There is nothing so implacable as aging, so sometimes I am surprised by how vehemently families deny its onset.
This is often far more so than the aged person, should they be aware of it. I think it must build an awareness of its inevitability.
This is fine, except when the aged person isn't aware of it, and can't make their own decisions, and family members who lack that experience are asked to make those decisions for them. It must create a huge awareness of their parent's mortality (if that isn't the issue at stake itself!) and also therefore their own.
Its reasonable to be angry at the injustice of the world, that rewards age and experience with illness and death. Sometimes though that gets misdirected into a "shoot the messenger" problem. I find this very difficult to to feel as somehow my fault, as do many of my colleagues. I often assume people will later realise this was misdirected and feel apologetic, however it is rare that they have actually apologised, so perhaps I am wrong.
Wednesday, May 30, 2007
Sunday, May 20, 2007
Phrases I'd like to remove from medicine 1: "just a mechanical fall"
I'm interested in how people think about things, in particular how doctors think about things and how that affects their practise. One of the ways this can occur is through terminology and the implications of this.
Falls can be broadly categorised into two - falls due to the immediate effect of a medical condition (for example losing consciousness from a sub arachnoid haemorrhage) and those not, said to be due to mechanical factors (for example a banana peel). This is a handy categorisation in younger people in whom the former requires careful consideration and evaluation for a potentially life threatening condition, and the latter not.
Unfortunately in older people so called mechanical falls THEMSELVES are a potentially life threatening condition, and require careful consideration and evaluation. However, by calling them mechanical falls creates an assumption that this is not the case, it is due to an accidental and unlikely to be repeated unfortunate event.
One of my professors had a particular concern about terminology - he felt the term CVA for CerebroVascular Accident had problematic connotations, was inaccurate and misleading and preferred stroke. At the time I didn't understand, but now things are evidently changing.
Falls can be broadly categorised into two - falls due to the immediate effect of a medical condition (for example losing consciousness from a sub arachnoid haemorrhage) and those not, said to be due to mechanical factors (for example a banana peel). This is a handy categorisation in younger people in whom the former requires careful consideration and evaluation for a potentially life threatening condition, and the latter not.
Unfortunately in older people so called mechanical falls THEMSELVES are a potentially life threatening condition, and require careful consideration and evaluation. However, by calling them mechanical falls creates an assumption that this is not the case, it is due to an accidental and unlikely to be repeated unfortunate event.
One of my professors had a particular concern about terminology - he felt the term CVA for CerebroVascular Accident had problematic connotations, was inaccurate and misleading and preferred stroke. At the time I didn't understand, but now things are evidently changing.
excellent post on www.pallimed.org
I found this excellent post on www.pallimed.org
http://www.pallimed.org/2007/04/video-assisted-advance-care-planning.html
TO summarise, it summarises an article in archives of internal medicine about video assisted advanced care planning.
In it is a link to a video showing a person with advanced dementia, which (although there wasn't a control group) probably significantly changed a group of people's opinions about how they would want to be treated if they had the condition. They did not have family members with dementia.
The truth about advanced dementia is hidden from the bulk of the population, and it's difficult to appreciate when described. The article will change my practice when discussing the intent of future cares with my patient's and their families.
Another barrier to appreciating quality of life in dementia is the stereotype of the (amusing) forgetful elder. I feel this creates the idea that dementia is funny, and by an inappropriate transference that the demented are amused by their condition. I feel it also delays diagnosis and potential treatment of this serious problem.
I'm not sure if this is something limited to western culture. I'd appreciate any enlightenment - please post on comments here.
http://www.pallimed.org/2007/04/video-assisted-advance-care-planning.html
TO summarise, it summarises an article in archives of internal medicine about video assisted advanced care planning.
In it is a link to a video showing a person with advanced dementia, which (although there wasn't a control group) probably significantly changed a group of people's opinions about how they would want to be treated if they had the condition. They did not have family members with dementia.
The truth about advanced dementia is hidden from the bulk of the population, and it's difficult to appreciate when described. The article will change my practice when discussing the intent of future cares with my patient's and their families.
Another barrier to appreciating quality of life in dementia is the stereotype of the (amusing) forgetful elder. I feel this creates the idea that dementia is funny, and by an inappropriate transference that the demented are amused by their condition. I feel it also delays diagnosis and potential treatment of this serious problem.
