“Geriatrics Saved His Life!” A True Story of Geriatric Heroism

“What are we going to do with him?”

Dale scope 2

I couldn’t help overhearing the oncologist talking to his team across the small space in our provider’s work room. An unusual work room, not because of what it looks like, but because of who’s in it. I am a geriatrician, and I work directly alongside my oncology colleagues in this room. I’m “embedded” in the oncology clinic, a bit like a medic among the soldiers in a war zone. They are constantly “fighting” the War Against Cancer—and I am always caring for the patients who are damaged in the fight. They are “saving lives” and I’m “saving” the quality of those lives—often even helping bring those lives to an appropriate close. I had created this clinic just for this reason.

My colleague went on …

“I don’t know. He needs treatment … his prostate cancer is metastatic … he’s losing a lot of weight … but he’s homeless. How do we treat a homeless guy? In the middle of a Chicago winter? On a Friday? Even if we admit him to the hospital for a ‘social admit,’ what are they going to do with him on a weekend? And then, he’ll be back out on the street, anyway.”

I listened while pretending not to. I have learned not to jump into the fray when oncology is wrestling with a problem. To avoid the “what do you want” look, complete with the eye-rolling. I kept listening, but without even looking.

“It’s a crazy story! He is an educated guy, married, recently retired, and then he got cancer. While he was trying to figure out what to do, his wife took most of his savings and left. He was hospitalized, placed in an assisted living facility afterwards for rehab, but hated it and left. Then he was in a shelter, and he left that because of the food. Now he’s homeless, with no money, and he’s got metastatic cancer. And his other family members don’t help out.”

“So what do we do?” asked the physician assistant. Long pause—nobody had an answer. “Why don’t we ask Dr. Dale? I think the patient’s kinda old—maybe geri can help.”

An opening. An opportunity.

“Is there something I can help with?” I asked.

Although I knew the story already, I patiently listened to it again.

Then, despite my hopelessly full clinic schedule, I went to see Mr. Lessman (not his real name). A thin, bony African American man sat there, with a bushy afro-style cut, shading from dark at the skull to white at the tips. He was disheveled, his clothes were torn and dirty, and his dentition was terrible. He smelled awful, as one would expect from a man with metastatic cancer living on the streets of Chicago’s South Side in the middle of the winter.

But he spoke carefully, articulately and precisely—no evidence of cognitive impairment. In fact, he talked exactly like my university colleagues; which was appropriate for a man with advanced education. And he took careful notes in a spiral binder he carried, asking me for clarification for the pronunciation and spelling of all the medical terms. I felt a bit like a student in a seminar.

I went back out to see my oncology colleague in the work room, and I told him I thought we could help. I was met with a wry, skeptical shrug.

But I knew something he didn’t: I had Erica on my side, who I was sure could help us. Because she’s a geriatrics hero.

———————–

I met Erica Riley when I decided to work at our inner city long-term care facility. She worked there, as a nurse, serving as the university liaison for our patients discharged from the hospital onto one of the floors. During my fellowship training in geriatrics, I found working in nursing homes bureaucratic, intimidating, and frustrating—and I vowed at graduation not to do it again. But when the faculty member serving as the medical director of this facility left precipitously, largely in response to being unable to effectively change the facility’s care quality, there was nobody else to step in. So, even though I was a researcher and the section chief, I decided to jump in myself.

Temporarily, I thought.

This particular nursing home is located in the middle of one of the poorer neighborhoods on Chicago’s South Side. Like many such facilities, it struggles financially, trying to survive on a combination of patients covered by Medicare, Medicaid, or no insurance at all. Most of the patients here don’t have other choices, and, like the people living in the neighborhood, almost all of the patients are African American. It is the kind of facility health policy experts like me write about—in the abstract—all the time, and usually in a vaguely negative way. Like many such experts, I had actually never worked in such a facility. And, I was sure, the people who worked there would recognize this right away. Erica Riley, LPN, certainly did.

When one meets Erica, one is immediately struck by her intensity. At the time I met her, she had been at the facility for two years. I have rarely met someone who is as committed to the care of older adults as Erica. She worked for five years in a surgical unit—but she loved working with older adults so much that she quit that comfortable job to work in long-term care.

