Being Mortal

We were barely on time to the assisted living home – arriving at the wrong entrance had not helped – and the rest of our class was already seated in what looked like a private dining room. As far as all of the facilities for seniors I’d seen so far, this was certainly a beautiful place, with quaint but sturdy furniture, and wood paneling that added warmth and a bed and breakfast feel. Fourteen of my fellow first year medical students and I would be performing “Falls Assessments” in pairs to asses each resident’s risk of falling. It was part of our school’s Practice of Medicine course; we had already gone over Falls Assessments in lecture and practiced in our small group sessions with standardized patients (actors pretending to be patients), or, as we called them, SPs.

“Everyone’s here then!” said the very cheerful director, who was going to brief us before we met the residents. The director shut the door and joined us at the table while I pulled out my notepad, ready to take notes. It was my OLDCARTS notebook, (OLDCARTS stands for Onset, Location, Duration, Character, Aggravating Factors, Relieving Factors, Timing and Severity) used to take notes during histories but I had a few pages in the back for additional facts. I like using it for all my clinical notes, mostly for consolidation, but also because it helps to review tips before meeting patients. I’d painstakingly sectioned each page from “CC” (chief complaint) to “PE” (physical exam). I’d added a tiny asterisk to remind myself to ask the patient what he or she thought the problem was. A family medicine attending had told me, “If you don’t know what your patient is concerned about, you’ll never know if you actually addressed those concerns.”

Today, although there would be no specific chief complaint, my partner and I would be taking a full history, including, but not limited to, past medical history, surgical history, social history, family history, medications and allergies. The director gave us a list for our patient’s medications since our patient was 92 years old and the rather extensive list would have been hard and stressful for the patient to remember. It was best for everyone that it was provided to us ahead of time. Taking multiple medications was on our list of risk factors for a fall. I made a mental note to add that to my write-up. We otherwise went through the paces of the history, taking turns with different sections, and completing the “Get Up & Go” test to measure mobility.

My time with our patient was somewhat like meeting a distant relative, in that there was a degree of comfort in the encounter, but still that ever present reminder to remain on your best behavior. There was a moment when we bonded over the books stacked nearby that sparked shared excitement that was purely human. It felt different from working with standardized patients, who will sometimes join in on a short digression, but there is always that feeling that it’s a perfectly orchestrated show. And there’s the added pressure of knowing we’ll be evaluated by our SPs, following the interview.

In all, the encounter was very straightforward and, of course, our patient was nice, enjoyed reading, playing cards and seeing family that came by frequently. The same family – with the help of the staff at the home – who took care of most, if not all, of the “Instrumental Activities of Daily Living,” including shopping, housekeeping, finances, transportation and a few others. And not – per our patient – because these tasks were difficult to complete, but rather just because the family seemed much more comfortable doing them. It reminded me of a book by Atul Gawande, “Being Mortal,” where he talks about the process of getting old and how society views it, how we handle the elderly, and how the emphasis really was on “handle.” I wondered how much our patient really was capable of doing, but wasn’t allowed. I wondered what life in the home, which had seemed so cozy when we arrived, must be like without independence. A problem with nursing homes and assisted living homes, Gawande had mentioned, was that the goals of the home and the resident were not necessarily the same. When one might place the greatest weight on safety – a worthy goal certainly – the latter may value autonomy more.

Our patient certainly seemed to enjoy the minor independences the home allowed, which were mostly only those that involved personal care. Our patient also enjoyed card games – unfortunately not an activity most of the other residents shared an interest in. That was the only complaint we got, when I had gotten to the end of my history and had asked what else we should know before moving ahead with the assessment. Well that, and the fact that the walker our resident used was mostly at the insistence of the family.

Perhaps it was the bonding over the books, which took just a few minutes, but there was an air of confidence-sharing in this revelation. It was almost like when an SP broke character to reveal an important hint, before slipping back into his or her role. However, unlike with an SP, I could do very little about the situation and could only nod understandingly, with this newfound knowledge. Our training in class simply provided for an understanding of the basics of a Falls Assessment, not the subtleties of an adult grappling with a loss of sovereignty. The room was uncluttered, there were no loose rugs, the patient appears steady while walking, the patient has not had any falls recently, I noted. I would add the patient’s medications with respective symptoms and that would accomplish the goals of the experience. A digression into the lack of card playing residents, would not. And neither would an observation on how perhaps our resident was capable of accomplishing more activities than currently allowed.

Gawande explains that with all faculties being equal, what we value as individuals and our perspectives on what’s important changes with age. It seemed to me, that what stays the same is how little we, as individuals, and certainly as healthcare providers, explore what others find important. Of course this is often difficult to ask and perhaps even more so to act on. And now, as a student, I see that even with knowing, there was too little I could do with the knowledge. Particularly when the system is set up with the focus on safety, the watchword we had learned from day one. However, there can be a great difference between what seems right to us from a healthcare perspective, and what’s important to the patient. Except that we are supposed to be on the side of the patient, too. It’s why that family medicine attending asks his patients what they think is wrong. It’s because care is only successful when we share the goals of the patient. It’s because we are only mortal and can so easily forget that.