Narrative Matters
DOI:
10.1377/HLTHAFF.2014.1238
Necessary Steps: How
Health Care Fails Older
Patients, And How It Can
Be Done Better
A chance meeting between an octogenarian and a geriatrician shows
how the US health system focuses on medical care at the expense of
older adults well-being.
BY LOUISE ARONSON
The clinic was in a dilapidated old building located down the hill from a recently renovated hospital, yet the entryway retained
a worn grandeur. Tapering, semicircular walls extended like welcoming arms
from either side of the sliding glass doors, and a half moon of sidewalk
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Thats where I first saw her. She stood
at the curb with her cane propped on her
walker squinting toward the nearby
boulevard. It must have been about
4:30 in the afternoon then, as Id asked
for the last appointment of the day with
the podiatrist doing my pre-op for a minor foot surgery and I was about to be
March 2015 late. The woman was clearly well into her eighties, with a confident demeanor and clothes and hair that revealed an attention to appearance and at least a middleclass existence. She had a cell phone in one hand and seemed to be waiting for
a ride.
This was just before Christmas, so
when I came back out after 5:00, night
had fallen. But for her tan winter coat
and bright scarf, I might have missed her
standing in the shadows leaning against
the curved wall. She still held the cell
phone, but now her shoulders were
slumped and her hair disheveled by
the increasingly cold evening breeze.
I hesitated. On one side of San Francisco, my elderly mother needed computer help. On the other, our dog needed a walk, dinner had to be cooked, and several hours of patient notes and work e-mails required my attention.
I asked if she was OK. When she answered Yes, I waited. She looked at the
ground, lips pursed, and shook her
head. No, she said. My ride didnt
come, and I have this thing on my phone
that calls a cab but it sends them to my
apartment. I dont know how to get them
here, and I cant reach my friend.
She showed me her phone. The battery was now dead. I called for a taxi with my phone and helped her forward to the curb. She was tired and cold by then and suddenly seemed frail.
We chatted as we waited. Her name
was Eva, and she owned a small business
downtownor she had. She was in the
process of retiring, having been unable
to do much work in recent months because of illnesses. Shed been hospitalized twice in the past year, she said.
Nothing catastrophic, yet somehow
the second stay had dismantled her life.
Things had never quite gotten back to
normal since then.
The geriatrician in me noted that she
had some trouble hearing, even more
difficulty seeing, arthritic fingers, and
an antalgic gait that favored her right
side. But her brain was sharp, and she
had a terrific sense of humor.
Finally, the cab arrived. The driver
watched as I helped Eva off the curb,
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Illustration by Brett Ryder
an awkward, slow process because of her
cold-stiffened joints, the walker, and our
bags. As I turned to open the backseat
door, he sped away without his passenger. I stared, dumbfounded, and pulled
out my phone to call the company and
complain. Eva was more sanguine.
It happens all the time, she said. Just
then, a taxi from another company
turned the corner. He slowed down for
my outstretched hand but saw Eva and
screeched off into the night.
Damn, she muttered.
Doing The Right Thing
It didnt take a rocket scientistor even
a geriatricianto figure out why taxis
didnt want to pick up Eva. Doctors
and medical practices often invoke the
same reasoning: The old move too slowly, making efficiency impossible. And
more often than not, there are complications.
Ill give you a ride, I said, having
refrained from making the offer until
then at least in part because of that
uniquely American quandary: What if
something happens to her and her relatives sue?
Her face lit up. Oh no, she said. I
couldnt let you do that.
It took almost as long to maneuver her
into my front seat as it did to get across
town. She directed me to an apartment
complex on the steep slope of one of San
Franciscos trademark hills. Twin rows
of stacked apartments, separated by an
expanse of shrubs and trees, rose up the
incline like terraced fields, their landings connected by flights of steep, poorly lit steps. As it turned out, Eva lived
toward the top. Before we started up, she
handed me her keys and pointed, explaining that she needed to exchange
her going-out walker and cane for her
at-home cane, which was in the garage.
