Tuesday, May 18, 2010
Older
Ok I'm back...
Before I wax lyrical about Geriatrics, I realized I missed out on one core aspect of Geriatric medicine.
Paediatrics isn't the only specialty where you have to treat the patient as well as the caregiver. It's the same in Geriatrics, just that the ages of the patient and caregiver are reversed. Also, caregiver concerns are different. in Paediatrics, parents are more concerned on whether the child's illness affects his/her long-term development. Caregivers of elderly patients are concerned instead with how the patient's illness affect his/her quality of life. In Geriatrics, like paediatrics, patient welfare indefinitely impacts on the welfare of the caregiver. Patients with dementia, especially the spouse, are distressed by their loved one's gradual but noticeable change from someone dearly familiar to a total stranger, even a nuisance, an outcast. Like children with debilitating illnesses, Geriatricians aim to palliate the patient as best as they can, and offer comfort and respite to the caregivers where possible. I have personally witnessed the sheer outpouring of gratitiude of a family to a geriatrician who helped them cope with their father who was ailing due to both cancer and dementia. The scene touched my heart.
And therein lies the beauty of Geriatrics. One wonders why it isn't given the same appreciation as Paediatrics, given their similarities. One need no more than look at societal priorities and biases to see why. And yet in this same society, Geriatrics is needed more than ever. The ageing population and the shrinking of family size forces us to confront the inevitable elderly dependant burden on society and forces us to decide the place of elderly in society. More and more families are casting their elderly out to nursing homes. The reasons for doing so include many genuinely distressing ones, but what is worrying is how some people can leave their mothers and fathers in the home and never return.
Can we accept this? I urge all to take a good look at your mothers and your fathers and think hard: will you want to take care of them in future? Will you shelter them in your home for as long as they live, or will you cast them out at the slightest bit of inconvenience? Will you bathe them when they are dirty, clean them when they soil themselves, feed them when they too weak to feed themselves, comfort them when they cry from sorrow of depression or worthlessness? We shy away from this, yet we were once given that amount of care by our beloved parents. Instead we care not about dirtying our hands when we tend to our young ones- but even that practice is now slowly being handled by strangers-maids. Unsurprisingly, children now also hand their elderly parents over to maids, even though I accept that increasing work demands may force the hand of even the most dedicated of children.
When I walk in the wrads of Renci, all around me are old men and women, frail and beaten down by age and disease. But look harder and the years roll back- see the construction worker whose hands grew coarse from the rough work in the day but still lovingly cradled his baby son at night. See the virtuous wife whose now-heavily varicosed legs covered every inch of the house floor as she cleaned, swept, cooked, cried. See the political leader whose heavily-creased brow underlined all his years of servitude to the nation. See the young man or woman who was once not very different from us- full of hope and promise, yet full of trepidation at the challenges of life that awaited them. Above all, see the collective effort of an entire generation that has taken this country from the slums that they inhabited to the skyscrapers we now admire- an effort that has caused their backs to grow crooked, their bones to grow brittle, their knees to stiffen, their bodies to become weak.
Truly, they deserve better.
Before I wax lyrical about Geriatrics, I realized I missed out on one core aspect of Geriatric medicine.
Paediatrics isn't the only specialty where you have to treat the patient as well as the caregiver. It's the same in Geriatrics, just that the ages of the patient and caregiver are reversed. Also, caregiver concerns are different. in Paediatrics, parents are more concerned on whether the child's illness affects his/her long-term development. Caregivers of elderly patients are concerned instead with how the patient's illness affect his/her quality of life. In Geriatrics, like paediatrics, patient welfare indefinitely impacts on the welfare of the caregiver. Patients with dementia, especially the spouse, are distressed by their loved one's gradual but noticeable change from someone dearly familiar to a total stranger, even a nuisance, an outcast. Like children with debilitating illnesses, Geriatricians aim to palliate the patient as best as they can, and offer comfort and respite to the caregivers where possible. I have personally witnessed the sheer outpouring of gratitiude of a family to a geriatrician who helped them cope with their father who was ailing due to both cancer and dementia. The scene touched my heart.
