Throughout his medical career, Dr. Carl Hammerschlag has challenged conventional thinking. This is evidenced by his philosophy and execution of his medical practice, his lack of pretense, and his conviction that embracing change is the only way to manage it. In this 5-minute Consult, aka the Geriatrics interview, Dr. Hammerschlag shares his insights on how physicians and other health care providers can engage and assist patients and their families in the practice of geriatric medicine. Q: The Institute of Medicine's (IOM) recent report on the sorry state of the geriatric workforce rightly points out the many things that are being done wrong. Yet you espouse the simple philosophy, "If it doesn't feel good, you aren't doing it right." You've used the example of Dr. Dean Ornish and his work with cardiac patients. How can the health care system and medical profession ?get this right? so we can better treat our geriatric population?

Dr. Hammerschlag • HealingDoc.com, his popular blog, features a weekly "Schlagbyte" video

We as physicians will do the reimbursable procedures. However, we don't take the time to listen to our patients, because we don't get paid for the cognitive part of our work. Yet we need to build relationships with our patients. This involves honest exchanges of heart and soul. All people need that, but we especially need that as we age.

Q: On your web site, you (jokingly?) state, "no more discounted fees for me," in reference to the work of Plassman et al.¹ They showed that the brain changes in anticipation of an enhanced experience if one pays a premium (they used pricey versus cheap wine?you wondered what Eliot Spitzer got for $1,000 that he couldn?t get for $100).

In this vein, the IOM (and others) have noted that one cause of the geriatrician shortage is the low pay relative to other specialists. Should geriatricians simply charge more, to make their services more hotly anticipated and valued? What constitutes the value that a geriatrician brings to the older patient and his or her family?

CH: Regarding Spitzer's expenditure, it turns out that it's not what "Kristen" did for "Client #9" that made her worth the money. Rather, as Plassman et al found, it was what he anticipated. Many studies have revealed that people's judgments about quality are powerfully influenced by price--ie, expensive things have higher quality. And this is not just a placebo effect; by using neuro-imaging studies, Plassman et al found that the brain actually experienced pleasure more intensely. The medial orbitofronal cortex, which makes judgments about pleasure, lights up more if you pay a premium for something, because your investment actually increases the motivation to be satisfied.

Translating this type of research into an increased value for geriatricians' services is not as easy as simply raising fees. Unfortunately, time is not a reimbursable commodity, which mitigates against the building of relationships. We have to somehow change the definition of "value" in medicine, and be willing to expand the treatment model. Most geriatricians are already doing this, even though they are not being reimbursed for it. And given the current reimbursement structure and mindset--which says that you can't spend time with your patient--it remains the case that we do our best at acute interventions.

Training in this new model must include training physicians to have relationships. We need people who can talk to the aged. People who ask, "tell us about your life." Or, "tell us your story." We must allow patients to participate in their health care. The health care professional who does this does not necessarily have to be the geriatrician, by the way. This is a team enterprise, and frankly, there are other people who can do this better. But the physician needs to be the captain of the team. The geriatrician is the ultimate collator of information, once it is collected. It is the geriatrician who must ultimately analyze the information and then act.

Q: You spoke at a recent American Medical Directors Association (AMDA) meeting, and challenged the audience with the question, "are you a healer?" It is not possible to "heal" old age. Many of the issues that the geriatric population brings to the physician are complex and won't necessarily improve. How does one "heal" in that situation?

CH: The professionals who comprise AMDA are geriatricians, gerontologists, and palliative-care specialists who run long-term health care facilities. I reminded them that there is a difference between curing and healing. They know their frail patients will not be cured of their debilities, but they need to be touched, loved, and reminded that they are not alone. This is the sacred work of medicine: to inspire hope and to walk the healing journey together.

Geriatrics may be the last place in clinical medicine where doctors still take time to talk to patients. These doctors spend less time prescribing drugs and procedures, and more time with patients and families, helping them come together and heal. The geriatrician allows people to "be where they are." I take this concept from Ghandi's line, "If you're going to be somewhere, be there." If you are 90 years old and frail, you have to learn to self-accept. If you are a geriatrician taking care of that elder and his or her children, you too need to fully be there. Not just with your head, but with your whole heart as well.

