Health AGEnda

Too Little Care? Too Much Care?

Posted in category Geriatric Medicine

2 comments

This blog by UCSF professor and geriatrician Sei Lee, MD, recently ran on the GeriPal blog on September 29, 2011. It explores the complex tension between under- and overtreating older adults.

I wanted to get this community’s thoughts on a recent article that made some headlines (see ABC news and New York Times for example).

In the Sept 26 issue of Archives of Internal Medicine, Brenda Sirovich and colleagues from Dartmouth report a survey of primary care physicians, where they found that PCPs felt they were providing too much care more often than too little care.

First, I want to concede the point that the ideal answer is that we need to individualize decisions and that even if most patients are getting “too much” care, there will be some patients who would benefit from getting more care.

Focusing on averages and a population perspective, I’ve become interested in this topic since I felt a slight tension between younger and older geriatricians about the care for older adults. It seems that in a previous generation of geriatricians, the primary concern about the care of older adults was that we were not providing enough care. For me, this is highlighted by the coining of the term “ageism” by Dr. Robert Butler in the late 60’s. The subtext seemed to me that older patients were being denied appropriate services even though they may benefit because they were old. Thus, a dominant theme was elders getting “Too Little” care.

Since then, it feels like a much more dominant theme in geriatrics is how elders are getting “Too Much” care. From studies focusing on poor outcomes associated with surgeries in elders to foley catheterization to medications to avoid, it feels like more geriatricians believe that too much care is being provided than too little. The studies that focus on undertreatment of elders seems to come more from subspecialists (e.g. oncologists showing that elders are being undertreated for cancers) than geriatricians.

Do folks think that geriatrics as a field has shifted from fighting to ensure that elders get appropriate care to fighting to prevent harmful care?

My sense (completely unsupported by any data) is that this has happened. Further, I think much of this reflects a shift in US medicine, where more and more interventions being done. Thus, ideal care for the older patient has not changed in intensity over the past 40 years. However, the standard of care has shifted, so that 40 years ago, the standard of care may have been slightly less aggressive than ideal and now the standard is more aggressive than ideal.

2 thoughts on “Too Little Care? Too Much Care?

  1. At JAHF we continually struggle with two issues: what is the core of geriatrics expertise, and how do we apply that expertise to the health problems of older adults? Sei Lee’s article made me realize that a good geriatrician must walk a tightrope between too little and too much care. Is the problem that older people receive too much care? If so, geriatrics experts can help reduce the burden of treatments (e.g., reducing the number of medicines, declining invasive tests). Or is the problem that older adults receive too little care, denied beneficial services because of their age? In that case, the role of geriatricians would be to treat and advocate for older people and get them things like knee replacements and chemotherapy.

    The general public is much more worried about the latter (being denied services), even though the incentives in our healthcare system are overwhelmingly for more care. A recent article in the Wall Street Journal [http://blogs.wsj.com/health/2011/10/05/how-quality-indicators-can-hurt-the-elderly/] pins some of the blame on quality indicators, which offer a “one size fits all” approach that is often too aggressive for certain older patients. Moreover, the overwhelming evidence suggests that especially lucrative high margin procedures are performed in many cases where they have no benefit and expose patients to substantial risks.

    Nevertheless, I favor a different question; instead of too little versus too much care, let us ask instead, “What does it take to be a geriatrics expert?” I think it requires absolutely the best minds and the best hearts. The essence of geriatrics is working with patients and all of their complex interrelated concerns, diseases, syndromes, and situations, advising patients and caregivers which approaches will be most likely to meet patient goals at the lowest risk. Only the best tightrope walkers need apply.

  2. Absolutely agree.

    The tightrope analogy is especially apt because older adults are often at higher absolute risk for diseases, they have more to gain from appropriate treatment. On the flip side, because they often have many other medications and diseases, an additional medicine is more likely to cause drug-drug or drug-disease interactions meaning they have more to lose to from inappropriate treatment.

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