Richard W. Besdine

Caring for older Americans: the future of geriatric medicine.

In response to the needs and demands of an aging population, geriatric medicine has grown rapidly during the past 3 decades. The discipline has defined its core values as well as the knowledge base and clinical skills needed to improve the health, functioning, and well‐being of older persons and to provide appropriate palliative care. Geriatric medicine has developed new models of care, advanced the treatment of common geriatric conditions, and advocated for the health and health care of older persons. Nevertheless, at the beginning of the 21st century, the health care of older persons is at a crossroads. Despite the substantial progress that geriatric medicine has made, much more remains to be done to meet the healthcare needs of our aging population. The clinical, educational, and research approaches of the 20th century are unable to keep pace and require major revisions. Maintaining the status quo will mean falling further and further behind. The healthcare delivery and financing systems need fundamental redesign to improve quality and eliminate waste.

Effects of Age, Education, and Physician Advice on Utilization of Screening Mammography

We investigated the utilization of mammography as a screening test for breast cancer in a middle‐income Connecticut suburban community of 30,000 people. The sampling frame was community‐dwelling women aged 30 years and over who had telephones. Random digit telephone survey methods were used to identify a sample of 470 eligible subjects. Of those eligible to be included, 350 or 74.4% completed the interview. Analysis of data from the 171 respondents aged 50 years or greater indicated that women aged 65–80 years had a significantly lower rate of screening mammography than did women aged 50–64 years (χ2 = 6.6, P = .01). When further analysis was done to take into account the effects of education and of income on these rates, the association of age with mammography utilization was no longer statistically significant. Among women who recalled their physician advising a mammogram, 88% had had one performed. Among women who could not recall their physician advising a mammogram, 7% had had one. The impact of physician advice was statistically significant (χ2 = 110.3, P < .001). Physicians recommended screening mammography less often for patients with low level of education (χ2 = 21.6, P < .001), low income (χ2 = 7.8, df = 2, P = .02) and greater age (χ2 = 14.2, P = .003). We conclude that utilization of screening mammography in the community studied is related more strongly to education and to income than to age. The bivariate association of mammography utilization with age may be attributable to a cohort effect, rather than an age effect. Physician advice appears to be an important factor influencing the decision to have the procedure.

Illness Behavior in the Aged: Implications for Clinicians

A better understanding of the processes through which elderly individuals perceive, evaluate, and act on symptoms will enable physicians to respond more appropriately to the needs of older patients. This paper reviews existing evidence on how the experience of chronic disease and the atypical presentation of symptoms influence symptom recognition and reporting among elderly individuals. A discussion of research on health perceptions suggests that some elderly may inappropriately deny illness and delay seeking medical care, while others with overly negative health perceptions may make excessive physician visits. An overview is presented of the process by which elderly individuals come to seek care from their physicians, combining evidence from the diverse literatures on chronic illness, atypical presentation of disease, and health perceptions. We conclude by discussing the practical implications of this information for clinicians working with the elderly.

The Educational Utility of Comprehensive Functional Assessment in the Elderly

Comprehensive functional assessment in the elderly (CFAITE) is important in organizing and providing health care to elders in all health care settings, including the community, the nursing home and the acute-care hospital. The educational value of performing CFA coordinated with traditional discipline-specific diagnostic assessment resides in enhanced care for elders and more effective teaching of that care to their providers. The educational opportunities intrinsic to a system of health care using CFA are numerous and provide stimulation and enthusiasm for all involved professionals.

