March 20 is the National Day of Recognition for Long-Term Care Physicians

karl_steinberg_w_dogsMost people probably don’t know that March 20 is the National Day of Recognition for Long-Term Care Physicians. In 2010, Congress made that designation to honor doctors like me, and Dr. William Dodd, one of the founders of AMDA and a luminary in long-term care medicine.

You might be wondering, what is AMDA? I’m glad you asked. AMDA—The Society for Post-Acute and Long-Term Care Medicine, was originally convened to serve as the organization for nursing home medical directors since this position was mandated by federal law decades ago. (Many still associate us with our old name, which was the American Medical Directors Association.)

I am blessed to have a job I love. Depending on what kind of mood I am in, I may tell people I am a SNFologist, a nursing home doctor, a palligeriatrician, or a variety of other labels. (A Skilled Nursing Facility is often referred to in the healthcare industry as a SNF, pronounced “sniff.”)

What do I love about being a nursing home doc? Well, among other things, I love:

  • The luxury of being able to take as much time as I need at the bedside of a patient—to discuss really important issues like goals of care and treatment options near the end of life—issues that a patient’s primary care doctor and specialists have rarely broached with them.
  • Getting to take my dogs to work every day.
  • The opportunity to de-prescribe: stopping unnecessary and toxic medications that have accumulated on my patients’ medication lists over the decades.
  • Being able to help patients and their families concentrate on quality of life and relief of symptoms—providing appropriate palliative care for people with a variety of chronic conditions, including dementia.
  • And, believe it or not—while not exactly Disneyland—nursing homes have their own special charm, color and culture. It’s not for everyone, but for those of us who choose to work there, for the most part, we do it because we love it.

Nursing homes have changed a lot over the last 25 years

Medical directors for nursing homes are “responsible for the implementation of resident care policies and the coordination of medical care in the facility.” This is a tall order!

Nursing homes look a lot different today than they did 25 years ago when I first started doing this kind of work. We have managed to reduce the use of physical restraints from around 30% to roughly 1%, and many facilities are restraint-free.

When I was in medical school and residency (back in the ‘80s before the implementation of the Omnibus Budget Reconciliation Act, or OBRA), many nursing homes (or “rest homes,” as they were sometimes called) looked like a scene from One Flew Over the Cuckoo’s Nest. Patient were kept highly sedated with traditional antipsychotics like Thorazine and tied to their recliner chairs or beds. Today, the rate of use of antipsychotics has been reduced substantially to less than 20% (and better still in California), and while they are still risky, the commonly used medications have significantly less of some of the serious side effects.

Another change in our nursing home setting is the types of patients. Skilled units in SNFs are more like units on an acute hospital’s medical/surgical floor than the rest homes of yesteryear. We do intravenous hydration and antibiotics, complex wound care, tube feeding, and high-level rehabilitation. We take care of very sick individuals—hospitals continue sending patients to SNFs “sicker and quicker” while nursing homes fear sending patients back to the hospital now that there are financial penalties to the hospital (and soon to the nursing homes too) for excess 30-day readmissions.

In the old days, family doctors would follow patients from their offices to the hospital and over to the nursing home. Starting with the introduction of hospitalists in the ‘90s there has been a tendency to compartmentalize (or silo-ize) care, at least in part for efficiency. SNFs have the unenviable distinction of being the most highly-regulated industry in the country (some say the nuclear energy industry is more highly regulated), and it’s important for docs who practice in nursing homes to know what we are doing both from a clinical and a regulatory standpoint. Where does a doctor, nurse practitioner or physician assistant gain that expertise? From AMDA!

So, if you know a doctor who works in a nursing home, please thank him or her for the important and sometimes not well-recognized services they provide. Or even give them a hug! And if you know someone who is a nurse, certified nursing assistant, rehab professional, housekeeper, dietary worker, administrator, or anyone else who works in a nursing home, thank them too!

It takes a special kind of person to work in this environment, with complex patients, serious illness, and fairly frequent progressive decline and death. Not many of us want to land in a nursing facility, but some of us will, despite our best-laid plans—and let’s hope there are enough compassionate, caring people around to provide the care and a sufficient workforce if that day arrives.

In the meantime, let’s celebrate on March 20 by recognizing and thanking the dedicated professionals who choose to work there now.


Karl SteinbergKarl Steinberg, MD, CMD, HMDC, is a longtime medical director in San Diego County and Board Chair of the Coalition for Compassionate Care of California. He has been medical director of Hospice by the Sea in Solana Beach, CA, since 1995 and is currently medical director of Kindred Village Square Nursing and Rehabilitation Center, Life Care Center of Vista, and Carlsbad by the Sea Health Center. He serves on the AMDA Board of Directors.

3 Responses to “There’s lots to love about (being) a nursing home doctor”

  1. Dear Dr. Karl,
    Happy day to you…I was so moved by the one line…”I get to take my dogs to work everyday” that touched my heart deeply. i will be presenting on the Animal-Assisted Therapy ( AAT) work I do with the annual palliative conference on campus. I would love to open my talk with a line from you…. when I started doing this work in the early to mid 90’s many people laughed at the goofiness of my working with my therapy cat and dogs in a day hospice in PA….however the clients LOVED every moment of engaging with my working animals. Thank heavens neurosciences gave the validity and credibility that the field of Animal-Assistance needed to hold its own. I am now on my second generation of working dogs and they have taught me more of compassion and how to be a better human than any printed book. My HERO dog (2005) named Tangus irrevokably changed my way of being in the world. Tangus indelibly marked my soul in ways words cannot express…all this by simply witnessing the emotional support work and comfort care he did with people in palliative care. I would love to hear about your thoughts when you first started taking your beautiful canine souls on your rounds and how you feel today after doing this work for so long. Blessings in advance for any kind or thoughtful words you might be able to share with me…my email address is strajalk@me.com and my current working dogs are Twillow Roses and Tala Rain (yes, they even have their very own Facelbook thing going on as well…lol). Thank you for your time.
    Warmly,
    Straja, Twillow and Tala ( oh yes and Tadileo my therapy cat too)

    Reply

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