There are 2.7 million adults over the age of 60 in Illinois, who make up about 21.9 percent of the current population. Per U.S. Census projection, the percentage of adults over 60 in Illinois is expected to grow from 17.4 in 2012 to 22.3 by 2030. Currently, there are 4,545 family physicians and 227 geriatricians in Illinois. With this growth, the panel of older adults in most primary care settings is likely to grow more in future. The growth in the older adult population provides a wonderful opportunity for both primary care providers and providers with added qualification in geriatric medicine to enhance our roles in serving our community better. Dr. Ng, MD and Ms. Nwokorie, MBA are IAFP Public Health externs working with the Geriatrics Member Interest Group, interviewed IAFP Life members and MIG members to document their stories and experiences with caring for older adults.

Lee Sacks, MD
Mayuri Dasari, MD
Raymond Weber, MD 
Robert Buckley, MD
Sheron Brown, MD 
William Hulesch, MD 
Wayne Carlson, MD 

“Every aspiring physician whether a current medical student or in residency should become a care manager”
Lee Sacks J. Sacks, MD, FAAFP

Dr. Lee Sacks is an IAFP past president who completed his residency at Advocate Lutheran General Hospital in Park Ridge. He practiced in the northwest suburbs of Chicago for 13 years after that. His leadership journey began when he became the Medical Director of a physician-hospital organization. He held executive positions at Lutheran General Health System and played a key role when it merged with Evangelical Health Systems Corporation to become Advocate Health Care in 1995. He then organized and led Advocate Physicians Partners, one of the nation’s largest accountable care organizations, where he served as Chief Medical Officer of Advocate Health Care for 21 years until he retired in 2018. Dr. Sacks served the Academy as an IAFP Board Member, Delegate to the American Academy of Family Physicians, and chaired AAFP commissions on healthcare services.

As a practicing physician, Dr. Sacks cared for patients from newborn to the end of life, but did not include obstetrics. One of his partners, Dr. John Sage (IAFP’s 2002 Family Physician of the Year), was co-founder and director of the Rainbow Hospice and Palliative Care in Mount Prospect Illinois, so he was able to cover for him and got early experience in hospice care. Dr. Sacks also provided care to patients in skilled nursing facilities once a month, and also made house calls for patients who were not able to come to his clinic.

The care of the elderly is complex compared to younger patient groups. Dr. Sacks noted that during his leadership duties that they started to do “deliberate planning that  geriatrics required with a special focus on functional status”. Much of Dr. Sacks practice career pre-dated the Americans with Disabilities Act of 1990, so there were no standards or guidelines to follow. For example, handicapped accessible bathrooms were not required nor common in the office. Dr. Sacks states that “Nowadays, you have to make sure you are paying attention to their needs for their senses; come to appreciate that dental care, vision care, and hearing probably trumps blood pressure” in terms of an older person’s ability to interact and enjoy a satisfactory life.

During his time in practice, geriatrics was still an evolving field. When asked when he felt a geriatrician should be consulted, Dr. Sacks mentioned it is used for more assistance such as providing support services for the patient and/or a spouse or a family member caregiver. He also stated geriatricians should be consulted for evaluations of degenerative or cognitive functions that are more complex. Evidently, the hardest part for Dr. Sacks about taking care of the elderly population is when you have to deal with a bad prognosis or outcome, because these patients you have seen for such a long time, and you get attached emotionally to them.

He recalled a patient in his practice who was an elementary school teacher with Sickle Cell Disease, which during the 1980s was not a common condition seen in his suburban practice. He diagnosed another woman with a cardiac defect, where a valve replacement was needed. Back then, cardiac surgery was still fairly risky and not as common as today. With a great team at his hospital, she ended up doing extremely well.

Dr. Sacks noted older adults have many hidden delights, such as abundant gratitude and the gifts he received for taking care of the patients. “I took care of one family and the wife passed away due to a cancer malignancy. The family gave me a tiny hand woven rug they got from a trip in Asia. Every time I look at that in my house, it reminds me of the gratitude and the impact I had in taking care of that patient."