She once told me, “I always desired to take care of geriatric patients. It reminds me of taking care of my mom when I was young and she was sick.” She was recruited to this particular facility specifically to run the University Program we were building, brought on board by an administrator who knew how dedicated and hard-working she was.

Erica is one of the most genuine healers I’ve seen; she has remarkable instincts for knowing just what a patient needs. She describes her own motivations this way: “Helping someone to get stronger mentally, physically, and emotionally when they can’t help themselves” is what drives her. “In school, we were taught not to get emotionally attached to patients, but for me that’s hard to do,” she says. “When I take care of patients, I feel like they are my family. Being there to listen, nurture, and provide excellent care means the world to patients—just to have someone that genuinely cares.”

Caring for the patients at our facility, one is constantly struck by how many of them count on, believe in, and trust “Miss Erica” to make sure they get the best care.

She also reflexively embodies the ethos of team care. She describes how much she enjoys working with our university team this way: “Coming together to provide consistency and continuity of care is great. Knowing that we can work together to provide exceptional care means everything to me. My being able to change the lives of our patients means a lot.”

The only way a nursing facility can maintain a constant culture of caring is through its nursing staff. Erica is the spiritual center for the facility; she ties the patients to the physicians and the rest of the care team, making it possible for us to provide excellent care in difficult circumstances.

As I said, I had a “secret weapon” for our fight against cancer. Erica, a geriatric hero.

—————-

Back in clinic, I told my oncology colleague, “Don’t worry. Let’s get Mr. Lessman admitted to our long-term facility. We’ll get his situation stabilized, straighten out his medications, get him eating, and then have him come back to clinic in a few weeks. Then you can decide if he can be offered treatment for his cancer.”

“Don’t we have to admit him to the hospital first? Isn’t that the rule?”

“Not necessarily. I’ll talk with the administration. I think it’s better to get him into the facility and get this started immediately. A weekend in the hospital won’t be as helpful.”

“Can he get some IV fluids there?”

“Sure.”

I texted Erica on my phone, told her about Mr. Lessman, and explained what I had in mind. “What do you think?” I asked.

“Of course! No problem.” No hesitation. “Give me a few minutes.”

Sure enough, within the next 30 minutes, an admission was arranged. I turned to my oncology colleagues and told them what was happening. They were impressed, bordering on amazed. They hadn’t seen anything quite like it. I could tell they were skeptical about what could actually be done. But I knew I had Erica on my side.

————-

Our multidisciplinary team in the nursing home met for rounds the following Monday. It’s led by Erica. For appearances, the team pretends I run the meeting, but everyone knows Erica really does.

“How’s Mr. Lessman?” I asked.

“He’s OK,” Erica reassured me. “Except for one thing. He won’t eat anything.”

“Why? Is he nauseated? Or does he have abdominal pain? Or constipation? What’s the matter?”

“No, none of that. He just doesn’t like any of the food. He’s very…” Erica had a funny grin on her face. “… particular.”

I frowned. “What does that mean?”

“He only wants grilled cheese sandwiches. No butter. White bread only. Nothing else. For every meal. And I’m being told we can’t do that here.”

“Let me talk with him. Then let’s talk with the kitchen and administration.” I talked to Mr. Lessman; the nutritionist talked with the kitchen; Erica talked with administration. As usual, Erica was exactly right, mostly because she had worked much of the weekend, although she wasn’t scheduled to do so. Without giving lots of details, Erica let us know that Mr. Lessman had quite a few of these personality quirks. And he had a long story to tell about his personal situation. He also had a notebook full of questions. And all of it fit together, in the way individual lives do, full of personal nuance, touched with tragedy, and played out over a lifetime to reach this point. A full life, lived fully. Learning about such lives is one of the joys of geriatrics. It’s also essential to helping patients improve.

