DEMENTIAINSIGHTS By David S. Geldmacher, MD

In Search of Marcus Welby

The spectre of the good doctor looms over modern medicine. Can we close the gap between patient expectations and the realities of clinical practice?

n the early 1970s, “Marcus Welby, like Marcus Welby, doesn’t it? patients may believe there is no reason for MD” was one the most popular These aren’t new themes. Several years them to be in the doctor’s office at all. shows on TV. Dr. Welby represent- earlier, the noted medical ethicist Edward Also, their ability to process and retain ed all that’s good in the medical Pellegrino described what he perceived to complicated information is, by defini- Iprofession. The show spawned con- be key virtues of a good physician. These tion, impaired. That may be why people troversy, not only because it broached included the similar ideals of benevo- undergoing cognitive assessments report topics new to TV like drug addiction, lence, compassion, courage, fidelity to anxiety and confusion about the purpose sexually transmitted disease, and even trust, intellectual honesty, prudence and and meaning of the testing.5 The same pedophilic rape, but because it also set an truthfulness.3 Probably most of us would deficits in information processing lead exceptionally (unrealistically?) high stan- come up with a similar list of ideals, but most physicians to rely on family mem- dard for physician competence, dedica- it is increasingly difficult to stick to them bers for information that might otherwise tion and humanistic interaction. in our current environment of declining come from the affected person. This pat- Some critics claimed that the show reimbursement, overwhelming paper- tern marginalizes the input of the “actual” contributed to the increase in malpractice work and tighter regulatory oversight. Dr. patient even more. As dementia progress- cases that was becoming evident at the Welby wasn’t often depicted as facing es nearly all communication bypasses the same time. Robert Young, the actor who those struggles while being a nearly per- patient entirely, being conducted solely played Dr. Welby, had chronic health fect physician, but they are inescapable with the caregiver.6 problems himself and believed strongly elements of the practice of medicine in Dementia care is also complicated by that all physicians should be like his char- the 21st Century. the fact that we often end up managing acter. He was once approached by an the needs of family caregivers right along- actual family physician who told him, Picking up Static side those of the patient. There are major “You’re getting us all into hot water. Our As practitioners seeing dementia patients differences between the usual dyadic patients tell us we’re not as nice to them today, however, we’re on the spot, because communication between patient and as Doctor Welby is to his patients.” while we’re dealing with those annoy- doctor, and what Richard Fortinsky has Young is said to have replied, “Maybe ances and high patient expectations for called the “health care triad” interaction you’re not.”1 Perhaps he was right, but physician performance, the physician is in dementia.4 In many ways, the caregiv- coming from an actor and not someone the first and only contact with the health er becomes a hidden patient—not billed, who had ever been responsible for deliv- care system for many families seeking not prescribed for, not directly managed, ering effective medical care—and earning dementia care.4 Unfortunately, relatively but still a recipient of our attention and a living by doing so—that must have little is known about the desires of the care. stung. patient with AD. Since it appears that the Caregivers have their own health and My thoughts turn to Marcus Welby person with AD retains a strong sense of social agendas and often pursue them in because of a recent study published in the his or her individual identity, it’s probably the context of care for the patient. This Mayo Clinic Proceedings that reported safe to assume that in the mild stages of has been particularly evident to me when patient perceptions of desirable physician the disease the patient’s desires would hallucinations are prominent in patients behaviors.2 Based on an analysis of overlap closely with those of the unim- with otherwise mild Lewy body demen- patient surveys, the authors identified paired people in the Mayo Clinic study. tia. The patients are often completely seven behavioral characteristics of an Nonetheless, the patients’ unawareness of untroubled by the hallucinations, but ideal physician. These were: confident, deficits that often accompany AD can caregivers become very distressed. The empathetic, forthright, humane, person- make things very difficult, because— caregiver is likely to be the one to raise al, respectful and thorough. Sounds just unlike headache or MS patients—AD the issue, too. So should we treat the care-

