The elderly fail to understand our complex health system

I was working overnight in Tiny Memorial Hospital, located in scenic rural America.  My call room there was a converted patient room.  As such, my bed was a hospital bed.  Lying there one night, I rolled to the side and raised the head of the bed using the button on the rail.  The blanket was standard hospital fare: stiff and thin.  And the television remote, fully two pounds and connected to the television by cable, was the latest NASA technology from about 1965.  I contemplated my surroundings, and noticed the nurse call button on the remote.  And I had a strange desire for Jello and my old cardigan, but I shook it off.

I began to imagine what it was like for the older patients in the facility.  And what it would be like for me one day, when I might be hospitalized or placed in a nursing home.  Admittedly, given my tendency to run my mouth and forget the contents of my carry-on, I’m probably more likely to be tasered to death in an airport in my late 80s, or 50s.  But one wonders about the future.

Tiny Memorial, which sees around 5000 per year in its emergency department, admits a small number of patients who are mostly seniors.  To that extent, the 25-bed inpatient side has the feel of a nursing home. Indeed, some of those admissions are termed “skilled care,” which generally means they aren’t strong enough for home, but don’t meet the criteria for a nursing home and thus can stay considerably longer without acute illnesses.

Watching those folks, walking by their rooms every day and talking to their families as they are admitted, I realized once more what I’ve seen over and over in emergency medicine, and in the startling changes affecting all of medicine. And it’s this:  Seniors don’t understand many of the changes they’re facing. Frankly, I don’t either.

But I do know that in the 20 years since I left residency, everything has become much more complex.  You know what I mean.  “Back in the day,” we could admit people who needed it.  We all knew that some of these were “social” admissions. Admitting physicians, who then often knew their patients, understood that when Mrs. Reid fell down and couldn’t get up, that it didn’t really matter what her sodium was, or whether or not the x-ray showed a hip fracture.  He knew her daughter lived 1,000 miles away in Omaha, and that she lived alone with her chihuahua, Pierre.  And he knew that she had no options except a couple of days of strengthening but would neither go to a nursing home nor be able to afford it.

Fast forward. Now I see Mr. Bowen, who is 90.  Until last year he worked cutting trees and could use a chain saw from dusk till dawn, leaving his grandsons in the dust.  Now?  He fell and broke several ribs over the summer, and since then has been declining.   Yesterday he fell in the living room and has facial fractures (they’ll need surgery eventually) and a broken right wrist. His son, who is 60, brings him in and I have the inestimable pleasure of telling him, “Mr. Bowen, there’s no indication to admit you to the hospital.  Here are some numbers to call for follow up.”

His son and daughter-in-law say, “But we just want to check him in for a couple of days, until he can get stronger.  He’s too weak and he’s in a lot of pain!”  His sweet wife pets his forehead, and is herself too frail to care for him intensely at home. I sit down.

“I understand, but Medicare won’t pay for it!”

They tell me that they are very disappointed.  Mr. Bowen just looks sad and tired.  “Well, take me on then.”

I think intently, and inform them I’ll talk to the hospitalist, who doesn’t know him “from Adam’s house cat, as we say down here.

“Sir,” I tell Mr. Bowen, “I’m calling the hospitalist.”  This gets his attention.

“Calling hospice?  Why?”  His son and wife look up.

‘No, hospitalist.  The doctor who admits people.”

“My doctor is Dr. Chapman,” he says weakly. “I know, but he doesn’t admit anyone anymore.”  (What I don’t tell him is that Dr. Chapman is dead and has been for about 5 years.) The hospitalist has zero interest in this situation.  ”

Try orthopedics,” he suggests.  I tell him that my patient’s sodium is 129.  “Yeah, but it has to be lower than that.  I’d love to help but administration is all over us about inappropriate admissions.”

I call the case manager, who interrupts her untold other attempts to justify admissions and looks over the chart.  “Sorry, he doesn’t meet criteria.  You can observe him but it’s all out of pocket.”

I tell him about the case manager, but he doesn’t understand.  In the end, he goes home.  I hope he can navigate the complexity of office visits; perhaps he can have some home health visits.  His family shakes their heads.  They just don’t understand.

Neither do I.  Nobody understands the rules, but most of all the elderly who were fed false promises of the care they’d receive when they were older.  They remember a time of “checking in” for some rest. The days of doctors they knew.  The days when a prescription wasn’t $500.  (I explained to my well insured mother how much my son’s insulin cost and she was incredulous … she has always had prescription coverage, which my expensive insurance doesn’t.)

Our seniors get sick, but have a hard time being admitted. And once admitted they have a hard time staying in the hospital.  They have a hard time getting into the nursing home, and once they’ve arrived, they have a hard time staying there, since every sniffle, fever, bruise or fall results in a mandated ER visit by ambulance, whether they want to go or not; whether they have a DNR or not.