As Erica tells it, Mr. Lessman “is one of the patients that’s dear to my heart. His appetite is extremely poor due to his diagnosis, but by sitting by his side, communicating with him, and encouraging him not to give up, it has made a tremendous change. The smallest acts of kindness can mean so much. … He has now started to consume more food, his appetite has increased, and he has gained weight. He has become a lot stronger.”

Which he has. We give him grilled cheese sandwiches all day long. He takes meticulous notes in his notebook, and he asks me questions each week. We have helped him straighten out his finances, and he has decided to stay at the facility long-term. We provide him transportation to his oncology appointments. And Erica makes sure everything is taken care of.

——————–

A few weeks later, Mr. Lessman returned to our Friday clinic is see the oncologist. I heard about it from my colleague, who came into the workroom, laughing and carrying on.

“Hey, Mr. Lessman is back. He looks fantastic! We’re going to treat him!”

“Great!” I said. “I thought he was a goner. You did a great job with him.”

“Not really me. The people in the facility are responsible, especially our nurse, Erica.”

“You know what?” My oncology colleague was laughing.

“What?” “Geriatrics saved his life!” More who-would-have-believed-it laughter.

I never thought I’d hear that phrase, especially coming from the mouth of an oncologist.

————————-

I’ll give Erica the final word: “This warms my heart; this is what nursing is about. Healing the sick and making the weak stronger physically, emotionally, mentally, and spiritually. This is what our program’s about. To have such dedicated physicians to care for our patients is unknown in our community. Our patients deserve better, and this program is a great start.”

This essay won the John A Hartford Foundation‘s “Heroes in Geriatric Care” essay contest in 2013. 

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Husbands of happy and more-educated wives are more likely to get a colonoscopy

Science Life

Dale scope 2 William Dale, MD, PhD, Chief of the Section of Geriatrics & Palliative Medicine, associate professor of medicine, and director of the SOCARE Clinic (Robert Kozloff/The University of Chicago)

If your wife says she loves you…check it out

A national study involving 804 couples found that married men over age 55 were almost 20 percent more likely to have had a screening colonoscopy in the previous five years than men who were not married. Men married to women who are happier with the marital relationship were nearly 30 percent more likely. That rises to more than 40 percent if their wives were highly educated.

For women, however, being married, happily or otherwise, made no significant difference compared with unmarried women. Neither the relationship happiness nor education levels of their husbands appeared to change colonoscopy rates for wives.

“Women are thought to control the health capital in most households,” explained study director

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Trumping the Second City

I usually love living in Chicago — a vibrant place full of character. Today, the private satisfaction of living here was scarred by the public embarrassment of being here.

I worked very hard in my SOCARE clinic today, seeing a variety of people from across the spectrum of patients we typically see: African Americans from the inner city south side, rural whites from nothern Indiana, and University of Chicago ex-faculty from Hyde Park. A colleague was out, but his patients were mistakenly scheduled, so I saw some of them on his behalf, doing my best to be helpful. Worked with the usual mix of co-workers from a potpourri of backgrounds, working harmoniously to deliver high-quality care under difficult cirsumstances. I honestly have no idea what anyone’s political views are, only a shared sense of mission against a common foe — cancer and the challenges of aging.

The workday ended long after everyone else had left, sharing a pleasant conversation with an oncology colleague, after a joint-consultation with a dying patient, both of us exhausted from a volatile mix of seeing too many patients, satisfied with having given our best efforts, and frustrated with the amount of work ahead of us over the weekend. Emotionally spent, but alive with the effort. 

On the way home, the forgotten trauma of politics in a city rich in such history, emerged through my car radio. This evening at UIC, a Trump rally was scheduled, a counter-protest was launched, the event was cancelled, and the police had to break it up. I dislike the behavior of everyone who feel hate and violence are a good answer to political differences, and I’m a little embarrassed for our city displaying this silliness. Rally, protest, or whatever you’d like, but don’t be hooligans.

Driving sadly through the south side to the athletic club where my boys are doing gymnastics, forcing my exhausted mind and body through a modest workout while watching my city’s worst side splashed across TV screens on the wall, displaying its bottom to the world, Trump’s face plastered everywhere, angry faces yelling all around, I felt annoyed.  Switching to my Twitter and FB feeds, I found they contained far too much contentless support for one side or the other, invective flung with little thought, emotions bubbling over at the evilness of Others, increasing my sadness for Chicago.

