In My Own Words

This feature is based on the author's own experiences, observations and thoughts, the articles may contain "opinions" and "methods" that the author believes facilitate better care for long-term care residents. These are not meant to reflect CALTCM official policy.

Check back often for more! If you have an "In My Own Words" article you would like to submit for consideration, please feel free to share with us.  


Palliative I Don’t Care - Seems Like!

by KJ Page, RN-BC, LNHA

“Almost everyone dies.”  These were the first words spoken by the physician at the start of the family meeting. 

Working in long-term care, in skilled nursing facilities, let me start by admitting my distress at this statement.  In all fairness, this physician did not know me, or what I do; I immediately gave up hope.

I quietly countered with: “Wow, in California, there is no way out alive, everyone dies.” Not willing to take the lifeline I threw to her, she responded with: “Well, sooner or later they die.”

The meeting went downhill from there.  Rose (I changed her name to represent the flowers she hates but grew with a nearly religious fervor in past years) is 85, diabetic, and now is in end-stage renal disease. She had an advance directive we spent agonizing hours over at a time when she was not in a medical crisis. She was very clear about no dialysis. She made me promise her I would help her get her way when the time came.  Since she lives on the Right Coast and I live on the Left, her son who lives with her gets to be the Agent. I am the second call if he won’t respond or freaks out. She wrote that into the DPOA.

The reason I insisted on this meeting, having flown to the East Coast in a mad dash after getting the 5 am phone call: “Mom was rushed to the hospital with kidney failure. They want her on dialysis and she is saying no. We need you here. All the plans are changing.” 

Ars Medica in the Time of COVID
In My Own Words
by Jessica Davidson, MD

In the world’s history of pandemics, doctors have taken center stage: as healers, as companions, as chroniclers, and as innovators. Doctors and scientists figured out the germ theory of disease, identified organisms, created vaccines and therapeutics, and advised nations on pandemic response.

In the COVID pandemic, a lot has changed. These changes have upset the entire foundation of medical practice, and yet there is very little discussion about them. I am talking about the disappearance of fundamental ethical principles of medicine, and the substitution of non-medically-based directives and prohibitions. 

Yes, doctors created the COVID vaccines and some new therapeutics, and a few doctors advised world leaders. But the response to this pandemic has been strangely non-medical. Common sense medical practice has been ignored in many instances. Ethical principles have been left quietly by the wayside. Doctors have been enjoined by politicians to treat a disease this way and not that way, and have largely been forbidden to question what is happening, or to assert those ethical principles that, until two years ago, we had all accepted as good and true. And there has been very little push-back by doctors and medical organizations. 


Coming to the finish line of my first 100 miler!
Congratulations to Mike Wasserman on his 100 Mile Run!
Michael Wasserman, MD, CMD, President of CALTCM, finishes 100 mile run in 40 hours!  In health he says quality has no finish line!  Watch the video here.  Join us in congratulating Dr. Wasserman!

“Coming to the finish line of my first 100 miler! Thank you for getting me into this Robert Key!”

In My Own Words
by Michael Wasserman, MD, CMD
(Social Media exchange, shared with permission.)
September 7 at 6:17 PM

I finally wrote my comments regarding the proposed changes to E&M coding, figured I'd share. This proposed change could destroy #Geriatrics and #HPM. Here are my comments:

I agree that the existing CPT coding system is inadequate. However, lumping together four E&M codes into one will have a serious unintended consequence. It will lead to clinicians spending less time with patients. When it comes to the care of older adults, this is profoundly disturbing. The simpler solution would be to pay physicians for the time that they take caring for patients. The risk of abuse of this methodology is very limited, especially because the patients themselves become the auditors! The greatest negative impact of this proposal will be its effect on the care of patients with complex problems, and frail older adults are the most obvious population that could be harmed by this change.

