Thursday, 3 October 2013
Empiricism in context
In my new role as a community geriatrician, I am exploring how to deliver what I think to be good geriatric care in a new environment. The challenge suits me: I work in nice hospitals, with caring staff, in nice part of the world. It feels like I am doing what geriatrics is all about: doing the right medicine for people who need a lot of care and attention. It is all about balance, judgement, and respect for the individual.
I have spoken before about the limits of practising geriatrics within an acute hospital setting, and how it is the wrong environment for confused, vulnerable men and women. Increasingly, acute hospitals are factories for technological care. They are busy, fast-moving and bewildering environments. The men and women I deal with often need the best technical care we can offer, but they also need to be in an environment that helps them find their feet again, and helps us decide what issues are really at the centre of their problems: the pattern of symptoms might be easy to discern, but determining their underlying cause takes a bit more nouce.
I said that I like my new job because it gives me the chance to deliver what I think to be good care. This element of subjectivity, of what I think is the best approach, is both the strength and weakness of modern geriatrics.
However confident we might be that we are acting in our patients' best interests, there is a need for circumspection. The rise of empiricism in medicine is unquestionably a good thing; but it is not without its flaws, and it is not without its areas of poor coverage. Geriatrics is one of these low signal areas: the elderly are often excluded from the big trials, and the application of the evidence base to even common conditions in the elderly is through extrapolation of data sets from younger patients. It might surprise you, but it wasn't until the HYVET trial in 2008 that we could say with any confidence that there was a benefit to treating high blood pressure in the elderly. And even then, the need for circumspection remains, as many of the trial participants were Chinese, and therefore of questionable equivalence to the patients that we deal with.
But let's not get stuck on this. The point I wish to make is that empiricism is an important aspect of modern medical practice. But where geriatrics is concerned, it is only one aspect. Of course, we need to know that the treatments and therapies we use on patients are effective, and not unduly harmful (that is always a question of risk vs benefit). But the care of elderly patients goes beyond the technical questions of the best treatments - it is more complex than that. Of course it is.
It is these non-empirical aspects of my job that I really love. The variety of approach, and the broadness of it. What I do may not be cutting edge, but I get the chance, as part of a team, to make a difference to the lives of our patients. Go fast, go slow, do nothing at all. Do the test, start the treatment, or hold off entirely. Tackle the physical problem, the mental health problem, or stand back and let the therapists focus on empowering the patient by improving their function and independence. Often, my patients teach me a thing or two about life, from the secret to a successful marriage, to dealing with loss, or what is was like making a dress for the Queen. It's all there if you give it time.
Geriatrics requires knowledge, skill, experience, team play, humility, and usually a clear articulation of what you are trying to achieve - all skills that you can never quite tick off as completed. We might aim to help someone get back to playing golf, or we might try to give someone some peace and dignity in their dying days. Geriatrics normalises normal stuff, and it highlights the unusual. There are themes and trends; there are frustrations and depressing realities. There are disappointments and regrets.
But above all, there is the knowledge that even if we cannot heal the patient, we can help them and their families cope with the reality.
Sometimes, perhaps quite often, there is the reality that we don't do things terribly well, but we can change that. We have to.
Moving to community hospitals has helped me to realise that there is a lot we can do to deliver care more suited to the needs of my elderly patients if we are prepared to work differently. But not everyone shares my view: the question I often get asked is what is the evidence for community-based care. The sub-text is always that they know there isn't really much, and that it is therefore not worth investing in. I smile, I nod, and I acknowledge their point. But I also tell them that we are not really trying to do things differently - we are trying to do the same things better.
What matters to my patients is not so much about mortality, or length of stay. It is much more about having the right care, the right expertise, good communication, and the best possible quality of life. And we will be content to be held to that account.