Friday, 12 October 2018

Every Older Patient Has a Story. Medical

Older Patient

Every Older Patient Has a Story. Medical Students Need to Hear It.

Whatever the cluster of second-year students at Weill Cornell Medicine in NYC expected to listen to from an 82-year-old woman — this probably wasn’t it.

At first, Elizabeth Shepherd, one among several seniors invited to satisfy with future doctors in an anti-ageism program called “Introduction to the Geriatric Patient,” largely followed the script.

As student Zachary Myslinski, 24, read off questions from a typical assessment tool, she responded in matter-of-fact tones.

Health conditions?

Macular degeneration, replied Ms. Shepherd, a working actor who also teaches Shakespeare at the Stella Adler Studio of Acting. But she was getting treatment.

Recent falls?

Just one, when she missed a bottom step. “In the subway! In public! That was no fun.”

Weight loss?

“Unfortunately not.”

Ms. Shepherd, elegant in an animal-print tunic and dangly earrings easily tucked her hands behind her head, displaying a good range of motion.

She remembered three words — “pineapple, blue, honesty” — when asked to recall them several minutes later during a cognitive test.

But after telling her rapt audience that she’d raised a son born “out of wedlock” in 1964 and had divorced twice, she added, “I emigrated to Lesbianland for touch while in my 50s.”

Eventually returning to heterosexual relationships, she continued, she met a 90-year-old online and had “the most wonderful summer with this man.”

She’s now involved a 65- year-old, she added.

But “he’s in Afghanistan at the instant, so my sex life isn't as active as I’d like it.”

Dr. Ronnie LoFaso, the school geriatrician guiding the session, said, “This is taking an interesting turn.”

But that was the point, really.

“It’s important that they don’t think life stops as you grow old,” Ms. Shepherd told me afterward. “So I made a decision I might be frank with them.”

Dr. Ronald Adelman, co-chief of geriatrics at Weill Cornell, developed this annual program — which incorporates a theater piece and is required for all second-year students — after he realized that medical students were getting a distorted view of older adults.

“Unfortunately, most education takes place within the hospital,” he told me. “If you’re only seeing the hospitalized elderly, you’re seeing the debilitated, the physically deteriorating, the demented. It’s easy to pick up ageist stereotypes.”

These misperceptions can influence people’s care. In another classroom down the hall, 88- year-old Marcia Levine, a retired family therapist, was telling students a few the gastroenterologist who once dismissed her complaints of fatigue by saying, “At your age, you can’t expect to have much energy.”

Then, in her 70s, she switched doctors and learned she had a low-grade infection.

At least 20 medical schools within us have undertaken similar efforts to introduce students to healthy, active elders, said Dr. Amit Shah, a geriatrician who helps direct the Senior Sages program at the Mayo Clinic School of Medicine.

The programs take many forms, from Weill Cornell’s two-hour introduction to a semester-long the curriculum at the University of North Carolina School of Medicine.

“You hear that folks aren't worth treating due to their age.”

Tracey Gendron Virginia Commonwealth University School of Medicine Some schools, like the Medical University of South Carolina and the Icahn School of Medicine at Sinai, match students with older patients they follow throughout their four-year educations, making home visits, accompanying their “senior mentors” to doctors’ appointments, and visiting them if they’re hospitalized.

Though the efforts can be voluntary or mandatory, can emphasize clinical skills or encourage new perspectives, they reflect broad agreement on the issues that ageism brings.

In health care, “you hear tons of infantilizing language: ‘sweetie,’ ‘cutie,’ ‘honey,’” said Tracey
Gendron, the gerontologist who started the senior mentoring program at Virginia Commonwealth University School of Medicine.

“You hear that people are not worth treating because of their age.”

Interruptions are “ubiquitous in medical encounters,” said Dr. Adelman, but older patients contend with them more often.

Dr. Adelman has recorded and analyzed doctor's visits during which a spouse or adult child accompanies a patient and begins asking and answering the questions.

“The older person, who is cognitively fine, is simply excluded, mentioned as ‘he’ or ‘she,’” Dr. Adelman said. “It can undermine the connection between the older patient and therefore the doctor.”

More broadly, medical research often continues to exclude older people, forcing their doctors to form educated guesses about drugs and procedures, and the way much they're going to help or hurt.

Yet most doctors, if they’re not pediatricians, will spend much of their careers working with older people, becoming — to borrow a phrase from Dr. Donovan Maust, a geriatric the psychiatrist at the University of Michigan — de facto geriatricians.

If medical students concentrate on pulmonology, they’ll find that about 35 percent of their patients with chronic obstructive pulmonary disease are over age 65 because of the Centers for Disease Control and Prevention has reported.

Endocrinologists treating diabetics will learn that nearly 40 percent are going to be 65-plus.

In oncology, more than half of the survivors of all types of cancer are over age 65.

We’ll never have enough geriatricians to worry for this the growing older population, in part because it’s hard for doctors to pay off student loans and make a living when virtually all their patients are on Medicare.

Last year, there have been just 7,279 certified geriatricians within us, only about half practicing full time.

The supply is rising only modestly, while the demand will increase a projected 45 percent by 2025, according to the American Geriatrics Society.

Accordingly, many anti-ageism programs mandate participation by all incoming medical students. “The elderly are whom they're going to be caring for,” Dr. Adelman said.

The efforts appear effective. Administrators mean that in longer programs, students and seniors often form friendships, sharing pizza or movies outside of the required interviews.

An evaluation reviewing 10 senior mentoring programs, published in the Journal of the American Geriatrics Society, reported that “the universal the goal of positively influencing student attitudes toward older adults were resoundingly achieved.”

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