Policy Options to Improve Discharge Planning and Reduce Rehospitalization

FRAIL OLDER PATIENTS AND THEIR FAMILIES ARE GENerally unprepared for the flurry of activity that occurs during a hospitalization and for how quickly they must decide where to go at discharge. Hospital discharge is not the time to undertake the extended process of long-term care planning and goals clarification. The biggest challenge patients and families face as they decide their discharge destination is to establish realistic goals of care in the absence of coherent information about their prognosis and options. This decision is particularly important because of the weighty implications of their choices. Decades ago patients remained in hospital until they recovered or stopped improving. Introduction of prospective Medicare hospital payment with diagnosis related groups in the United States in 1983 and other industrialized countries in later years changed all that. Hospital stays became shorter and illness episodes more disjointed between acute and postacute care, a process exacerbated a decade ago by payment changes to postacute care and the rise of an industry largely separate from hospital-based and primary care physicians. Although evidence suggests that the hospitalist movement has reduced hospital stays and improved inpatient quality indicators without clear deleterious effects on patient outcomes, some observers have worried that such services may complicate discharge transitions to primary care physicians, particularly for the most frail patients. Policy changes in payment for acute and postacute care and their sequelae are widely recognized as contributing to the rising rates of rehospitalization and the increased frequency of transitions among health care settings and teams, particularly during the past decade. In 2006, some 40% of fee-for-service Medicare beneficiaries discharged from the hospital transferred to some form of postacute care. These patients can be grouped into 3 types: those expecting to recover following rehabilitation; those who will require housing, supportive services (eg, nursing home or home care), or both for the long term; and those needing palliative care, including hospice care and management of complex, progressive disease–related symptoms during the end of life. These groups are neither mutually exclusive nor static; what may begin as postacute rehabilitation may rapidly evolve into a more complicated set of long-term care support services delivered in a nursing home, at home, or in one of the various alternative settings enumerated by Kane in this issue of JAMA. As such, hospital discharge is a critical point in a patient’s medical course; however, it occurs when no specific health care professional is accountable for patients’ experiences. The complexity of identifying appropriate goals of care, not to mention the multiplicity of possible service options available, would be difficult to navigate even without the pressure of a hospital discharge deadline. Nonetheless, decisions have to be made quickly with a high degree of ambiguity regarding goals and with even less time to consider the quality of the different options, regardless of type. In the estimated 70% of US hospitals with inpatient services having hospitalist attendings, these decisions generally are made with limited involvement of the primary care physician to advocate for the patient and family’s preferences. Indeed, in many communities, urgent hospital admissions occur without the primary care physician’s knowledge, complicating communication and care both during and after the hospital stay. Because many older patients have multiple chronic conditions, each managed by a different specialist, it is not always clear which physician should be notified in the event of a hospitalization. The challenges of transitions among medical care settings and clinicians have received increasing attention. Over the last decade, the Centers for Medicare & Medicaid Services has made minor revisions to hospital reimbursement rules designed to penalize hospitals for discharging patients prematurely to postacute settings. However, the length of hospital stay has continued to decrease, and rehospitalization rates have increased. It is no surprise, then, that the Affordable Care Act has multiple provisions designed to reduce rehospitalization. In the next year, the Centers for Medicare & Medicaid Services is charged with developing penalties for health care organizations whose patients are

Teaching communication and compassionate care skills: An innovative curriculum for pre-clerkship medical students

Background: Physicians require communications training to improve effective and compassionate care. Clinicians discuss challenging communication issues in existing hospital “Schwartz Rounds.” Aims: To improve communication skills, the Warren Alpert Medical School of Brown University designed “Schwartz Communication Sessions” for the mandatory 2-year pre-clerkship Doctoring course. Alongside learning interviewing, physical examination, and professionalism skills, the new Schwartz curriculum provides medical students with the rationale and proficiency for effective communication with patients, families and the healthcare team. Methods: First-year students experience a graduated curriculum of three sessions on themes such as empathy and professionalism using innovative methods. Sessions highlight cases and videos depicting successful and ineffective interactions, large and small group discussions, role play and skills practice, guest patient presentations, and multi-disciplinary panels. The second-year students’ session focuses on communications with challenging patients. Results: Students and faculty rate the sessions highly on effectiveness of enhancing communication skills, gaining perspective in healthcare communication, and appreciating the complexities of healthcare situations. Expansion of the program using case-based sessions for clerkship students is planned for a continuous and graduated experience. Conclusions: Integrating a pre-clerkship communications curriculum may help improve future physicians’ interactions with patients and families. Implications of this curriculum for medical education are discussed.

