LOS ANGELES, California / The Los Angeles Times / Health / May 30, 2011
Elderly mother takes issue with daughter's doctorly caution
A doctor upsets her 86-year-old mother after questioning the need for certain screening and personally confronts a long-running issue: Everyone deserves the best healthcare, but it's difficult deciding what that is.
It may be hard to tell a patient, or mother, but a mammogram
may not be recommended for a woman older than 80.
Ben Edwards, Getty Images / May 30, 2011)
By Pamela M. Davis, Special to the Los Angeles Times
My mother has always had a special way of teaching me lessons, and a recent discussion about her healthcare was no exception.
She knows that healthcare costs are an area of concern for our country and for her doctor-daughter. We all hear daily from the pundits that we must tame Medicare or face financial ruin. This focus on Medicare leaves the aging feeling that their future health and well-being may be jeopardized by attempts to reduce what is spent on them in an effort to hold down the costs for the younger population.
As a family physician educator who teaches young doctors on a daily basis and cares for my own longtime patients, I discuss these issues every day. But I've found that the hardest battles can be fought right at home.
My mother is a charming and vivacious 86-year-old. Blessed with a strong Minnesota constitution, she is still driving, volunteering at a grade school, attending weekly genealogy meetings and is learning to paint with watercolors, a hobby she picked up some time after her 80th birthday. She is also more informed on national news topics than most young people. She is interested in what happens to our country.
The small details of life can fluster her, however, such as recently, when she called me about losing some paperwork she needed before her next doctor's visit. When I asked what she was looking for, she said it was her mammogram slip and some stool cards that test for colon cancer.
I was surprised that she was doing both tests and made the mistake we doctors make when we speak as daughters, not in our family doctor role.
"Why are you doing those? They aren't necessary at your age."
The mistake was made. I had said it — "your age." My mother was furious.
"Why shouldn't I get these tests? I'm just as important as the next person. You doctors just want to save money to spend on the young people and just let us old folks die."
My jaw dropped at her anger. Surely my mom, who was smart enough to understand the fiscal policies debated endlessly in the news, could understand the meaning and value of screening tests — when they made sense and when they didn't.
Mammograms and colorectal screening tests are meant to screen a healthy population for conditions in which it's proved that treatments give significant benefit, i.e. longer life or better quality of life. In order for a screening test to be helpful, the patient has to live long enough to make the follow-up tests and treatments worthwhile.
The studies show that mammograms probably aren't beneficial after 80 because cancer rates drop by that age and those cases that are picked up are slow-growing and easily treated even when they've reached the size of an easily detectable lump.
Colorectal cancer screening was developed to find polyps and precancerous growths that can turn into cancer in 10 to 15 years. Although recommendations indicate there are increasing numbers of precancers with age, many physicians question the value of screening in this population, because studies to prove long-term benefit don't exist at this time. The U.S. Preventive Services Task Force, which makes science-based recommendations on best practices in preventive medicine, recommends screening for colorectal cancer only until the age of 75.
The conversation only worsened when my mother declared, with obvious dismay and disappointment, "I guess you think I don't even need a doctor anymore."
I replied that yes, she does, but that she knows I worry that unnecessary contact with healthcare at her age can be detrimental to her health. Hospitals are sources of infections, tests such as colonoscopies come with risks. Even the prep for such a test is much harder on an octogenarian than it is on a younger person.
That did it. This conversation proved it: I really was a bad daughter.
I struggled again later to explain these concepts to my mother, and she was resistant and aloof. When it was her life we were discussing, she was either unwilling or unable to rationally analyze the statistics about longevity.
I've wondered since then where this leaves the debate on healthcare. As doctors struggle to be stewards with our resources, will we face these conversations over and over with our patients? If a mother doubts even her doctor-daughter's desire to give her the best care, how can we expect patients not to question our motivations?
Every day, physicians strive to do the right thing for our patients without doing more than is necessary, to prevent complications as well as conserve resources. Yet this issue is wrought with difficulties, as patients feel that any attempt to avoid high-tech tests or treatments is somehow taking something important from them — something that they deserve. There is always pressure to do more.
All of my patients, like my mother, deserve the best. It's just not always so easy deciding what the best is.
For doctors, patients and public policymakers to ever come to a consensus on healthcare, we need to educate ourselves on and agree upon the interventions that evidence and experience have proved to be beneficial — or we will be forever linked to a healthcare system that does too much for those who don't need it and not enough for those who do.
I hope that we find this balance, just as I hope that my mother will understand that I only want what is best for her.
Pamela M. Davis is a family physician and director of the family medicine residency program at Northridge Hospital Medical Center. She can be reached at firstname.lastname@example.org.
Copyright 2011 Los Angeles Times