By DEBORAH AFEZOLLI, CARL-PHILIPPE ROUSSEAU, HELEN FERNANDEZ, ELIZABETH LINDENBERGER
“Why did you choose this field?” This is a question most doctors ask at some point in their early career. We are geriatric and palliative medicine specialists. When we are asked this question, another one inevitably follows: “Isn’t your job depressing?”
No, our job is not depressing. We are trained in the care of elderly and seriously ill people and find this work very enriching. What really depresses us is how many at-risk patients have died during the pandemic and how the scourge of COVID-19 has exposed the rifts in our healthcare system. Never before in modern times have so many people been affected by serious illnesses at the same time, nor have so many suffered from the challenges of our dysfunctional health system. Our nation has now seen the medical system fail to fully care for its sickest patients. Our colleagues saw this long before the pandemic and are trying to improve.
Each of us who practice geriatrics and palliative care has a loved one who has been challenged by aging, by a serious illness, or even by the health system designed to help them. As medical students and interns, we have personally dealt with these systemic deficiencies and thought about alternatives for patients with the most complex needs. We chose geriatrics and palliative care grants because we wanted to try to make a difference in health care for our most vulnerable patients.
During the New York spring 2020 boom, we were at the forefront of a major academic medical center. While the global pandemic took us all by surprise, our clinical training and passion for treating vulnerable populations made us feel able and ready to go. In response to the urgent need of an overwhelming number of extremely ill patients, our department was tasked with rapidly expanding access to geriatrics and palliative care in our seven hospitals. We were embedded in emergency rooms (EDs), hospital services, and intensive care units. We roamed the hospitals with electronic tablets, holding hands to dying patients while urgently reaching out to families to clarify care goals. For those who wanted to be cared for in the community, we made an effort to set up telemedicine visits and coordinate the necessary support. Far too often we were unable to meet their needs with adequate services, forcing them to go to crowded emergency rooms.
While we were helping individual patients and relieving our hospitals somewhat, our system was overwhelmed and the mortality rate was overwhelmed Numbers continued to rise steadily. In our hospitals, staff to care for the seriously ill in emergency rooms and intensive care units has been switched. During this hectic time, we were fortunate that our hospitals had sufficient medical resources to care for the most severe patients and staff. However, the subacute care facilities (SNSF) and long-term care facilities tried to protect their residents and their employees. The lack of PPE, staff, space, testing materials, and funding all contributed to the high mortality rates we saw in many NYC facilities and across the country. There were also limited funds available for outpatient care for our patients living in the community. The rapid transition to telemedicine was not feasible for many of our elderly patients, and even when it was possible, the provision of diagnostic and therapeutic care was limited and suboptimal.
The data now shows that older adults and people with underlying chronic diseases were disproportionately affected by the COVID-19 pandemic, with higher hospitalization rates and higher death rates. Although adults over 65 make up only 16% of the US population, they represent 80% of COVID-19 deaths. Nursing home residents, frail homebound and elderly black people were hardest hit. Thirty-five percent of deaths in the US from March to May 2020 occurred under Nursing home residents and employees. Nationwide, over 600,000 nursing home residents were infected with COVID-19 and above 100,000 died from the disease. These data are underestimated and the death toll is likely to be higher. We cannot explain why older black Americans were 1.2 times more likely to die than white Americans, nor why those living in South Dakota were nearly twice as likely to die from COVID as compared to Wyoming or Nebraska . Often times, the paid caregivers for these vulnerable patients were themselves at risk of underpaid black women who were at higher risk of contracting COVID. to get sick.
Unfortunately, many of these deaths could have been prevented. The cracks in the health system that were already visible to us before the pandemic now look like deep cracks. The COVID-19 pandemic exposed longstanding weaknesses in our health system that are rooted in its foundation and are a direct cause of the health inequalities that we have personally experienced. This is the time to restructure our system and challenge government and private insurance providers to better target funding to the basic needs of the population.
Medical education, health infrastructure and payment models were created at a time when life expectancy was limited and living with chronic illness, multimorbidity, functional impairment and dementia was rare. Our current hospital-centered care is designed to cater to the needy population at the time – that is, middle-aged adults and acutely ill children. Although health screening practices of the 1980s and biomedical research changed the length and experience of aging, our healthcare system remains stuck in the last century. This is a call to action for major system-level changes, both within our health system and within our society at large.
- Hospitals can no longer be the anchor of medical infrastructure and that our patients need quality care in the community most urgently, whether at home or in long-term care facilities.
- The “Greenhouse project“The nursing home care model has shown us a vision of effective and compassionate long-term care that we can be comfortable with for our own family members.
- The transformation of healthcare requires a rethinking of our medical education programs.
- Medical students spend more time on required rotation in obstetrics giving birth than on “elective” rotation in geriatrics or palliative care, which is not the realities of modern medical practice.
- Most doctors have never set foot in a subacute rehab or nursing home when many of their patients have come and gone from these facilities.
- Most doctors, regardless of their specialty, will care for older adults and people with serious illnesses, and it is crucial to understand the basic principles of geriatrics and palliative care and out-of-hospital care settings.
- We need to shift our focus from medical care to health care, recognizing that psychosocial support, practical care needs, and caregiver support are as important to longevity and health as medication and diagnostic tests.
- Instead of spending health care dollars on expensive, limited-potency drugs like the recently FDA-approved aducanumab for Alzheimer’s disease, we need to financially support caregiver care, home services, and alternative care models that have been shown to have a direct impact on the health of our society strengthen the most vulnerable. While community-based dementia care models have been thoroughly studied and proven to be of great value, they are not supported in fee-based care models.
- We need to invest money and support in programs whose values lie in improving the quality of care, not in accounting. In this way, our health system can better align itself to the needs of its patients.
We pride ourselves on being specialists in geriatrics and palliative medicine. We see ourselves as experts in maintaining quality of life despite the inevitability of age and illness. And this work is not depressing – it brings us limitless joy and personal fulfillment. With our skills in caring for complex populations, we are poised to lead the healthcare revolution, and the time has come from medical education and program development to public health advocacy and national health policy. We see a bright future where our patients, our loved ones, and our future selves receive comprehensive health care, not just medical care. Why shouldn’t we choose geriatrics and palliative care?
Debora Afezolli, Carl-philippe Rousseau, Helen Fernandez, Elizabeth Lindenberger are all Professors of Geriatrics and Palliative Medicine at the Icahn School of Medicine at Mount Sinai.
They would like to thank Suzanne L. Goldhirsch for reviewing this article and providing invaluable feedback and suggestions.
Categories: COVID-19, Doctor’s Office, Patients, Doctors
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