The Sins of the CCFP Consultee

Part II of Patients Suffer When Consultant & Consultee Beg to Differ

A. Mark Clarfield, MD

For those FRCPC's who felt aggrieved by my last month's column, take heart. In this month's column, I shall address the sins of the CCFP consultee. I am attempting this here because these examples of malfeasance pertain most especially to the elderly--patients who are the most vulnerable when caught in the crossfire between those that seek and those that give advice.

As I mentioned in my last epistle on the subject of consultation, the older person tends to have multiple, chronic diseases that may present atypically, often making it difficult, at least at first, to make an accurate diagnosis. As a result, many elders are subjected to the perils of polypharmacy. In addition, older patients, when admitted to hospital, have an increased length of stay and often present with a more complicated history than their younger counterparts. Thus, appropriate consultation is of great importance to the older patient.

I will now endeavor to discuss the mistakes in the consulting practices of Canada's family doctors, especially with relation to the geriatric patient.

I feel well qualified to write on the subject, since I practiced family medicine for several years before becoming a geriatrician. During this period, I committed all (and perhaps more) of the obliquities that are discussed below.

To Live or Not to Live Longer

To Live or Not to Live Longer

A conference, convened by Dr. Arthur L. Caplan of the University of Pennsylvania's Center for Bioethics with support from the John F. Templeton Foundation, was held in Chicago in early March to debate the ethical implications of extending human life. Although disagreement arose regarding the means, with some scientists arguing that eradicating the major diseases would do much to extend life, the larger part of the theoretical discussion focused on gene manipulation as a way of slowing the aging process. All this, however, was not nearly as interesting as the ethical debate these scientific prospects engendered. Ethicists and religious leaders argued passionately about both the advantages and the evils that a longer life span would bring about. Those against life extension argued that death helped shape the meaning of life and that 80 years of life were adequate for career and family purposes. Rev. Richard J. Neuhaus of the Institute of Religion and Public Life, described the research as "a pagan and sub-Christian quest" propelled by an "essentially amoral and mindless dynamic of the technological imperative joined to an ignoble fear of death."

Pardon me, no disrespect intended--but WHAT A LOAD OF NONSENSE! Ask a healthy octogenarian whether she has had her fill of life. Is there a point at which she could simply cease enjoying the company of her children and grandchildren? Or can she suddenly become impervious to the beauty of spring and autumn? If human life is sacred, who is to say when it 'should' end. As the saying goes, G-d helps those who help themselves. If another forty years of life were possible, I'd take them. Who in all honesty wouldn't? Permit me to make a toast to all those who share my view--live, live at least until one hundred and twenty?

Modern Prognostics: How Accurate are the Predictions?

To "buoy up a dying man with groundless expectations of recovery is really cruel." It may lead to "overlooking the important concerns of futurity and involve families in confusion and distress."

Samuel Bard, 1769

How we choose to live our lives largely depends on our perception of the future. Should we strive for maximum comfort "today" or make a sacrifice anticipating a later reward? What should we focus on: career, family, a dying relative, children, spirituality, finances? Should a cancer patient accept a rigorous treatment hoping to recover or a palliative care knowing the end is near? Is it time to fight or time to reflect?

Traditionally, patients and their families rely on physicians to make a prognosis of a life-threatening illness. Unfortunately, the accuracy of these predictions is generally rather poor. According to a recent study, which assessed survival estimates of 343 doctors for 468 patients, "only 20% predictions were accurate". "Accurate" means within 33% of actual survival. From the remaining 80%, 63% of predictions were overoptimistic and 17% were overly pessimistic. "Overall, doctors overestimated survival by a factor of 5.3".

This lack of predictive accuracy had little to do with the doctor or patient. Generally, more experienced doctors were more accurate. "Non-oncology medical specialists were 326% more likely than general internists to make overly pessimistic predictions". Also, if a doctor-patient relationship was longer, the error in prediction tended to be greater. In addition, "male patients were 58% less likely to have overly pessimistic predictions".