I'm not sure if this is something limited to western culture. I'd appreciate any enlightenment - please post on comments here.
Tuesday, May 15, 2007
Why I chose Geriatrics/ why is it rewarding?
Having just talked about why geriatrics is unpopular I thought it worth talking about why I went against the grain and chose it as my specialty.
Briefly, my goal in life has always been to leave this Earth a little better for my passing. The way I've chosen to do that is through medicine, because it's rewarding and enables me to comfortably provide for myself and my family as I had always hoped.
I chose geriatrics because I found it the most rewarding of any area of medicine.
It's a field I think is actually quite easy, once you understand the underlying principles.
Once you understand the goals it is also very satisfying. I don't start my day thinking "today I'm going to save someone's life!" although I might. I always know that I'm going to make someone's life better. It might be something as simple as making someone continent again. Imagine your quality of life if you were incontinent, and how that would change. Then imagine being able to bring that back. It might not even be the patient that I make better, for example by simply explaining the diagnosis of dementia I have seen a wife burst into tears with relief that there was a reason for her husbands increasingly odd behaviour. It might be just letting people know they can choose the goal of therapy, returning control of their destiny to them and not aging or their disease
Because of that recognition of underlying factors in geriatrics that I wrote about in an earlier post, I feel that where appropriate I can often not just return my patients to their state of health before they became unwell but actually improve their health. Not many of my colleagues can claim that.
Its rewarding obviously financially, and I have a secure career for as long as I chose to pursue it. That means I have financial security, which to me is far more important than the possibility of making massive riches, with the possibility of bankruptcy.
There is a shortage of geriatricians, so I know that its not just a case of "If I don't do it someone else will" I'm actually adding not replacing the pool of geriatricians.
I can't say I specifically like old people, but I do like people - some of them happen to be old.
As a relatively new field of medicine, there is more scope for research and career advancement. Call me lazy, but the thought of working 20 years to finally attain the professorship of another specialty seems excessive to me.
It's a field where teams are paramount, and I like working with a team. Because of this there is far more to geriatrics than just the medicine - you need to build skills in teamwork, management both of individuals and services, psychology of same.
All these are my personal reasons for finding geriatrics satisfying, but surveys have shown that overall geriatricians are the most satisfied of all medical fields. DOn't believe me? I direct you to
Physician Career Satisfaction Across Specialties
Briefly, my goal in life has always been to leave this Earth a little better for my passing. The way I've chosen to do that is through medicine, because it's rewarding and enables me to comfortably provide for myself and my family as I had always hoped.
I chose geriatrics because I found it the most rewarding of any area of medicine.
It's a field I think is actually quite easy, once you understand the underlying principles.
Once you understand the goals it is also very satisfying. I don't start my day thinking "today I'm going to save someone's life!" although I might. I always know that I'm going to make someone's life better. It might be something as simple as making someone continent again. Imagine your quality of life if you were incontinent, and how that would change. Then imagine being able to bring that back. It might not even be the patient that I make better, for example by simply explaining the diagnosis of dementia I have seen a wife burst into tears with relief that there was a reason for her husbands increasingly odd behaviour. It might be just letting people know they can choose the goal of therapy, returning control of their destiny to them and not aging or their disease
Because of that recognition of underlying factors in geriatrics that I wrote about in an earlier post, I feel that where appropriate I can often not just return my patients to their state of health before they became unwell but actually improve their health. Not many of my colleagues can claim that.
Its rewarding obviously financially, and I have a secure career for as long as I chose to pursue it. That means I have financial security, which to me is far more important than the possibility of making massive riches, with the possibility of bankruptcy.
There is a shortage of geriatricians, so I know that its not just a case of "If I don't do it someone else will" I'm actually adding not replacing the pool of geriatricians.
I can't say I specifically like old people, but I do like people - some of them happen to be old.
As a relatively new field of medicine, there is more scope for research and career advancement. Call me lazy, but the thought of working 20 years to finally attain the professorship of another specialty seems excessive to me.
It's a field where teams are paramount, and I like working with a team. Because of this there is far more to geriatrics than just the medicine - you need to build skills in teamwork, management both of individuals and services, psychology of same.
