Speaking of Nursing Homes

“I guess old Snodgrass had the last laugh.”  I told Lapius, after his uninspiring appearance before the August body. “I don’t know if you were embarrassed, but actually he practically asked you to sit down and be quiet.”

“Of course I was not embarrassed,” Lapius fumed, “I expected nothing more from a man whose mind is as arcane as the dark side of the moon.”

“So why did you go in the first place?”

“Civic duty.”

“I really believe that you meant that,” I said.

“Of course I mean that.  One of the terrible things that has happened to this country since the McCarthy era is that people no longer speak out as individuals.”

“Come on, Simon,” I chided, “actually everyone is speaking out.  There is Woman’s Lib, union leaders, the AMA, the AHA.  Each has its spokesman.”

“Precisely my point," Lapius said smugly.  “People speak out only in groups or as representatives of a crowd or a mob.  They are afraid to speak independently as individuals, representing their own point of view. First they find a group that approximates things they believe in.  Then safely within the confines of the crowd, they speak.  The McCarthy era.  Charlie not Joe.”

“Well, you saw what good it did to present yourself at the August body and speak as an individual.”

“Yes.  No good at all. But it kindled satisfaction in my soul.  Actually, there is a point to be made.  The fact is that nursing homes are medically wrong.  In the first place too many are substandard. Secondly patients cannot easily be examined in these places, because there are usually no examining rooms and doctors must see their patients in the confines of a semiprivate room.  The beds are so low that a sacroiliac sprain is the reward of a proper examination. The rooms are poorly lighted.  There isn’t enough help to properly position the patient.  The records are unkempt.  The laboratory work is often disorganized.  And the places are not convenient for doctor visits.”

“What I was trying to point out to the August body, was that the nursing home should best be handled as a group practice.  There should be an examining room or two, staffed by trained nurses. A group of doctors should hold an outpatient clinic daily, so that all patients can get immediate care for even minor complaints and not have to wait until their doctor comes to see them.”

“You are getting into dangerous ground there, Simon,” I said.  “That would clearly interrupt the doctor-patient relationship.”

“Of course.  But the doctor-patient relationship really applies to the younger age group.  We must not be deceived that this same relationship is as important to the very old, crippled and senile in nursing homes as it is to the young family.

“In the first place, residents of convalescent homes are already under domiciliary care.  Secondly, their medical problems have already been defined.  Thirdly we are not going to do major surgery on the 85 year old paralytic. We are just trying to maintain him in comfort and dignity.  Patients in convalescent homes have multi-system diseases.  Their bones are soft, their joints ache, their hearts are distant, blindness of one degree or another accompanies partial deafness.  Each patient is a virtual clinic of diseases.

“Their family doctors really don’t have time to run over to see them as often as their complaints warrant.  How much better off they would be with a doctor on premises for a few hours a day so that there could be continuous care and reassurance.  It could easily be set-up.”

“You make a persuasive argument, Simon.  What is stopping it?”

“Probably the medical society misguidedly trying to preserve the doctor-patient relationship.”

“But they should, shouldn’t they?”

“Of course they should.  But in the larger arena, where it counts.  The society feels it is against their canons to institute a group practice in a convalescent home, but on the other hand they support PSRO, and utilization review in private practice, measures that are certain eventually to intrude into the relationship between a family and its doctor.”

“You agree, then, that the instinct to preserve the relationship between the patient and his doctor is correct.”

“Of course the instinct and purpose are correct.  But they are being misapplied.  A nursing home is not really the best arena for private practice.  It lends itself in particular to the HMO concept.  The ingredients are conventionally gathered.”

“Maybe you are right, Simon, but I am afraid that nobody will buy it.”

“Well, another alternative would be to have at least one wing of every nursing home equipped as a non-surgical hospital, so that patient’s ill in the nursing home part could be moved to the wing to receive the benefits of hospital care.  This would add countless beds to the hospital system at much lower cost than those in hospitals equipped for surgery. And if the hospital beds are empty, they can be used for convalescent beds.  In other words, take the rigidity out of the system.  Make it more pliable in response to the needs of the community.”

“Sounds great Simon, but who is going to listen to you?”

Lapius peered at me over his bifocal lenses.  “You listened, didn’t you?” he asked.