One of my goals over the last few months has been to improve my efficiency. Coming from a health care system where physicians are salaried, I was incentivized to prioritize comprehensiveness over efficiency. The more time I spent with each patient, the less patients I saw, follow up becomes easier, and my exposure to litigation is minimized. However, this did not translate well in the Canadian health care system where physicians are incentivized to maximize the number of patients they see in a day. Both models have their pros and cons and I was reminded of the cons of the Canadian way in my geriatric rotation.
Patients who are referred for a comprehensive geriatric assessment have specials needs that render the traditional Canadian model of health care ineffective, despite its efficiency. If you are an internist who is referred an elder patient with weight loss, you may be able to perform your tried and true clinical screening assessment for patients with weight loss and not identify any causes. After a 30 minute clinic visit, the patient goes home with appointments for a full body CT scan, an endoscopy and a colonoscopy. Within two weeks, he’s back in clinic with a wealth of information about his body. However, despite your new knowledge of his previous exposure to asbestos, a left adrenal nodule, a right renal cyst, atrophic gastritis and a colonic polyp, you still don’t have an explanation for his weight loss.
The truth is that your patients wife died a year ago. They lived together for 65 years and she cooked all his meals. Since the passing of his wife, he moved in with his 64 year old son. Your patient doesn’t like the taste of the food they prepare at the sons house. He is also finding it difficult to chew on this food with his poorly fitted dentures. The passing of his wife prompted him to seek medical advice as he hasn’t seen a doctor since his last family physician retired five years ago. His new family physician diagnosed him with type 2 diabetes based on a hemoglobin A1c of 6.8% and started him on metformin 500 mg twice daily. Those are all the reasons why he’s losing weight. But you would not diagnose any of that in your typical 30 minute internal medicine clinic consult.