Old and Sick in America: The Journey through the Health Care System

Old and Sick in America: The Journey through the Health Care System

Old and Sick in America: The Journey through the Health Care System

Old and Sick in America: The Journey through the Health Care System

Synopsis

Since the introduction of Medicare and Medicaid in 1965, the American health care system has steadily grown in size and complexity. Muriel R. Gillick takes readers on a narrative tour of American health care, incorporating the stories of older patients as they travel from the doctor's office to the hospital to the skilled nursing facility, and examining the influence of forces as diverse as pharmaceutical corporations, device manufacturers, and health insurance companies on their experience. A scholar who has practiced medicine for over thirty years, Gillick offers readers an informed and straightforward view of health care from the ground up, revealing that many crucial medical decisions are based not on what is best for the patient but rather on outside forces, sometimes to the detriment of patient health and quality of life. Gillick suggests a broadly imagined patient-centered reform of the health care system with Medicare as the engine of change, a transformation that would be mediated through accountability, cost-effectiveness, and culture change.

Excerpt

Every so often during my years as a primary care geriatrician, a new patient landed in my practice who hadn’t seen a doctor for forty or fifty years. Sometimes, the last direct personal encounter with a physician had been during childbirth. I faced patients like that with a shiver of dread because they usually turned out to have something terrible wrong with them, like the woman who had been healthy all her life, who exercised regularly and ate a good diet, and who came to see me because she’d woken up one day feeling as though she’d been hit by a Mack truck. She might as well have been hit by a truck: she proved to have widely metastatic cancer and would be dead within six weeks. Or there was the 82-year-old woman who had never been sick a day in her life and, according to her, still wasn’t. She was dragged into the office over her vociferous protests by her son and daughter because she went out into the snow wearing sandals and left the teapot burning on the stove long after all the water had evaporated. She had Alzheimer’s disease which had progressed to the point where she could no longer safely live alone. Her judgment, markedly impaired by her dementia, didn’t allow her to grasp her situation. She refused to accept the various creative compromises her family and I devised to provide support for her while allowing her to maintain a mea sure of autonomy. I thought that if only I had known her for years and been able to establish a relationship with her, I could have chipped away at her denial. She might have trusted me and let me gradually arrange increases in the amount of supervision she had, allowing her to stay at home. Instead, she lost her zest for life after her daughter, at her wit’s end, placed her in a nursing home.

These health care virgins were the exceptions that proved the rule—almost all older people have a long history of interactions with the health care system, and most of those interactions take place in the doctor’s office. Even the outliers, like my patient who had stayed away from the medical profession for decades, sought help in the outpatient setting when they finally developed problems that either they or their families could no longer ignore. the doctor’s office, for the vast majority of patients, is where the journey through the health care maze begins. and the tour guide, the person most likely to accompany them through sickness and through health, is their personal physician.

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