Going against the doc-in-a-box style of medicine, Dr. John Sloane of Vancouver pays an office call to 92-year-old Jim Steele, who gets a gets blood pressure test at his business place. Photo: Bill Keay, Vancouver SunVANCOUVER (Vancouver Sun), November 17, 2007:
At a time when Canada's aging population means that seniors are this country's fastest-growing population group and the fastest-growing segment is 85-plus, Canadian medical schools are barely turning out a handful of geriatric specialists every year.
Even young people are having trouble finding a family physician.
Where, then, does that leave the elderly, often with complicated medical issues that require much more time than the fee-mandated few minutes of an office visit?
The elderly often find a visit to the doctor's office virtually impossible, and instead end up rushed by ambulance into overcrowded emergency departments when a health crisis hits.
Once in hospital, the situation can go from bad to worse. During a week in a hospital bed, they can go from being mobile to being unable to stand, let alone get themselves to the bathroom or do any of the things that were so vital to their independence.
The fortunate ones have family to help navigate their way through the medical system.
But that takes its toll, with caregivers burning out. One elderly Ontario woman recently had to sleep in her car overnight while her husband was being treated for the after-affects of a stroke. They simply lived too far from the only centre that could provide the rehabilitation he needed, and she couldn't afford a hotel room.
The stress can bring out old grievances and sibling rivalries as the debate rages over just how to care for mum or dad. As one doctor points out, if your kids didn't get along when they were 16 and 17, they'll still be fighting at 50.
Medical care for seniors doesn't stop with the doctor. Best practices suggests it takes a team, with nurses and social workers involved with doctors and specialists who get to know the patient and their circumstances and liaise with family or other caregivers. But unless you're fortunate enough to live in centre that has the services, plus live long enough to get to the top of the waiting list, you might be out of luck.
Faced with such an urgent demand for geriatric specialists, you'd think students would be lining up to fill the spots. They're not. Geriatrics is a poor cousin to the more lucrative specialties like cardiology or neurology. Students graduating with crippling loans have to maximize their incomes to pay them off -- not see one patient in the same time their cardiology colleague sees six.
Yet while students are steering away from a geriatric specialty, the reality is the average doctor will see more seniors than anyone else.
"Except if you are a pediatrician, the classes graduating now will spend 50 per cent of their time with people over the age of 65," said Dr. Laura Diachun, a geriatrician, associate professor of medicine at the University of Western Ontario and co-author of a study pointing to a shortage of doctors who practice geriatric medicine.
Dr. Janet Gordon, a professor in geriatric medicine at Dalhousie University, did a survey of medical schools across Canada and found that students were exposed to anywhere from seven to 200 hours of geriatrics.
"In medical school, people do close to two years or more of classroom learning and then clerkship, on the floor-clinical learning," Gordon said. "Only half the schools have people do geriatrics even though all have them do pediatrics."
Gordon said in problem cases set for medical students at her university, she found only seven per cent of the cases had patients over the age of 65 and none included patients over 70.
"I think there is a belief geriatrics is too complicated to teach them early on," said Gordon.
Geriatrics is a complex and challenging field. It's not like a 40-year-old landing in emergency with a heart attack or pneumonia. Treat the problem in the younger patient and chances are the patient will be up and on his or her way.
For an 80-year-old, one ailment may be complicated by a range of other conditions. Is the confused patient suffering dementia or is the confusion coming from an infection and dehydration? If he's sent home after days in the hospital, is there someone there to ensure he eats? Takes medication?
In medical school, students spend days and weeks gaining pediatric experience. They spend only hours with the elderly.
"The bottom line is this is not a sexy place to be," said Lynn McDonald, director of the Institute for Life Course and Aging and a professor in the faculty of social work at the University of Toronto. "It is not glamorous like brain surgery or saving children who are dying from leukemia.
"We live in an ageist society; there is the feeling, 'who cares?' They are going to die anyway. . . . There is no prize, no glory.
"It is hard, hard complicated work and it is work that requires many disciplines. It is an interdisciplinary team approach. Older people don't just have one problem, they have many problems, it is very complicated and there is a special knowledge base."
