Lament

My mother’s doctor runs a concierge practice—he charges his patients several thousand dollars a year on top of what they pay Medicare ostensibly so that he can provide a more personalized type of medical care. He is more available, provides more coordination of services, and has a nicer office than he did when he was part of a conventional group practice. I’m not fond of concierge medicine because it creates a two-tier medical system and it worsens the already existing shortage of primary care doctors. But I have to admit that my mother, who is 90 years old and is in fairly good health (she proudly points out that she takes only three medicines a day, one of which is a vitamin), has gotten the attention that she deserves from her doctor. He’s smart, caring, and competent. I figured he was doing a decent job providing medical care to octogenarians and nonagenarians even though he is an internist and not a geriatrician. Now I’m not so sure.

What changed my mind is that my mother needed a few forms filled out for an independent living complex to which she is applying. It asked the usual questions—about diagnoses, medications, and vital signs. But it also asked another kind of question that is equally important for a facility trying to decide if my mother is able to live on her own, with just one communal meal, weekly housekeeping, and on site social activities. It asked about what we in geriatrics call functional status: her ability to walk without an assistive device (she needs a cane or, for uneven terrain, a walker), her vision (she wears reading glasses as do almost all people her age), her hearing (she wears hearing aids, or at least she has a pair and some of the time she wears them), and her memory (she’s a bit forgetful). And it inquired about advance care planning: health care proxy designation and goals of care. Her physician didn’t know the answers to any of these questions. Why not?

My mother’s physician evidently doesn’t ask my mother about these issues unless she brings them up. He apparently doesn’t routinely test her gait or evaluate her memory or check her hearing. He watches her walk to the exam room and he talks with her. He figures that’s good enough. It’s something, but it’s not good enough.

If internists and family physicians are to provide the bulk of primary care to older patients, especially to those over 80 or with multiple chronic conditions, they need to think and act more like geriatricians. They have to be as interested in and knowledgeable about geriatric syndromes (falling, incontinence, dementia) as they are about standard internal medicine diseases (high blood pressure, diabetes, pneumonia). They have to incorporate the major elements of comprehensive geriatric assessment into their daily practice—things like mental status exams and advance care planning. They have to accept that lots of “minor” conditions such as osteoarthritis and eczema have as much or more of an effect on quality of life as “major” organ dysfunction such as heart failure or chronic obstructive pulmonary disease.

We can’t as a society rely on geriatric specialists to provide this kind of care—we just aren’t training enough of them and we’re unlikely to do much better in the near term. We have to use internists and family physicians. That means we need to do a better job in medical school and residency teaching them basic geriatric principles. Or perhaps we need to systematically assure that they work together with geriatric nurse practitioners and other advanced practice clinicians to compensate for their deficiencies.