All these are my personal reasons for finding geriatrics satisfying, but surveys have shown that overall geriatricians are the most satisfied of all medical fields. DOn't believe me? I direct you to
Physician Career Satisfaction Across Specialties
Arch Intern Med. 2002;162:1577-1584.
Why is Geriatrics unpopular? 2
There are lots more reasons why geriatrics is unpopular than the above.
By the way, I'm not going to talk about whether geriatrics is unpopular, others have done a far better job of that than I.
On a more personal level, taking care of old people can be physically unpleasant. They are not attractive, they do tend to talk at length, they're often hearing impaired so you have to shout to be heard, they sometimes are confused so you can't tell them what's wrong or why you are doing this unpleasant thing to them, they can be just plain verbally or physically hostile, incontinent, dirty and smelly.
If you never want to encounter any of that then not only should you avoid geriatrics, medicine is not the job for you at all, because I guarantee in ANY field of medicine, even cosmetic practice or epidemiology, you'll find that stuff.
Old people remind us too of our own mortality and frailty, and that can be very challenging for a young person at the peak of their powers. We all know that someday it will be one of us there. The temptation is to avoid or dehumanise the old to disconnect us from that realisation.
Financially Geriatrics is not as rewarding as other specialties, although I should say that earnings are still well beyond the reach of most people. I've seen figures of $160-170K average in the US and first year in Australia in public practice around $140K is to be expected.
Finally, the aged are perceived as useless, disgusting and unworthy of attention and resources in western culture, and this directly impacts the status of geriatrics as a profession.
By the way, I'm not going to talk about whether geriatrics is unpopular, others have done a far better job of that than I.
On a more personal level, taking care of old people can be physically unpleasant. They are not attractive, they do tend to talk at length, they're often hearing impaired so you have to shout to be heard, they sometimes are confused so you can't tell them what's wrong or why you are doing this unpleasant thing to them, they can be just plain verbally or physically hostile, incontinent, dirty and smelly.
If you never want to encounter any of that then not only should you avoid geriatrics, medicine is not the job for you at all, because I guarantee in ANY field of medicine, even cosmetic practice or epidemiology, you'll find that stuff.
Old people remind us too of our own mortality and frailty, and that can be very challenging for a young person at the peak of their powers. We all know that someday it will be one of us there. The temptation is to avoid or dehumanise the old to disconnect us from that realisation.
Financially Geriatrics is not as rewarding as other specialties, although I should say that earnings are still well beyond the reach of most people. I've seen figures of $160-170K average in the US and first year in Australia in public practice around $140K is to be expected.
Finally, the aged are perceived as useless, disgusting and unworthy of attention and resources in western culture, and this directly impacts the status of geriatrics as a profession.
Why is Geriatrics unpopular?
Earlier I talked about the need for a different paradigm in geriatrics. I think one of the reasons Geriatrics is unpopular is because doctors try to apply that hypotheticodeductive paradigm to geriatrics with frustrating ineffectiveness.
The hypotheticodeductive model is also appealing, simple and easily explainable to the patient, so even doctors who do understand that it isn't relevant to geriatrics might prefer another field where it is of more utility.
Finally, the Geriatrics model applies most to those major problems of geriatrics, but certainly not all, and to be an effective geriatrician you need to be able to know when to apply it and when not, for example, in incontinence it is clearly very relevant, in acute chest pain the hypotheticodeductive model is superior.
That's clearly not all the reason.
Those not in or close to the profession may not believe this, but almost all doctors want to make people better. The best way to do that is to cure them of their disease so it never comes back, explaining the appeal of surgery as a career. Most problems in internal medicine (see a future post for the difference between surgery and internal medicine) are not curable, especially so in geriatrics, and even if they were its certainly true that older people are unable to enjoy the cures for as long.
The antidote to this in my opinion comes from palliative care - goal directed medicine. In their are usually implicit assumptions about the goal - for example in surgery the goal is the cure of the disease via surgery. In pathology on the other hand the goal is diagnosis of the disease. In neurology frequently the diagnosis is often pursued to a point where I personally feel it has become irrelevant to the treatment of the patient and has become a goal in itself. In palliative care it the comfort of the patient and family.
