The Question: At the long-term care home where most residents on my mother's ward are in their late 80s, the doctor was due every Thursday. He did not do rounds or examine residents. Instead, he sat in the nurses' station and leafed through the notes nurses had written. I found it disgustingly neglectful. What should I do?
The Answer: It sounds as if the doctor isn't doing anything wrong, but he's providing the bare minimum. This is likely why: Most physicians are remunerated on a fee-for-service basis which means they are paid the same amount per visit whether they look at a chart or examine every resident. Since long-term care homes have trouble attracting doctors, there is little competition for the job.
I asked Paddy Quail, president of the Long-Term Care Medical Directors Association of Canada, what he thought about your mother's situation and he seemed similarly concerned. While the physician is technically providing the required care, "it doesn't seem right to me."
Nursing and long-term care homes are institutions where residents – mostly women, aged 85 with dementia – reside. They stay, on average, 18 to 24 months before they die. Comfort and ease of suffering are the goals of care. These homes are a last port of call, and are heavily regulated by government; the medical portion is funded by the province and residents pay a boarding fee.
A doctor in a long-term care or nursing home reviews the care plan of each resident. About once a year, that plan will be reviewed in a family meeting; more often if there is something pressing.
On weekly visits, doctors rely heavily on information from nursing staff, who know the residents more intimately. If a nurse suggests a resident needs to be examined, the doctor will do so.
Dr. Quail, medical leader for integrated home care, Alberta Health Services, Calgary zone, says he likes to be more engaged in a patient's care. That can include strategies to help prevent falls and wounds, make sure medications are correct, treating infections and ensuring residents are not wet and are comfortable.
"I make a point of seeing my patients once a week and I try to see everybody, even if they are at lunch just to touch base," Dr. Quail said in a telephone interview from Calgary. "It's partly the relationship, it's partly social, it's partly that I want to see with my own eyes that they are having their breakfast and eating independently. I feel happier when I've left the building having seen everybody."
Dr. Quail said there's reluctance for families to complain for fear of retribution, but he thinks your concern is "fairly significant" and that, in your shoes, he would speak to the director of care for the home.
Ask what the role and expectations are of the physician visiting the home, and then articulate your concerns.
It's a tough conversation to have, given thepower imbalance, but I think advocating for your elderly mother is a risk worth taking.
The Patient Navigator is a column that answers reader questions on how to navigate our health-care system. Send your questions to firstname.lastname@example.org.