Kenneth E. Covinsky, MD, MPH; C. Bree Johnston, MD, MPH
Covinsky KE, Johnston CB. Envisioning Better Approaches for Dementia Care. Ann Intern Med. 2006;145:780-781. doi: 10.7326/0003-4819-145-10-200611210-00011
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Published: Ann Intern Med. 2006;145(10):780-781.
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Department of Internal Medicine, Easton Hospital, PA 18042
November 29, 2006
Role of Caregivers and Geriatricians in Dementia "“ Under appreciated, overlooked and undervalued
It is paradoxical that the editorial "Envisioning better approaches for Dementia Care" (1) is sandwiched between two articles on career decisions of internal medicine residents during training (2,3). While the latter articles focused on general internal medicine, I noted the percentage of medicine residents interested in geriatrics. Less than one percent of residents envisioned geriatrics as a career path when they started residency training. As an academic geriatrician, I am perturbed by this appalling figure. It clearly reflects our society's attitude to our elder patients, especially for those who need considerable love, attention, care and time. In a capitalistic society like ours, fancy new technology often gets more attention and money compared to the more old fashioned virtue of spending time to care for our elderly. The caregivers of dementia patients and the physicians who take adequate time and measures to care for them are among those begging for a shift in priorities.
To say that the role of the caregiver in dementia is undervalued is an understatement. The typical caregivers not only lose potential income to care for their loved ones, but also are prone to numerous physical and psychiatric disorders. The economic value of this informal care giving can never be accurately calculated though studies show it to be worth hundreds of billions of dollars (4). All this care helps in delaying nursing home placement and research shows that this saves billions of dollars in healthcare costs. Yet, our system does not provide adequate financial support to encourage multidisciplinary team approaches in care for dementia patients and their caregivers. On the contrary, our system handsomely reimburses some newer cardiological techniques like ICD placements, where there is still debate about the actual economic value in reducing morbidity and mortality. No wonder then that we have more of our medicine residents wanted to pursue careers in cardiology than general internal medicine or geriatrics. While, I am not undermining the value of research and development of technology, there needs to be a change in our current reimbursement model.
I wholeheartedly support restructuring of the payment system to include an array of dementia care and caregiver support services that have been shown to improve care. I do believe that this will require advocates and champions and the American Geriatric Society is among those lobbying for the same. If we do not do act now, we will have even fewer medical students and internal medicine residents wanting to pursue a career in geriatrics. The ultimate sufferer will be the elder Americans and our society will be poorer for the same.
1.Covinsky KE, Johnston CB. Envisioning better approaches for dementia care. Ann Intern Med. 2006 Nov 21; 145(10): 780-1
2.West CP, Popkave C, Schultz HJ, Weinberger SE, Kolars JC. Changes in career decisions of internal medicine residents during training Ann Intern Med. 2006 Nov 21;145 (10):774-9.
3.Sox HC. Career changes in medicine: Part II. Ann Intern Med. 2006 Nov 21; 145(10): 782-3
4.Arno PS, Levine C, Memmott MM. The economic value of informal caregiving. Health Aff (Millwood). 1999 Mar-Apr;18(2):182-8.
J. Dennis Bender
U. of Cincinnati, Genome Research Institute
December 2, 2006
Role of Psychiatric Social Workers
Let us not forget that psychiatric social workers, such as my wife Pat Bender, provide exactly the sort of coordinated dementia-care services being described here. This report fails to even mention the important role of psychiatric social workers in providing exactly this sort of care and providing it at a cost that is far less than that of having internists or family-practice practitioners providing this sort of coordination. The coordination is provided by the psychiatric social worker while the medical treatment is provided by the physician, who has little time and even less interest in providing "coordination" services -- this is and always has been the job of the psychiatric social worker.
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