Nursing home headaches often begin the day someone is admitted. Too often the choice for a home is a decision made when a discharge planner at the hospital announces, “The patient will be going home tomorrow. The social worker will be in to see you.” You are flabbergasted and protest to no avail. The choice is often between a "so-so" and "oh-no" home because the goods ones have long waiting lists. Families often choose the best of a bad lot and despite dissatisfaction are lulled into believing that a move is detrimental to the elderly. It isn't.
But when one comes face-to-face with poor quality physician care from part-time consulting physicians, courageous families take action. Baby Boomers: Start Turning Nursing Homes Upside Down - New America Media.
Belief in the on-site physician
Jonathan M. Evans, M.D., M.P.H., is a geriatrician who teachs "Aging and the Law" at the University of Virginia School of Law. Earlier this month he wrote When Long-Term Caregivers Have Ethical Obligations.
A firm believer in on-site physicians at nursing homes, he explained: “The thing that matters most is being there – being there for patients when they're sick; being there for families when they're in need; being there for staff to provide support and ongoing education. You can't be part of a team if you're not present.”
As such when asked, “Should the nursing home physician communicate directly with patients and family members rather than through the staff?” he was quick to answer: “Why the hell not?”
Dr. Evans pointed out: “On a basic human level communication is critically important. As human beings we should expect communication between ourselves and, when we are talking about loving relationships, we broaden it to communicate caring. A doctor should always communicate with a patient directly unless a patient is not able to make medical decisions and has a medical proxy to guard confidentiality.”
Part-time physician problem scenario
In the absence of a full time physician, dementia patients are at a disadvantage. The doctor reads charts, talks to staff, talks to patient but fails to communicate with family. One family member voiced a complaint often heard at professional meetings – “My father doesn’t remember if he has had breakfast as he gets up from the table. And when the doctor asks him how he feels, he says fine. Never mind that we were getting middle of the night calls from him. And then there were all those calls to 911 he made.”
Had the physician talked with family rather than reading charts, the patient might have been helped sooner. Essentially in the absence of a full time physician, there is a disconnect.
Brown University is looking at the 911 situation with the elderly: http://news.brown.edu/pressreleases/2013/01/diamond
Annals of Internal Medicine
Several years ago Paul R. Katz, M.D., and colleagues at the University of Rochester wrote a journal article about the problem with nursing home physicians. They made a compelling argument for a new model:
“We contend that rather than accepting a diminished presence of physicians in nursing homes and finding alternative care models, it is time to fully consider, appropriately fund, and test the nursing home specialist model. If nearly half of the baby boomers spend some time in a nursing home, the question 'Is there a doctor in the house?' will take on new urgency and meaning.” Nursing Home Physician Specialists - Annals of Internal Medicine
Nursing home care is a calling
Dr. Evans is a proponent of the nursing home specialist model and has been involved in nursing home care for more than 20 years. He is also a defender of those who work there. He pointed out that “despite what we hear in terms of nursing home turnover because of low pay, when people leave a nursing home it is often to go to another one.” He added, “They need some type of fulfillment from their workplace. Caring for others becomes a part of their identity, their values."
But he also acknowledged that “Many who went to school hoping to work with patients as their life’s work, instead many find themselves with checklists. Ritual practice is different than caring for others. We check off what we should do on a list. It makes us feel safe. While we need the checklist for quality assurance, when we are interacting with patients, there is no checklist to measure caring, respect, and empathy,” said Dr. Evans.
An advocate of face-to-face conversations or phone conversations with patients, he says that with emailing and texting “as physicians we miss the verbal cues and silences,” adding, “I like to remind myself and my students as to why communication with patients is so important.“
"As someone once reminded me: ‘Love unspoken sounds the same as indifference,’” said Dr. Evans.
Overuse of medication
Recently I was at a unit that pointed dramatically at the difference between a full time physician on staff vs the use of medication to calm unruly patients by a part time physician. A patient was visibly haranguing a family member of another patient. A nurse walked over to her, called her by name, and said, “Hi there. I haven’t seen you all day. What a beautiful sweater you’re wearing. Let’s take a walk and look at some other sweaters.”
The woman was calmed. The situation was diffused. And there was no order written for an "as needed” drug to settle her down. Knowing a physician is available, however, gives staff a measure of confidence. This same patient would have been an easy candidate for medication in a nursing home with a once a week physician.
As Dr. Evans, who was recently named medical director for Life Care of Tennessee, said: “We have built a system of providers. We need to change the model to focus on patients.” Jonathan Evans - U.S. Senate Special Committee on Aging
Calling attention to the needs of our aging population has become a crusade for many of us -- 2013 MetLife Foundation Fellows in Aging.* Should every nursing home have a full-time doctor? We have seen how patient rights and “the best interest of ” can be so easily manipulated. There are few substitutes for individual patient advocates during an era when the physician shortage continues. Whatever happened to doctors who took pride in knowing patients -- their words, their expressions, their sighs?
Copyright 2013 Rita Watson/ All Rights Reserved
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* The Fellows in Aging Program is a collaboration of the Gerontological Society of America and New America Media.