In geriatrics the goal could be any one of these, so it is very important to START with identifying with the patient and the family what is the goal of the interaction.
More on this topic soon.
The hypotheticodeductive model is also appealing, simple and easily explainable to the patient, so even doctors who do understand that it isn't relevant to geriatrics might prefer another field where it is of more utility.
Finally, the Geriatrics model applies most to those major problems of geriatrics, but certainly not all, and to be an effective geriatrician you need to be able to know when to apply it and when not, for example, in incontinence it is clearly very relevant, in acute chest pain the hypotheticodeductive model is superior.
That's clearly not all the reason.
Those not in or close to the profession may not believe this, but almost all doctors want to make people better. The best way to do that is to cure them of their disease so it never comes back, explaining the appeal of surgery as a career. Most problems in internal medicine (see a future post for the difference between surgery and internal medicine) are not curable, especially so in geriatrics, and even if they were its certainly true that older people are unable to enjoy the cures for as long.
The antidote to this in my opinion comes from palliative care - goal directed medicine. In their are usually implicit assumptions about the goal - for example in surgery the goal is the cure of the disease via surgery. In pathology on the other hand the goal is diagnosis of the disease. In neurology frequently the diagnosis is often pursued to a point where I personally feel it has become irrelevant to the treatment of the patient and has become a goal in itself. In palliative care it the comfort of the patient and family.
In geriatrics the goal could be any one of these, so it is very important to START with identifying with the patient and the family what is the goal of the interaction.
More on this topic soon.
What's different about geriatrics? Paradigm
There are some important differences between the rest of medicine and geriatrics. The first I want to discuss is paradigm.
To me, a paradigm is a particular way of thinking which involves certain assumptions, implicit or explicit, about how things work and allows humans to think about topics and to work with them. Paradigms all have strengths and limitations.
An example in medicine is the biological model of disease. Briefly, the physical organism has an external influence which alters it's function. That produces changes which are sensed by the mind, producing unpleasant sensations - disease. To remove disease then, find the external influence and remove it or if that's not possible return the function to normal and no more disease. This paradigm has strengths but also weaknesses - it ignores the effect of psychological and social influences on the progression of disease.
A similar paradigm of thought in medicine is the hypotheticodeductive model. IN this way of medical thinking, the doctor interacts with the patient and step by step gathers information, along the way forming hypotheses about what is causing the disease, testing them by gathering more targeted information, and refining or discarding them. Information can be gathered by talking, testing or even trials of treatment. Finally one diagnosis is reached and the appropriate treatment can be prescribed. Again this model has strengths and weaknesses.
There are other models of medical thinking however, for example, in intensive care units, the hypotheticodeductive model is used, but treatment can also be prescribed without a diagnosis, on the basis that although the cause is unknown, it is clear which organ is not functioning and needs support.
The hypotheticodeductive system is appealing in it's utility and simplicity and is the major model used in medicine, but it often fails in geriatrics. This is because problems in geriatrics are rarely the result of a single diagnosis. One of the fundamental factors in aging is homeostenosis - if you're not familiar with this I will be posting on it soon. Homeostenosis is not an even process however, and some processes are more susceptible to than others. A factor, indeed sometimes it seems like almost any factor results in a perturbation in homeostasis, which produces disease. Most sensitive to perturbation are the the homeostatic processes whose dysfunction results in the giants of geriatrics - balance so falls, continence so incontinence, intellect so confusion, movement so immobility.
Another way of explaining this more simply is the weakest link. As you age, some systems become weaker than others. when something happens to cause a disease, where in a young person that might affect the particular organ that's in, in an older person it affects the weakest link first.
The factor that affects homeostasis could be anything, and usually there is more than one. I've found it useful to borrow a classification from the psychiatrists, the predisposing/precipitating/perpetuating way of classifying factors contributing to disease. In this way of thinking, disease is caused by combinations of underlying or predisposing factors, often with a precipitating factor, and prolonging or perpetuating factors that continue the illness. The psychiatrists also classify these factors by their type - biological, psychological or social, which I find less though sometimes still useful.
The problem comes when doctors trained in hypotheticodeductive thinking apply that to geriatric problems. The result of that thinking is that they will come up with a single diagnosis and expect treatment of that to improve the problem, ignoring all those other factors.
