Long after the patient has gone, their shared wisdom remains. And perhaps
more than anything, it's that constant personal learning that makes geriatricians
hold their patients, and their work, so dear.
It's a trait Dr. John Burton shares with many other geriatricians
-- a love and respect for elders.
"As a group, they're an extraordinarily interesting population," says
Burton, director of the division of geriatrics at Johns Hopkins University
Medical Center in Baltimore. "They have enormous histories, enormous interests,
and that's interesting and challenging to me."
Burton started out in internal medicine, but found that focusing his attention
on one organ wasn't offering enough variety. It was the early 1970s and
he opted to pursue geriatrics -- long before anyone knew how enormously important
the field would become.
Now he rushes from one part of his job to another, doing rounds in the
hospital, seeing a select number of private patients in his office, and his
favorite part of all -- house calls.
Burton says the elderly are "extremely appreciative." Unlike younger people,
who expect a complete cure with the gulp of a pill, the elderly look for "old-fashioned"
medicine.
"They don't expect cures often -- they expect support," he says. "It's
challenging. I expect my patients to die. I guess I feel like family in that
way. But there aren't any downsides to what I do. There's just not
enough time to do it all -- the teaching, the administration, the program
development, even the clinical care."
Burton recalls one patient who came to see him at age 89. He wanted to
make it to his 90th birthday, but had spent the last year bedridden. He had
seen seven different doctors and was on 12 different medications. "But he
had no problems with his cognitive functioning -- he was sharp as a tack."
Over time, Burton brought down the number of medications and gave the patient
strategies to improve mobility.
"Have I cured him? No. But what's important is that he has a sense
of well-being."
During that time, Burton got some personal rewards too. His patient had
been a federal government policy maker during the Vietnam War. He shared some
of that history with Burton -- a gift that couldn't be replaced. Burton
attended his patient's 90th birthday, with all the family around.
"I never met an older patient that I haven't learned things from,"
he says. "It's a great calling. It's the low end of reimbursement
of medicine, so people go into it for the right reasons."
Dr. Lynn Beattie, head of a division of geriatric medicine, says working
with the elderly challenges every aspect of care. Recently Beattie had a patient
who came in after a fall. After examination, it became apparent the woman
had suffered a mild heart attack, which resulted in the fall. Beattie also
learned the patient had anemia and bowel cancer.
They performed surgery, but when it was time for the patient to be released
from hospital, the manager of her apartment refused to take her back into
the building. He produced some photographs showing the state of the apartment.
"There were ongoing negotiations, and it required the cooperation of the
family physicians as well. We were able to talk with the apartment manager
and the community resource people."
Eventually the woman was provided with Meals on Wheels, plus homemaker
assistance. From start to finish, the case meant Beattie worked with nurses,
social workers, and even rehabilitation people. "The whole system only works
if there is a good continuum of care," she says.
Beattie entered the field in the 1970s -- long before it became one of
the largest growing areas of medicine. "It's never boring. There's
always a new challenge ahead, and you're working with people all the
time."
Dr. Robert Stall is a geriatrician in Buffalo, New York. "A
lot of people are not afraid of dying," says Stall. "They're afraid of
pain and mental suffering.
"Too often the medical profession doesn't know how to treat the elderly,"
Stall says. "They send their patients off to one specialist after another.
With that approach, it doesn't take long before one patient can be on
as many as 17 different medications. Ultimately, the symptoms are treated,
but not the cause."
Stall asks his new patients open-ended questions such as, what is the main
thing keeping you from enjoying life to its fullest? Or, what are you most
thankful for at this point in your life?
"A doctor might find the patient has heart disease, but the thing that
is keeping the person down is that their son or daughter doesn't call
enough, or that their pet just died," Stall says. These other, more psychological,
factors must be taken into consideration when caring for the patient. Otherwise,
you can end up simply adding more medication to an increasingly long list.
Stall recalls one patient who was on 17 regular prescriptions. After speaking
with her, he was able to have her discontinue 11 of them at once, without
any qualms. A few weeks later, he saw her again and she wanted to be withdrawn
from more. She's still on a few medications, and her quality of life
is vastly improved.
Of course there are difficult times when dealing with the elderly. Patients
do die: it's a fact of the profession.
"There are some days when I leave my program notes for another day," says
Stall. "You can get somewhat overwhelmed at times. But then, I think to myself,
if you aren't doing it, no one else would be doing it. I'm not there
to cure, but there as a professional to relieve these global diseases."
Age has also taught Stall an important lesson: no one is going to be giving
him regular pats on the back.
"I have to be satisfied with knowing that what I'm doing is the right
thing to do." And that, perhaps, is one of the hardest lessons of aging.