Also, she added, it would be a big help if
Id carry her mail.
I phoned my mother to reschedule and
called home to say Id be late. Getting up
the steps was slow going. Along the way,
I learned that Eva had been to the podiatrist that afternoon because she could
no longer cut her own toenails. I told her
what I do for a living.We discovered that
she got all her medical care except podiatry at my institution and that I knew her
primary care doctor and several of her
specialists.
As I would write in an e-mail to my
general internist colleague the next
morning, getting Eva out of my car
and up the forty-nine stairs to her apartment took nearly an hour because of
her grave debility. She is very weak,
has audible bone-on-bone arthritis in
all major joints, frequent spasms in
her left hip, minimal clearance of her
right foot and could not move her left
foot; I basically had to hoist her. I had
no idea how Eva ever made it up the
steps unassisted and couldnt imagine
how long it might take when she did.
We took frequent breaks so Eva could
catch her breath and have a reprieve
from the pain she felt with every step.
During each rest stop, she told me more
about her life. Shed had several romances but no children. Most of her friends
were also old and ill, so she didnt see
them as much as shed like. She had lived
in the same apartment since the early
1970s, loved it, and would never live anywhere else. She had a blood cancer that
hopefully was cured, asthma, some kind
of heart problem, and both glaucoma
and macular degeneration. After a recent hospitalization for pneumonia,
she had been sent to a local nursing
home and said shed rather die than
go there again, though she wasnt at
all keen on dying. She hated that she
could no longer work and couldnt understand why people looked forward to
retirement.
Forty some minutes after starting our
ascent, we arrived at her apartment. Inside, there was a living room crowded
with stacks of books, magazines, and
mail, and a small cluttered kitchen. It
also had what a friend of mine, in reference to her own octogenarian mother,
recently referred to as that old lady smell.
Shut the door, she said suddenly,
but not soon enough. A blur of dark
fur grazed my leg, and her cat disappeared down the steps into the night.
We both called him. No response. I
walked down the steps, calling and looking. Nothing. After ten minutes of
searching, there was still no sign of
the cat. This wasnt the first time hed
escaped, but, she informed me, when an
indoor cat got out, you never knew
whether hed be back.
I should have stayed longer to look for
him, but I went home.
The Chart Biopsy
Before I left, Eva gave me permission to
access her medical record, contact her
primary care doctor, and make recommendations to help improve her function and well-being. What I found in
her chart speaks with tragic eloquence
to some of the fundamental ways in
which our health care system undermines both patients and clinicians.
Logging into the electronic record the
next morning at work, I learned that Eva
had made thirty visits to our medical
center in the previous year. This included nine ophthalmology appointments;
five radiology studies; four appointments with her lung doctor; four visits
to the incontinence clinic; three appointments with her cancer doctor; two
emergency department visits; and one
appointment each with her cardiologist,
a nurse in the oncology clinic, and her
primary care doctor. This tally does not
include the appointments she missed
because, as is noted in at least two places
in her chart, the taxi never showed up.
Eva also made frequent phone calls to
her doctors offices and was taking seventeen medications prescribed by at
least five physicians.
There are words for patients such
as Eva and this pattern of care. On the
patient side, the words are: complexity,
multimorbidity, and geriatric. On the
system side, they include: fragmented,
uncoordinated, and expensive. How and
why this happensand it happens far
more often than not for all patients,
though its impact is far greater on the
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Narrative Matters
mediate family, no one documented her
life priorities and goals of care, or who
she would want to make medical decisions on her behalf if she were unable to
do so herself.
Over My Dead Body
old, ill, and frailhas at least as much to
do with medical training and culture and
the economics of medicine in the United
States as with the challenges of old age
itself.
The notes in Evas chart revealed clinicians providing thorough, evidencebased evaluation and treatment of the
issue or organ system in which they specialized. Sometimes in medicine we see
notes that suggest the doctor doesnt
really know the patient or is just going
through the motions, cutting and pasting from past notes. These notes were
different. Evas doctors and nurses knew
her, seemed to care about her, and were
applying all of their considerable expertise on her behalf. Unfortunately, their
expertise didnt include any of the skills
that would have addressed Evas most
pressing needs.