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giver’s concerns by giving the patient a like to be informed of the results of the drug? Probably not, but the time it takes Ideal physician behavioral evaluation. Sharing the sad news of an to sort through these third-party issues characteristics AD diagnosis in a forthright yet humane can be prohibitive in the office setting. manner that neither candy coats the diffi- Although it’s not “right,” sometimes it’s Confident cult truth, nor denies hope, rounds out just easier to write the prescription. the basics of the seven principles. The general preferences of caregivers Empathetic Beyond that, the literature tells us that in the dementia encounter have been Forthright caregivers want to know what to expect identified over the years. Some of those next and how they can get help for the include a desire for a clearly stated diag- Humane social and psychological needs that are nosis, practical information on how to Personal sure to emerge. To meet those needs, and manage symptoms, anticipatory guidance simultaneously reduce the burden on our (answering the question of “what comes Respectful offices for providing that help directly, we next?”), referral to community-based Thorough can learn what resources are available in resources, provision of emotional sup- our own communities and refer families port, and balanced discussions of medica- to them or to a nationwide organization tions. Historically, caregivers have Source: Benapudi et al, Mayo Clin Proc like the Alzheimer’s Association expressed dissatisfaction with the diag- 2006;81:338-344 (www.alz.org or 1-800-272-3900). nostic and management process in Do I meet every family’s needs as well dementing disorders, especially when it as I should? Certainly not. There are comes to sharing information about how many who choose never to come back to the diagnosis is obtained, what commu- me. For one reason or another, I didn’t nity resources are available, and the social meet their needs or expectations. But and psychological consequences of the how do I measure up on the “Marcus dementia. Perhaps not surprisingly, we Welby” test? Reassuringly, I fare pretty seem to do best when it comes to dis- well, as do most of you. After all, Dr. cussing medicines.4 Welby got canceled after just seven sea- Of course, not all caregivers have the sons, and I’m still going strong after a lot same opinion on how to handle inform- ers. Unfortunately, as neurologists, we are longer than that. PN ing them and the patient of a dementia the recipients of those ignored and 1. Turow J. Marcus Welby, MD. Archives of the Museum of Broadcast diagnosis. In one survey, 56 percent of referred problems. Communications. http://www.museum.tv/archives/ etv/M/htmlM/mar- caregivers wanted to hear the diagnosis of cuswelby/marcuswelby.htm. Accessed 4/15/06. dementia separately, before the patient is Improving the Reception 2. Benapudi NM, Berry LL, Frey KA, et al. Pattients’ perspectives on ideal physician behaviors. Mayo Clin Proc 2006;81:338-344. told, but 31 percent said they wanted to So what should we do? Well, first we 3. Pellegrino ED. Professionalism, profession and the virtues of the good receive it with the patient present. Most would all probably do well to think about physician. Mt. Sinai J Med 2002;69:378-384. families who want the diagnosis to be those seven qualities of the ideal physi- 4. Fortinsky RH. Health care triads and dementia care: integrative frame- work and future directions. Aging & Mental Health 2001;5(Suppl.1)S35- shared with the patient want the bad cian and make a conscious effort to apply S48. news to come from the doctor, but some them in the setting of dementia care. I 5. Keady J, Bender MP. Changing faces: The purpose and practice of assessing older adults with cognitive impairment. Health Care in Later want that information to come from fam- don’t think we can go wrong there. Being Life 1998;3:129-144. 7 ily members. But, the key phrase in that confident and thorough arise naturally 6. Beisecker AE, Chrisman SK, Wright LJ. Perceptions of family care- sentence is “who want the diagnosis to be out of a solid knowledge of the epidemi- givers of persons with Alzheimer’s disease: Communication with physi- cians. American Journal of Alzheimer’s Disease 1997;12:73-83. shared.” Depending on the study, the ology, clinical expression and diagnostic 7. Brodaty H, Griffin D, Hadzi-Pavlovic D. A survey of dementia carers: proportion of caregivers who want the criteria for various dementia types while Doctors’ communications, problems behaviours, and institutional care. patient to be given a specific diagnosis, following the published practice parame- Australian and New Zealand Journal of Psychiatry 1990;24:362-370. like AD, ranges from 17 to 100 percent! ters for the assessment of people with David S. Geldmacher, MD is Associate No wonder so many primary care doctors apparent dementia. The empathetic, per- Professor of Neurology, Director of the report that providing dementia care is sonal, and respectful qualities might Memory Disorders Program and extremely challenging, and some avoid bring us to tell the patient and family Medical Director of the Fontaine Adult Neurology Clinic at the University of the issue altogether by ignoring it or together what we plan to do to assess the Virginia in Charlottesville, VA. referring their dementia patients to oth- problem, and ask them how they would

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