I'm pretty lucky having a primary physician whom I consider a friend. I guess I'm also lucky in that well into medicare age, I'm relatively healthy. Especially since all of my direct male progenitors were long gone at my age. What looms over my head is Alzheimer's disease, those who lived long enough in my family having been so afflicted. My mother's beginning around my current age, which gives the probability for me as well over 1 in 3. My response to this fear has been something like the main character in the 1965 film, "Charly." It was about a man, born with severe mental retardation who was able to take a compound that supercharged his intellect, allowed him to do advanced biological research, and form his first romantic relationship; only to discover to his dread from the decline of the original lab rat that this medicine was only a temporary fix. He passionately applied his fading skills to understand the biochemestry of the drug, day and night in the lab, as his intellect, and his love affair with his scientist lover, all faded away-- until the final scene of him on a swing in childlike simplicity.
Like Charly I am using my intellect and my academic training, not to prevent the inevitable decline (in a year, a decade, or several, but inevitable as death itself) rather to make it no more painful than it need be. Yesterday's "Annual Wellness Visit" or AWV with Dr. Bob was a part of that quest, as is writing about it on this site. I have done extensive research on this procedure, AWV, which on its face seems like a way to provide all the benefits of modern medical science to extending the well being of the elderly-- a gift from God, or President Obama, or from the taxpayer, whatever your conceptual preference.
Just this week, I discussed this issue with some friends, who are never shy in telling me when I'm way off base about anything. They challenged me to make my point succinctly, or it will be lost, so here goes. When your doctor asks you whether you would like the annual examination that you are now allowed under Medicare, ask him/her whether they are referring to "The Annual Wellness Visit" which is called AWV. This is not a full examination, which is why they use the word "visit" but it does touch on some quite sensitive areas where the patient should not be a passive participant. ANW is part of a sequence that is meant to start when a person reaches 65 and is allowed "Welcome to Medicare Preventive Visit" (Officially described here, with the AWV and further detailed links)
These sensitive issues are assessments of depression and cognition,which tend to become more of a problem as people age. During that first Welcome to Medicare visit, another sensitive issue, defining end of life directives, was dealt with by explicitly requiring that the physician get permission to talk about this. This leaves the impression that the patient must cooperate in the discussion of other elements, that they must submit to a cognitive test and a screening for depression. From my experience yesterday, that's not the case.
But that doesn't solve the problem, not by a long shot. The asymmetric interaction between medical authorities and others is defined by culture more than by law, as Stanly Milgram showed us. For many people entering a doctor's office means relinquishing autonomy, "Doctor knows best" becomes the operative rule; even when for a given "condition" such as one's deepest feelings of unhappiness with life, there is little evidence of an effective treatment.
While the Welcome to Medicare-AWV could be valuable as a list of conditions that are amenable to being treated, the very act of becoming more passive, of learning about conditions such as memory decline with no current effective treatment, has been shown to increase emotional distress. Whether my relationship with Dr. Bob is the norm or the exception matters. He knows and respects my academic interest in this subject, but he went through the list of mandated procedures required by Medicare. When he asked the question about my memory, it was direct and he is sensitive to the various responses that he gets, from shrugging off a bit more forgetfulness to someone who is seriously concerned. He has a standardized test available that he will offer to those who want it, and he will help the patient understand the meaning of it.
But how will Dr. X handle this, or perhaps a young PA, physician's assistant, who saw a new elderly patient. Or how about a very busy Physician who assigned a dietitian on her staff to handle the entire ANW with a new patient (yes this is allowed.) Will they know the full consequences of informing someone that their cognitive decline is greater than normal? Will this lesser trained professionals have the disciplined empathy to handle this precipitated crisis, when even those with a decade more training can fail.
My friends told me that I should keep this brief, so I will finish this one with an invitation for those who are interested in this subject to follow up. My research has been on the adverse side effects of these two Medicare preventative visits, which like any treatment should not negate their usefulness, how they can be of great benefit to those who avail themselves of it.
The purpose of my research and writing (other than the "Charly" factor) is improvement of these Medicare preventative services to address the vulnerabilities I describe. For those who are interested in looking under the hood, digging into the law, the research and the deeper consequences of this subject, this detailed essay that expands on what is discussed here would be good place to start.
Like all of our important interactions some balance between trust and cynicism is appropriate, different for every person and occasion. Under ACA we are embarking on a major restructuring of medical care delivery that will necessarily impact some of our fundamental cultural assumptions. We as patients, and as citizens, have an obligation to be active participants in continuing to refine this landmark legislation.