During the late 1970s, there was an influx of evacuees from Vietnam. Some of the local churches were settling Vietnamese refugees and they needed health care. The residency program at the hospital (Lutheran General) offered to take care of these refugees. “Some of these Vietnamese families I took care of then, and afterwards welcomed them into my practice and watched them grow up and become successful members of the community.”
 
When Dr. Sacks served as IAFP President from 1988-1989, he noted the geriatric population was not well served at that time, but that geriatric fellowships were just starting to be developed. During his time in practice, he did not pursue a geriatrics fellowship as he did not want to limit his practice at that time, but appreciated that family medicine would intrinsically adapt with our growing population. “More are coming to the conclusion that family medicine will span the depth and breadth of the population, there will be more subsets with it, and we have to be geared towards being able to provide specifically for the geriatric population. For example, you need to have support staff that are trained in seeing the geriatric population, have wellness exams geared towards them, or having an office where you are able to provide materials in larger print.”

With our growing older adult population and prolonged longevity, many advances have helped our elderly patients to age well. Dr. Sacks believes that the creation of Medicare, followed by the prescription drug coverage helped more people with access to expensive medications. The ADA act of 1990 also led to improved facilities and safer access for the elderly. He also noted our growing understanding of exercise and nutrition as vital to improving the longevity of patients.

Dr. Sacks became a care manager for his mother-in-law while she was living in an assisted living facility until she passed away three years ago at the age of 99. His own mother passed away at age 96 in the summer of 2020 from COVID-19 while under hospice care. “I learned a lot more about the field of geriatrics and also problems that continue to arise within the health care system when I was taking care of my two mothers from a distance,” he shared. “Every aspiring physician whether a current medical student or resident should become a care manager.” Those words resonated with both Dr. Ng and Ms. Nwokorie who are planning to pursue this pathway in becoming a geriatrician.

When his mother passed away from COVID-19, Dr. Sacks talked about the barriers created by the pandemic. “Our government failed us and we were not prepared; there was not enough personal protective equipment, not enough testing, and too slow to do things. There were so many mixed messages.” Dr. Sacks also noted that telemedicine became an integral tool in many practices; but it was not always accessible for patients. Furthermore, physician burnout was also tied to the limits of video visits, as many physicians were eager to provide in-person care again.

Dr. Sacks also suggests that we will be living with COVID to some extent for a long time, and that vaccinations will be an annual ritual like influenza. He is also somewhat shocked that none of the healthcare systems are mandating COVID-19 vaccinations for staff. During his time as Chief Medical Officer, he led the system to mandate flu vaccines. He advocated for the pertussis vaccine for newborns. Recently, his wife had a healthcare encounter and asked the medical assistants at that time if they were vaccinated, which they were not, by their choice.  “Most patients coming to your office would expect all healthcare professionals to be vaccinated,” says Dr. Sacks. “We need an organization to step up with this mandate COVID-19 vaccination; once a group is successful, everyone will probably follow suit afterwards.”

Our interview concluded with some final comments for future medical students and residents interested in pursuing family medicine and geriatrics. Dr. Sacks suggests that anyone in their fourth year of medical school find a clerkship with a good role model family doctor to experience what life is like. Practice your communication skills and understanding of patients and what they want. Dr. Sacks stated that it is not so much the knowledge, but your interaction and empathy with patients. “In geriatrics, it is understanding what is important to the patient and a lot of the times, it is not what you would think or as a physician, what you would rank as the most important. If you can help them deal with that, they do better.”