A systematic review of curricular interventions teaching transitional care to physicians-in-training and physicians.

Purpose To systematically review and describe published interventions about teaching continuity-of-care best practices, embodied by transitional care, to physician–trainees and physicians. Method The authors performed a systematic review of interventions indexed in PubMed, ISI Web of Science, Educational Resources Information Center, professional society Web sites, education databases, and hand-selected references. English-language articles published between 1973 and 2010 that demonstrated purposeful, directed education of physician–trainees and physicians on topics consistent with the contemporary definition of transitional care were included. Abstracted data included intended audience, duration/intensity, objectives, resources used, learner assessment, and curricular evaluation method. Results A dramatic increase in the number of published interventions teaching transitional care was noted in the last 10 years. Learners included preclinical medical students through attending physicians and also included allied health professionals. Brief, self-limited interactions in large groups were the most frequent mode of interaction. A wide array of objectives and resources used were represented. Most interventions provided a method for assessing knowledge acquisition by the learner; however, few interventions provided a mechanism for eliciting feedback from learners. Conclusions Proficiency in providing transitional care is an essential skill for medical practitioners. Historically, there have been few curricular interventions teaching this topic; however, recently a dramatic increase in the number of interventions has occurred. A diverse range of learners, modes of delivery, and intended objectives are represented. In establishing a pooled description of published interventions, this review provides a comprehensive and novel resource for educators charged with designing curricula for all medical professionals.

Tuboovarian abscess with recovery of T-mycoplasma☆

Abstract T-mycoplasmas are commonly found in the genitourinary tracts of normal women, but evidence associating them with disease in women is limited. 1 Mardh and Westrom 2 isolated T-mycoplasmas from the Fallopian tubes of 2 of 50 patients with salpingitis. Similarly, Kundsin recovered organisms from a Fallopian tube and suggested a relationship between T-mycoplasmas and abortion. T-mycoplasmas have been associated with low birth weight in a prospective study of pregnant women. Two recent reports describe puerperal septicemia with T-mycoplasmas. This report describes the isolation of T-mycoplasmas in the absence of other pathogens from a tuboovarian abscess in a 36-year-old woman.

Stroke Prevention in Atrial Fibrillation in Older Adults: Existing Knowledge Gaps and Areas for Innovation: A Summary of an American Federation for Aging Research Seminar

Atrial fibrillation (AF) is a common and morbid cardiac arrhythmia that increases in prevalence with advancing age. The risk of ischemic stroke, a primary and disabling hazard of AF, also increases with advancing age. The aging of the population is anticipated to contribute to a rising burden of AF‐related morbidity and economic costs, given the close association between the arrhythmia and aging. Recent biological, diagnostic, and therapeutic developments raise hope that AF‐related stroke can be largely prevented, yet despite advances in stroke prevention for individuals with AF, numerous scientific and clinical knowledge gaps remain, particularly as these developments are applied to older adults. Given the public health importance of AF‐related stroke in elderly adults, a group of clinician‐investigators convened on April 5, 2012, to identify promising areas for investigation that may ultimately reduce stroke‐related morbidity. This article summarizes the meeting discussion and emphasizes innovative topic areas that may ultimately facilitate the application of novel preventive, diagnostic, and therapeutic insights into the management of older adults with AF. The opinions of those that participated in the meeting limit this report, which may not represent all of the questions that other experts in this field might raise.

Geriatrics content in residency curricula

T wo trends drive curricula for geriatric training development: the rapid growth of the very elderly population, with their disproportionate use of health care, and the ascendancy of primary care. This article will outline the nature of the geriatrics knowledge base, the relationship of geriatrics to primary care, the faculty development needed to teach geriatrics, and the curriculum needed to train residency graduates in the care of older people.