The Doctor is On Line

The Commonwealth Fund just released a study reporting on primary care office visits in the COVID-19 era and it’s disturbing. In-person office visits fell by 60 percent in March and remained down to nearly the same extent in April. While telemedicine substituted for some of these visits, it did not come anywhere near to compensating for the decline. 

Clearly the precipitous fall is disastrous for primary care medicine, which has seen one practice after another furlough physicians or close altogether, but it also bodes ill for patients. While some of those vanishing visits were probably unnecessary or could easily be postponed, there is reasonably good evidence for the efficacy of robust primary care medicine in improving health and increasing longevity. What can we do about this problem—apart from eradicating COVID-19?

            

The popular answer is to increase the use of telemedicine. Telemedicine—principally video calls by patients to physicians that allow both parties to remain home—have had considerable successes: Jefferson Health has made extensive use of the technology to screen for COVID-19, to enhance prevention and, to some extent, to treat common conditions. The use of telemedicine has been rising dramatically, with some analysts reporting a 50 percent increase since March and others predicting a billion remote visits by the end of 2020. Moreover, the regulatory changes introduced by Medicare to facilitate billing for telemedicine visits have had a major beneficial impact. 

But before we get carried away, we should consider who is not currently using the technology and what adaptations will be necessary to maximize its efficacy. I worry that older people in general and the oldest old in particular are not availing themselves of telemedicine, despite having the greatest need. Older patients who are poor, have little education, or are non-English speakers are at the greatest disadvantage of all. But to assume that the only barrier to effective utilization is lack of access strikes me as naïve: surely new skills and a new approach will be necessary, both on the part of physicians and of patients.

First, the barriers to access. My mother is 94. She is intelligent, she has a master’s degree in social work, and she owns a computer and a tablet, both of which she uses to read her email. But video calling is just beyond her. I’ve tried FaceTime and Zoom. I sat with her (in the days when I was able to do so) and coached her. I’ve attempted to walk her through the process while we are on the phone together. No luck. And she is not unique. Her friends have not been able to master this skill either. Generations on Line, an organization which for decades has been trying to improve digital literacy in the elderly, identifies three obstacles: lack of access (not an issue with my mother or most of her friends), lack of skill, and intimidation. She is convinced she cannot learn to use this technology. “I’m not made for this century,” she tells me and she is not alone in her conviction.

Now consider all the older people who do not have a computer or a tablet. Internet use has been steadily rising in those over age 65 and is now about 73 percent—but among those age 80 or older, it’s only 44 percent. And use falls further with lower income and lower levels of education. 

Then think about those who are hearing impaired—you might imagine that the computer's capacity for amplification would be a benefit of the technology, but for many people with hearing loss, the main problem is discrimination, the ability to distinguish different sounds, and that does not disappear with amplification. Next, throw in non-English speakers. Good systems are available for dial-in interpreters, which works well in the office setting, when the patient and the physician are in physical proximity, but is more challenging when a three-way video call is required. Until these barriers are overcome, telemedicine will be limited to telephone calls in those who are neediest and most vulnerable. 

Even if we could wave a magic wand and all older people would have a computer, smartphone, or tablet and broadband access and the ability to use the device to communicate with their physician, we would still need to address the issue of reaching the doctor in a timely fashion. If telemedicine is supposed to replace urgent care as well as evaluation of new, slightly less acute problems along with chronic disease management, then we will need a systematic way to triage visits. 

If all older people could communicate with the physician via the internet promptly and effectively, there would remain the question of the substance of that interaction. Medical students are taught that a good clinical history results in (presumably correct) diagnosis 80 percent of the time. But a more sophisticated analysis suggests that how likely the history is to prove adequate depends on the prior probability of the condition—that is, if a patient is extremely likely to have pneumonia, then a physical examination or chest x-ray has relatively little to add to the history, but if the chance of pneumonia is small, then these other modalities can add significantly. For telemedicine to be effective, we will need to compensate for the lack of a physical exam and lab tests.

Video adds an important dimension to the visit—physicians can learn a great deal, for example, from observing if the patient is struggling to breathe or has blue-tinged lips. But even in dermatology, physicians rely on touch as well as vision to evaluate a rash. To maximize the effectiveness of telemedicine, patients will need to be able to provide their physicians with critical data. They will have to have a thermometer at home to report their temperature. They should have an electronic home sphygmomanometer to measure blood pressure and, ideally, a pulse oximeter to measure the amount of oxygen in their blood. They should know how to check their pulse (though typically home blood pressure cuffs will do this) and respiratory rate. Obtaining the necessary equipment and learning to use it should be feasible, but it will take time and effort.