Mayuri Dasari, MD

Dr. Mayuri Dasari specializes in family medicine and geriatric medicine. She currently works as Center Medical Director at Oak Street Health providing primary care for adults, especially in an underserved population in East Garfield Park in Chicago. Dr. Dasari’s interest in geriatrics first started when she completed her clinical core clerkship at the Veterans Association Clinic during her second year of medical school. She enjoyed helping out, and listening to their stories, noting that the geriatric population is unique to care for. She states “getting to know them more helps you understand how to meet them where they are, and help them work through their chronic conditions, such as things they were neglecting or things they are good at taking care of. This really helped me learn a lot of geriatrics, and being there I got exposed to palliative care in the hospice unit”

With this rotation setting her foundation into pursuing geriatrics, Dr. Dasari completed her family medicine residency at Cook County-Loyola-Provident Family medicine Residency Program. Dr. Dasari’s residency training included working in a primary care clinic in the Englewood neighborhood of South Chicago, which was heavily populated with patients in Medicare who needed a primary care physician to listen to them and take care of them. She continued on her path to work with the older adult population, and completed a one year geriatrics fellowship at Rush University Medical Center. Dr. Dasari has been a geriatrician for almost seven years now, and at Oak Street Health for the last three and a half years.

Dr. Dasari also provides care for younger patients, so sometimes when she introduces herself as a geriatrician, she would explain to them that “I am a primary care physician, but my primary focus is a subset of the population of the community which are patients that are older than 65.” Her clinical practice at Oak Street Health does have patients under 65 because under the dual-eligible Medicare and Medicaid system.

Dr. Dasari describes the many hidden delights in taking care of geriatric patients ranging from listening to their stories, particularly their background, social history, and their upbringing that you would have never known simply from a health history. She states her role as “wholesome” because it is a complete experience for the patient and taking care of their medical aspects and social needs. "Everything kind of factors into taking care of the older adult, from waking up in the morning into the rest of the day, everything plays a role.” Dr. Dasari also described how her geriatric medicine training allowed her to have goals of care conversations, and how important it is for patients, at any given time. She states “it should be an ongoing conversation and you usually do not experience elaborate training in having these conversations during residency.”

Although there are many rewards as a geriatrician, Dr. Dasari also pointed out the challenges with her role. Some of the challenges include needing a reliable caregiver for a patient. “You might need someone to come with them to the clinic, speak for them, maybe they have dementia, or they might be a poor historian due to some other underlying condition.”  These were some of the challenges with pre-appointment work. “It is not challenging once it becomes familiar and incorporated into your daily routine. Without gathering all the pertinent information and not addressing the hidden gaps, that can lead to more interruptions in patient care.”

Dr. Dasari’s practice at Oak Street Health also faced challenges when the COVID-19 pandemic began in March 2020, especially for their senior population. During this time, a lot of social connection between her patients was lost. Many of her patients did not have video capability to complete video conferencing or telemedicine calls. Although Oak Street Health was able to switch to a telemedicine platform quickly, she felt her patients suffered from lack of contact since having a phone conversation is not the same as seeing a patient in person.

Oak Street Health provided a community center where seniors can hang out with their friends and socialize, have coffee together, browse on the internet, and participate in community events. When her patients missed out on those social gatherings, their mental health was extremely affected. She noted that she had diagnosed more patients with major depressive disorder during the pandemic.

Despite the challenges, her advice for medical students and residents interested in pursuing the field of geriatrics is to keep an open mind and explore as many opportunities as possible. She recommends pursuing a fellowship in Geriatrics if possible. “I learned so much during my fellowship, for example, creatinine clearance plays an important role in elderly patients when it comes to adjusting medication dosage. You get to explore different topics in geriatrics including decisional capacity in the setting of Dementia. When a patient lacks the ability to make complex medical decisions, they often require social support and need a POA (power of attorney) to take over. Fellowship training allows the additional time you need to focus on these skill sets.”

Raymond Weber, M.D.

Dr. Raymond Weber retired as of January 2020 after practicing for 41 years. He earned his medical degree from the University of Illinois College of Medicine in Rockford and completed his family medicine residency at Mercy Hospital in St. Louis (formerly known as St. John’s Mercy Medical Center). He then returned to his hometown of Glen Carbon, Illinois, to begin his medical practice in 1979. Dr. Weber served in the Illinois Academy of Family Physicians as a member of the board and later as President of the Academy from 1992-1993 and a delegate to AAFP Congress. “If you do anything in your career, be active in the Academy,” he suggests.

