Many of us don't remember -- or even know -- what it used to be like in medicine, when doctors spent more time asking patients about their interests, family and even their emotional health. But there is a medical specialty that offers this type of care, at University of California, Los Angeles' geriatrics clinic.
David Reuben, chief of geriatrics at UCLA and president of the American Geriatrics Society, is clearly an expert in his field. But that doesn't make his job any easier. In fact, doing a "good" job, as Reuben sees it reflects a lot more thought and purpose than it might at first seem.
Today's he's visiting Stella, a petite woman with a sweet face. Reuben, with a sparkle in his eye and a snap to his step, remarks on her make up and tells her how great she looks.
"When I go into an examining room, you've got to be "out there" for the patient," says Reuben. "Its very much like going on stage. Its not that it's insincere, but you have to be optimistic for the patients. You need to engage them completely with your attention and be observant of everything that's going on with them."
Seeing patients every 20-30 minutes requires tremendous energy. And it can be stressful, even for upbeat, energetic Reuben. By the time he's through with the day, he says he's beat.
Reuben focuses on all of his patients with enormous scrutiny. This is what he means when he describes geriatric care -- as "holistic." His eyes and ears are "wide open" as he scrutinizes a lot more than physical appearance. In all cases, he starts the exam with questions that really have nothing to do with physical health.
Answers to questions about hobbies, family, friends are small clues, says Reuben, to overall health. Not doing yoga could indicate a certain lethargy or weakness. Not playing bingo or reading could mean depression. Not caring about the dogs could mean not getting out and not getting exercise.
"A patient of mine who was an avid golfer, I asked him how many times he played golf last week," says Reuben. "If he didn't play, it's a tip off to me that something's going on."
These tip offs can lead to changes, which can have a dramatic impact on quality of life. Fatigue may be lessened with medication to help a person sleep through the night. Medication can also diminish the need to get up to go to the bathroom every few hours. A good night's sleep can help patients maintain their activities or get more active, even if they think they're too old.
Reuben is examining another patient who is too thin and too frail. Reuben performs his standard exam, listening to her heart and lungs, checking her blood pressure and pulse, her hearing and eyesight. And very important for older patients, Reuben checks her strength and balance.
At 96, this patient is remarkably alert and astute. But clearly, the hospitalization has weakened her. Reuben's prescription, whether the patient likes it or not, is physical therapy.
"You've slipped since you've been in the hospital," he tells her, "And you're not as strong as you were, and not as safe. I want you to be as safe as possible, so the stronger you are, the safer you're going to be."
"At my age, will I get stronger," she asks. Yes, Reuben tells her.
Studies have show this, says Reuben. One study with 90-year-olds showed via CAT scans and muscle-strength measurements that there's really no age at which patients can't improve or that muscle can't respond to exercise and physical activity. And keeping patients strong, says Reuben, helps keep them at home and independent as long as possible.
UCLA even sends home-health aides to patients home to make sure lighting is adequate and throw rugs are secured to help prevent falls. Falls can have disastrous consequences for older people.
But when its clear patients are entering their final days, Reuben says good geriatric care also includes helping them die.
"Sometimes I talk about us being the 'closers,' the final chapter of people's lives. It is meaningful to me.," he says. Reuben wants to help patients achieve their goals, whether that means holding on for bar mitzvah, a wedding, or keeping them in their homes for as long as possible.
It also means helping his patients to the very end. "If they're going to pass and they want to pass in certain way -- at home, with family -- I can make this orchestrated ending so they're not suffering," says Reuben. "These are valuable things, valuable to patients, families and me as a physician."
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