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Thursday, 22 March 2001

How to Choose a Doctor

Written by  Leah Abramowitz

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Old people use medical services much more than any other segment of the population. Yet many of them are dissatisfied with their family doctor or go "shopping" and continuously try a new specialist, a different type of treatment or alternatively, due to lack of trust, stop going to any doctor.

Yet there are some very competent, well-trained and empathetic doctors available in every community. Some of them are general practitioners and some have specialized in geriatric medicine. A physician who has certain characteristics is most likely to succeed with the older patient.

When looking for a physician for an elderly patient choose a doctor who:

IS EMPATHETIC -- A recent research project showed that most patients, of all age groups, are not necessarily interested in the Latin definition of their illness or condition. They want to know that their complaints and suffering have been registered by a competent, understanding doctor who sincerely wants to help them.

LISTENS-- Every professional working with the elderly has to be a good listener. There's a famous movie which depicts a daughter who brings her mother to the doctor. The doctor addresses all his questions to the daughter who explains that the mother has been having back pains and has trouble walking. Following the young woman's description, he examines the patient's mobility, the tenor of her knees and the condition of her spine.

All the while, the mother is trying to get in a word. She keeps pointing to her chest, and mumbling that "Here, it hurts here doctor," but nobody is listening to her. Finally at the door, as the doctor is saying good bye, and after having written a referral for a CAT scan, the older woman is finally able to say, "But doctor, why do I have these pains here in the chest?"

The doctor looks at the daughter in amazement and then looks back at the mother. "What, what did you say? You have chest pains. Why didn't you say so?" he asks, as he quickly takes out his stethoscope.

"But I said so from the beginning," says the patient apologetically, and the doctor begins the examination over again.

IS PATIENT AND TOLERANT -- The talented geriatrician is not only good in medicine, but is also good in inter-personal relationships. He takes time to draw out the elder patient. He understands it's difficult to remember details, to undress, to overcome inhibitions. So many older people have learned to distrust medical experts and specialists, but the wise physician won't let these prejudices get in the way of his objective examination and diagnosis. It takes time to become 85, and it takes time to treat a patient who is 85.

IS FAMILIAR WITH THE WAYS OF THE OLD -- Many old people complain of sundry aches and pains. This can make an inexperienced doctor send them for unnecessary and expensive scopes and scans, or at the other extreme, can cause him to brush off the complainer as "nudniks" or hypochondriacs who are wasting his valuable time. The more experienced doctor will hear those same complaints and ask about the old person's sleeping habits, his bowel movements and his relations with his kids. Nine times out of ten, the latter are the real underlying problems.

CAN TACKLE ETHICAL DILEMMAS -- Robert came for a medical assessment. His memory wasn't as sharp as it had been once and he admitted in confidence to the doctor that he sometimes didn't remember how to drive home. The examination revealed more severe mental impairment than was apparent on the surface, and tests revealed that Robert's judgment and orientation were especially decreased. In addition to giving his family a rather bleak diagnosis, probable Alzheimer's disease, the doctor was faced with a dilemma: to report Robert's condition to the motor vehicles department or not. Robert's wife told the physician that revoking her husband's license would probably "kill him," but hiding the facts could lead to him killing others. This is one example of the kind of ethical issues with which geriatricians have to deal. There are many more.

SEES THE WHOLE PERSON, NOT JUST THE SYMPTOMS -- A baby comes to the pediatrician and he's a complete package with great potential, all the genes in place, but a blank board as far as environmental influence is concerned. An elderly person presents a history book of experiences, a rich past (no matter what kind of influence he has had on society) and a reflection of his generation. When a doctor meets a man of 80 or 90 he must relate to the period in which that person lived and who he was. A Holocaust survivor, a former Hollywood star or the self-made man who pulled himself up out of an impoverished childhood, all carry remnants of their past in their personality, in their outlook and in their physical make-up. These elements cannot be ignored.

RESPECTS THE OPINIONS OF RELATIVES AND CAREGIVERS -- A famous geriatrician once wrote: "Those best qualified to teach geriatric medicine are patients, relatives, neighbors and caregivers. Use them."