His rural suburban area boasted about 15,000 people when Dr. Weber began his practice. Many of his patients were elderly farmers, which Dr. Weber described as “really interesting people.” Stepping back into this familiar territory, he knew many of his patients particularly well. He became the primary care physician for many people he knew growing up from peers, and also their parents, of course. One of his patients was the mother of one of his best friends from childhood, and he found it quite interesting that she was willing to trust him with her healthcare.

Dr. Weber’s practice was full family spectrum care. At the beginning of his practice, he was delivering babies and assisting in surgeries. Young Dr. Weber ended up with most of these new young patients as part of his panel. Dr. Weber described this experience as “the practice grew old with me.” He had the privilege of taking care of multiple generations of a family - the most he had was five generations at one time! Most of the seniors in his care were moving in with one of their children. As health care delivery changed in the 1980s and 1990s, more older adults were moved into nursing homes, which also changed the care provided. “Nursing homes provided very marginal care. Many of the caretakers at the nursing home were very good people and cared deeply for them. However, they were understaffed and under-equipped. Today, many nursing homes are improved but are still not the most optimal. I had to rely on many systems that were not ideal.”

How is the care of older adults different?
As their primary care physician, it is very important to listen. “You have to get them to open up. The best way is to be friendly and be willing to talk about different things. Once you have their trust, they will open up to you (about their health). Pay attention to their mood, their appearance, and look for the details,” he states. Dr. Weber added that you “need to be honest and transparent. Always be hopeful. If you develop that trust with the patient already, they will have the best faith knowing that you’ll take the best care of them and that you’ll do your best”.

Do you have any memorable stories about your patients?
One of Dr. Weber’s elderly patients, a farmer, was having abdominal discomfort and he wanted to collect a urine specimen. One of his assistants handed the cup to the patient and asked him to “provide a specimen in this cup.” The patient was in the bathroom for a very long time, and instead of a urine specimen, he delivered a fecal specimen. The key message from that experience is that “instructions are always key. Make sure you use language that the patient understands.”

What are some of the advances that allowed the elderly to age well?
Dr. Weber suggests that we did not pay enough attention to diet, exercise, and mental stimulation. He recalled having a few octogenarians in his practice, and the very rare occasion a centenarian early on. When he left practice, things had changed dramatically. He had a patient who was age 90 and still riding a bicycle five miles a day. Our advancements in the understanding of aging well and longevity played a big role. “We don’t want seniors who stay inside all day watching TV. We have to pay attention to them getting regular exercise, pay attention to their environment, and bring awareness to taking care of themselves.”

What advice would you give to medical students and residents who are interested in pursuing your specialty?
“Family medicine works best when you take care of the whole family.” One thing that helped him was to have a relationship with the older patient and also a relationship with their son, daughter or grandchild.

Dr. Robert Buckley, M.D.

Dr. Buckley retired 10 years ago. His career started in the U.S. Navy, with stops in Florida, on a ship in South America, and the Bethesda, Maryland naval air station. His practice was predominantly younger people and some retired naval personnel as well. He described his practice as “bread and butter” family practice with adult medicine, obstetrics and gynecology, surgeries and pediatrics. He spent time in Australia, where he also went to high school. He was one of two doctors in a remote area in northwestern Australia. There were two Australian doctors and two American doctors, where he became the local doctor for Australian civilians and the military. There were not a lot of facilities and the next town away was 250 miles away, which included a general surgeon and two general practitioners. The internist was about 600 miles away, and general specialists 850 miles away.

He retuned to the US, specifically Macon, Georgia and served as faculty of Mercy University, and as well as program director at the family practice residency at the medical center. His new practice included more geriatrics patients and he became a medical director at one of the local nursing homes and developed an interest in fall prevention.

He then went to serve as a program director for seven years in Chicago WHERE?. Over time, his practice included more older adults, as kids grew up and the parents and grandparents were still his patients. He cared for patients in nursing homes and made house-calls to a retirement community.

