David Reuben, MD, a longtime Hartford grantee, is chief of Geriatrics at UCLA and directs the Hartford Center of Excellence in Geriatric Medicine there. In July, Dr. Reuben became the Chair of the American Board of Internal Medicine (ABIM). He spoke with Health AGEnda about recruiting geriatricians, teaching teamwork, new models of care, and his new play.
Health AGEnda (HA): Who needs to see a geriatrician?
The people who would likely benefit the most from it. If you are 75 years old and playing tennis and you have hypertension and diabetes, you may not need to see a geriatrician. But if you’re 88 years old and most of your time is spent in a wheelchair, the situation and the conversations about health are different.
Those conversations, and determining what the patient’s goals are and what resources need to be mounted to get to those goals, are where the geriatrician really earns her or his stripes.
HA: You’re describing a very personal and intimate type of care.
It is always personal and it is always intimate – it just has to be. These are issues that are most important to us. It’s about life!
But what I mean by personal is not going back to Marcus Welby. It’s taking advantage of other systems of care that are available now.
For example, if somebody has bad congestive heart failure, we might have to have a conversation about whether they want to go on hospice or palliative care. A geriatrician does very well in leading that discussion. If the choice is hospice then the geriatrician often follows the patient through hospice working with its team.
But let’s say the person wants to try to do everything possible and is really willing to work at it. That may require a team of health professionals, and non-health professionals, to implement using disease management principles. So when we’re talking about personal care, that doesn’t always have to be one-on-one personal care with the physician. It’s the person interacting with the physician and a team.
HA: Does medicine conceive of that team too narrowly?
Yes. When I was a kid growing up, it was an artisan model—a doctor and a patient. And frequently the other person in the office was the doctor’s wife, who was checking you in and running the business.
We have evolved clearly from that. Still, doctors are really smart people but they don’t think team-y.
HA: Most doctors see a lot of older patients. What do you wish more of them brought to that care?
Perspective. Being able to focus on the road ahead, not the hood ornament. Let’s say you’re a surgeon and you’re discharging a patient from the surgical service. What do you need to have in place so that person is able to stay out of the hospital and get better rather than bounce back into the hospital because something went wrong?
I’m not sure all health professionals, or even all physicians, can do this. In some sense it’s like playing chess. You really want to say, if such and such happens, they’re going to be in one position. If none of that happens, they’re going to be in a different spot. You need to be prepared for all of the expected and, as much as possible, the unexpected. Then be prepared to make changes as situations evolve.
HA: Let’s talk about recruitment. What is turning medical students and residents off from careers in geriatrics?
Historically, almost everything we do turns residents and medical students off. For example, we tend to expose our trainees to the worst examples of aging in hospital settings. We spend enormous amounts of time with assessment, frequently with standardized instruments.
One of the reasons doctors go into medicine is they can cure people. Take a cataract out and restore sight. Or replace a hip and get somebody walking again. That’s incredibly gratifying.
Those kinds of victories are less common in geriatrics. They’re smaller. They may not be any less meaningful for a patient, but they’re often more subtle.
HA: What do you enjoy most about geriatrics?
I love helping people work through where they want to be, and helping them get there. An example is a patient I saw on Monday, one I’m really happy about. This patient is a 76-year-old physician who became very depressed and was self-medicating with Valium. He wasn’t able to work any more.
I started an anti-depressant, and over a period of about two to three months, his mood symptoms improved tremendously. And gradually we weaned him off the Valium. Now the man is functioning well again, he’s happy, his family is happy. It’s not taking out a cataract but it’s incredibly gratifying for me to see this patient getting his life back together.
HA: If medical education offered more geriatric perspective, what would you want to see?
Medical education is really at a crossroads--we have been doing more or less the same kinds of things, with tweaks, for decades. If we refocused it on what the patient really needs and how best to provide that, it would be exceptionally difficult but might have really high yield.
Geriatrics is a very good vehicle for teaching not only about acute illness but also about chronic illness management. In fact, geriatrics is a great vehicle for teaching almost anything in medicine because you are frequently managing very complicated situations that require trade-offs and choices. Many older people have many morbidities and multiple diseases and may have social issues as well as cognitive issues.
And certainly medical education is really lacking here, particularly in the whole idea of providing team care and mobilizing resources.
HA: Do you expect health care reform to have much impact in this area?
I do. I’m very optimistic that a lot of this will be propelled by health care reform. There’s a lot of investment in innovation, new models of care, this Medicare and Medicaid innovation center that’s been funded. So hopefully, these new models are going to be tested, they’re going to be implemented, and they’re going to be adopted.
My suspicion is that there’s not going to be one model that emerges; there will be a number of them. But they have some common features: a lot of delegation, shared responsibility, teamwork, and communication. And they’re patient centered.
HA: Many studies have shown that only about 30 to 40% of recommended geriatric care is delivered, especially for conditions like falls and dementia. Just how bad is that?
Well, it’s bad! If you went to your mechanic and they only did 30% of what they were supposed to do for your tuneup, you’d be pretty upset. If you went on an airplane and your pilot only did 30% or 40% of the checks, you’d be a little nervous flying.
It never gets to be 100%. That’s probably an unobtainable goal for a variety of reasons: co-morbidities, patient preferences, and a lot of other things. But 30 to 40% is pretty bad.
HA: Do you think most patients and their families know this?
No, I don’t. I think that most patients and their families think they’re getting really good care.
HA: You’re also a playwright, currently working on your fourth play.
It’s a comedy, about a family of husband, wife and two near-teenage, hockey player sons. And they’re invaded by the husband’s brother, who is this ne’er-do-well, out-of-work screenwriter. There are a lot of things taken from the Marx Brothers, Monty Python, maybe a little Neil Simon. A couple of little allusions to medicine, but it’s lighthearted.