I truly wish people would spend more time trying to make the world a better place through their own efforts, rather than tearing down some other part, and ignoring the mocking Fool at the center of it all.

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Star Wars: The Force Awakens (Sort of)

“That’s not how The Force works!”  Han Solo to Finn, Episode VII

I saw the new Star Wars movie today. While a significant improvement on Episodes I -III, it still didn’t rise to the level of the original episodes IV – VI. It captured a bit of the original spirit, including the cheeky interplay between the original band of reluctant rebels. I didn’t find the hearkening back heavy-handed, although some did, with charming re-introductions of Leia, Han, and Chewy. The new droid, BB-8, deserves the attention he’s getting — the R2D2 for a new generation.

JJ Abrams is at his best with the action sequences, the tongue-in-cheek repartee, and the droid humanization. The newcomers Rey and Finn, are well done by Daisy Ridley and John Boyega. The story line with Finn’s struggles to move on from Stormtrooper life is a nice addition to the saga.

My biggest complaint, besides the comical Emperor, is the way the underlying “philosophy” of the Force is handled. Without giving away too much, its coherence as a combination philosophy, religion, training-method, and mentored ability isn’t consistently upheld. Abrams et al. don’t seem to grasp the essence of the thing, so it doesn’t hold together, in a distracting way. It leaves the plot lines dangling, too-often bringing the viewer out of the action, to wonder about how it fits together, and losing connection with the characters. The whole thing comes across overly hollow. I was fully with Han when he yells at Finn, “That’s not how The Force works.”

My kids (12, 9, 9), action movie gurus already, thought it was “good”, and they were intrigued enough to want to watch some of the originals.  And my oldest son can now apparently do this.

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A Doctor’s “Creed” – A Medical Review  

Creed

“I’ll fight, if you fight.”  Adonis Creed, to Rocky Balboa.

“First, do no harm.”  Hippocrates.

————————-

History of the Present Movie

The newest addition to the “Rocky” franchise, Creed, has gathered critical commendation as the best entry in years.  Like many of my generation, I was a convert to the original Rocky (1977), rooting for the workingman’s underdog from Philly against the Hollywood champ, Apollo Creed.  I delighted in the moral victory earned for completing the fight, despite the official loss on the judge’s score cards.  I absorbed all the iconic scenes: running up the courthouse stairs, chasing a chicken around the yard, and punching the slabs of beef.    Like many, I followed Rocky Balboa’s transformation over the years, holding my nose at his transformation into a cultural icon and buffoon-like superhero.  Even as future medical student, the horrific violence that was at the center of the storyline never troubled me.

It was with some trepidation, then, that I let my 12-year old son talk me into seeing this newest entry.  It was his preference over that other movie-saga of my youth, Star Wars.  But I had heard good reviews, including from a social worker colleague and an overheard locker-room comment that Stallone was a candidate for an Oscar for his role, a nomination which would be his first since Rocky.  The nuanced updating of Rocky as a mentor to Apollo’s kid promised a breath of fresh air into the storyline.  “Fine,” I thought, I’ll give it a try.”

 Review of Symptoms (No Spoilers)

The critics are right – it is the best Rocky movie since the original.  It is an inspiring story on two related fronts: the importance of pursuing your own vision while owning one’s past.  These themes play out in both main characters, Adonis and Rocky.  Over the course of the movie, each avoids owning their past, leading to difficulties in dealing with the present.  Conflicts arise, especially between the two, as the past threatens the future. As the climactic fight sequence arrives, both slowly own their past, and that emotional catharsis clears the field for moving into the future.  While predictable, the understated dialogue and tough-love demeanor make it work.  And then the overstated punches get thrown.

