsibility for this and should obtain the cooperation of the other faculty members, since many disciplines may be involved. This study should fit into the department of medicine or family practice if the head of that department is sympathetic and will support it. It does not seem advisable to develop geriatrics as a Vol. 54, No. 6, June 1978
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limited specialty with a certification board. This discipline involves all physicians who deal with adults and constitutes a major health challenge for the foreseeable future. REFERENCES 1. Wright, I. S.: The case for the primary /06:135, 1977. physician. Cornell Univ. Med. School 4. Busse, E. W.: Hypochondriasis in the Alumni Assoc. Quart. 32:7, 1968. elderly: A reaction to social stress. J. Am. 2. Federated Council for Internal Medicine: Geriat. Soc. 24:145, 1976. Bull. Am. Coll. Phys. 7:10, 1976. 5. Butler, R.: Geriatric medicine, the imper3. McDermott, W.: Evaluating the physiatives. N.Y. State J. Med. 77:1470-72, cian and his technology. Daedalus 1977.
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