They don’t get hospitalists and length of stay rules, or rehab days or any of the complexities imposed by a system with lots of nice ideas and ideals, but with nowhere near the money to pay for all of it; nor any real interest in doing so.

To be fair, sometimes the expectations of our seniors are too high. They want the best (don’t we all?) but they want it to be covered at little extra cost. And those days are gone.  But then again, they believed the line: “The government will never stand between you and your doctor.”  What poppycock.

In the end, we’ll have to adapt to doing less, with less.  Unfortunately, that will be hardest on our seniors, who have spent their lives working and raising children and fighting wars and keeping the country running while we had existential crises and wondered if our expensive educations were fulfilling enough.

For better or worse, I don’t think they’ll be around long enough to fully understand the ever changing nuances of our shrinking, complex system which, in many cases, may be their undoing.

Dang it, where’s that Jello?

Edwin Leap is an emergency physician who blogs at edwinleap.com and is the author of The Practice Test. This article originally appeared in Emergency Medicine News.

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  • SteveCaley

    We will not be honest with ourselves; this is filtering. It is Kafka at his finest. The bureaucracy has its Rules – if you do not obey the Rules, you will not progress.
    Those of us who are young and clever, have support and are fortunate, can learn the rules and pop about the system, obtaining the benefits. We rather disdain those who cannot keep up – they should learn the rules.
    It is the old, slow, demented or developmentally impaired who are left behind in this steeplechase of Weberian nature, the Iron Cage. You have no merit as a customer – you must perform the tricks to get a treat.
    That way, we can assuage our guilt – if there still is any – of the unfortunate suffering. Why, if they just filled out a DL-1052, they could have a Services Administrator assigned to their case.

    • ninguem

      By the way……….

      Franz Kafka (1883-1924) had a day job.

      He was a lawyer for the Worker’s Compensation Board in Prague.

      When you know this, Kafka then begins to make a lot of sense.

      • SteveCaley

        Touché I don’t even think he could stand this crap.

    • Patient Kit

      Survival of the fittest, American hospital style! In the year and a half since I fell into this rabbit hole with ovarian cancer, it has felt like I’ve been living in the missing season of The Wire — the season that focused on how our healthcare system “works”.

      Initially, I was covered by Blue Cross, then uninsured, then Medicaid, soon to be possibly uninsured again as punishment for living instead of dying. It’s nearly impossible to figure out all the nonsensical rules of this game — which door to choose, which button to push, how many times to jump through the hoop. Is 8 too few, 10 too many? It’s like being in a Beckett play or maybe Vaclav Havel’s The Memorandum or Catch 22. The rules are all secret and constantly changing so it’s like playing a shell game or Russian roulette.

      I honestly don’t know how I’ve managed to navigate this intentionally daunting system all year and basically get what I needed. My elderly Mom tells me all the time that she couldn’t have done it. And I am sure she is right about that.

      • SteveCaley

        Just wait until the EMR deployment proceeds, and ICD-10 coding system unfolds. There will probably be no ability to obtain care whatsoever in private practice – they’re done for.
        I recommend reading The Lottery, by Shirley Jackson, to see that this awful type of thinking is new or original to this generation, or the previous one.

        • Patient Kit

          You know, I read The Lottery many moons and decades ago in junior high school and never forgot it. A child of the sixties myself, I remember it as a warning against blind conformity and acceptance of tradition. I should revisit and read it again. But I don’t think what she was talking about was new to humans then or now. It would be interesting to reread it in the context of today though.

        • querywoman

          Those of us with chronic skin disease are always at the bottom of the medical lottery.

          • SteveCaley

            About chronic skin issues, too, it’s such a shame. Given a stable doctor/patient relationship – something that’s in the rear-view-mirror, unfortunately – gaining effective control of such things as psoriasis can be very satisfying to doctor and patient alike. As an internist, I am delighted to work with patients with psoriatic illness. Talk about a process that won’t behave like the cook-book promises it will!

          • querywoman

            Gee, I just met you on KevinMD. Glad you take an interest in skin patients.

            I have atopic eczema, and I have a wonderful derm after a lifetime of searching. He’s a psoriasis doctor.
            I slowly get better with him. It slowly flakes off with his help.
            In January 2014, I had pneumonia. I told them the stuff on me is atopic eczema, and that I slowly get better with my decent doctor.
            Yet, at every turn, I heard, what’s that on your skin? The eczema? From scratching? Don’t pick.
            I always wonder, now that I have a good doctor, if these others who are mildly interested would bother to help me find a skin doctor if I didn’t have one.
            It’s also viewed as unimportant and trivial.
            Plus, if anyone doesn’t want to take time to learn about the process or what he is doing for me, then he or she needs should help me find another doctor.
            One of the problems is that, as it peels, it goes through stages where it looks worse. But, with modern digital photography, I can prove that I am getting better.
            Even the dermatologists still blame patient! Mine does some, but he’s softened. I do fight it with his young residents. They can’t change dermatology without stopping blaming us!