And therein lies the beauty of Geriatrics. One wonders why it isn't given the same appreciation as Paediatrics, given their similarities. One need no more than look at societal priorities and biases to see why. And yet in this same society, Geriatrics is needed more than ever. The ageing population and the shrinking of family size forces us to confront the inevitable elderly dependant burden on society and forces us to decide the place of elderly in society. More and more families are casting their elderly out to nursing homes. The reasons for doing so include many genuinely distressing ones, but what is worrying is how some people can leave their mothers and fathers in the home and never return.
Can we accept this? I urge all to take a good look at your mothers and your fathers and think hard: will you want to take care of them in future? Will you shelter them in your home for as long as they live, or will you cast them out at the slightest bit of inconvenience? Will you bathe them when they are dirty, clean them when they soil themselves, feed them when they too weak to feed themselves, comfort them when they cry from sorrow of depression or worthlessness? We shy away from this, yet we were once given that amount of care by our beloved parents. Instead we care not about dirtying our hands when we tend to our young ones- but even that practice is now slowly being handled by strangers-maids. Unsurprisingly, children now also hand their elderly parents over to maids, even though I accept that increasing work demands may force the hand of even the most dedicated of children.
When I walk in the wrads of Renci, all around me are old men and women, frail and beaten down by age and disease. But look harder and the years roll back- see the construction worker whose hands grew coarse from the rough work in the day but still lovingly cradled his baby son at night. See the virtuous wife whose now-heavily varicosed legs covered every inch of the house floor as she cleaned, swept, cooked, cried. See the political leader whose heavily-creased brow underlined all his years of servitude to the nation. See the young man or woman who was once not very different from us- full of hope and promise, yet full of trepidation at the challenges of life that awaited them. Above all, see the collective effort of an entire generation that has taken this country from the slums that they inhabited to the skyscrapers we now admire- an effort that has caused their backs to grow crooked, their bones to grow brittle, their knees to stiffen, their bodies to become weak.
Truly, they deserve better.
Old
By now people who have talked to me about specializations and what I am interested in would have known that I have for the better part of the year been struggling with what to choose. I basically have narrowed down the list to 2 primary considerations-Geriatrics and Emergency Medicine, though it is prudent to say I haven't thoroughly ruled out any others yet.
The people who have spoken to me would usually have been taken aback at my preference for two specialties of apparently polar opposite nature.
This is not the post where I attempt to thrash out my thoughts and come to a conclusion, I suspect it will come but not so soon. Instead, this will be my attempt to coalesce my feelings and reflections on both specialties so that when the time comes, I have these written entries to look back on and aid my eventual choice.
I realize I should have started this when I was in the midst of my Emergency Medicine posting, but it's better late than never. I'll start with Geriatrics first, since ruminations of it are freshest in my mind.
I realised right away when I stepped into ward 8 @ Renci that I had made a terrible mistake, and also what an idiot I was to not have realized it way back earlier. Why put a Geriatrics psoting immediately after an Emergency Medicine one? The abrupt change in pace hit me like a wall. I had little time to adapt when I was ushered into my first ward round. Amazingly, I was still scanning the ward for people to set plugs on (Emed had driven me nuts I tell you, but in a good way- more on that next time).
If you haven't been paying attention to Pharmacology, or like me and most of the general medical student population have conveniently forgotten details like drug interaction and elimination etc, then Geriatrics will drive you up the wall. Each patient has a corundrum of comorbidities, and an accompanying cornucopia of medications. Every ward round is among other things an intense exercise on finely balancing patient physiology against multiple drug effects and interactions. Getting asked "why is the dosage so high? Can we lower this and increase that, take this out and replace it with this other one?" is NOT FUN, as a medical officer and even more so as a sotong student. For the first time in months I was dusting off the covers of my Katzung and flipping through the pages. Even now, 2 weeks into the posting, I can assure you I haven't sorted everything out.