McDonald said when she first went to work in gerontology in 1970, no one even knew what the word meant. "Society is catching up, but not fast enough in my opinion," she said. "I think it was in 2001, seven doctors went into geriatric medicine in all of Canada -- we need hundreds."
Geriatrics is also lacking in nursing training, McDonald said, but the curriculum is so stretched there is little room for geriatric medicine.
"Maybe we get three or four nurses in the program a year," she said of a multidisciplinary program at U of T in aging, palliative and supportive care.
"That's not very many when you think most old people end up on the medical wards in hospitals and they end up in long-term care.
"Who's looking after them? People off the street -- that's who is looking after them, with a nurse in charge if you are lucky."
McDonald says in the United States, the John A. Hartford Foundation, dedicated to improving health care for older Americans, is putting millions of dollars into training professionals in nursing and social work in geriatric medicine.
"They know they are going to have an age wave," she said. "They are preparing and they are throwing money at the problem big-time, and it works.
"If you start to pay students for doing it, they are a lot happier than if they are doing it because it is noble."
Drawing on the Hartford example, McDonald wrote a proposal for a national centre of excellence in aging focused on the three professions that provide social, psychological and physical care to Canada's older population, the National Initiative for the Care of the Elderly.
"We were shocked when we got this letter saying 'congratulations,' " said McDonald of the success of her proposal. But the dollars are not lavish. While Hartford is pouring $25 million into a single profession -- nursing -- McDonald said that in Canada, by the time overhead is paid, there will be $1.6 million left for four years.
The centre has put together academics and practitioners working with older people and is focusing on best practices, with the aim of providing community agencies and institutions across Canada the tools they need to work with them.
"That's turning out to be a big winner," she said. "People don't have that information in one spot."
The institute also has a mentorship program for students in gerontology from the three professions, and it pays their way to an annual knowledge exchange.
McDonald said one way to get people involved is to offer scholarships and money for students to do research.
"Once you start to do it you love it," she said. "People who are in gerontology and geriatric medicine love it.
"It really is a challenge -- it is really exciting whenyou can make a difference for an older person and their family."
OLD SCHOOL DOC BUCKS THE TREND
VANCOUVER -- It's a sunny fall afternoon and 82-year-old Rose Sorrenti turns her attention away from her afternoon television to point to a swollen and gaping wound on her calf the size of a baseball.
"My sister-in-law saw it and she said, 'you'd better get hold of your doctor and let him see that,' but I knew you'd be here," says Sorrenti, gesturing to Dr. John Sloane, who is perched on a nearby stool, his tablet computer open and ready for the scribbled notes that will record his patient's condition.
It's a somewhat complicated condition, as it is with most of the frail, elderly patients who make up Sloane's practice.
It is a practice that has taken him from an office to his Mercedes, appropriately enough a geriatric model itself, in which he tours around Vancouver seeing patients where they live.
In an age where "doc-in-a-box" drop-in clinics have replaced trusted family doctors making house calls, Sloane is from another era. And while a program out of Vancouver Coastal Health promises to continue serving his patients when Sloane retires in the new year, medical students aren't lining up to follow his lead.
Instead, many of them will end up being the doctors who see elderly patients when they land in emergency rooms and hospital beds, an outcome Sloane says is exactly counter to what the frail elderly need.
"As funding for reasonable coordinated home care of house-bound people has fallen, the venue of default has remained the emergency room," he said.
"If you are in trouble, you push 911. Bang, in comes the ambulance and the person is hustled out and the next thing they know they are a bed-blocker in an emergency room."
"The truth of the matter is, the service of an acute-care hospital can't help the frail elderly, they just don't benefit. We have a frail elderly person occupying these terribly expensive and much-needed acute-care beds, and those people aren't benefiting."
"It all boils down to the need for an effective strategy for keeping the frail elderly out of the hospital."
"Frail, elderly" isn't defined by age as much as health."
"Once a person goes through a gate which we call frail, there is a linear deterioration punctuated by dying," said Sloane.
