Lisa Norton, a geriatrician and clinical assistant professor at the School of Medicine, strides towards her first home visit, briefing her student on the health challenges of 87-year-old Pauline Harris. Harris resides in the South End, and as they approach her apartment, Norton adds a crucial detail: “She’s not terribly compliant with her meds.” This understatement soon becomes apparent.
Upon entering her second-floor apartment, Pauline Harris welcomes Norton and Eugene Lee (CAS’08, MED’12), a medical student, with Southern hospitality into a cozy, albeit cluttered, living room. She gestures them to seats amidst the décor, including prints of Mary Baker Eddy, and settles into a red velvet armchair. Over the next hour, Norton and Lee engage with Harris, conducting a thorough examination, drawing blood, and monitoring her vital signs.
Norton is part of a dedicated team of six geriatricians and several nurses within the MED’s Bu Geriatrics Home Care Program. This program extends care to approximately 570 patients who face difficulties leaving their homes. Notably, it stands as the nation’s oldest home care program of its kind, integrated into the University’s curriculum since the 1870s. Fourth-year MED students benefit from a month-long geriatric rotation, learning core practices and attending lectures covering diverse topics from insurance to end-of-life care. This initiative represents one of the many ways MED faculty and students actively engage with the wider community.
During the visit, Lee inquires about Harris’s breathing, balance, and dietary habits, while Norton diligently records observations on her laptop. Norton’s gaze sweeps over the room filled with stacks of papers, magazines, and various items, before she addresses the crucial question of medication: “Where are your pills, Pauline?” Harris scans her surroundings and eventually retrieves several yellow and blue medication cards, designed for daily dosages, all tragically empty and dating back seven months. Norton gently states, “I think there’s some compliance issues here. We definitely need to get you new pills.”
Such critical details regarding Harris’s medication adherence, along with insights into her Christian Scientist beliefs evident from the room’s literature, might have remained unnoticed during a conventional clinic appointment.
Home visits, a cornerstone of the BU Geriatrics Home Care Program, provide Norton and her colleagues with invaluable perspectives into their patients’ lives, enabling them to deliver holistic care. Norton emphasizes, “That’s really important in geriatrics. You can lose the forest for the trees.”
Lisa Caruso, a MED assistant professor of geriatrics, reinforces this point: “There’s so much more that we can understand about a patient just by doing one home visit.” These visits allow doctors to assess a patient’s living environment, their ability to manage daily tasks like navigating stairs and stocking their refrigerators, and crucially, their medication habits.
The significance of training future physicians in elder care is increasingly vital. The American Geriatrics Society estimates a significant shortage of geriatricians in the US, with approximately 7,100 board-certified specialists currently practicing. To adequately serve the projected 71 million Americans over 65 by 2030, this number needs to increase nearly fivefold, according to the American Medical Student Association.
Geriatrics, while crucial, is often perceived as a less appealing specialty within medicine. Compensation surveys, such as those from the Medical Group Management Association, indicate that geriatricians’ average salaries are considerably lower than those in more specialized fields. Furthermore, the daily pace of geriatrics may not offer the high-adrenaline environment found in specialties like cardiology or emergency medicine.
A Dedicated Field of Practice
Geriatricians at Boston Medical Center (BMC), MED’s primary teaching hospital and a key partner of the BU Geriatrics Home Care Program, are driven by a deep commitment to their field. They leverage the Home Care Program to demonstrate the intrinsic rewards of geriatrics to medical students. Daniel Oates (CAS’00, MED’00, SPH’05), the program’s medical director and a MED assistant professor of geriatrics, explains, “You have to get them to fall in love with what you do.” While acknowledging that many students will pursue more financially rewarding or high-profile specialties, Oates and his colleagues aim to instill valuable experience and a geriatric perspective that will benefit them in any chosen field.
Lee, for instance, believes his geriatrics rotation will be highly beneficial to his future practice in primary care. Back at Harris’s apartment, he and Norton continue to unravel the medication puzzle. They learn that Harris’s son, Billy, previously assisted with her medication management, but no longer resides with her. Examining the medication packaging, they attempt to determine the most recent delivery. (Harris explains she “keeps empties to recycle.”) While Lee contacts the pharmacy, Norton proceeds with drawing blood. Lee soon confirms the concerning reality: Harris’s medication deliveries were halted four months prior, indicating inconsistent medication intake.
The challenges faced by BMC’s geriatric patients, like Harris, are often multifaceted. They typically are in their mid-80s, live with limited financial resources, and qualify for subsidized health insurance. Many are also non-native English speakers. They frequently manage multiple chronic conditions, such as hypertension, diabetes, and anemia, each requiring specific medications. A geriatrician’s expertise lies in understanding the complex interplay of these medications, particularly in elderly individuals, and recognizing that common illnesses may present differently compared to younger patients.
Oates points out, “Elder adults sometimes get marginalized. They sometimes get forgotten. People don’t know what to do with them.” He emphasizes the necessity of a team-based approach in geriatric care, involving various specialists.
Effective communication is paramount in geriatrics. Oates highlights that a significant portion of the population has limited health literacy, and misunderstandings can lead to serious health consequences. He conducts workshops for students focusing on clear, jargon-free communication, particularly with elderly patients. Oates advocates for care plan reviews and encourages patients to “teach it back” to ensure comprehension.
However, Norton emphasizes that active listening is equally crucial. Despite medication inconsistencies, Harris reports feeling well. Her vital signs, taken two days after her last medication dose, are stable. There are no signs of swelling. Norton suggests to Lee that a reassessment of Harris’s medication list may be warranted.
“The most important thing,” Norton concludes, “is not really how the disease is doing, but how the patient is doing.” And Pauline Harris, in her own home environment, appears to be doing just fine. Norton and Lee conclude their visit and head out to their next patient, mindful of the many individuals relying on the BU Geriatrics Home Care Program for essential medical care.
