(Editor's Xote: This position paper will be the foundation of the Academy's presentation to the White House Conference on Aging, whicli will be held in Xovember i081. We welcome readers' comments about this position paper.)
Statement of the American Academy of Family Physicians to the 1981 White House Conference on Aging
The American Academy of Family Physicians, representing over 49,000 family doctors nationwide, is actively concerned with the problems of aging and health care of the aged. Our members provide a great deal of health care to the elderly. Results from a recent survey of our office-based active members in direct patient care indicate almost one-fourth of their patients are 65 years of age or older. The 1977 National Ambulatory Medical Survey showed that 41.9% of all office visits by patients age 65 and older are handled by family physicians or general practitioners.
While family doctors are actively providing care to the aged, we recognize that aging is a lifelong process and believe that the problems of aging cannot and should not be narrowly defined in terms of physical age. We believe that the highest quality and most cost effective health care is provided as a continuum throughout the patient's life, and that the family physician is in a unique position to contribute to the total care of the patient at any age. Our concept of total care includes the maintenance of health as well as care of the ill, while taking into account the psychological and socioeconomic aspects of aging.
As family physicians, we agree with other experts who've pointed out that people do not suddenly transform into a different species at an arbitrarily predetermined age. Our practice philosophy of comprehensive, continuing care is based in part on the belief that health in later years is vitally affected by lifestyle and health care patterns established throughout life.
The American Academy of Family Physicians shares w the delegates to the 1981 1 te House Conference on Agint a serious concern about the effect which general health and health care delivery patterns have on thequality of life for our older citizens. It is our goal as family physicians to keep elderly persons functioning independently with self-respect, preserving their life-style as much as possible. To this end, we welcome this opportunity to suggest several points for your consideration.
Care with Caring
The practicing family physician brings a unique perspective to health care for the elderly. Patients, regardless of age, expect to receive continuing, comprehensive care from their family doctor. This implies advocacy in providing patients the best health care possible, including appropriate use of consultation and referral to other specialists when necessary.
Many of the essential ingredients of family practice are of the utmost importance in treating elderly patients and their families-compassion and humanism, continuity and comprehensiveness of care, bolstering of family and home, communication and counseling skills, preventive medicine and health maintenance, and an understanding of psychosocial and family problems. As a patient ages, it becomes increasingly important that the same personal physician serve as a friend, advisor, and advocate to the elderly person proceeding through the labyrinth of medical care. The term "geriatrics" as commonly used-to define care of the aged- separates such care from the preventive and comprehensive measures that should be a part of every individual's total health program. The family physician provides a continuity between health care in the doctor's office and care in the hospital or long-term care facility which may become necessary as the patient grows older.
Care of the elderly requires, above all, a concerned and humanistic attitude toward the whole individual and the family. This is what family practice is all about.
The American Academy of Fam ily Physicians believes that the most effective and positive approach to improving health care for the aged is a proper emphasis in each of the appropriate specialties, and family practice is working to accomplish this objective. Programming is under development to further assure that family physicians are well trained in problems of aging and medical care of the aged, and that a substantial part of their continuing education is directed toward these goals. We would urge a similar commitment within all existing specialties. Family physicians need to be certain in the case of that small percentage of patient problems which they appropriately refer to a limited specialist, that the consulting physician is thoroughly versed in the special problems and needs of the aged patient. The cardiologist... the gastroenterologist... all of the traditional specialists should be encouraged to gain a thorough understanding of the impact of advanced age in their areas of expertise.
The Academy's Congress of Delegates has endorsed multi-disciplinary efforts to establish undergraduate training programs, research, faculty development, graduate training programs, and continuing medical education in health care for this important and growing segment of our patient population. Further, the American Academy of Family Physicians has established an Ad Hoc Task Force on Aging to aid in the direction of these developments within family practice, as well as to study and make recommendations regarding areas in which family doctors and this association can have a positive impact in improving the health of this nation's elderly.
Other organizations in family practice are also moving ahead to emphasize this important aspect of the family doctor's practice. The Society of Teachers of Family Medicine has established a Task Force on Geriatric Education and is planning a national conference on this subject for the fall of 1981. The American Board of Family Practice is placing additional emphasis on problems of aging and care of the aged in their certifying examination.
The Academy is concerned that the burgeoning interest in geriatrics may give new life to the trend which has prevailed over the past thirty years-that is a commitment to disease and technology. America needs the best in research and sophisticated medical technology. But what our patients need most, the elderly included, is a good doctor. We believe the commitment to the individual person must not be sublimated to impersonal scientific technology. Funding for research efforts in problems of aging should not be directed from a reductionist point of view, with a subsequent failure to appreciate the full scope of environmental, psychological, family, and social factors which affect health.
To assure a continued commitment to the individual over technology, the American Academy of Family Physicians would urge delegates to this Conference to listen to the growing number of experts who are counseling against the formation of a new practice specialty in geriatrics. One of the major problems confronting health care today -over-specialization -tends to deprive the elderly individual of a doctor with responsibility for caring for a whole, aging human being. We submit that it would be a form of "ageism" to require an individual of age 60 or 70 to leave his or her personal physician and turn to a new practice specialist, the geriatrician. We believe the best geriatrics in America will be accomplished by capturing the interest of all medical specialties represented in the academic community.