Lastly, physicians will need to tailor their approach to a visit to accommodate the strengths and weaknesses of the technological medium on which it is based. A video visit is not identical to an office visit, which in turn is not the same as hospital care. Just as physicians discovered that they could not simply extrapolate from inpatient medicine to the outpatient setting but rather had to learn different strategies for caring for ambulatory patients, similarly they will need to adapt to the brave new world of telemedicine. 

Over the long run, the adaptation will be worthwhile. Better home care can lead to fewer hospitalizations. Fewer hospitalizations means better outcomes for frail older patients: they were at risk of adverse consequences of hospitalization (falls, confusion, decline in self-care ability) long before they were at risk of COVID-19. But we have a long way to go.

What Does Dying Have to Do With It?

What Katy Butler gets spectacularly right in her new book, The Art of Dying Well, is that if we want life's last chapter to be a good one, there’s a great deal more to talk about than death and dying. She understands, which so many writers about aging do not, that maintaining function—the ability to walk, to see, to hear, and a host of other verbs describing the actions that are critical for a fulfilling life—is of paramount importance in this phase of life. She understands that medical tests, procedures, and treatments often do more harm than good and this danger becomes greater as the number of underlying medical problems grows, which happens more and more often with advancing age. So why, then, does she call her book the “art of dying well?”

At first, I speculated that the title had been chosen by the publisher’s marketing division, as often happens, chosen perhaps because books about dying are in vogue, or at least more so than are books about frailty or chronic disease. Then I wondered whether the problem was merely semantic—after all, the formative experience that awakened Butler to the issue of “dying well” was that of her father, which she poignantly describes in her previous book, “Knocking on Heaven’s Door.” Her father had a stroke, only to spend the next seven or so years declining, his life prolonged by medical technology such as a pacemaker. From his daughter’s point of view, that entire period of decline could be viewed as “dying,” even though it was measured in years, not days or months. But Butler says that her goal in her new book is to provide readers with “a step-by-step guide to remaining as healthy and happy as possible, and as medically and unafraid, through the predictable health stages of late life, from vigorous old age to final breath.” Although I would argue with the implication that everyone goes through “predictable health stages”—some people plunge headlong into frailty, for example, whereas others move towards it gradually and others go directly from being robust to dying with virtually no time between the two—she does acknowledge that there’s more to old age than dying. In the very next breath, however, she says that “the goal of each chapter is to help you thrive and keep you on a path to a good end of life.” In other words, a major part of the point is to act today to assure a good death tomorrow. I would emphasize optimizing each day, rather than assuming that the purpose of your behavior today is to prevent a bad death.

The same phenomenon of grasping what old age is all about but not quite getting it is evident in Butler’s misconception about the “goals of care.” In Chapter 4, “Awareness of Mortality,” she asserts that discussing the goals of care is “medical shorthand for exploring what matters most to you [yes!], and how medicine can help you accomplish it [yes!], when time is short and cure is not in the cards [no!]” I think that patients and their physicians need to clarify the goals of care at every stage of life, not just when the end is near. It’s true that most people who are vigorous and are not afflicted with a fatal illness will choose life-prolongation as their main goal. But it is also true that many people who suffer from multiple chronic conditions but who do not have a terminal diagnosis and who can anticipate another ten years of life may choose as their principal goal of care “maximizing function.” Butler is right that for some physicians, discussing the goals of care is a euphemism for moving from treatment that seeks to cure to treatment that seeks to comfort--but goals of care discussions ought to be far more than that.

Then there's Butler's curious discussion of why you should cultivate a network of friendships in old age and find ways to remain engaged with life. Both are decidedly beneficial, as Butler asserts, but not just because they will prove useful “later on.” Relationships and engagement are ways to find meaning in life after the children have grown up and moved away and after retirement. This is yet another instance of the author seeming to understand what’s important as people age but then backsliding into thinking it’s important only as a means to assuring a good death. Befriending your neighbor can be rewarding in and of itself, not just so she will buy groceries for you when you are too ill to do so yourself.

Butler does an admirable job of conveying some of the main insights of geriatrics and palliative care. She understands, for instance, that the hospital is often a perilous environment for an older person, leading to loss of some of the functions most critical to remaining independent. She recognizes that physicians often focus on the benefits of medical technology, whether an implanted cardiac defibrillator (ICD) or an artificial heart valve, and fail to consider their risks. She rightly identifies home care programs, advance care planning, and enrollment in hospice as potentially life-enhancing strategies. But then she makes statements about medicine that are at best misleading and at worst simply wrong. For example, she says that “Benadryl and the sleeping pills are…anticholinergics, an insidious group of commonly prescribed drugs that befuddle thinking and substantially increase the likelihood of developing dementia.” Yes, anticholinergics can result in delirium, a form of acute, reversible confusion. But dementia? 