The reasons for this undue optimism may be related to the physician's natural desire to be reassuring and to avoid being the bearer of bad news. Physicians may be more concerned with the effects of prognostication on patients and their families than with empirical accuracy. As well, modern medicine is oriented around diagnosis and accepted therapy; prognosis is presumed to be dependent upon the symptoms and complications and not on the individual characteristics of a patient.

Whatever the reason, this optimism in estimating life expectancy undermines the quality of care given to a patient at the end of life. For example, dying patients are not referred to hospice care in time. A US study showed that seven percent of patients referred to hospice care died within hours of admission. Also, a majority of patients have only one month of such care even though three months are recommended. The question of whether or not admission to hospice care may shorten a patient's life is not an easy one to answer. It is generally believed to be of benefit to the patient.

According to Colin Murray Parkes, a psychiatrist, "prognoses should be based on proved indices, not intuition". He praises recent research instruments such as Morita's palliative prognostic index and Maltoni's palliative prognostic score in his commentary on the above-described study. "These short and simple instruments make use of a mixture of performance measures and systemic symptom assessments rather than relying on intuition and clinical judgement alone". These recent scales have been shown to be fairly good predictors of short term survival.

In conclusion, prognoses of survival for terminally ill patients are extremely inaccurate. This adversely affects the final care offered to the patient as well as relevant family management. It is important for physicians to try not to be overly optimistic. Ideally, new assessment scales should be used instead of clinical judgement.

Suggested Reading

1. Christakis NA, Lamont EB. Extent and determinants of error in doctor's prognoses in terminally ill patients: prognosis of cohort study. BMJ 2000, 320(7255):459.
2. Christakis NA. The elipsis of prognosis in modern medical thought. Soc. Sci. Med. 1997, 44(3):301.
3. Forster LE, Lynn J. Predicting life span for applicants to inpatient hospice. Arch Intern Med 1988, 148:2540.

Diagnosis and Management of Dementia: A Manual for Memory Disorder Teams

"DIAGNOSIS AND MANAGEMENT OF DEMENTIA A MANUAL FOR MEMORY DISORDERS TEAMS"

Oxford University Press, New York, 1999
Edited by G.K. Wilcock, R.S. Bucks and K. Rockwood

Reviewed by Barry J. Goldlist, MD, FRCPC, FACP

Dementia, and Alzheimer's disease in particular, have become "hot" areas. After almost a century of therapeutic nihilism and clinical despair, we have now at least a glimpse of light at the end of the tunnel. Currently, modestly effective therapies are available for Alzheimer's Disease, and the future is promising. With growing understanding of AD, and with increasing expectations from patients and families, physicians will have to become better informed. This book is a manual on how to establish a multidisciplinary memory disorders service. One of the editors is the eminent Canadian Geriatrician, Ken Rockwood, from Dalhousie University. This book is superb. The important contributions from all disciplines, e.g. neurology, psychiatry, neuropsychology etc, are clearly explained. The first chapter by Beattie et al., is an excellent resource for those wishing to start their own clinic. Although not meant to be a clinical text, the sections on the diagnostic process are excellent summaries, and certainly highlight what a primary care physician should know about distinguishing the various dementias. Although primary care physicians are not the main targets of this book, they will get some practical information about diagnosing the common types of dementia, and a good understanding of the complexity of the diagnosis and management of dementing disorders. For those intending to establish a memory disorders team, this is a must read. For those already in the "memory business" there is still much practical information to be gleaned from this book.

The “Nine Ds” of Determining the Cause of Weight Loss in the Elderly

The "Nine Ds" of Determining the Cause of Weight Loss in the Elderly

David M. Kaplan, MScHA

Weight loss in the elderly should always be a great concern for the clinician because it can be an indicator of malnutrition. Involuntary weight loss has been shown to be highly predictive of morbidity and mortality.¹ All physicians who treat geriatric patients need to have a framework for identifying and evaluating weight loss in this patient population. One Canadian study found that 40% of elderly persons receiving home care services reported involuntary weight loss over a period of one year.² This practical approach to involuntary weight loss in the elderly will begin with a definition and then present a simple and organized approach to diagnosis and evaluation.