For our part, we believe family physicians are well qualified to provide effective health care for the elderly, stressing health maintenance and disease prevention. By coordinating health care over a number of years, the family doctor endeavors to keep older people well enough to work and function independently. The family physician is attuned to the loss of selfesteem which may result from the multiple losses encountered in aging. His on-going relationship with the patient aids in gauging the effects of chronic and degenerative disease, as well as the effects of psychological, socioeconomic and environmental handicaps, limitations of activities, and loss of functional effectiveness.
In the best interest of the patient, the family physician often must apply the principle of minimal interference-not only in drug therapy but also in such decisions as surgical intervention, the use of diagnostic tests and institutionalization. Intelligently viewing the patient's total situation results in more humanistic and cost-effective health care. Decisions based on an orientation toward technology and disease rather than toward the person can be absurd. The family physician can make more intelligent treatment decisions when he is aware of the patient's total medical picture, home environment, and family constellation.
Alternatives to Institutionalization
This knowledge of the patient's home and family also helps the family physician evaluate those means which would permit the patient to remain at home either with spouse, with family, or alone. It may be more critical for the patient to remain in the comfortable and familiar environment of his or her own home, or in the homeof a family member-despite limited access to therapy-than to reside in a longterm care facility at some distance from home. We believe the prescription for a nursing home should be as specific as a prescription for any drug. The family doctor is in a position to be aw^e of the full range of resources whiai are available for patients and their families, encourage their appropriate usage, and to play a key role in therommunity in developing these needed resources.
There is evidence that although American life has stressed independent living, there are still many families attempting to keep an elderly member at home. It has been estimated that for every person in a nursing home there are as many as two equally disabled persons living in other settings, either in an extended family or in the individual's own home. These families may be faced with several problems. Increased mobility may put familymembers at a great distance from their elderly relatives. Many homes are not adequate physically to house an elderly person. Women joining the work force are finding themselves under great personal stress in their attempts to handle both their new job positions and the care of impaired elderly patients at home.
The American Academy of Family Physicians believes the White House Conference on Aging should place special emphasis on bolstering the family and home and establishing alternatives to institutional care. In the near future, we will see the emergence of many options. Among these, we believe that home care, day care and experiments in transportation and housing will represent important developments and deserve your careful attention.
Appropriate Revisions in Reimbursement Policies
We believe the White House Conference on Aging can help effect vast improvements in health care for the elderly by strongly supporting appropriate changes in third-party reimbursement practices. Currently, such practices are woefully inadequate when it comes to comprehensive and preventive care. The Medicare system, for example, provides reasonably good coverage for the acute phase of health care. But beyond that, there is little help for the chronically or terminally ill patient. That is. of course, until medical expenses reduce the elderly citizen to poverty. Then, and only then, does the Medicaid program offer a wider range of benefits for long-term care of the elderly patient. As family physicians, we cannot accept a policy which forces our aged patients to endure a loss of financial security in order to qualify for assistance in obtaining comprehensive health care.
We believe the delegates to this Conference can make a significant contribution to the health and wellbeing of this nation's elderly by calling for a redirection of thirdparty reimbursement toward supporting prev entive and comprehensive care. Further, the current system of long-term care must be revised. Society is currently willing to spend large amounts of public funds for the institutional care of the elderly with no equivalent support to families who choose to shoulder the burden of providing care in their own homes.
Bolstering the Family and Home
Present governmental programs often penalize the elderly who live with their children or relatives. Supplemental Security Income (SSI) payments may be greater for those who are living alone or in an institution than for those elderly who are living with a family (where there may be no payment at all). Eligibility for programs such as Meals-on-Wheels and home health care might be denied if an elderly person is living with family, but would not be denied for an elderly person who is living alone.
We believe that changes must be made to encourage the extended or multigenerational household. Problems of adjustment in these families could be eased through modifications in the Internal Revenue Code to assist such arrangements. Of great interest would be the development of tax credits for family-oriented care. A recently completed demonstration project in Maryland provided financial assistance to families caring for elderly impaired relatives at home. Results from this project will provide information as to the types and range of expenses involved in providing family oriented care. This should prove to be an important step in developing fiscal policies which will support the family setting, rather than actually penalizing attempts to keep an elderly parent in the extended 01 multi-generational home.
The family physicians of this country are deeply committed to providing comprehensive care to the elderly patient-integrating biomedical, psychosocial, family, and cultural information. We believe that the perspective we gain by caring for the aging patient over a period of years, as well as our training and experience in the special problems of the elderly, allows us to offer intelligent treatment utilizing the principle of minimal interference. The American Academy of Family Physicians is working to assure quality education in this arena for the young doctors in our residency programs, as well as continuing medical education on the problems of aging and care of the aged for our physicianmembers in practice.
We urge you, as our patients and as concerned citizens, to work for positive changes in the current system which will bolster the family and home, provide adequate reimbursement policies, and allow your family physician to utilize appropriate support services in health care treatment. All these changes will further our goal of working toward independence and dignity for our elderly patients. The American Academy of Family Physicians wishes the 1981 White House Conference on Aging the very best in its deliberations, and looks forward to thoughtful recommendations which will improve the quality of life and health for our nation's aged.