Q: Does that mean accepting the situation you find yourself in and moving forward? Is that what geriatricians need to do--make peace with the difficulties of their practices?

CH: Exactly. However, as much as I believe that truth, it's always been easier to talk about it than to do it. One of my recent blogs (May 25 weekly "Schlagbyte") consists of my public statement that I'm going to take this healthful step and practice truly being where I am. I find it almost unfathomable that I'm getting close to 70 and increasingly being reminded of my mortality. I tire more easily and take longer to heal; I'm slowing down by every parameter. Slow is not stop, mind you --I swim regularly, have a daily yoga practice, I continue to work and write. But I want to relax more and do what I really want to be doing: teaching, traveling, fishing, and telling stories to my grandkids while they're still listening to me.

It's been hard for me to slow down; at first the justification was funding my retirement plan. Then it was those old tapes playing in my brain: slow is just a step away from stop; slow down and you'll lose the competitive edge, become less competent, yada, yada, yada. It's time to get over it, tame the ego, acknowledge my truth in every moment and truly be where I am.

Geriatricians need to do this as well. I know that many already do, which in turn allows their patients and their families to "be where they are."

Q: Sort of a "doctor, heal thyself" mindset?

CH: Yes.

Q: You're an expert in the practical applications of psychoneuroimmunology (mind-body-spirit medicine). What does that mean, and how can practitioners who treat older adults incorporate its tenets into their practice?

CH: You can learn so much in a 10-minute interview. For that interview to be effective, you must make a connection. If you do that, you'll get more out of those 10 minutes than you'll get from multiple diagnostic studies and lengthy questionnaires. So how does one do this? Ask patients, "how is it that you've come to this stage in your life, to these events"? Do not merely ask about how many pills per day they are taking. It is a matter of helping people become agents in their own healing process. It is not just you, the physician doing the "healing." It is a team process, and the patient is a key player.

By the way, the stories of your patients' adulthoods should be told sitting down--both the patient and interviewer. You can have volunteers or other staff members take these histories. There are particular questions that will help you get the most out of these interviews. The Life Stories program questionnaire used by Banner Baywood Heart Hospital is excellent and available to all (Life Stories program explained). When you look at the questions, you'll notice that they tend to be open-ended, which elicits more complete responses from older persons.

Once the stories are collected, they need to be made available to everyone who comes in contact with the patient. I strongly advocate placing the stories in the medical chart, in the clinical notes. This way, everyone has access to these histories, and can avail themselves of the richness of the material. It also serves to give points of identification to these patients, who are so much more than bed numbers.

Q: Please comment on the concept of the "dread zone" as it applies to people's dread of getting older, and physicians' dread of treating the Boomers.

CH: In the current culture, the idea of the aged or aging is anathema. We are all terrified at the thought of death. Youth is the ideal in this society, and we relegate older people to what I call "grey leper" status. Instead of being something that is natural, growing older is a shortcoming.

Look at the stories that are circulated in the larger culture. Those who tell the stories--in any culture--define that culture. In this culture, the stories are told by the movies, and video. In those stories, being old is unacceptable.

The dread is really a desperate bid to avoid aging--to avoid what is a biological decree. On the other hand, with new technologies and health developments, we as a species have a shot at getting to age 100 within the next 50 years. We are on the edge of a new future of prevention and prediction.

Q: Thanks for this 5-minute consult. Any final thoughts for your colleagues to help them better meet the challenges in today's practice of geriatric medicine?

CH: Geriatricians should know:

• It's the story. Everything begins and ends with the patient's story.
• Geriatricians are blessed.
• They care for a population who welcomes them now and will welcome them into their ranks in the future.
• Their work is holy work.
• They are the last bastion of medicine that is making soulful connections to patients.
• Practice radical self-acceptance as humans, and as doctors. Remember, "Where I am is where I am supposed to be." Bring that mindset to patient-care encounters and you will have done your patients a great service.
• We cannot alter completely the biological decree to age, but we can walk the path with our patients, talking to them, and teaching them.
• Be that healer who connects with the soul of a patient--so that even the Alzheimer's patient, who may be only able to smile and blankly respond, or the stroke patient, who feels locked inside their body--will know that they aren't alone.