Several notes hinted at what I saw as
Eva and I made our slow trek up the steps
to her apartment. They documented terrible arthritic pain, significant mobility
issues, and ongoing transportation
problems. One physician commented
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that Eva does not walk much in her
own apartment but does utilize a walker.
Often, however, she is semi chair
bound. Despite these important observations about Evas most bothersome
medical condition and significant life
challenges, none of the clinicians seeing
her evaluated her joints and gait, did a
functional assessment, treated her pain,
or referred her to either a social worker
or another clinician who might address
these crucial needs.
Equally significant were the problems
that no one mentioned. No physician
commented on the number of doctors
Eva had or visits she made, both of
which might reasonably raise questions
about fragmented care and the need for
care coordination. Nor did any of her
clinicians address her use of a very long
list of medications, a situation known as
polypharmacy and associated with adverse drug reactions and bad outcomes
including falls, hospitalization, and
death. Finally, and particularly remarkable for a woman in her eighties with
multiple medical problems and no im-
March 2015
After exchanging e-mails with her doctor, I called Eva to tell her what to expect.
She wasnt nearly as concerned about
her medical care as I was. She liked
her doctors and, as is the case for many
people, seemed to take for granted that
each body part required its own specialist. It also became clear that her medical
visits served an important social purpose. When I mentioned that she could
get her toenails trimmed by a home visit
podiatrist instead of making bimonthly
trips to the clinic where we had met, she
exclaimed, But Ive been going there for
years. And theyre so nice to me!
I tried to take a casual, conversational
tone for my next question and asked
whether shed ever considered moving.
I was thinking that a building on flatter
terrain, without stairs, and closer to
shops would offer her greater independence. Assisted living, if she could afford
it, would provide those advantages plus
cleaning services, meals, and a built-in
social network.
The only way Im leaving here, she
said, is feet first.
I didnt press her. As is often the case,
Evas choices made her life more difficult. Yet it was also true that the apartment had been her home for decades,
and anywhere she moved would be many
times the cost of her 1970s-era, rentcontrolled apartment. Like the vast majority of older adults, what Eva wanted
most was someone who would help her
maximize her health and function so she
could continue in the life and home
shed created for herself.
Before hanging up, I asked if I could
put her on the wait list for our geriatrics
practice. I explained that if she agreed,
she would get a new doctor who would
take a different approach to her care.
The geriatrician would manage her diseases as her previous doctors had, but he
or she also would begin by establishing
Evas life and health priorities, address
her function and transportation challenges, review her medications and appointments to see if all were truly neces-
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sary, and be available by phone or to
make a home visit if she got sick to try
and prevent hospitalizations.
Eva was silent for a moment. Then she
said, That sounds too good to be true!
What Good Health Care Looks
Like
I know most of Evas doctors. Each one is
compassionate, smart, and dedicated.
Indeed, her diseases were largely under
good control. Yet Evas health was declining, she was missing appointments,
and she was less and less able to care for
herself and her apartment. Several of
her clinicians recognized this, but none
took action. This was not because of personal or professional failings. Most
physicians would have taken the same
approach to Evas care as these doctors
did. Their actionsand inactionwere
the inevitable result of their medical
training and our medical systems sometimes myopic focus on medicine at the
expense of health.
Medical education prioritizes the
same specialties today as it did a century
ago, when the average age of death was
forty-seven and when tuberculosis and
childbirth were among the leading killers. People in their eighth, ninth, and
tenth decades are as different, physiologically and socially, from middle-aged
adults as children are, yet all medical
students learn pediatrics and adult medicine, but there are no universal requirements for geriatrics training. This
makes no sense demographically or
medically. There are forty-eight times
more octogenarians now than there
were in the first half of the last century,
and older patients are the age group
most likely to be harmed by medical
care. The hospitalization in which Evas
pneumonia was cured, but her life
ruined by hospital and nursing home
time without adequate or appropriate
exercise, provides a typical example of
how usual adult care fails older patients.