Definition and Risk Factors
Weight loss in the elderly becomes worrisome when the patient has involuntarily lost five percent of their body weight over a six-month period.³ Social Isolation has been identified as a risk factor for weight loss. While the mechanisms are not clearly understood, it is thought that poor physical functioning may be linked to a decrease in social support.⁴ Social isolation has been demonstrated to be detrimental to health and health outcomes.^3,4,5 Sensory decline, poor oral hygiene, disease, polypharmacy, drug-nutrient interactions, poverty, and alcohol abuse have been found to be risk factors for involuntary weight loss in the geriatric population.

Approach to Weight Loss
Before the clinician adopts an approach to determine the cause of weight loss in a specific patient, she must first be astute enough to perceive a problem. Recognizing weight loss in the elderly can often be problematic. Our pediatric colleagues place great importance on following and charting weight and height parameters in all their patients. It is best to follow their example in this regard. Geriatricians, family physicians, and other primary care providers should, at the very least, record the patient's weight and height at every visit. By adopting this practice ritual, they will become aware of subtle weight loss in their elderly patients.

Once established, involuntary weight loss can be handled by utilizing a broad-approach differential diagnosis. Bianchi divides weight loss into three possible, but not mutually exclusive, etiologies.⁵ Of the three basic causes of weight loss, decreased intake (table 1) is the most common in the elderly. The second cause, increased fluid-nutrient loss (table 2), is caused predominantly by malabsorptive disorders and by diabetes. Lastly, states of excess metabolic demand (table 3) resulting from gastrointestinal, genitourinary and breast carcinomas are also a basic cause of weight loss.

Diarrhea, dysphagia, dysgeusia (impaired taste), and abnormal dentition are obvious causes of weight loss in any population and must be kept in mind while examining the patient. Numerous studies have linked dementia to weight loss in the elderly.⁴ One of the outcomes of dementia, dysfunction (problems in physical, cognitive and psychosocial function), is itself an independent cause.4 Food shopping, and the preparation and eating of food are integral parts of our daily life. And yet, Markson reports that 23% of older people in the community have health-related difficulties with activities of daily living (ADLs) such as bathing, dressing, feeding, and using the bathroom.⁸ Moreover, 28% of the same population has difficulties with independent activities of daily living (IADL) (using the telephone, shopping, banking, laundry, and transportation).⁸ Clearly, patients who have had a decline in their functional ability are at risk for involuntary weight loss.

Whether due to a single pharmaceutical agent or to polypharmacy, drugs can also cause weight loss in the elderly.⁴ Beta-blockers and anticholinergic agents cause cognitive changes, which lead to functional decline. Narcotics, benzodiazepines, neuroleptics, and selective serotonin reuptake inhibitors (SSRIs) can produce anorexia. Lastly, use of tricyclic antidepressants to treat depression can cause dysgeusia and dry mouth. Now that a general approach to diagnosing the cause of weight loss in the elderly patient has been described, we can begin to illustrate a more individualized approach to a particular patient in the office.

The physical exam is guided by what one uncovers during the interview. While working up these patients from a general standpoint, the physical exam should include the measurement of vital signs, the patient's weight and height, and a calculated body-mass index (BMI: weight(kg)/height (m)²). Healthy, elderly people should have stable weights and a BMI higher than 23 kg/m². One should look for evidence of dementia by doing cognitive tests such as repeated Folstein Mini-Mental State Examinations. The presence of lymph nodes, evidence of previous chest or abdominal surgery, abdominal masses, abdominal distention, ascites, or organomegaly should be noted. A digital rectal exam should also be performed along with fecal occult blood testing. Next, a full musculoskeletal exam should be conducted to observe evidence of osteoarthritis, which could be affecting the patient's ADLs and IADLs. Lastly, a screening neurological exam should be done to elicit any focal neurological lesions.

