Am Fam Physician. 2010 May 15;81(10):1200.
Related article: Nursing Home Care: Part 1. Principles and Pitfalls of Practice
Related article: Nursing Home Care: Part 2. Clinical Aspects
It has been demonstrated that the presence of a certified medical director is an independent predictor of nursing home quality.1 Medical leadership and expertise are critical given the complex medical care of persons living in nursing homes and other long-term care settings.
In addition to the role of the medical director, the quality of care in long-term care settings also hinges on a second and more traditional medical role—the attending physician. The perception of many medical directors, as well as family members of nursing home residents, is that attending physicians are too often missing in the nursing home.2 The American Medical Directors Association (AMDA) has recognized this problem and is expanding its educational offerings and advocacy to enhance the skills of physicians and other interdisciplinary team members who practice in long-term care settings.
Many foundational elements of the family medicine specialty suggest that family physicians are likely to have the attitudes, knowledge, and skills needed to optimally care for nursing home residents. Frail older patients with complex medical needs benefit from a physician whose professional approach emphasizes the biopsychosocial model and the importance of working with families. Family medicine training programs often include non-physician faculty, which leads to improved attitudes and skills in working with other members of the interdisciplinary team. Who would be better prepared to discuss a patient's goals of care or end-of-life wishes than a physician who has cared for the patient over time, in many settings, and through prior medical crises?
Graduating family medicine residents report high levels of comfort in caring for older patients (94 percent being “somewhat” or “very” prepared) and chronically ill patients (92 percent); however, preparedness to practice in the nursing home setting is lower, at 79 percent.3 Use of the nursing home as a site for medical training, which is recommended by the Institute of Medicine,4 would likely increase the percentage of graduating residents who feel prepared to practice in this setting.
It may be challenging for physicians to find continuing medical education offerings specific to practice in the long-term care setting. The two-part article by Unwin and colleagues in this issue of American Family Physician provides an insightful update on the care of nursing home residents.5,6 Additional opportunities for enhancement of skills and knowledge in long-term care medicine are available through AMDA's Web site at http://www.amda.com.
There has been a call for creation of a nursing home physician specialist, who would likely practice as part of a structured nursing home medical staff and have a high level of commitment to long-term care medicine and achievement of competencies specific to long-term care.7 A specialty in long-term care medicine would likely provide leadership and enhance development of a more robust evidence base; however, because there are 1.5 million nursing home residents, many in rural areas, nursing home attending physicians will often be family physicians.
Committed and skilled family physicians can provide medical care that, at its best, improves the quality of life and family support of nursing home residents, empowers the nursing home interdisciplinary team, and enhances the care provided in nursing homes and other long-term care settings. Ultimately, we have the opportunity to demonstrate the unique and valuable perspective of our specialty in yet another arena of care.
Address correspondence to D.A. Brechtelsbauer, MD, CMD, at David.Brechtelsbauer@usd.edu. Reprints are not available from the author.
Author disclosure: Nothing to disclose.
1. Rowland FN, Cowles M, Dickstein C, Katz PR. Impact of medical director certification on nursing home quality of care. J Am Med Dir Assoc. 2009;10(6):431–435.
2. Shield RR, Wetle T, Teno J, Miller SC, Welch L. Physicians “missing in action”: family perspectives on physician and staffing problems in end-of-life care in the nursing home. J Am Geriatr Soc. 2005;53(10):1651–1657.
3. Blumenthal D, Gokhale M, Campbell EG, Weissman JS. Preparedness for clinical practice: reports of graduating residents at academic health centers. JAMA. 2001;286(9):1027–1034.
4. Institute of Medicine. Retooling for an Aging America: Building the Health Care Workforce. Washington, DC: The National Academies Press; 2008. http://www.iom.edu/Reports/2008/Retooling-for-an-Aging-America-Building-the-Health-Care-Workforce.aspx. Accessed March 8, 2010.
5. Unwin BK, Porvaznik M, Spoelhof GD. Nursing home care: part I. Principles and pitfalls of practice. Am Fam Physician. 2010;81(10):1219–1227.
6. Unwin BK, Porvaznik M, Spoelhof GD. Nursing home care: part II. Clinical aspects. Am Fam Physician. 2010;81(10):1229–1237.
7. Katz PR, Karuza J, Intrator O, Mor V. Nursing home physician specialists: a response to the workforce crisis in long-term care. Ann Intern Med. 2009;150(6):411–413.
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