Opinion: Specialisation in the era of chronic illness by Dr Ludomyr Mykyta
Dr Ludomyr Mykyta is an ANZSGM past president, he has had a long career in geriatric medicine with a strong interest in the management of dementia in all settings.
2020 and the COVID Crisis will never be forgotten. It was and continues to be the greatest challenge that the healthcare systems of all nations around the world have ever had to face. The way that these systems are structured, staffed, organised, managed, delivered, and funded has been shown to be of critical importance. The power of misinformation has also been shown to be a huge obstacle to effective delivery.
As a Specialty we have been subjected to scrutiny and have provided evidence to the Royal Commission into Aged Care Quality and Safety, which is due to deliver its final report this month.
Entering a new year is a good opportunity for introspection and considering who we have become, how we have evolved, and what should be our role in the future healthcare system. I was present in the infancy of Geriatric Medicine in Australia and am still actively practising it in 2021.Long ago I become convinced that there is only one legitimate specialty based on age. That is Paediatric Medicine which is generally defined to cover the period from infancy to the age of 18 years. This is the period in which we grow and develop to maturity in every way including neuropsychologically.
We have stood by and allowed the creation and perpetuation of a large and growing proportion of the adult population, people over 65 as a discriminated against minority group. What is discrimination in this context? Discrimination in any context is defined as: “The act of denying rights, benefits, justice, equitable treatment, or access to facilities available to all others, to an individual or group of people because of their race, age, gender, handicap or other defining characteristic. (Webster’s New World Law Dictionary)”. To put it simply, it is treating old people differently than other adults in a similar predicament.
Our practice in dealing with disturbed behaviour in Residential Aged Care facilities exemplifies the issue.
I have always visited people in residential facilities to assist in the management of disturbed behaviour “the BPSDs” in nursing homes and have done so throughout the COVID crisis. In recent times, everyone that I have seen had already been seen by DBMAS. There is a letter signed by a highly qualified specialist – a very influential clinical expert whose opinion is supported by Dementia Support Australia.
The “assessment”, is not conducted by the clinical expert and is largely based on populist benevolent mythology and not based on knowing and understanding an individual human being. The advice is similarly populist and generic, and the prescribing advice suggests homeopathic doses of psychoactive medication given with a complete lack of understanding of the individual’s predicament. There is no sense of urgency in dealing with a crisis confronting a distressed individual and equally or more distressed partner and carers. All this is happening to someone who is in the palliative phase of the illness (multifactorial syndrome) where prescribing rules must be adapted to reality.
I almost never give a clinical opinion on a living person that I have not at the very least sighted and attempted to engage in communication. How else would I be able to answer the question put to me by a Court or a Tribunal, “Doctor, what did you find when you examined the patient”? The ethics of this approach is highly questionable and certainly not an example of best practice. Would a middle-aged schizophrenic who stopped taking his medication and became violent and aggressive have been dealt with in this way?
This has led to an ACRC interim recommendation that greatly limits the prescription of psychoactive medication and is doing more harm than good.
Marjorie Warren, “the mother of geriatrics” in the UK, introduced comprehensive assessment and rehabilitation to a previously ignored group, who were not all old people. These practices are applicable to people with all types of disability at any age.
As soon as I returned to Australia, I applied these practices personally and through the services that I developed. In South Australia there was a period when Adelaide was covered by four Regional Domiciliary Care and Rehabilitation Services that looked after thousands of people in all situations, homes, hospitals, and clinics.
Why I suggest we should look at what we have become is because we have not evolved, but devolved to being just another hospital and clinic-bound super specialty of internal medicine.
I began doing rural visits about half a century ago. I quickly learned that rural communities and their general practitioners were not looking for general medical support, but help in dealing with dementia and disability. I began to focus almost entirely on dementia. There has always been a demand and referrals that I have never been able to keep up with. In many situations I became the psychiatrist of last resort, because I was prepared to see younger people face-to-face in their own communities in a timely fashion, unlike the Mental Health Services.
I believe that as the specialty of Geriatric Medicine, our niche is the management of dementia in all situations, and the management of complex chronic syndromes in all settings and at any age. We understand that all chronic progressive illness must be analysed and managed from the Bio-Psycho-Social perspective that recognises that we are dealing with a unique individual in a unique predicament, which includes being in a deep relationship with a life partner, relative or friend.
The knowledge base and technology base of healthcare, which is much more than just Medicine, has grown and continues to grow exponentially in the last two centuries. Unfortunately, the Healthcare System, the way it is structured, organised, staffed, funded, administered, and delivered remains firmly entrenched in the 19th century.
The management of hospitals in the healthcare system has succumbed to managerialism, and CEOs and Executive Officers are no longer clinical.
Health Care, and Aged Care are no longer services and elements of the Welfare State that we purport to be. They are businesses. There is no public service. The most important tier of Health Care, Primary Care is also being commercialised in line with business model.
Years ago, at an international Gerontology Conference, a PhD student was interviewing geriatricians and asked me why I became a geriatrician. I said that it was the job satisfaction, because every day I had a big win when some very minor piece of advice, such as teaching someone to use a walking frame, made a huge difference to that person’s sense of independence. I live in hope.