Armed with the data from the complete, focused history and physical, the basic laboratory screening tests may include a complete blood count, electrolytes, blood glucose, urinalysis, liver and renal function tests, calcium, thyroid function, hemoccult stool tests, and a chest radiograph. The special tests, which may be necessary based on history and physical exam findings include: ESR, HIV test, blood cultures, upper GI series, esophagealgastroduodenoscopy, and colonoscopy.^3,7 A CT scan or ultrasound study may be indicated to investigate abdominal masses or abscesses.

Summary
Involuntary weight loss, defined as a five percent of body weight reduction over a six-month period, has been shown to be a cause of poor health outcomes in the elderly patient. This approach highlighted the necessity for clinicians to be cognizant of the many etiologies of weight loss in this population. A good history and physical followed by appropriate laboratory tests is necessary in order to diagnose and successfully develop a comprehensive treatment plan.

References

1. Wallace, JI, Schwartz RS. Involuntary Weight Loss in Elderly Outpatients: Recognition, Etiologies, and Treatment. Clinics in Geriatric Medicine: Failure to Thrive in Older People 1997;13(4):717-736.
2. Payette H, Gray-Donald K. Risk of malnutrition in an elderly population receiving home care services. Facts and Research in Gerontology 1994;2(suppl):71-85.
3. Verdery RB. Clinical evaluation of Failure to Thrive in Older People. Clinics in Geriatric Medicine: Failure to Thrive in Older People 1997;13(4):717-736.
4. Markson, EW. Functional, Social, and Psychological Disability as Causes of Loss of Weight and Independence in Older Community-Living People. Clinics in Geriatric Medicine: Failure to Thrive in Older People 1997;13(4):717-736.
5. Berkman LF, Berkman CS, Kasl S et al. Depressive symptoms in relation to physical health and functioning in the elderly. Am J Epidemiol 1986;124:372-388.
6. Bianchi A, Toy EC, Baker B III. "The Evaluation of involuntary weight loss." Primary Care Update Ob/Gyns 1998; 5:263-267.
7. Robbins LJ. Evaluation of weight loss in the elderly. Geriatrics 1989;44:31-37.
8. American Association of Retired Persons and Administration on Aging, U.S. Department of Health and Human Services: A Profile of Older Americans, 1996. Washington, DC, Program Resource Department, American Association of Retired Persons, 1996.

A Word from the Managing Editor

I would like to introduce myself as the new Managing Editor. As a regular contributor to Geriatrics & Aging, I have come to know the publication and have developed over the last two years a close relationship with many of the individuals involved with organizing and editing the publication. I bring to this exciting task a masters degree in pharmacology, with a special interest in the elderly and a keen interest in medical journalism and communications.

I am joining the publication at a particularly propitious and interesting time. The year 2001, will mark the year when the first baby boomer turns 55. A demographic watershed, this coming year signals the start of the movement of one of wealthiest, best educated and most dynamic generations towards retirement age. A strident and demanding generation, the baby boomers have been at the forefront of societal changes for the last forty years. Proven innovators in almost every area of endeavor, this generation is surely set to drive changes in how we understand and see aging. The aging of this generation, coincides at the same time with extroardinary insights into the aging process and with sweeping innovations in drug design and development.

The demographic facts are striking: In 1900 only 4% of the population was over the age of 65; today that number is 12.4%. It will rise to a projected 25% by the year 2021. People over 65 now account for one third of all health care spending, more than 40% of all doctor visits, and one-third of all presciption drug sales. At the same time, those over 65 see their physicians on average 11 times per year compared to the five times per year that younger patients visit their doctor. It should also be noted that the visits of seniors take up as much as 56% more time than other patients' visits. The rapid aging of the population will only exacerbate these trends. Translated into daily clinical significance, these numbers mean ever more complicated demands on your practice.

Geriatrics & Aging has been solely designed to assist you with your patient-care decisions and to bring you timely and well-researched information. My aim as the managing editor of Geriatrics & Aging is to deliver a well-organized, coherent and balanced package of information to your desk every month.