How is geriatrics care different from other patient groups?
Expectations are different, meaning that “my goals are a little different for my own health than compared to when I was a younger age.” There is a difference between living and existing. The goals are more in maximizing function. For example, in Georgia, he had a large portion of minority, poor, older patients. The challenge (especially at a time before Medicare Part D) was to find resources to help with their healthcare. Part of the dilemma Dr. Buckley sees for increasing geriatrics fellowships is that the healthcare system reimbursement does not reimburse for the assessments needed for older adults. The skill sets and extensive geriatric evaluations are undervalued.

Dr. Buckley has enjoyed his patients’ stories. He describes himself as a history buff and loved to hear the military history while he was in the Navy. One of his patients was a prisoner of war in the Philippines. He took care of another patient who was a part of Admiral Chester Nimitz’s staff during the Battle of Midway in World War II. Even though he has been retired for 10 years, he keeps in touch with a 90-year-old patient and her kids, and their children as well.

Dr. Buckley has four pieces of advice for medical students and residents.
#1: Don’t be afraid when you hear a lot of people being negative. Every generation feels they had the better deal and change is bad. Physicians as a group tend to be more conservative when it comes to change.
#2. Never pick a specialty because of the money. All the money in the world does not get you out of bed for a while.
#3. For residents, never marry a diagnosis meaning “don’t fall into a trap of questioning your diagnosis and questioning if things do not fit.”
#4. There are two things in the world: “There is a god, and I am not him.”

Sheron Brown, M.D.

Dr. Brown is a retired Life member who practiced family medicine for almost 30 years. Before medicine, she worked as a graphic designer. She entered medical school at the age of 35; when her son was in first grade and daughter was in third grade. She started her own solo practice at age 50 and sold her practice 13 years later to a large multi-specialty group and stayed with them for another six years until retirement.

She developed a specific interest in menopause medicine and became certified menopause practitioner (NCMP) from the North American Menopause Society. When she was a NCMP, she had more women patients come to her specifically for these concerns. Within about six years, almost 50% of her practice was women experiencing menopause. Even in retirement, she hopes to continue working in menopause medicine by either creating a documentary series or lecture series or writing blog posts.

Dr. Brown enjoys her older patients because you can strike up a conversation at any time. “If you listen to them, they have a lot of life experiences and trust what they’re telling you. If something is different, then you need to pay attention to it. It may not be clear cut at first, but sometimes changes in health as you get older can be subtle.” Her advice is to develop a way of talking to your patients that is somewhat tactful, for example not using the word “age-related” such as if a person is feeling more tired, it can be a part of normal aging. Polypharmacy is another key issue in the geriatric population.

On the plus, side, the elderly like to bring you gifts! They really appreciate that you don’t feel rushed. They have a lot of life wisdom, and some of the stories they get to share are very interesting.

When caring for older adults, you must have a system approach with this, as patient appointments are limited by time constraints. “You must first address their chief complaint, and always review medications. She had a piece of advice that she remembered from Dr. William Nelson, who was a prior residency program director at the La Grange Memorial Hospital, who said, “if you have a lot of older people, you will find some that will have a lot of symptoms and call you all the time. Bring them in regularly to touch base on their problems; sometimes they are just lonely and need someone to talk to as well just so they have that reassurance.”

William Hulesch, M.D.

Dr. Hulesch grew up in Cleveland, Ohio, graduated from Loyola University Stritch School of Medicine and completed his residency in family medicine at MacNeal Memorial Hospital in Berwyn, Illinois. He started his own practice in Downers Grove, Illinois in 1975 and has been there ever since. He also served as president of the Illinois Academy of Family Physicians from 1986-87, the first IAFP president that graduated from a family medicine residency.

