The answers might help you reach a diagnosis, and even brighten your day.
The answers might help you reach a diagnosis, and even brighten your day.
When I was in medical school, I learned to ask new patients about childhood ailments, gather an extensive family profile, and record the date of every procedure and illness. These days, the availability of accurate and rapid diagnostic testing has reduced the need for such detailed information gathering. Still, a thorough history can aid the diagnostic process. During my 20 years of working with older patients, however, I've modified my approach.
Childhood diseases and distant family history are less important, since they're usually poorly recalled. I do ask about any significant family or personal illnesses, but if I'm going to help my patients I need to know where they came from, where they are now, and where they're heading.
To find out, I ask the following questions:
Charles Campbell (I'm not using real names), an 83-year-old about to be evicted from his fourth extended care facility in a year, had not responded to multiple psychoactive medications. "He hates everybody," his daughter-in-law told me.
I walked into the exam room to find a small man in a wheelchair; he had a dense hemiparesis. Mr. Campbell wouldn't give me any medical history, wouldn't tell me how he was feeling, and answered most of my questions with, "That's none of your damn business."
"Mr. Campbell," I said, "since you don't want to talk about what's going on now, perhaps you can tell me something important that happened to you when you were younger. What was the most memorable experience of your life?"
That was a question Mr. Campbell hadn't heard before. "Why do you want to know?" he asked.
"If I'm going to take care of you, I need to know something about you. Tell me the most important thing that ever happened to you."
The angry expression on his face seemed to soften.
"Okay," he said. "It's 1941, and I'm the backup quarterback on the local college team. In the final game of the season our starter goes down, and I come in. I throw three touchdowns and run for one more. We win, and everyone talks about next season and what a great player I'm going to be.
"Then Pearl Harbor comes along. I do my duty and sign up, and a year and a half later I'm sitting in the bus station with a dead eye, a busted eardrum, and a medical discharge. So instead of going back to college football and maybe even the pros, it's 30 years in the plant and a lousy pension. Then the stroke. You expect me to be happy? Not in this lifetime, Doc."
I asked him about the game, what kind of a day it was, what plays he called, how it felt to score. His eyes lit up as he talked: "I was pretty nervous at the beginning, and the first touchdown pass was mostly luck. But that run won the game, and it was a beaut. Fake the pass, fake it again, then tuck it in and run for the corner. They carried me off the field, and they started calling me Charlie the Cannon. Doc, that was the best thing that ever happened to me."
Then Charlie the Cannon Campbell, the nasty old man who hated everyone, started to cry. And just for a moment, so did I.
"Mr. Campbell," I said, "I can't fix what happened, but I am going to do the best I can to make things as good as possible for you. Can we work together on that?" Through the tears, he nodded Yes.
I still see the Cannon at the long-term care facility. He has become a favorite of the staff, and he's one of my favorites, too. He tells me what's bothering him, and I tell him I'll try to fix it. Then we talk some football. I won't tell you that he is the happiest man on earth, but he's doing much better. And not because of some costly procedure or miracle drug. It's because I asked the right question.
Physicians walk into the exam room with an agenda. For an established patient, it's usually to update chronic problems, fine-tune meds, and make sure that screening studies are current. For a new patient, we want to draw up a problem list and formulate a treatment plan. We sometimes forget that our patientsespecially our older patientsmay not have the same concerns we do.
Recently I saw Martha Clark, a retired high school English teacher. She's 84, suffers from heart disease and diabetes, and was on nine medications. Her past medical history was three pages long. Frankly, I was a bit overwhelmed. But when I asked about her biggest health concern I got an unexpected response: "I'm afraid I'm getting Alzheimer's disease."
Her reason? The previous week she didn't complete the crossword puzzle in The New York Times, something that hadn't happened for several years.
By then I had spent enough time with her to know that she was cognitively intact. Still, I had her do several standard mental status tests; she got perfect scores. That eased Mrs. Clark's fears. I also told her that I was thrilled when I could finish half of the Sunday puzzle.
The important point here is that if I hadn't asked about her biggest concern, she likely wouldn't have offered it, and she would have gone home worried and unsatisfied.
Some older patients come to us with walkers, wheelchairs, emphysematous lungs, irregular heartbeats, and sad faces. No wonder that many of my colleagues have told me that they shy away from older patients "because I don't think I have anything to offer them." I've reached the opposite conclusion. I believe I can do something for every older patient who comes to see me.
When Marilyn Williams, 79, became a patient, she was receiving chemotherapy for advanced breast cancer and had left-sided weakness from a stroke. After reviewing her records, taking her history, and examining her, I feared that she might be the rare patient for whom I could do nothing. But I asked just the same: "Mrs. Williams, is there anything I can do today that might make you feel better?"
"Doc," she said, "I'm a tough old bird, and I can handle a lot, but running to the bathroom nonstop is really bugging me. Do you have anything for that?"