For example, a patient presents with urinary incontinence. The hypotheticodeductive thinker finds a urinary tract infection and treats it, but the patient doesn't improve. Why? THe underlying predisposing factor may well be benign prostatic enlargement resulting in retention of abnormal volumes of urine in the bladder after voiding. The acute precipitant to the incontinence was the urinary tract infection, but the perpetuating factor is the constipation resulting from decreased fluid intake as the patient tried to treat the incontinence himself, which worsens the urinary retention causing overflow incontinence. Treat just the infection and the patient not only will not get better, but also you will miss an opportunity to prevent further problem by correcting the underlying predisposition.
That was a fairly simple example. Often, there are many factors fitting into all categories, some of which are reversible or treatable, some of which aren't.
To me, a paradigm is a particular way of thinking which involves certain assumptions, implicit or explicit, about how things work and allows humans to think about topics and to work with them. Paradigms all have strengths and limitations.
An example in medicine is the biological model of disease. Briefly, the physical organism has an external influence which alters it's function. That produces changes which are sensed by the mind, producing unpleasant sensations - disease. To remove disease then, find the external influence and remove it or if that's not possible return the function to normal and no more disease. This paradigm has strengths but also weaknesses - it ignores the effect of psychological and social influences on the progression of disease.
A similar paradigm of thought in medicine is the hypotheticodeductive model. IN this way of medical thinking, the doctor interacts with the patient and step by step gathers information, along the way forming hypotheses about what is causing the disease, testing them by gathering more targeted information, and refining or discarding them. Information can be gathered by talking, testing or even trials of treatment. Finally one diagnosis is reached and the appropriate treatment can be prescribed. Again this model has strengths and weaknesses.
There are other models of medical thinking however, for example, in intensive care units, the hypotheticodeductive model is used, but treatment can also be prescribed without a diagnosis, on the basis that although the cause is unknown, it is clear which organ is not functioning and needs support.
The hypotheticodeductive system is appealing in it's utility and simplicity and is the major model used in medicine, but it often fails in geriatrics. This is because problems in geriatrics are rarely the result of a single diagnosis. One of the fundamental factors in aging is homeostenosis - if you're not familiar with this I will be posting on it soon. Homeostenosis is not an even process however, and some processes are more susceptible to than others. A factor, indeed sometimes it seems like almost any factor results in a perturbation in homeostasis, which produces disease. Most sensitive to perturbation are the the homeostatic processes whose dysfunction results in the giants of geriatrics - balance so falls, continence so incontinence, intellect so confusion, movement so immobility.
Another way of explaining this more simply is the weakest link. As you age, some systems become weaker than others. when something happens to cause a disease, where in a young person that might affect the particular organ that's in, in an older person it affects the weakest link first.
The factor that affects homeostasis could be anything, and usually there is more than one. I've found it useful to borrow a classification from the psychiatrists, the predisposing/precipitating/perpetuating way of classifying factors contributing to disease. In this way of thinking, disease is caused by combinations of underlying or predisposing factors, often with a precipitating factor, and prolonging or perpetuating factors that continue the illness. The psychiatrists also classify these factors by their type - biological, psychological or social, which I find less though sometimes still useful.
The problem comes when doctors trained in hypotheticodeductive thinking apply that to geriatric problems. The result of that thinking is that they will come up with a single diagnosis and expect treatment of that to improve the problem, ignoring all those other factors.
For example, a patient presents with urinary incontinence. The hypotheticodeductive thinker finds a urinary tract infection and treats it, but the patient doesn't improve. Why? THe underlying predisposing factor may well be benign prostatic enlargement resulting in retention of abnormal volumes of urine in the bladder after voiding. The acute precipitant to the incontinence was the urinary tract infection, but the perpetuating factor is the constipation resulting from decreased fluid intake as the patient tried to treat the incontinence himself, which worsens the urinary retention causing overflow incontinence. Treat just the infection and the patient not only will not get better, but also you will miss an opportunity to prevent further problem by correcting the underlying predisposition.
That was a fairly simple example. Often, there are many factors fitting into all categories, some of which are reversible or treatable, some of which aren't.
Subscribe to:
Posts (Atom)