Dr. Hulesch started out full scope family medicine with obstetrics. There were not a lot of specialists in his area at the time, so the practice did colposcopies, stress tests, general surgery, casting, and sigmoidoscopy. He also was a part of Good Samaritan Hospital and taught at the residency program at MacNeal Hospital. He also helped to establish a family medicine residency at the Hinsdale Medical Center. Many of his patients have been with him since he first saw them during his residency training. Now his is taking care of multiple generations of those patient’s families.

Dr. Hulesch defines aging as “accumulated losses, such as worsening hearing, worsening eyesight, etc” so basically preventing fast loss. They need to be managed. There are also more complex issues to deal with during the COVID-pandemic. Older adults who suffered the most are the grandparents who couldn’t see their grandkids. A significant component are the psychosocial aspects that we need to deal with - such as loss of spouses and loss of friends. “A huge amount of geriatrics involves the medical aspect, but the psychosocial aspect is more important than the medical aspect.”

Dr. Hulesch states that the geriatric population deals more with external stress, as imposed to internal stress. He recalled his mother saying “getting older is not for the faint of heart” meaning that they are tough as a group. “These patients have gone through the wars, polio, and now the COVID pandemic. They can manage a lot of stress through supportive care.”

Older adults have so many life experiences and done so many things. “They have been through things that we only read about in books. I just let them talk and then discuss what we're trying to do medically and how it will fit into their life at the moment.” He spoke of a memorable lady who declared during a visit that “I’ve been bowling for such a long time, and now I’m bored.” So, she took up golf at the age of 92!

In patients facing the end of life, Dr. Hulesch says, “Life is a terminal diagnosis. You don’t come in with dignity, you should leave with dignity. You should take control of your life at the end. You don’t want to burden others in making decisions for you, you should make the decisions for yourself. If you do it right, it is a beautiful time.”

Wayne Carlson, M.D.

Dr. Carlson was in practice for 40 years and retired two years ago. His father was a medical doctor in Africa and his mother was a nurse. He met his wife, Becky, a nurse, in Alaska. He spent four years in service, stationed in Becky’s hometown of Norm, Alaska followed by 10 years in private practice doing full spectrum family medicine. They sold their practice and relocated to the Algonquin, Ill. area seeing patients from pediatrics to geriatrics. As Dr. Carlson got older, his patient population skewed towards 55 years and older.

Dr. Carlson says it can be harder to plan for the office visits with older adults. For example, a patient that came in for a blood pressure check and revealed her husband had died a few days prior. The office visit pivoted to grief, and potentially dealing with depression. “Plan for the unexpected because the 10-to-15-minute visit turned into an hour.” Becky added that geriatric patients rarely come in for one specific reason, “Everything plays a role - they also are from the older school, where you save your lists or needs. If a patient brings a list, find the most important complaint and start there.”

Many of their patients that were local farmers. One patient presented with shortness of breath getting into a tractor, and even just walking down to the exam room in his office had to stop to catch his breath. He was admitted to the hospital that night and required bypass surgery that evening. “A lot of the older people do not complain. Listening and being aware that many of them have limited financial resources. Some medications cost an abundance, which Medicare does not cover a lot of, which can be problematic.”

In Dr. Carlson’s experiences and opinion, hospitalists are not able to fill in the gap for primary care. With the aging population, geriatrics and hospice will be more required in the near future. Furthermore, electronic medical records need to be more centered around patient care. “If electronic medical records are supposed to improve patient care, I am not seeing that. They are designed to meet requirements, to document certain things, to bill and to justify it.”

On the positive side, technology allows the elderly to be able to feel connected to the outside world. Being able to stay in touch with families promotes longevity and helps with the psychosocial aspects of medicine. Technology can make people less isolated, and has been a game changer in enabling telehealth options for patients.

Dr. Carlson is not sure what the future holds for full family spectrum practice. Doctors are changing practices more often, which defeats the purpose of family medicine. We need to have a health care system where the older adult’s family physician is the captain of the ship. With the electronic records, we have the capability to keep these people healthy and see the problem coming and take care of it before they break their hip. We can see them before they go into hypoglycemic coma. We have the tools, we need the training and health care systems to let these people lead.”