Tuesday, September 22, 2009

Belaboring the Obvious

Much of medical research is exciting and important and filled with hope for curing cancer and stopping the scourge of epidemics.  Then there is the research that has to do with what, for most, seems like the obvious.  I thought about this in the context of end of life counseling when I wrote about HR 3200, the house health reform bill.  If someone is dying, isn’t it obvious that the doctor should counsel them? Does that have to be law, with specific instructions on how to counsel a dying patient with specific options proscribed by law?  But this blog posting is not about the reform issue but instead is about new articles in the scholarly medical literature.  It is just In this month’s Journal of the American Geriatrics Society the mundane and the seemingly obvious is the topic of a number of the lead articles.  Lest you think I am just mocking these dedicated researchers in geriatrics, the older I get the more these mundane issues touch me directly.  I know these studies are important and may one day (very soon) may affect me and even you.

Someone Who Is Elderly Can Become Frail

The first two articles in the September issue have to do with deciding when someone who is elderly is also frail.  These authors from UCLA define frail to describe “older adults with low functional reserve who are vulnerable to stressor experiences and at risk for adverse health outcomes”.  (whew!)  They use a formula which includes a number of tests reflecting different body systems to indicate if someone is actually frail.  The second article written by a group in Boston from Boston University and Harvard, compared two different indexes to measure frailty.  It found that both were effective although one was simpler.  Both articles are actually important as they both challenge a disease focused approach that is embedded in the way medicine is conceptualized and the way it is practiced.  An editorial in the journal by George Kuchel at the University of Connecticut points out that the specific disease in someone who is elderly is often less important that the overall health that is implied in these different definitions of “frail”.  That too is obvious in many ways but often ignored in the practice of medicine.

Sending Elderly People Home from the Hospital Requires Planning

The third article in the journal is about a team at the Johns Hopkins Medical School who came up with a “Safe STEPS” program to help the elderly transition from the hospital to home after an acute illness.  There are some very radical approaches in this such as the physician and the pharmacist collaborating and the team having a discharge meeting to make sure everything the person needs to go home has been done.  It turns out that when you do this, those patients have fewer returns to the Emergency Room and fewer readmissions.  Isn’t that surprising.  If you think this too is obvious please note that it is very unusual to see this collaboration in care.

Advance Care Directives Have to Be Individualized

The easiest thing to do to describe the fourth article is just to quote the conclusion from this group from Yale.  They conclude that patients need “customized, stage-specific interventions based on individualized assessments to improve advance care planning”.   How radical can you get?  Patients need care, especially when they are incapacitated that is unique for them!  The study makes the point that people vary in their readiness to listen, their barriers to listening and even in the potential benefits such directives can give them.  Thus they must be approached and spoken to as individuals with specific needs and desires.

The Simple is Difficult

I could continue to go on.  Other studies in this September issue of the Journal of the American Geriatrics Society include articles about pain causing functional limitation and yoga helping spine problems.  It may all sound obvious, mundane and simple but the impact these “little” items have on health and wellbeing is often immense and the difficulty of having them done often overwhelming.