To rectify this situation, two things
need to change. First, the groups
charged with accreditation of medical
schools and residency training programsthe Liaison Committee on Medical Education and the Accreditation
Council for Graduate Medical Education, respectivelymust mandate training in geriatrics for all medical students
People in their eighth,
ninth, and tenth decades
are as different,
physiologically and
socially, from middleaged adults as children
are.
and for residents in all specialties where
doctors routinely provide care to older
adults. Importantly, such training cannot merely consist of providing standard
adult care to patients over a certain age.
Nor can it be narrowly focused on conditions known as geriatrics syndromes,
such as dementia and falls. Instead,
trainees must be required to attain competence in the unique approach to care
that distinguishes geriatrics as a specialty: individualized, coordinated, teambased care that prioritizes patients
goals, function, and quality of life. Given
that the principal source of funding for
residency and fellowship training is the
Medicare trust funds, it should be relatively straightforward for policy makers
to insist on links between graduate medical education payments and training
that benefits the Medicare population.
Second, we must have billing codes
and appropriate reimbursement for care
that improves the health and lives of
older adults. Currently, many critical geriatric interventions are either unfunded or funded at such low rates that growing numbers of doctors will not see
Medicare patients. For example, a clinician who implemented evidence-based
recommendations, such as design of
an individualized exercise program or
multifactorial intervention, to reduce
Evas recurrent fallsthe fifth leading
killer of older adultscould not easily
or straightforwardly bill for that work.
Nor could the clinician bill straightforwardly for assessment and management of Evas functional status, multimorbidity, goals of care, or caregiver
needs and caregiver effectiveness. Moreover, there would be no reimbursement
for phone calls with Eva to assess response to treatment changes or troubleshoot her challenges. While Medicares
new Chronic Care Management policy
enables billing for time spent communi-
cating with her caregivers, physical therapist, and social worker, the clinician
would receive just $41 per month, regardless of how many calls and how
much time was required. A system for
both services and coordination based on
time and with levels of payment that
increased with increasing time required
would encourage clinicians to provide
the care a patient needs instead of providing inadequate care in artificially limited time frames.
A Happy Ending
Eleven months after I met her, Eva finally made it off the geriatrics practice wait
list. During her first visit, the geriatrician elicited Evas health and life priorities and documented the name and contact information of her health care
proxy. Because she listed arthritis and
pain as her biggest problems, she received steroid injections in her two most
painful joints and a pain medication safe
in older adults. As her specialists had
noted on her recent visits to them, her
blood pressure was quite high. It turned
out Eva wasnt taking several medications because she hadnt been able to
get to the pharmacy for them. She was
taking a medication known to worsen
incontinence, another shown to benefit
middle-age patients but not those older
than age eighty, and a few that might no
longer be necessary. The geriatrician adjusted the timing of her medications so
the schedule was simpler and less burdensome, and arranged for home delivery from the pharmacy.
Evas geriatrician also learned that
on days when Eva couldnt manage her
stairs at all, getting to the medical center
was outrageously costly. She had to pay
three dollars per step to be carried first
down and later back up the steps to her
apartment. Since there were forty-nine
steps, this meant $147 each way or $300
per appointment, not including the fare
for the ride itself. Fortunately, she didnt
need to visit the medical center nearly as
often as she had been. The geriatrician
could treat her incontinence, stable lung
disease, and other chronic conditions,
and could monitor her for cancer recurrence, during home visits. Other members of the teamin this case, a nurse,
physical therapist, and social worker
helped align Evas self-management
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Narrative Matters
skills, activities, and home environment
with her goals. The only specialist Eva
still needed was the eye doctor. Equally
important, with the money she saved on
transportation, Eva could hire more
help at home.
Helping an older adult find a caregiver, delineating the caregivers tasks,
monitoring the caregivers work with
the older adult, and ensuring the caregivers own well-being are not traditional medical tasks. They are, however,
among the most important interventions to ensure the well-being and safety
of frail older adults. Once in place, Evas
caregiver picked up medications, assisted with cooking and exercise, and
cleaned the apartment. She also provided Eva with much-needed social interaction and foot care.
