The case for mandatory full-time nursing home doctors

18th March 2013   ·   0 Comments

By Rita Watson
Contributing Writer

PROVIDENCE, R.I. (Special from Psychology Today/New America Media) — Nursing home headaches often begin the day someone is admitted. Too often the choice for a home is a decision made when a hospital discharge planner announces, “The patient will be going home tomorrow. The social worker will be in to see you.”

You are flabbergasted and protest to no avail. The choice is often between a “so-so” and “oh-no” nursing home because the good ones have long waiting lists. Families often choose the best of a bad lot, and despite dissatisfaction they are lulled into believing that a move is detrimental to elders. It isn’t.

But when one comes face-to-face with poor quality physician care from part-time consulting physicians, courageous families take action.

Advocate for Onsite Physician

Jonathan M. Evans is a geriatric physician who teaches “Aging and the Law” at the University of Virginia School of Law. Earlier this month he published the article “When Long-Term Caregivers Have Ethical Obligations.”

A firm believer in onsite physicians at nursing homes, he explained, “The thing that matters most is being there – being there for patients when they’re sick; being there for families when they’re in need; being there for staff to provide support and ongoing education. You can’t be part of a team if you’re not present.”

Should the nursing home physician communicate directly with patients and family members rather than through the staff? Evans’ answer is—“Why the hell not?”

Evans pointed out, “On a basic human level communication is critically important. As human beings we should expect communication between ourselves. And when we are talking about loving relationships, we broaden it to communicate caring. A doctor should always communicate with a patient directly unless a patient is not able to make medical decisions and has a medical proxy to guard confidentiality.”

In the absence of a full-time physician, dementia patients are at a disadvantage. The doctor reads charts, talks to staff, talks to patient, but fails to communicate with family.

One family member voiced a complaint often heard at professional meetings – “My father doesn’t remember if he has had breakfast as he gets up from the table. And when the doctor asks him how he feels, he says fine. Never mind that we were getting middle of the night calls from him. And then there were all those calls to 911 he made.”

Had the physician talked with family rather than reading charts, the patient might have been helped sooner. Essentially in the absence of a full time physician, there is a disconnect.

Brown University’s Program in Public Health is looking at the 911 situation with the elders.

Nursing Home Care is Calling

Several years ago Paul R. Katz and his health care-research colleagues at the University of Roch­ester wrote a journal article about the problem with nursing home physicians. They made a compel­ling argument for a new model of care.

“We contend that rather than accepting a diminished presence of physicians in nursing homes and finding alternative care models, it is time to fully consider, appropriately fund, and test the nursing home specialist model. If nearly half of the baby boomers spend some time in a nursing home, the question ‘Is there a doctor in the house?’ will take on new urgency and meaning.”

Evans is a proponent of the model of care requiring a nursing home specialist and has been involved in long-term care for seniors for more than 20 years. He is also a defender of those who work there. He pointed out, “Despite what we hear in terms of nursing home turnover because of low pay, when people leave a nursing home it is often to go to another one.”

He added, “They need some type of fulfillment from their workplace. Caring for others becomes a part of their identity, their values.”

But Evans also acknowledged, “Many who went to school hoping to work with patients as their life’s work; instead many find themselves with checklists. Ritual practice is different than caring for others. We check off what we should do on a list. It makes us feel safe. While we need the checklist for quality assurance, when we are interacting with patients, there is no checklist to measure caring, respect, and empathy.”

An advocate of face-to-face conversations or phone conversations with patients, Evans said that with e-mailing and texting, “as physicians we miss the verbal cues and silences.” He added, “I like to remind myself and my students as to why communication with patients is so important.“

“As someone once reminded me: ‘Love unspoken sounds the same as indifference,’” said Evans.

Change Focus to Patients

Recently I was at a unit that pointed dramatically at the difference between a full-time physician on staff vs. the use of medication by a part-time physician as chemical restraints to calm vocal or unruly patients.

A patient was haranguing a family member of another patient. A nurse walked over to her, called her by name, and said, “Hi there. I haven’t seen you all day. What a beautiful sweater you’re wearing. Let’s take a walk and look at some other sweaters.”

The woman was calmed. The situation was diffused. And there was no order written for an “as needed” drug to settle her down. Knowing a physician is available, however, gives staff a measure of confidence. This same patient would have been an easy candidate for medication in a nursing home with a once a week physician.

As Evans, who was recently named medical director for Life Care of Tennessee, told the U.S. Senate Special Committee on Aging in 2011, “We have built a system of providers. We need to change the model to focus on patients.”

There are few substitutes for individual patient advocates during an era when the physician shortage continues. Whatever happened to doctors who took pride in knowing patients—their words, their expressions, their sighs?

Copyright 2013 Rita Watson/ All Rights Reserved. Rita Watson, who wrote this article for Psychology Today, is part of the MetLife Foundation Journalists in Aging Fellowships, a collaboration of the Gerontological Society of America and New America Media.

This article originally published in the March 18, 2013 print edition of The Louisiana Weekly newspaper.