Apart from polypharmacy, there is the effect of multiple comorbidities itself on elderly. We have the triumvirate of conditions drilled into medical students ad nauseum and chanted like a Buddhist scripture at almost every patient's round- hypertension, hyperlipidaemia and diabetes, the "Big Three". Then there are their complications- stroke, ischemic heart disease, pheripheral neuropathy, peripheral vascular disease, etc. There are the other conditions associated with elderly-osteoporosis with fractures of the long bones, osteoarthritis, and the inevitable malignancy. But what burdens both patient and caregiver the most must be the diseases that affect the mind and affect. Dementia and associated psychosis and depression are the most frustrating and energy-sapping conditions in the elderly. But they are also why the elderly are such a sorry lot of people. Imagine having your intellect and awareness and eventually self-dignity and civility slipping away into nothing-death- but then again if you were the patient you wouldn't feel it, instead your friends and loved ones suffer as your consciousness and their patience erode away slowly and painfully. Watching an old lady cry sorrowfully for her daughter every waking moment was so painful. Witnessing a previously vivacious lady reduced to nothing different from a very old baby-like creature was heart-rending. After 1 week in the subacute ward, I went home and cried.
But within all the burdens, the heartaches, the stresses, lies the beauty of Geriatric Medicine. As many have come to discover, it is worth all the effort to discover. More on my next entry, as I have run out of time. Perhaps you should relfect on what has been written...
The people who have spoken to me would usually have been taken aback at my preference for two specialties of apparently polar opposite nature.
This is not the post where I attempt to thrash out my thoughts and come to a conclusion, I suspect it will come but not so soon. Instead, this will be my attempt to coalesce my feelings and reflections on both specialties so that when the time comes, I have these written entries to look back on and aid my eventual choice.
I realize I should have started this when I was in the midst of my Emergency Medicine posting, but it's better late than never. I'll start with Geriatrics first, since ruminations of it are freshest in my mind.
I realised right away when I stepped into ward 8 @ Renci that I had made a terrible mistake, and also what an idiot I was to not have realized it way back earlier. Why put a Geriatrics psoting immediately after an Emergency Medicine one? The abrupt change in pace hit me like a wall. I had little time to adapt when I was ushered into my first ward round. Amazingly, I was still scanning the ward for people to set plugs on (Emed had driven me nuts I tell you, but in a good way- more on that next time).
If you haven't been paying attention to Pharmacology, or like me and most of the general medical student population have conveniently forgotten details like drug interaction and elimination etc, then Geriatrics will drive you up the wall. Each patient has a corundrum of comorbidities, and an accompanying cornucopia of medications. Every ward round is among other things an intense exercise on finely balancing patient physiology against multiple drug effects and interactions. Getting asked "why is the dosage so high? Can we lower this and increase that, take this out and replace it with this other one?" is NOT FUN, as a medical officer and even more so as a sotong student. For the first time in months I was dusting off the covers of my Katzung and flipping through the pages. Even now, 2 weeks into the posting, I can assure you I haven't sorted everything out.
Apart from polypharmacy, there is the effect of multiple comorbidities itself on elderly. We have the triumvirate of conditions drilled into medical students ad nauseum and chanted like a Buddhist scripture at almost every patient's round- hypertension, hyperlipidaemia and diabetes, the "Big Three". Then there are their complications- stroke, ischemic heart disease, pheripheral neuropathy, peripheral vascular disease, etc. There are the other conditions associated with elderly-osteoporosis with fractures of the long bones, osteoarthritis, and the inevitable malignancy. But what burdens both patient and caregiver the most must be the diseases that affect the mind and affect. Dementia and associated psychosis and depression are the most frustrating and energy-sapping conditions in the elderly. But they are also why the elderly are such a sorry lot of people. Imagine having your intellect and awareness and eventually self-dignity and civility slipping away into nothing-death- but then again if you were the patient you wouldn't feel it, instead your friends and loved ones suffer as your consciousness and their patience erode away slowly and painfully. Watching an old lady cry sorrowfully for her daughter every waking moment was so painful. Witnessing a previously vivacious lady reduced to nothing different from a very old baby-like creature was heart-rending. After 1 week in the subacute ward, I went home and cried.
But within all the burdens, the heartaches, the stresses, lies the beauty of Geriatric Medicine. As many have come to discover, it is worth all the effort to discover. More on my next entry, as I have run out of time. Perhaps you should relfect on what has been written...
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