A Warning Regarding Future ‘Medical Homes’
Winakur J; Caring for the Ages; January 2011

Way back when, I was trained as an over-all internist, a pathologist. I recall that the surgeons described us as “fleas” simply because, by their own estimation, all we did seemed to be buzz around and suck blood from those within our charge, dithering as we evaluated listings of differential diagnoses, monitoring our boring trade in annual physicals, flu shots, mammograms, prostate checks, and on and on. Surgeons are tigers. Internists are fleas.

These days, virtually no medical students (loaded down with debt) desire anything regarding outpatient-based primary care – specifically of the seniors. In a period of growing demand, only 2% of physicians in their residency training espouse any kind of interest in geriatric medicine. Even worse, the number of students choosing to enter primary care medicine has declined by 50% in only the previous few years.

Yet the catchphrase today is the “patient-centered medical residence.” Every patient requires a place where the “provider-patient” relationship is valued, where advocacy on behalf of individuals and loved ones by those plugged into the system is fully necessary. This idea isn't fresh to me or to those who assist me: Our office has been a “medical home” for no less than 3 decades.

Here is what I have done with my life in medicine: shepherded several thousand multigenerational, coordinated families and friends through their coughs as well as colds and their heart attacks and cancers; untangled medical dilemmas; loaned an ear to people needing one during life's tragedies and disappointments; contended on the part of numerous with insurance companies, hospitals, government bureaucracies, and even colleagues apathetic to the problems they might trigger when they market their procedural wares.

A maturing internist-geriatrician, I see myself now ministering to legions within their seventies and eighties and past. Nowadays I am pondering more than merely sickness and disease. Of course, I wish to make the best diagnosis and designate the correct treatment. But the practice of geriatric medicine demands a lot more: tolerance, thoughtfulness, and judgment.

I am much more worried than ever with the ecology of my patients' lifestyles: Is she residing alone since her husband has died? Is she eating correctly? For all those within my charge, I'm trying to sustain freedom, quality lifestyle, as well as the capability to carry onthctivities of t most of us take for granted. And find myself personally becoming more and more vociferous on my patients'their behalf. The flea finds their self always facing down the tigers.

Last night I went to two rosaries. Mr. Isom and his wife have been my patients for more than twenty years. I had admitted him numerous times for his cardiovascular disease, recurrent bowel obstructions, blood clots, joint surgeries, and so on. He'd experienced persistent pain for many years; I turned to narcotic analgesia, and it kept him going and at home.

He was seventy five, fragile, and fatigued, and his belly had blown up once again, this time from a perforated ulcer. He had a cardiac arrest and was on a respirator. The surgeon had been waiting inside the wings. I sat down with Mrs. Isom and also her son. No, we opted together. It was time to let him go.

Mr. Davids was 86 years old. He and his wife had been coming to me for 3 decades but then moved a hundred and fifty miles away. A month back, I visited the Davids and we decided on dinner together.

Though he was slowing, he enjoyed his existence every day. He was even now doing a bit of consulting work Within a couple weeks of our visit, he suffered from a seizure and wound up in a different hospital in a city faraway from me. He ended up being diagnosed with a large cancerous brain tumor, The relatives called me. Whater all of the proper discussions and opinions, we determined hospice care. Mr. Davids died with his family by his side, his wife's hand in his.

Every single American should get a medical home with somebody educated, skilled, and wise in attendance when ever the time arrives. Long before it comes. But it is one matter to advertise the patient-centered medical home, as “health reform” wholeheartedly yet somewhat vaguely does, and something else to make it real.

I believe that due to the fact I am a flea, I've always practiced within the methodical method that provides my clients a medical home. That is not to say I'm perfect. My failures still ghost me. Dr. William Osler, the renowned attending internist at Johns Hopkins in the late 19th and early twentieth centuries, annce wrote: “The good physician cures the sickness; the fantastic physician treats the patient who has the disease.”

I've come to learn that “to attend” means not just showing up for hospital rounds or seeing one's patients every single day until a diagnosis is reached or a course of treatment takes effect. It's not simply coming to the office every day to resolve this issue or that for patients who've become aged friends. Or making the month to month nursing home rounds or house visits or answering the frightened phone calls.

“To attend” is always to listen, to weigh, to shoulder, to cajole, to aide, to advocate, to worry, to curate, to wait, and lastly to mourn.

If healthcare is really to be reformed within this country, it must build structures which will provide the supportive environment required to “hold” – as the pioneering psychoanalyst Donald Winnicott conceptualized the term at the start of the 20th century – our clients and their families through the hardest times during their life.

Several real-world structures for this task do exist and are supposedly operating well – so the literature says. But I wish to see versions that will work all over the broad socioeconomic range of America. I wish to see models in which devoted primary care practitioners, be they geriatricians or pediatricians, can once more hold their heads high as they curate to their sufferers. I want to be able to urge my colleagues as well as my pupils to welcome these new paradigms. I'd like to see the fleas once more in ascendance in American medicine.

Sadly, given the state of primary care nowadays – after previously being brought to its knees by procedure-oriented mhysicians,; ill-conceived compensation formulas, money grubbing insurance companies, and even our own medical schools – the dilemma now is, Who'll be there to answer when you knock on the door of your medical residence?




“Under the care of Leo J. Borrell, M.D. since December 2001, I have seen a remarkable improvement in my mother’s condition. She is responding dramatically to the new regiment Dr. Borrell has prescribed”

- Beth Rose


Feb 3, 2008

The Interdisciplinary Team; The Role of the Psychiatrist

by Dr. Leo J. Borrell, featured in Assisted Living Consult for November/December 2006. A HealthCom Media Publication