"Once they go into that situation, all of this preventative stuff, everything we do in hospital, most of the investigations are actually counterproductive and useless.
"What we need to be doing for those people is keeping them happy and comfortable and home. Nobody wants to spend a nickel on home care, but boy, is it cheaper than sending Grannie through emergency."
People become frail through the irremediable inability to perform the activities of daily living. Many people may suffer that inability at one time or another, either through illness or an accident, but what separates the frail is that they will not get better. There won't come a day when they will be able to fend for themselves again.
"If you fix stuff and the person goes right back to being normal like you and me, they are not frail," said Sloane. "Frailty and homebound-ness approximately coexist. "My practice is homebound. All of my patients are frail and all of my patients are homebound and it is about the same group."
But when it comes to medical care, often the frail 85-year-old is treated as if he or she was 39 and all that is needed is for that broken hip to repair, or the heart problem to be stabilized and they'll be back up and running almost like new.
That doesn't happen. The 85-year-old stranded in the emergency department may suffer some form of dementia along with the ailment that landed him in hospital. He could already have several diseases from diabetes to Parkinson's to respiratory problems to a range of conditions -- a complexity that can overwhelm a medical system geared to dealing with what is wrong with a patient, not seeing the whole person and all the underlying issues.
"So what do we do with frailty is, you talk to them and get them to understand what is going on in their life," said Sloane. "We treat their illnesses from a medical point of view, we treat their disabilities, and we look after them psychologically.
"We do it at home and we do it on a primary-care level."
That, argues Sloane, is where the money should go and where the care should go.
"That kind of shutting them off from the acute-care system is the opposite of abandonment," he said. "Just ask any old person who has been in emerg in the last six months, or who has ever spent a couple of nights in hospital.
"They don't ever want to go back."
Sorrenti appears to share that sentiment.
"Oh, I hate that hospital," she said, recounting a litany of ailments from broken bones to heart troubles that have landed her in one hospital or the other -- some getting a better report from her than others and one clearly a target of her wrath: "I call it murdering hospital," she said.
Sloane ignores the jibes and, convincing Sorrenti to turn down the volume on the television, carries on his questions and examines the angry-looking wound. He calls in a prescription to the pharmacy from his cell phone and calls to arrange for a public-health-care nurse to come by to change dressings and monitor the infection.
Sorrenti, who looks younger than her 82 years -- "You should see me with my makeup and you'd think I was even younger," she says -- has definite ideas about checking out of this life and it doesn't involve hospitals.
"My mother had the perfect death," she said. "She went to sleep at 99 and didn't wake up."
At 88, Mary Goulah manages with the help of some home care, but she doesn't stir far from her chair in her living room -- certainly not far enough to get to a doctor's office.
"I had trouble with my feet for one thing," she said. "That was when he (Dr. Sloane) first started coming to see me.
"I wore him out, that's why he is retiring," she said with a laugh, her sense of humour clearly not dimmed by a range of ailments. "It's too much for me to go out to a doctor."
Sloane will likely be retiring before one of his patients, Jim Steele, does. The 91-year-old isn't quite ready to calls it quits with the wholesale bakery business he took on as a retirement project after his retail bakery closed.
One of Steele's sons was in school with Sloane in Kerrisdale from kindergarten on, and the elder Steele remembers the doctor as a young lad at class events.
Steele's balance is unsteady and he leans on a walker, but asked how he negotiates steep stairs at his premises, he is indignant.
"I walk up them just like any other human being," he said sharply when asked about the stairs Sloane aptly describes as "breath takingly steep."
Paul Steele, another son and the brother of Sloane's classmate, doesn't think Sloane can be easily replaced.
"It's going to be difficult if not impossible to replace people like John," said the younger Steele. "To find people with that experience in family practice and in gerontology, and who care enough to do this."
Watching Sloane care for his father, Steele is convinced that the health-care system would save money if there were more doctors ready to take on the care of homebound seniors. But it won't happen, he said, unless public policy makes it a worthwhile option for doctors.
"You have to make it attractive," he said.
By Gillian Shaw
© The StarPhoenix (Saskatoon) 2007