A Personal Perspective on Obesity and Bariatric Care
In My Own Words                                   
by Tim Gieseke MD, CMD

In my PA / LTC practice I have been admitting more young patients with complications of serious obesity.  In recognition of this emerging consequence of our obesity epidemic, our CALTCM Education committee has designed a half-day workshop for our 2017 annual meeting on Bariatric Care.  One exciting aspect of this workshop will be the emphasis on improving the health and wellness of not only our patients with obesity, but also our staff and ourselves.  A number of years ago, I had the privilege of learning motivational interviewing at an AMDA annual meeting under the instruction of Drs. Daniel Bluestein and Patricia Bach.  This has revolutionized how I approach difficult lifestyle problems integral to successful self-management of many chronic health problems like obesity, drug misuse disorders, diabetes, and most chronic diseases.

My experience from Hospitalist to SNFist
by John Hurwitz, DO
In My Own Words

Two years ago I made the transition from full time Hospitalist to full time SNFist.  I am quite satisfied with this change, for a number of reasons. It is very clear that the changes in the delivery of healthcare will make the post-acute space one of the most highlighted and focused places for improvement in the care continuum.

Physician Burnout

by Dan Osterweil, MD, FACP, CMD

Reflecting on the increase in physician burnout and attrition and my own struggle to balance the Industrialization of medicine with the old person-focused compassion, I stumbled upon this article in WSJ,  When Doctors Stop ‘Seeing’ Patients By Abraham M. Nussbaum, which resonated with me by a physician lamenting the loss of humanity from the practice of medicine. I am inspired by the quote of the last line of the Hippocratic Oath: "May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help". He believes, as do I, that "finest tradition of physician physician's calling are those moments when we look patients in the eyes, understand their pain and anxiety and help the resolve, relieve or endure it." That means not staring at the computer screen while talking to our patient in distress and saying everything is fine, but rather listening to the patient's concern who may be far removed from the numbers on the screen."

How come I did not know that? Pharmacogenomics, Pharmacy Consultants, and Adverse Drug Events
In My Own Words
by Dan Osterweil MD, FACP, CMD
CALTCM CEO and Past-President

A recent article in the WSJ (95% of people have genetic variations that affect if a drug will work for them or not points out an important phenomenon of gene variation and its effect on drug metabolism. The article points to variations in enzyme activity that impact clearance of various drug classes. While in many instances the variation has minimal clinical relevance, in selected cases, such as multiple drug use, lack of effect of certain medications used concomitantly with others or in smokers, there may be adverse effects or lack of effect. 

Will Aid in Dying become Assisted Suicide?
by Timothy Gieseke MD, CMD
Former Chair of Education at CALTCM

As a senior clinician working full time in the LTC setting, I am fully committed to an interprofessional approach that provides high value care to our vulnerable patients.  I am pleased that the Coalition for Compassionate Care of California recently updated the CARE Recommendations (Compassion and Respect at the End of Life) for SNFs.  I welcome their efforts to help my teams provide optimal care for those with serious illness.  Like Atul Gawande in his book, Being Mortal, walking with our patients, families, and colleagues during these troubling times has value not only for them, but also for us as caregivers.  To a large extent, palliative care advances have occurred as we learn from situations and strive to do better.  I realize there are moments in the care of some patients where patients are overly burdened with unrelieved suffering and the future looks grim.  However, with the extra layer of care that palliative care offers, and with time, sometimes unexpectedly, good things happen.

Measles Vaccination Decisions: What’s Best for the Health of the Most Vulnerable?

by Flora Bessey, Pharm.D., CGP

On May 6, 2015 my husband and I will welcome our beautiful baby into this world.  We haven’t found out the gender.  We call the baby Poppy since when we found out we were pregnant, the baby was the size of a poppy seed.  I am sure all the parents reading this can imagine the excitement, hopes and dreams we have for the baby.

With my husband and I both working in healthcare, we are at times overly cautious about things.  Imagine our alarm when we learned of the recent measles outbreak.  On further review, our Poppy can’t get vaccinated against measles until 9 months.  That is when an infant’s immune system can process and build a response to the vaccine.

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