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Currently, many critical
geriatric interventions
are either unfunded or
funded at such low rates
that growing numbers of
doctors will not see
Medicare patients.
Nearly three years later, Eva is looking
forward to her ninetieth birthday. She is
frailer than when I first met her, but all
her primary goals have been met: She
has remained out of the hospital, out
of nursing homes, and in her beloved
apartment with her cat, who did eventually come home. Those who argue that
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health care consists primarily of prescriptions and procedures, or treatment
of body parts and diseases, have created
a system that prioritizes medicine to the
detriment of patient health. Its time we
took a broader view of health careone
that puts the well-being of patients first
and trains and rewards clinicians who
work with patients, caregivers, and other health professionals to achieve that
goal. ?
Louise Aronson ([email protected]) is an
associate professor of medicine at the University
of California, San Francisco (UCSF), where she
holds an Arnold P. Gold Foundation Professorship
and directs the Northern California Geriatrics
Education Center and UCSF Medical Humanities.
She is also the author of a short story collection, A
History of the Present Illness. The womans name in
this essay was changed to protect her privacy.
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PEX 7310 LPE 1
Reflection #1 Assignment
Purpose of assignment: The purpose of this assignment is to utilize reflection skills and
write a complete reflection using one of the prompts listed below after reading the
article Necessary Steps: How healthcare fails older patients, and how it can be done
better by Dr. Louise Aronson.
Instructions for assignment: The article and rubric are both posted in Blackboard. After
reading the article, select one of the two prompts below and write a 200-400 word
reflection addressing the prompt and the article. You may use the 5R framework or any
other reflection model of your choosing for guidance or brainstorming, but when
crafting your final reflection, please submit a complete written reflection for the
assignment.
The assignment should be emailed to your P3 and uploaded to Blackboard as a word
document. The assignment is worth 100 points and is due to both your P3 and
Blackboard no later than 3/4/24 by 5:00pm. Please discuss with your P3 mentor their
expectations for the assignment deadline. Assignments will not be accepted after the
deadline. Please confirm in Blackboard your assignment was successfully uploaded.
**Please include your name and the prompt you selected in your assignment.
Prompts (select 1 to respond to for your reflection):
1. After reading this story, if you could change healthcare in one way to benefit
older adults, what would it be and why?
2. In this story, Eva lived in an apartment that required her to go up 49 steps to get
to her room. This was very physically taxing on her body, yet she refused to
move. Why do you think older adults refrain from making changes in their life
even if it would make their life easier in the end?
PEX 8330 LPE V
Grading Rubric for P1 Reflection #1
This is a 100 point assignment (50 points from P3 Mentor, 50 points from Drs Carr and Greene)
Criteria
Achievement Level
Outstanding
Proficient
Developing
Unacceptable
Completion
35
Topic addressed thoroughly
and masterfully.
30
Topic addressed, but not
fully articulated.
25
Topic addressed, but
lacked cohesion and not
articulated fully.
0
Topic poorly addressed
and content
underdeveloped and
insufficient.
Expectation
10
P1 met P3s expectations for
P3s assignment due date.
8
P1 did not meet P3s
expectation for P3s
assignment due date.
Assignment 1-2 days
late.
6
P1 did not meet P3s
expectation for P3s
assignment due date.
Assignment 3-4 days late.
0
P1 did not meet P3s
expectation for P3s
assignment due date.
Assignment 5 or more
days late.
Structure and
mechanics
5
Reflection well-constructed
(paragraphs), used correct
spelling and grammar, no
obvious errors and
students name included on
reflection.
3
Reflection wellconstructed but there
were 1-2 obvious
spelling/grammatical
errors or students name
missing from reflection.
2
Reflection poorly
constructed, somewhat
hard to follow, with 3-4
obvious errors.
0
Reflection poorly
constructed, hard to
follow, with 5 or more
obvious errors.