Thousands of hours of research, organization, editing, medical illustration and other types of professional expertise are invested in each and every issue of Geriatrics & Aging. This effort and work is condensed, for your benefit into 60 meticulously constructed pages. A sophisticated medical communications product, Geriatrics & Aging is designed to augment and support your practice--it is a time-saving device.

I look forward to establishing a long-term relationship and rapport with each and everyone of my readers. I would encourage you to e-mail me directly any suggestions or thoughts at geriatrics@ribosome.com.

Patients Suffer When Consultant and Consultee Beg to Differ

A. Mark Clarfield, MD

Having spent several years as a family doctor before becoming a consultant geriatrician, I have stood on both sides of the fence. As a primary-care physician, I was subjected to the humiliations dished out by many a consultant. Yet, to my chagrin, in later years, I found myself perpetrating similar outrages on physicians seeking my help.

As patients, the elderly are particularly vulnerable to getting caught in the crossfire when consultant and consultee do not see eye to eye. The main reason for this is that no one needs the services of good primary care with appropriate consultant backup more than the older patient.

In this article as well as in the March issue, I shall describe mistakes that I have made (or seen colleagues make) on both sides of the great divide between consultant and consultee.

Sins of the Consultant

1. Arrogance: Chapter 1

The specialist has, by definition, a very comprehensive knowledge of a specific area of medicine. This knowledge can be used to beat the consultee over the head with implied or overt criticism.

History of Medicine

Reviewed By: Barry J Goldlist, MD, FRCPC, FACP

HISTORY OF MEDICINE:
A SCANDALOUSLY SHORT INTRODUCTION
Jacalyn Duffin
University of Toronto Press, 1999
Toronto, Buffalo, London
ISBN 0802079121

Why would anybody other than a medical historian (or an aging doctor such as myself) be interested in a book on the history of medicine? Jacalyn Duffin gives us all the answer in the final chapter of this book (How to Research a Question in Medical History) when she writes: "No medical subject--be it a person, a practice, an institution, a technology, or an idea-- can be fully explored without also studying its political, social, economic, and cultural environment." In this introductory text (compiled from medical student lectures at Queen's University) one gets a clear view of how medicine reflects society, and how health care providers are influenced by non-medical factors in society at large. Although this is not a textbook of Canadian medical history, it is written by a Canadian for a Canadian audience. This is particularly valuable as many of us who are wondering where the Canadian health care system is heading, can get at least an overview from this text of how our current system developed.

The text is organized by topic (e.g. History of Anatomy) rather than as a continuous chronology. This makes the reading much simpler for a relatively uninformed reader, as only one concept at a time is explored. As well, chapters can be read in any order, depending on the reader's particular interests. The exceptional nature of this book is probably based on the relatively rare characteristics of the author: she is a practicing physician (haematologist) as well as a formally trained historian. As a result the book covers both important historical trends as well as the difficulties facing individual practitioners as they try and alleviate human suffering.

My favourite chapter was entitled "Science of Suffering: History of Pathology." The reader is given a clear understanding of how the concept of 'disease' developed, and both the strengths and weaknesses of this diagnostic labelling. The chapter on blood (Why is Blood Special?) literally 'pulses' with excitement and enthusiasm, obviously reflecting the author's particular interests as well as the historical importance of the topic.

Throughout this text, there is a refreshing absence of both medical jargon and dense academic prose, making reading the book an enjoyable process. My one quibble is that Professor Duffin's elegant descriptions of the importance of a population approach to health fails to ask one question that always intrigues me. Does the focus on a population health approach have within it the inevitable potential to put differential values on human life? Was the eugenics movement a result of a 'population health' perspective? In Canada, with universal medicare and no private practice option (as occurs in the United Kingdom), might someone with an 'unimportant' disease eventually be 'uncovered' by medicare? Does focusing on the greater good inevitably result in inhumane or unfair treatment to some? Perhaps a topic for a second edition.