The director faces a similar challenge, trying to advance the new themes, while echoing the past,without descending into a cheesy reproduction.   The allusions to the private Rocky vs Apollo “third fight” that freeze-frames to end the second film is a nice touch – didn’t you really want to know who won the deciding match?   An appearance of the actual Rocky Balboa statue, with photographing tourists, is a perfect touch.  The re-ascent of the Courthouse stairs is imagined with a deft nostalgic touch.   Overall, the call-backs work, fitting smoothly into the narrative flow.rocky1

One bit of nostalgia doesn’t quite fit: I’m not sure Stallone’s performance is Oscar-worthy.  His genuine skill as an actor shakes off decades of shlock, a surprising butterfly, perhaps with crippled wings, emerging from its shell.  His understated charm works as an older man passing on the torch of fame.  One roots for the character and the actor to pull it off, and it really happens.  The buzz for awards is a consequence from the low expectations he’s set over the years.  But ultimately, this is Stallone as Rocky, a near-enough match to credit too much to acting brilliance.  It’s a ultimately a bit sad to see Stallone, the genuine actor, whose been lost over the years to the action-hero automaton.

 Medical Decision Making (Spoiler Alert)

My biggest problem with the movie was from a medical perspective.  A number of issues distracted me from the storyline, and they stemmed from the lousy doctoring, bad medicine, and questionable morality.

  1. First, Do No Harm — Cancer is featured as a significant part of the storyline. After a sparring session in which Rocky ends by vomiting and passing out, he is hospitalized. Following a hospitalization, he returns to the doctor’s office to find out he has non-Hodgkin’s lymphoma, a type of cancer of lymph nodes.  He is told by the doctor that he needs surgery and chemotherapy.  He refuses to consider treatment, saying that he saw his wife Adrian go through that, and “it didn’t go so well.”  He asks the flabbergasted doctor to keep this private.  She apparently agrees to do so, but gives him some pamphlets to read.  He sticks them in his pocket and heads out.  Most of the scene plays out with both parties standing up, rather than sitting for a heart-to-heart conversation.
  • So many things bothered me about this scene: the doctor’s paternalistic approach to the care, the blunt delivering of a life-threatening diagnosis, and the heavy-handed insistence on treatment without further discussion.  What about shared decision making?  What about asking about the patient’s experience?   When the patient says he had a prior “bad experience” with his wife, aren’t you going to explore this?  I was applauding internally when Rocky walked out the door, until I realized HE was supposed to the one acting inappropriately.
  • Ok, I admit that it’s a movie, that nobody wants to observe a 15 minute shared-decision-making conversation, and the plot needs to move along.  I also understand that doctor’s sometimes, perhaps often, act in this heavy-handed way, as Amy Berman has so eloquently taught us.  But I was appalled to see this portrayed so clumsily in a movie for mass consumption.  It feeds into the perception that cancer is a death-sentence, that heavy-doses of chemotherapy is the only way to cure the disease, and anyone thinking otherwise is misguided as best and foolish at worst.  This is a dangerous perception, with each element of the above containing falsehoods.
  1. The “War against Cancer” – A primary storyline for the movie is that Rocky’s legendary hardheadedness is at fault for his decision-making about cancer – that he is “giving up” by refusing to undergo chemotherapy. Adonis threatens not to fight in the championship bout unless Rocky “fights” against his cancer – i.e. he chooses to get accept chemo. Stemming back to the “War on Cancer”, we have continued to propagate the imagery of “fighting” or “battling” against an enemy, with the image of “giving up” or “quitting” on the other side of the ledger.  Given an opportunity to use Rocky’s cancer diagnosis as a metaphor for wisdom, understanding, and communication, the film falls into the same cultural trap of a war.
  1. Head trauma – Who can forget Rocky, in the midst of being pummeled by Apollo, his eyes swollen shut, telling his trainer to “cut me, Micky” – to cut his eyelids so he can see? The dramatic scene is a consequence of all the head trauma from the fight. One of the themes of Creed is that Apollo DIED from being punched in the head, which is why Adonis’s step-mother won’t let him fight.  One of the least believable parts of the movie, frankly, is that Rocky has lived long enough to get cancer, rather than suffering from Traumatic Brain Injury from repeated concussions.
  • The film doesn’t shy away from illustrating the damage occurring.  In the final dramatic scene, Adonis is knocked cold, blood flying, (with significant screaming from a woman in our theater) – only to literally spring up from the mat to finish the fight.  With his formerly anti-violence step-mother at home cheering him on, he finishes the fight, eyes swollen shut and massive bruising on his face (and presumably to his brain).  It was difficult to walk out of the theater, directly past the marquee for the movie Concussion, and not reflect on the glorification of head trauma we had just witnessed.

