Written in June, 2012
I had an 80 year old lady in my office today accompanied by her two daughters. She was referred to me several weeks ago because she was fainting several times a day. Remarkably, she did not injure herself during these events. Her primary care doctor sent her to me. When I first met her she said, almost immediately upon entering my office door, “I think I am fainting because the medicine THEY have me on is making my pulse too low. It’s below 50 most of the time”. I think it was Osler who admonished us nearly a century ago that if you listen to the patient, the patient will TELL you what is wrong with her.
I am a pretty smart doc. I listened to her. I re-adjusted one of her medicines. Her drug regimen seemed to me to be a very odd and strange potpourri of potent chemicals. When she came back today she was happy. Her pulse was 80 and she had not fainted in many days. Good. A victory easily won. The battle before us now was trying to sort out the polypharmacy she was taking. Again, she had told me during our first meeting what the root cause of her problem was — the medicines THEY had her on.
My patient was frustrated. She told me that over the last four years she had been assigned no fewer than five PRIMARY care doctors. “You see them once, then they are gone. They go from base to base so fast. Then they send them off overseas for months and when they come back they don’t remember you. You have to tell your medical story over and over again. No one has time to listen to you. You get LOST!”
Then she asked me the most telling question of all . . . “When are YOU going?”
“I’ll be leaving in five months. It is time to go home”, I responded.
“Well, at least you have an excuse. You must be retiring.”
When doctors of my rank talk of “going home” it usually means they are at the end of their 20 year stint for retirement benefits in the military. I did not have the heart to try to explain to her that I was leaving her after only four years in the military.
Her story is so common in the military health system, especially when it comes to care of the elderly retirees. Their doctors or providers move very quickly and seldom stay in one place more than three or four years. The pressures of deployment during wartime exacerbate and magnify this Brownian motion. As a result, the patients lack longitudinal care. They do not have a consistent care giver who gets to know them, work with them, learn from them, and find out who they are over years. Her helter skelter medication list reflected perfectly the number of primary care providers she had been subjected to in a very brief period of time. That list had never been tailored, trimmed, and designed by a single doctor for a single patient. It was medicine by incident upon incident upon incident by doc after doc after doc.
Indeed she was lost. She was lost in a system not designed for a large population of the frail elderly. This system was designed to deliver care to rather young troops, troops on the move. The elderly retirees, in my opinion, have been shoe-horned into this system. As a result, the care is fragmented, inefficient, expensive and in some cases unsafe (I am a patient safety expert, by the way. I have earned the right to use the dreaded “unsafe” word).
We need a better approach for these older folks. We owe a great debt, as a Nation, to these veterans and their dependents. Surely we can do better by them. Morally, we MUST do better by them.