The Patients Doctors Don’t Know
Below is the link to an older article; it is one I should have read at the beginning of residency, when it was originally published. I was fortunate that, despite not ever consciously acknowledging the fact that Family Medicine residency (in Canada and the US) requires no rotations in geriatrics, I found the gap in my learning.
Through the good fortune of working with a preceptor who was the “house doctor” at two extended-care facilities, I was introduced to the joy of elder care. It was with great pleasure that I would accompany this less-is-more doctor to the care conferences. I became as passionate as he about stopping dangerous or unnecessary medications, about falls prevention, and sitting at a care conference with family and allied health (and sometimes the patient), coming to consensus about the direction of care. I began to have favourite residents and started reading more about geriatrics. I loved seeing how intimately the nurses knew the people. “Well it’s Tuesday and Jim doesn’t usually like when we sit him on the far side of the dining room, but he really enjoyed sitting with Tom today,” or “Yeh, Betty has been a bit off lately. I think it’s that hip. She never asks for pain medications but we tried some Tylenol and even her family noticed she seemed a little more herself.”
At the table, I tried to offer helpful suggestions based on large meta analyses I had just discovered. “Well, the Cochrane database does support cranberry supplements in certain populations…” or “hey, did you see that CMA infoPOEM? NNT of 12 with Vitamin D to prevent one fall…” It was not hard to be passionate about small and easy developments with few side effects. It was easy to recommend stopping calcium tablets for the 90 year old with end-stage dementia with terrible constipation, rather than adding 3 more drugs to treat the problem. The team found creative solutions for each problem and genuinely enjoyed enabling our elders to thrive.
Quality over quantity and if the quality is good then some reasonable but not invasive attempts at quantity, that seems to be the general theme. I was so lucky to get some time under the wing of a local geriatrician. Living on Vancouver Island means a disproportionately elderly population which translates into an enormous workload for this specialist. It is not surprising that so many GPs and specialists consult him, given that geriatrics is so rarely a part of our training.
Balance, neuropathy, bradycardia, valvular disease, new infection, hypoglycemia, medications, dehydration, and deconditioning. He taught me to look at these and solve the “4 falls this week” or the “weak and dizzies.” Is it delirium or is it dementia? Both? A lot of nurses and FP residents can’t tell the difference and yet I would say this is one of the most common presentations seen in hospital.
During hospitalist electives and now, on the job, I love pouring over the consult notes of the geriatric psychiatrists. It’s not uncommon that they have a great observation that I completely missed or they have a big picture suggestion which realigns my perspective. I feel like an idiot sometimes but their expertise is exactly why they are involved in a case and I hope that I continue to learn from their contributions.
It’s great to work both in a community hospital and fly up north to Nunavut for the diversity of work it provides. Just as I can apply my emergency and procedural skills honed up North to my Van Isle patients, I am able to apply and adapt my growing geriatric knowledge to Inuit elders. Some stick their tongue out at me, but generally they love stopping medications as much as I do. And it’s a pleasure to see the 83 year old ride off on his skidoo.
Op-Ed Contributor – The Patients Doctors Don’t Know – NYTimes.com