Geriatric Medical Care Research Articles

FAMILY MEDICINE AND GERIATRIC MEDICINE: ECONOMIC AND IDEOLOGICAL CONFLICT

As the needs for geriatric medical care increase, it becomes important to identify sources of care for this expanding population. This paper focuses on the supports and impediments inherent in the provision of geriatric medical care by family physicians. Supports include a community and family oriented approach, a generalist perspective, experience in coordination of inpatient and outpatient services, and an educational commitment to geriatric training. Impediments include an excessive and inaccessible knowledge base, the conflict between biomedical and psychosocial approaches to care, inadequate reimbursement for comprehensive care, and difficulties in educating family practice residents. As family physicians have traditionally provided the majority of geriatric health care, particularly in the rural United States, these issues are important to address.

A Geriatric Day Hospital and its system of care

This study set out to describe the organisation of a Geriatric Day Hospital in order to study the relationship between its stated aims, which were briefly, help with the rehabilitation of the chronic sick and the saving of hospital inpatient beds and these were agreed by all concerned, and its day to day practice. Data about their work and time at the day hospital were collected from medical, nursing and administrative staff and from a third of the 120 registered patients. In order to become registered patients had to be physically but not mentally handicapped, and so they were brought by ambulance to spend one day in each week at the day hospital. We called the day hospital's system of care Total Supportive Care (TSC) because it set out to be as sensitive as possible to patients needs, mainly by way of a system of constant observation by all members of the staff. The sister received all reports of observed changes in the patients, and decided whether to take action herself or to refer the problem to a doctor or the medical social worker. The majority of patients saw the sister as a person from whom they received most help. Total Supportive Care was evidently valuable to the staff, and provided a central figure to whom patients could relate at all stages of a course of treatment. A disadvantage of this care system for staff lies in the potential threat of the central co-ordinator role to other professional roles, and for patients in the ease with which dependency on such a total and personal system may develop, as our findings showed: indeed, the sister said there was a natural tendency to “hang on to” patients and develop a kind of therapeutic community. This tendency is at variance with the aim of saving hospital inpatient beds, which requires a rapid change of patients. Such findings indicate the need for a wider view of rehabilitation which, as Scheff points out should not assume “normal life” but which should prepare patients for their own reality outside the institution. Medical studies of elderly populations emphasize the increased vulnerability to accidents, and the dangers of lowered self respect of those living alone, and an increasing apathy towards the use of medical and social welfare. “Routine surveillance” and “timely intervention” are frequently mentioned. We conclude firstly that planning care for the elderly should allow for someone—preferably from outside the institution's own care team—to assume a dependency object role, secondly that medical and social co-operation needs to develop flexibly and together in the light of each case, and also that current British proposals for separate medical and social care teams are unlikely to assist this development. In addition we are led to agree with McKeown's proposals for complete integration on all levels of geriatric medical care, and with his suggestion that some general practitioner specialization in geriatrics would be an advantage. Finally we suggest that operations research represents only one aspect of medical planning, and that the process of disentangling the patient from the effects of institutional care requires much consideration, especially in the case of elderly patients, both for the welfare of those patients and for the success of any operations research plans to make best use of hospital time.