Thankfully, after the movie, I asked my son what he thought about boxing, and he said, “I’ll stick with gymnastics.”

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Micro Review: The Crossing

Just finished the latest from Michael Connelly, The Crossing, adding it to my bookshelf that contains every one of his novels in hardback. He is the most consistently high-quality hard-core detective-thriller novelist alive, and belongs in the all-time top 10.

He has a unique ability to combine a logically-rigorous plot with a consistency of purpose in his characters. Much like the experience of the best magicians, one never notices the sleight of hand that guides the action, even when one is looking for it. His lead character, Harry Bosch, combines a hardened righteousness for justice with a deep humanity for the most vulnerable that ultimately wins the day. One deft touch in this book is the vulnerability Harry displays as a single-parent, trying to reach out to his teen-aged daughter, while struggling with his own confusion about her inner life.

For those looking for a last minute gift, or for someone receiving the right gift card, I highly recommend this, or any other, of his novels.

 

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Chicago Sadness

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I’ve been trying to figure out how I’m “supposed” to feel over the past 24 hours.  I spent the day away from my office in Hyde Park in response to a credible threat of “gun violence” reported to the University of Chicago by the FBI.

As it turned out, the person posting the threat online was a student at the University of Illinois in Chicago.  The threat was a response to the recent horrific shooting of a young African American man by a Chicago police officer.  The officer shot the young man 16 times, and this was captured on video; the video was released to the public recently, in conjunction with a murder charge against the officer.

One of the specifics of the student’s threat was to kill “white male students and/or staff”.  Which meant, had I gone to work, I would have been a prime target, had the threat been real and gone unnoticed. There is a reasonable chance I would have been walking across campus at the 10am time given.

One emotion I don’t feel is anger.  I keep searching my mind for such feelings toward someone who, knowing nothing about me, would put me in a category based on nothing by my gender and skin color, then decide that it might be reasonable to kill me.  Sorry, it’s just not there.

What I primarily feel is sadness.  Sadness for Laquan McDonald’s family for his unnecessary death; sadness for the violence in my city that sometimes seems unending; sadness for the fear this all generates for decent people; and even sadness for the young man who felt compelled to post, just for a moment, his rage at the world that seems stacked against him.  Realizing, that for his anguished moment of misplaced judgement, he now faces the possibility of 5 years in jail – and the agony his mother must feel for him.  May fate spare me anything similar.

One of the joys of working at the University of Chicago as a physician is all the interesting people from every imaginable background that I am privileged to meet, work with, care for, and get to know.  Mostly, I’m thankful to be taking care of people, often with deadly diseases, too often near the end of their lives.  Last week, I spent much of my Thanksgiving holiday talking with people in pain and distress about the rapidly approach end of their lives.  All of which made me thankful for the opportunity to do so and still be healthy enough to help.

I spent the unexpected day away from work with my family, a rare weekday to enjoy them.  I helped the kids with their schoolwork (they are in a unique Chicago school program which has them working “virtually” many days), took them to their gymnastics practice, and took a walk through our south side neighborhood.  My 12-year old son asked me why I didn’t go to work, and I tried my best to explain honestly what was happening.  He asked some appropriate questions, which I answered, again as honestly as possible.  He accepted this, openly, and moved on with life.  It seemed surreal – to have an extra day enjoying time with my kids as a consequence of other, slightly older kids enduring life’s awfulness, mostly due a societal inability to deal with differences between people due to the color of their skin.  All of this turned my sadness into a sort of variegated melancholy – an amalgam of sadness about the world we live in, satisfaction in keeping the violent ugliness out of my kids’ lives a little longer, and the difficult realization that I don’t really know how to control either one.

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