Desmond O’Neill: Fresh approaches to long term care medicine in Washington, DC

Desmond O'Neill Washington in spring is a visual treat, the spectacular arrays of cherry trees in bloom adding a frothy filigree to the sober magnificence of the iconic National Mall. Throw in blue skies and crisp spring weather, and it is not surprising that crowds flock to its Cherry Blossom Festival at weekends in March and April.

This vernal efflorescence provided a refreshing backdrop to the annual conference of the American Medical Directors Association (AMDA), the main organization for doctors working in nursing homes in the USA. The provision of formal guidance and continuing professional development to doctors in nursing homes is relatively underdeveloped in Europe , and the main organization for European geriatricians, the European Union Geriatric Medicine Society (EUGMS), has developed a special interest group to engage with the issue.

The chair of the EUGMS Special Interest Group, Prof Finbarr Martin (London), led an initiative by the British Geriatrics Society on quality of care in nursing homes, and the group’s secretary, Prof Iva Holmerova (Prague), has been leading on a similar initiative, ELTECA.

The formalization of medical care in nursing homes in the USA has been prominent for longer than in Europe, partially arising out of a number of nursing home care scandals in the 1970s and 1980s and an influential Institute of Medicine report in 1986 which gave rise to the Federal Nursing Home Reform Act, commonly known as OBRA 87, referring to the legislative manoeuvre by which it was introduced.

As well as mandating a formalized and nation-wide care assessment of residents (the Resident Assessment Instrument – Minimum Data Set), the act also firmed up the stipulation of appointing medical directors to each nursing home to oversee the medical care of residents. It is this role which has been central to developing a more structured and scientific approach to the medical care of older people in nursing homes.

AMDA was established in 1978, and in the intervening 35 years, has developed an impressive array of educational initiatives to support medical care in nursing homes. Our European society is keen to work in harmony with AMDA in the development of excellence in medical care in European nursing homes, and as the representative of the EUGMS, my role was to present a lecture on European initiatives in long-term care medicine.

The conference was impressive in its combination of breadth and practicality, and I enjoyed the sessions on problem-solving in the nursing home, the assessment of decision-making capacity, and teaching strategies in long-term care medicine. The style was very interactive, and I was taken with the openness and honesty of the participants on areas with they were less familiar, a trait perhaps less commonly encountered in the learning style of European physicians.

Plenary sessions gave interesting insights into the funding and regulatory background to nursing home care, and there was quite an emphasis on post-acute care from hospitals to degree significantly more widespread than in Europe.

The trade exhibition also had a very different flavour, with outsourcing of various services, including laboratory and X-ray tests. One particularly fascinating initiative was a commercial service providing distance consultations using telemedicine with psychologists and psychiatrists, particularly for the behavioural and psychological symptoms of dementia.

One notable feature of the conference, despite geriatricians both attending and presenting, was what seemed to be a fairly marked separation between the business and policies of AMDA and the American Geriatrics Society.  As gerontology is at the core of the care of older people regardless of where they happen to be, and as both societies are modest in size in terms of the huge amount of older people in the USA and the enormous apparatus of its medical system, from the outside it would seem that maximizing a joint approach wherever possible would benefit both organizations.

For me, the highlight of the conference was the address from the incoming president of AMDA, Dr Jonathan Evans. Delivered in a sober and restrained manner, the text combined the aspirational with the personal and the pragmatic in a way that was touching, sincere and visionary. It can be difficult, in an ageist world and often ageist profession, to crystallize into words the rewards of caring for frail older people. Dr Evans created a shared vision which bound delegates together into a community with a shared mission. His language also shared an emotional aspect of love and affection that is all too often underemphasized in the discourse and practice of medicine.

Geriatric medicine is now well established in much of Europe, but Dr Evans provided words which provided an articulacy for my own reaction to the resistance, particularly from internists, to the principles of geriatric medicine earlier in my career.

“It has never bothered me too much that our field, our work, even our place doesn’t get the respect from other doctors and from all other clinicians and health care settings that it deserves. But it has always bothered me a great deal that our patients and their families do not get the respect that they deserve.

“It is therefore imperative that together we awaken the consciousness of our society, about all of the people whom we honor and celebrate every day by caring for them, and about the places where they live. For while we do not seek nor do we ever expect glory or prestige for ourselves, together we have to raise the profile of our community, in order to give greater recognition to the importance of our work, the people for whom our work is done, and the millions of others in long term care with whom we share this journey.”

His speech should be required reading for all who care for, or have responsibility for the care of, older people, and in the UK might usefully be considered as a part of the fresh start required after the disturbing findings of the Mid Staffordshire report.

Desmond O’Neill is a consultant in geriatric and stroke medicine in Dublin, and immediate Past-President of the European Union Geriatric Medicine Society.