So once again who should read this book? Clearly it is a must read for medical students and doctors interested in medical history. However, it would be a shame to limit this fine text to that small audience. This book can be enjoyed by anybody interested in understanding health care or who is just interested in medical history. It deserves a wide audience.

Clinical Cardiology in the Elderly

Reviewed by: Barry J Goldlist, MD, FRCPC, FACP

CLINICAL CARDIOLOGY IN THE ELDERY
2nd EDITION
Chesler, Eliot M.D., Editor

Futura Publishing Company, Inc
Armonk, New York, 1999
ISBN #0-87993-421-2

Why produce a textbook on geriatric cardiology? The obvious answer is the incredible growth of the elderly population and the tremendous increase in the prevalence of cardiac disease (clearly and elegantly described in chapter one of this text by McLaughlin and Cassel). However, as a practising Geriatrician, I think there is another important reason to produce such a volume. There is ample evidence in the literature that effective treatments for cardiac disease (e.g. ASA, beta-blockers, and thrombolytic agents) are underused in the elderly. Any publication that might change this is indeed welcome.

Like any multi-authored text, there is some variability from chapter to chapter, and some authors do not use enough tables or charts, thus making their chapters intimidatingly dense. As well, the inevitable delay between writing a chapter and the publication date of the book means that few chapters have any references past 1997. Nevertheless this is an excellent text. It is not likely that any reader would read this text cover to cover. Rather the reader would use the book to review particular topics or answer specific clinical questions. The chapter on 'Physiology of the Aging Heart' is tremendously helpful to a practicing physician. The chapter on 'Management of Lipid Disorders' clearly summarizes the current literature and notes where data is insufficient for firm recommendations (primary prevention in the elderly), and gives practical management advice to the physician. The chapter on 'Congestive Heart Failure' unfortunately was written before the role of beta blockers and spironolactone were clearly established, but does review vasodilators, diuretics, and digoxin very clearly.

In summary, this is an ambitious, and for the most part, very successful textbook. It would be particularly useful for Geriatricians, Internists and Cardiologists. However, primary care providers with large numbers of elderly patients in their practice could also profit from purchasing this book.

Felix d’Herelle and the Origins of Molecular Biology

Reviewed By: Barry Goldlist, MD, FRCPC, FACP

FÉLIX D'HERELLE AND THE ORIGINS OF MOLECULAR BIOLOGY

William C Summers
Yale University Press
New Haven and London
1999
ISBN 0300071272

This textbook is a combination book, partly the biography of an exceptional individual and partly a history of scientific discovery. The author, William Summers, is eminently qualified to write such a text, being a physician, scientist, and historian at Yale University.

D'Herelle is a renowned Canadian Scientist about whom I was totally ignorant. Born in Montreal, he traveled and lived in numerous areas around the world, although France became his eventual home. He never gave up his Canadian citizenship, however. D'Herelle was born to a wealthy family in Montreal, and after high school he traveled extensively, thanks to a gift from his mother. He never found time to return to formal schooling, but he learned enormous amounts in his chosen field, microbiology. His seminal scientific discovery was the description of bacteriophages, and their possible application in human infectious diseases. For this he received numerous awards, and at one time was a research professor at Yale University despite his own lack of formal education. Dr. Summers clearly delineates the process of scientific discovery, and the subsequent controversies over the nature of this new discovery (was it really a living organism or an enzyme?), and the determination of scientific priority. There is a fair amount of technical description, but Dr. Summers is a clear and logical writer who is able to guide the reader through the scientific process.

This book is an incredible work of scholarship, with extensive use of primary source documents. However, because the main thrust of this book is one of scientific discovery, we get very little analysis of d'Herelle's personality. I would have been interested in some speculation on how his lack of formal education might have influenced his often-stormy relationships with other scientists. Also, why was such a distinguished scientist so poorly treated at the Pasteur Institute, his spiritual home? There would be much to learn from a biography of this highly complex individual. Meanwhile, this is an excellent book that helps us understand the nature of scientific enquiry while saluting an outstanding scientist, who just happens to be Canadian.