I’m hearing from my elder clients’ children that they cannot get a time to talk with the doctor about what is going on with their parent, what the prognosis might be, and what the best course of treatment ought to be. One client scheduled a time at the nursing home for a care planning session, and only the nursing staff will be attending. He was hoping to have the doctor there, too.
Doctors are in danger of relegating their profession to the role of technicians, to be consulted only when there is an unusual problem or when we need a prescription-writer. Day to day and month to month care plans are abdicated to the people who are there daily: nurses, social workers, and family. But wouldn’t doctors want to be part of this?
:- Doug.
A friend of mine, a medical ethicist from the east coast area, USA, has asked that I post this reply:
There is quite a bit of literature out there looking at the “physician as technician” model of care. It degrades the physician and minimizes their expertise. Unfortunately, the world of medicine is controlled by money, not medicine. So the doctor’s expensive time is only spent on high level issues and the rest is delegated or ignored.
In rural communities, you probably find the old version of family practice and knowing your patients still in place. But most of medicine has become compartmentalized with the doctors barely being able to work with the other physicians on the case. The person is divided into body parts with each technician focused on a certain area. Kinda like a factory. Because of the practice requirements most do not see the big picture, just the organ system in front of them.
Hi!
Thanks for letting me post your response.
So if we want to find out about how our loved one is progressing, what their prognosis might be, and what the best course of treatment is, especially in the nursing home, we need to rely upon the nurses and social workers? This can be good, because they know what is going on with Mom or Dad, and they have a wealth of practical experience. Yet it puts them in a box does it not, if the doctor and they disagree? And it means that messages get relayed to us second hand. How do we get better care for Mom and Dad?
:- Doug.
A friend of mine, who works in home health care in the Midwest, offers this observation:
“I think there are some physicians that will revert into the role of technician, especially considering some of the regulations coming down the line. However, there are many others who are actively involved with planning care for their patients. We see a wide array of approaches in the physicians we work with. I think the issue becomes amplified in facilities due to the nature of the care provided and acuity levels, plus the multitude of physicians involved. Often times, that leads to the question of which one is responsible for what… kind of like too many cooks in the kitchen and who is the head chef?”
Part of the problem is the current reimbursement system. Doctors are paid for procedures, not consultations. Some bail out of the system and practice medicine they way they feel they should be done. One of the ways of doing that is to practice “concierge medicine.” Doctors who change to this way of working do not take insurance, in general. You pay a monthly fee and have access to your physician whenever you need to see him. I have heard of a few physicians, mostly women, who insist on 40-minute appointments. The physician’s assistant who owns a walk-in clinic in Shelton is a good intuitive diagnostician, has a good network of specialists to refer to, takes a sensible approach to most problems, keeps me current with standard lab tests, is careful about prescribing antibiotics and other drugs. If I need extra time, she will put me in a comfortable place to wait, and come back to give me additional time, whether for conversation or a procedure.
Some hospitals today have added palliative care to services they offer, and they do just what you were asking for. So some doctors do these things, but it is unusual. The kind of consultation your client’s family is asking for was a part of the originally-proposed health reform package, but that was taken out after loud accusations that the government was supporting “death panels.”
When my father-in-law was nearing the end of his life, we sometimes took him to his doctor appointments, and could usually find time for conversation about his prognosis, after the doctor attended to the immediate problem. Care conferences with the nursing home staff were helpful, but I do not remember the doctor attending the conferences. A social worker at the hospital was helpful in resolving certain issues that came up during a hospital stay.
I think it might be possible to find a doctor that would provide the kind of care you are wanting for elderly clients. You might look for a gerontologist, whose practice is more attuned to older patients. Ask around to see if someone can recommend a doctor who is willing to spend more time when needed. They may have an independent practice, rather than being part of a large clinic. Older, more experienced physicians might have these qualities. On the other hand, you might find a young woman who has a lot of idealism and empathy. You are absolutely right about what is needed; don’t give up on it.