In fact, I did; the once-a-day medication I gave her reduced her urinary frequency considerablyand very much to her satisfaction.
I hadn't reduced the burden of her other problems, but with a simple intervention I had significantly improved the quality of her life. She sent me a card: "Thanks for making my life better, from your happy, dry patient." That note improved the quality of my life.
When I opened my practice, I almost always had a family member come back after my evaluation of an older patientsooner, if I thought that was what the patient wanted.
Ben McDonald, 78, didn't seem to mind when his daughter answered almost every question I asked him. She also was actively involved in his meds and treatments. One afternoon, though, when the daughter had to leave the exam room for an emergency phone call, Mr. McDonald said, "If I tell you something, will you promise not to tell my daughter?"
After I assured him that I would keep his confidence, he told me that he wanted to see a urologist. "But Mr. McDonald," I said, "I check you every year, and I've never noticed a problem."
"Doc," he replied, "there's a woman in the building and, well, I think I need a little help. I've been hearing about these new medications." I told Mr. McDonald that I could give him such a medication, and I asked what he wanted me to tell his daughter.
"If you don't mind, Doc, let's keep her out of it. It's really not any of her business, is it?" Of course, he was right. I gave him some samples and an instruction sheet, which he put away before we invited his daughter back into the exam room. I assured her that Mr. McDonald was doing just fine and could come back in two months.
The message? Let's encourage family members to be involved in the lives of their older relations, but at the same time, let's give our senior patients the privacy and confidentiality they deserve.
At 83, Jack Bledsoe was relatively healthy, but whenever he came in he reminded me, "I'm counting on you not to hook me up to any machines." I acknowledged his request and had him sign a statement to that effect.
One Monday morning I came in to find that my associate on-call that weekend had Mr. Bledsoe on a ventilator. "He arrested on the golf course, and they called 911. We didn't know what he wanted, so we put him on the vent. Three of his daughters are here, and they can't decide what to do. Sorry."
I went to Mr. Bledsoe's chart, pulled out his statement, and headed for the ICU. There, I met his daughters. All were very determined to do what was best, but each had a different idea of what that might be.
After confirming that Mr. Bledsoe would not be able to make a meaningful recovery, I showed his daughters his statement. They agreed: It was time to let Dad go. Each daughter went in to say her final words to him, then they all stood by the bedside as I turned the machinery off. Mr. Bledsoe died comfortably within several minutes.
I'm grateful that I had asked Mr. Bledsoe to put his end-of-life wishes in writing. With that information, we were able to give him the gentle death he wanted, and ease his daughters' pain and stress.
I learned then to ask all my older patientsnot only those with advanced illnessfor their end-of-life wishes, and encourage them to come to a decision if they have not yet done so. Particularly in the elderly, life-threatening illness may appear at any time, and I want to be ready.
When I was a medical student on a clinic rotation, I was handed a fat chart that, according to an ominous notation on the cover, was "part five of five."
The patient, 89-year-old Catherine Fiorini, was complaining of unremitting itching "down there." Reviewing her chart, I found that she had already gone through multiple exams, tests, and treatments. I did a vaginal exam and found nothing wrong other than signs of itching.
I was out of ideas, so I asked, "Mrs. Fiorini, what do you think is wrong?"
Tearfully, she explained that when she was 14 she had "relations" with an older relative. The itch, she said, was God's punishment for her sin of long ago.
I drew two tubes of blood and walked them over to the hospital lab, where I asked the lab tech to discard them. Then I told Mrs. Fiorini that the tests were negative.
I suggested she take a warm bath every night, apply some moisturizer to the irritated area, and come back in two weeks. She returned with a smile on her face and an invitation for me to attend her 90th birthday party. Mrs. Fiorini was my first "cure" and in some respects my most satisfying one. And I didn't need any "high-tech" help; I just had the good fortune to pose the right question.
This may be the most important question of all. Recently, Lorna Driscoll, an 84-year-old whose colon malignancy I had diagnosed five years ago, seemed sad. I asked her if she wanted to ask me anything.
"Dr. Waltman, "she said, "I've had five good years, and I will always thank you for that. I got to see my first great-grandchild. But I am tired now, and the chemotherapy treatments are very hard on me. Would you be mad at me if I decided to stop?"
I hugged her and said that if and when she wanted to stop treatment, I would support her completely.
"And will you still be my doctor?" she asked.
"Mrs. Driscoll," I said, "I'll always be your doctor."
I encourage you to include these questions and some of your own in your initial assessment of older patients. You will learn important information about them, show them that you care, and be better prepared to meet their needs.
You'll find more important elements of running a senior-friendly practice in "Practical approaches for senior patients" in our Sept. 23 issue.
Richard Waltman. 7 questions to ask senior patients. Medical Economics 2002;20:29.