Butler goes on, a few pages later, to report on a “landmark study” that found that people who used anticholinergics heavily were 50 percent more likely than those who took few to develop dementia. What she doesn’t say is that it’s very misleading to cite relative risk rather than absolute risk: going from a risk of 1 in a 100 to a risk of 1.5 in a 100 constitutes a 50 percent increase in risk, but the outcome in question remains very rare. She doesn’t say that this study lumped many different medications with anticholinergic activity together, including a variety of drugs that are no longer in widespread use, such as the tricyclic antidepressants. She also does not mention that drugs that block acid production (the proton pump inhibitors such as Prilosec and Prevacid) have also been associated, statistically, with developing dementia, and so have anti-anxiety agents. Is it really the case that all these drugs “cause” dementia? Or might it be that people who take certain kinds of drugs—perhaps because they are already exhibiting the earliest signs of dementia—are more likely to go on and develop the full-blown disease? Before jumping to conclusions, observational studies of the kind Butler cites (as opposed to a randomized controlled trial) need to be replicated or, ideally, followed up with a study in which some people are given anticholinergics for a given condition and others, chosen at random, are given something else. 

To be fair, the author of the “landmark study” has gone on to carry out many other observational studies. Her most recent report on this subject appeared in the British Medical Journal last year partially confirmed her earlier findings. But expert analysis of this paper is mixed. At best, it is reasonable to conclude that anticholinergic medications might be a risk factor for dementia.

The Art of Dying Well has much to offer. I only wish it had been more scrupulously reviewed by geriatricians before publication.

Ready, Aim, Fire

Firearms are a geriatric issue. The reason: suicide is more common in older people than in the general population and guns are the method of choice for older people who kill themselves. In fact, elderly white men have the highest suicide rate in the country (29/100,000 compared to the national average of 12.4 deaths/100,000). White men over 85 have a particularly high suicide rate: 47/100,000. A study in the Lancet could in principle help remedy this problem by shedding light on which of the existing firearms laws have any effect.

Examining data on suicides and homicides in the United States between 2008 and 2010, the researchers identified 32,000 gun-related deaths. They then looked at the site of death and existing firearm legislation. The results: 25 types of firearm legislation are found across the 50 states. Of these laws, 9 were associated with a decrease in mortality, 9 with an increase in mortality, and 7 were equivocal. The 3 state laws with greatest evidence of statistically significant benefit are universal background checks to buy guns, universal background checks to buy ammunition, and ID requirements for buying firearms. The single law most likely to lead to an increase in violent deaths is “stand your ground” legislation. The authors of the study projected that if there were federal level implementation of universal background checks, gun-related deaths would fall from 10.35/100,000 to 4.46/100,000.

Now there are serious methodological problems with this study, as US newspapers were quick to point out: basically, it compares what was happening in various states before a particular law was enacted to what happened afterwards and assumes that any changes in gun violence were due to the law. But it’s entirely possible that there were other things going on in those states that led to the change in gun violence. In some cases, especially states where the law seemed to make matters worse, the changes that were occurring might have led to the decision to enact the legislation in the first place. But this kind of study is the best we have right now. And there’s a reason we don’t have anything better.

The reason we don’t have better studies on the effectiveness (or lack of effectiveness) of various gun control measures is that the CDC, and to a large extent, the NIH, are prevented from funding such studies. Thanks to the “Dickey Amendment,” passed by Congress in 1996, “none of the funds made available for injury prevention and control at the Centers for Disease Control and Prevention may be used to advocate [for] or promote gun control.” This clause effectively scared the CDC, which spends millions on studies of highway safety, from supporting any research on guns. And in 2011, the Dickey amendment was extended to the NIH.

Congress has made a few attempts to repeal the Dickey amendment as recently as in January, 2016, after the San Bernardino shootings. They went nowhere. The irony is that even the most rabid right-wing politicians and their supporters who want to shrink the federal government, in the most extreme cases eliminating Medicare, Medicaid, social security, and the income tax (the view of the Koch brothers, according to Jane Mayer’s book, Dark Money) believe that the one role the federal government is to protect its citizens from physical harm. 

If the federal government is to keep us safe, it has to know how best to achieve that end. Neither ideology nor common sense are the best guides to determining effectiveness. Research on how to reduce gun violence is essential—and it’s a geriatric issue.