American College of Physicians: Internal Medicine — Doctors for Adults ®

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President's Column

How we can better care for an aging population

By William J. Hall, FACP

An 85-year-old patient of mine came in recently for a routine appointment. A retired physician, he arrived as always with high expectations for the immediate outcomes of this encounter. He pointedly gazed at his watch when I marched in 15 minutes late, tacitly reminding me of my apparent disrespect. In so many ways, he keeps me honest.

When he developed the first signs of congestive heart failure, he came to the office armed with his own appraisal of the literature on ACE-inhibitors. A quintessential academic detailer, he methodically lectures me on drug interactions, possible side effects and cost-benefit analyses. Although he never touched a computer during his years of practice, he is now a maven of health-related Internet sites.

I confess that I wonder at times why he has stayed with me for these past two decades when he is often more versed in current medical literature than I. What value do I add to his overall health care, given his knowledge base? I would like to think that perhaps my knowledge of him beyond his ejection fraction has something to do with it. Despite an age difference of some 20 years, we are aging together and know firsthand what aging implies for both the human body and spirit.

I know, for example, that his pursuit of medical knowledge is partially a way to constructively fill the hours left empty by the premature death of his wife. I also understand that his refusal to limit salt intake is not intractable "noncompliance," as one of my residents recently wrote in his chart. Rather, it is the result of his greater need for social interaction, which he finds principally by going to restaurants with friends.

Time constraints

Many of us find enormous satisfaction in providing primary care to older adults. The constant opportunity to mix high-tech with high-touch is part of the essence of internal medicine.

But there are problems. In providing this care, skilled internists use time as the key diagnostic and therapeutic tool to interpret symptoms and to place treatment choices in the context of human values that change with age. Yet I rarely have sufficient time to spend with older patients, especially those with complex chronic illnesses. If I depended solely on caring for older adults for my livelihood, I would starve.

Time is the most valuable resource in caring for older adults. How tragic, then, that time is in the shortest supply and is the least understood concept in health care planning and finance.

The College is seeking to address internists' time conundrum in many ways. We have established lines of communication with the Centers for Medicare and Medicaid Services (formerly HCFA) to advocate for Medicare reform. As part of those efforts, the College is pushing for proper reimbursement for evaluation and management services and regulatory relief.

But we need to do even more. We are all aware that the proportion of older adults will explode over the next 40 years. Are we, the doctors for adults, ready for the clinical demands and opportunities that this unprecedented demographic shift will bring?

Embracing demographics

College Regent Eric B. Larson, FACP, suggested in the May 15, 2001, Annals of Internal Medicine that internists-particularly generalists-should begin to embrace the care of older adults as a key element of our specialty's identity. I couldn't agree more. Our core competencies in cognitive services and patient-physician communication, along with our skills in managing complex chronic illness, are precisely the skills required to care for aging patients.

Many practice management issues that contribute to physician dissatisfaction revolve around caring for older adults. How do you properly code for a visit requiring a mental status evaluation, functional assessment and review of eight to 10 medications? If we can more positively declare our resolve to be the preferred physicians of older adults, we may find other professional and consumer groups willing to help us achieve meaningful legislative reform to get on with the challenge. In addition to legislative initiatives, we must also consider how these new realities should influence our educational priorities. Older adults are simultaneously over- and undertreated. End-of-life care varies substantially around the country. Effective office-based strategies for evaluating functional status and "geriatric syndromes" are poorly understood, and often neglected for that reason.

As College members, we enjoy the most sophisticated educational infrastructure in medicine. This aspect of the College, in fact, has always been our core strength. ACP-ASIM can use this infrastructure to provide geriatric-specific knowledge to our members.

The College, for example, has been partnering with the Hartford Foundation on an innovative initiative known as the Practicing Physician Educational Project. The project has identified local physician advocates and sent them to "train-the-trainer" programs at Annual Session, where they learn methods to evaluate geriatric syndromes in the office setting. The Board of Governors may wish to extend this kind of very practical education to our regional meetings. At a recent office visit, I asked my patient-mentor if internists simply have to age with patients for several decades to appreciate the nuances of geriatrics. (Many of my colleagues who enjoy geriatrics say this has been the case with them.) He had no answers, nor apparently even much interest in the question.

The next day, however, he sent (via e-mail!) this quote from William Osler, MD: "The important thing is to make the lesson of each case tell on your education. The value of experience is not in seeing much, but in seeing wisely."

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