IAFP Life Member Stories - a Geriatrics MIG Project

 

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.

“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 Desari, 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.”

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