          • SteveCaley

            I have a remorseless patient with atopic eczema that I cannot get away from, being my wife. She helps me keep from being overly-impressed by myself.
            Every patient comes in to see me with interesting things, and I try not to be too thick not to notice them. Since I am interested in the
            entire person, well and sick, being an Internist, I would be curious – a history of atopic asthma in a patient with pneumonia might be related things. Or might not. But it’s worth asking the patient about, for sure. “Is this how it usually
            is, or did it get worse? When did it get worse? What usually works on it? What makes it worse, what makes it better?”
            I am a great fan of Jean-Joseph Jacotot, who wrote about the philosophy of education, and it applies to many parts of healthcare.
            He wrote:
            1) all persons have equal intelligence;
            2) every person has received from God the faculty of being able to instruct themself;
            3) we can teach what we don’t know;
            4) everything is in everything.

            The last one sounds ’60′s but is quite true in patient care; nothing is trivial, although it might be unrelated.
            For #3, I am not an expert on YOUR chronic illness; I am an expert about many manifestations of that particular chronic illness. I have to train YOU to be the world’s expert on YOUR illness, as YOU are the one who takes it home when the visit is over.
            The concept of “disease” is usually very nominalistic – no disease is the same in two patients.
            And any time I get too full of myself, I know where to go to let a little of the self-importance out.

          • querywoman

            Steve Caley, I’m starting to really like you.

  • querywoman

    Was there ever a time when people could choose to just go in a hospital for a couple of days?

    • Trish Browning

      Let’s not forget that most adults with at least a moderate income were admitted to the hospital for a day or three for their ANNUAL PHYSICAL and all of the attendent tests….

      • querywoman

        I didn’t know that. I did know that people used to have to be admitted to hospitals for a few days to get some routine tests covered.
        I suspect hospitals have become much more of a business and are also doing more on the patients they have now.
        Hospitals used to be dread places where you went to die. Now many people get aggressive successful treatment and get out.

  • jerseydevil

    I started my career in nursing in 1974…right at the cusp of the biggest
    changes in “medical care”…the advent of “HMOs”…where insurance companies rewarded doctors for not sending their patients to specialists, or for “second opinions” and hospitals for sending patients home from surgery as soon as they could respond to their names coming out of anesthesia to be “taken care of” on “out-patient care”. Navigating forms to pay for this care, and making ever more
    increasingly hard to make “timely appointments” while “involving family members in their care” …who had to take unscheduled days off from their employment to ferry family members to appointments that they could only make in morning or afternoon hours because evening hours were not available. And “Mom and or Dad” are concerned that “Son
    and or Daughter” have to work, care for children, carry on their own lives…and are frustrated, themselves, by the lack of independence in their own lives. And what of the new “non-nuclear families”? Parents living in their homes in one State and the children having moved across the Country for jobs… Older citizens, surrendering their much desired/worked for independence to move into “Assisted Living”…feeling “warehoused in ‘God’s Waiting Rooms’…” Letting a
    “one size fits all” government run healthcare system will prove fatal to more than just our fragile elderly citizens…it will tear our Country even farther apart. It is to dispair.

    • SteveCaley

      Could the last one to leave the nursing profession please turn out the lights? Thanks.
      The turn of American healthcare from admirable to horrible directly follows the turn of American nursing from being honorable and rewarding to exasperating and dehumanizing. As an MD, I’d be more of an optimist if it wasn’t for the devastation of the nursing profession in America.
      As below, quoth RF’s Mom – “why do they treat us like sheep?” The good news is – the problem is not with nursing. It is not with doctors.
      The bad news is – it is with our civilization, society, civitas, whatever you want to call it, it’s gone flat inhuman, unlikable, getting in the direction of unlivable.
      And unlivable societies don’t last. They fall apart. Societies that don’t make way for humans to live there – who will?

  • jerseydevil

    BTW…the article commented: “…They remember a time of “checking in” for some rest…” I find it ironic that recently, Harry Reid…the biggest cheerleader of PPC-ACA (yet opted out of taking these benefits for himself), checked into GWU Hospital for “exhaustion”… http://www.businessinsider.com/harry-reid-hospitalized-2013-12

  • querywoman

    To be fair, we’d really have to see how per capita utilization of hospital services has gone up.
    The old Blue Cross/Blue Shield card was like gold. I hated the Blues Medical Entity the last time I had them.

  • SteveCaley

    Kafka, yes. Max Weber took it seriously in a grim review of future society (that’s now, folks.) Our near-colleague, Aldous Huxley (he dropped out of medical school with keratoconus, apparently) wrote of similar things in Brave New World; also Zamyatin’s We and 1984 runs a nice gamut of bureaucratic dystopias.
    Having to live one’s life in fear of some meaty-handed dullard interpreting a mash of “rules and procedures,” and hoping one has not crossed some spiteful whisperer, that’s life under Stalin. It’s uncomfortably close, I fear.

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