Often in an emergency room the harried staff will say, "There's nothing wrong with that man. He should go home." His spouse or family caregiver will insist, "No he's not himself. I know. I've been taking care of him for many years."

The emergency room doctor or nurse may think, "These people want a vacation; that's why they refuse to take their relative home." But in most cases the family caregivers are justified in the end. Even if they're convinced or forced to take their relative home, one, two or even three times, in the end it will turn out that the patient had a silent heart attack, a stroke in evolution, a change in their metabolism or whatnot...and it was the caregivers' untrained but sensitive sense that something was wrong that first alerted medical staff to the symptoms.

TAKES A DETAILED HISTORY -- Sarah came into the hospital with acute confusion. She attacked anyone who came near her, didn't sleep for two nights and days, talked nonsense and hallucinated that all kinds of animals and strange figures were coming to attack her. The doctors thought she must have some severe infection, or unbalanced diabetes; the psychiatrist thought she was psychotic; the social worker advised placement in a closed unit. It was the intern who took the trouble to get her past and present history and it was he who discovered l) that Sarah had just arrived from a foreign country and didn't understand a word of the local language; 2) she had been in a plane for the first time in her life and for many hours during which time she hardly ate or drank; and 3) she hadn't taken her regular medication for the past two weeks. Once these facts were taken into account Sarah's condition improved dramatically and she was able to return home to her family.

USES DRUGS RELUCTANTLY -- During a recent doctor's strike in Israel it was found that the national death rate actually decreased. Could it be that fewer people suffered from mixing medicines or overdoses? It has been shown that in our modern society many people suffer the consequences of modern medicine, especially the adverse effect of powerful drugs that are often misused or misunderstood. Old people who have memory problems as well as sight impairment are especially prone to mixing up instructions or prescriptions. Old people also tend to visit different doctors and get different medicines without telling one about the other. Therefore the discerning physician will keep prescriptions to a minimum or prescribe natural and non-harmful drugs whenever possible.

IS SENSITIVE TO THE NEEDS OF THE FAMILY -- As in pediatrics, the state of the family and their well being have a direct effect on the well being of the elderly patient.

GIVES HIS HOME PHONE NUMBER -- A study conducted by a home care team in Canada found that families of the elderly who received the home phone numbers of the physician in charge rarely used it, but had a much higher feeling of confidence and security than did those who were not given the number.

MAKES HOME VISITS -- Prof. Bernard Isaacs once wrote: "To know your patient visit him at home (in his natural environment); become his guest." Dr. Weiss couldn't understand why Carl, an elderly gentleman with courtly European manners, was continually being hospitalized for pneumonia and respiratory infections. He had been a senior government official, and had a lovely, cultured wife. The family lived in one of the nicer neighborhoods of the city. So the doctor made a house call and then he understood it all.

Although the childless couple had a beautiful home their income was very limited. They were ashamed to apply for welfare. Instead they cut back on food and couldn't pay heating costs, or even fix a broken window in the apartment. Dr. Weiss saw that the house was practically empty of furniture and that it was freezing. His recommendation that oxygen be installed to alleviate Carl's breathing problems was not followed because there was no one to bring the oxygen cannisters to the apartment. Once these problems were brought to the attention of a municipal social worker, Carl's condition improved immensely.

Prof. Isaacs also wrote: "A geriatrician is a doctor with a soft heart, a hard head, a thick skin and a chip on the shoulder... With his soft heart he feels; with his hard head he decides; with his thick skin he fights (for his patients); with his chip on the shoulder he suffers." It is encouraging that there are a good number of doctors who fulfill these "requirements" in the field of aging today.

Last modified on Tuesday, 19 April 2011 16:45
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Leah Abramowitz

Leah Abramowitz

Leah Abramowitz is a geriatric social worker with more than 30 years experience. She founded a day center, called Melabev, for the cognitively impaired in Jerusalem and the vicinity. She is also a free lance writer and the author of "Tales of Nehama", on the late biblical scholar Professor Nehama Leibowitz.

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