During the
third year of medical school, all students are required to rotate through a
variety of services. This is partly to
establish that we can apply the knowledge learned during the first two years,
but mainly to learn the difference between the book and the practice of
medicine. During my family medicine
rotation, I was asked to do a ‘home-visit’ to a family under the care of my
preceptor. Working a small rural family
practice has it’s own challenges and benefits.
My preceptor additionally has developed his own ACO (essentially a
revamped approach to healthcare management that is based on the old HMO
model). He is starting to develop and
expand his practice to look more like a ‘medical home”; a concept of having one
stop shopping for multiple specialties and expanded access to those seeking
care. While the full model has not been
realized, the practice is on it’s way to trying to maximize the benefits of the
‘Obamacare’, or the ACA as it is more formally called.
Home visits
at this practice are not uncommon. While
the rest of medicine has given up on the idea of home visits, Dr. T. has been
trying to revive them, so it was fairly straight forward when he asked one of
the families to allow students into their home.
The Hs live
in a small rural area of Massachusetts.
They grew up in the same small town, raised a family, and continue to be
the pillar on which the other leans. At
96, DH still cuts an imposing figure.
When DH and HH stand together, their smiles light up a room. I recently had the honor of spending some
time with these two this past week. And
the pair were unforgettable.
DH
graduated High school and entered the military during WWII. HH says that when they met, it was love at
first sight; but her husband says it was the uniform. Looking through old pictures, it was clear
what a handsome couple they were in their youth. What is striking is the contrast between the
black and white photos and how I see them now.
Out of context, one might easily mistake either of these two for a frail senior citizen at the last stretch of life. And yet, seen side by side in the home they built together, they seem vibrant and full of life. HH still gives DH the occasional coy smile from the corner of her lips as they spoke about how they started their family. Standing next to his wife, DH’s pride and joy makes him look like the kind of tree that one seeks out when trying to escape the heat of a midday summer’s sun.
Their story as a family is full of both the joys and hardships of life that one expects from a life well lived. DH built their home with his own two hands and they have been there ever since. They were active in their church for many years and their faith continues to give them strength. The oldest daughter, S, was born with Down’s Syndrome. As though stepping into the past, they speak lovingly about the daughter who was born as a “mongoloid” and passed when she was sixty. However, there was no sadness there. “She lived a good and happy life, and in the end it was time,” Mrs. H noted warmly. Another child, one of their sons, had passed away in Vietnam during the war. Four other siblings remain and have full and healthy families of their own.
To this day, they continue to draw strength from their family. Two of their sons live within a mile of the family home. One of them lives just across the street. My colleague, another student from BU, and I flipped through photos of grandchildren and great grandchildren. The close family unit has had immeasurable benefit to the Hs. Some things that we take for granted are often not as simple for our seniors in the community. Who shovels the walk for a couple of 90 somethings after 3 feet of snow suddenly falls in a small, rural, Massachusetts town? What happens when the power goes out? Many of these concerns can be life threatening to our elders who live alone at home.
This becomes more complicated when the slights of many years translates to chronic illness. Mr. H has had prostate cancer, high cholesterol, hypertension, episodes of acute renal failure, and diabetes. Mrs. H has had to deal with hypothyroidism, hyperlipidemia, and cardiac conduction problems, to name a few. And yes, there is an element of dementia for both the Hs. With all this, it would seem a miracle to most that these two manage to stay in their own home.
To some degree, any health care provider would want to know how they have managed to do so well and stay in their family home, when this is such a struggle for many families across the country. There is no simple answer. One important point is that there are stages of life beyond 55. A senior citizen is not simply that alone. Early in their lives, the community played an important role in mitigating hardship. As active members in their church, it is clear that their church community was central in helping them transition to retirement. The Hs speak with pride about their charitable work with the church after retirement. Mrs. H worked as a home health aid before retiring. To some degree, she carried skills learned in her professional life that she could apply to her community work with the church. For both, community work through the church was full time work after work. The payoff was a community of like-minded people who looked after the Hs and met their social needs during this transition in their lives.
When the years passed and they could no longer keep with the hours, the favor was returned. The church helped with some basic services and there were people to check in with the Hs. This was not limited to DH and HH, but extended to their children as well. We often forget that the work to maintain the lives of the ones we love is more than a full-time job. Through it all, the Hs children have been pivotal in maintaining the health and well-being of DH and HH. But they have not always been able to do it alone.
Like any old, country, Yankee home, the Hs home rolls over with the spirit of reusing anything that passes the threshold. There were old desk lampshades that were made out of teacups and pumpkin pine whittled from scrap. The old tractor that used to sit in DHs field now sits across the street in his son’s. When a tree falls in the field, that old tractor gets started up and the tree is hauled to the house, chopped up, and offered up as firewood. Nothing is discarded, nothing is wasted, and everything is used. Even uneaten food is prepared as bird-feed or fertilizer. The home may seem cluttered from the glance of an unindoctrinated eye, but there is no real clutter there. What isn’t actually used directly, reflects multiple generations of precious keepsakes. The Hs are not so much hoarders, but the heads of a household consisting of multiple generations of lives well lived.
And yet, there is reason to be concerned. Old throw rugs that lack the luster they had when new now present trip hazards. Hand-made bookshelves stay precariously upright based on a balance that has developed over years. As they navigate their home with the adept steps of a well-rehearsed ballet, one cannot help but worry that the warmth and life of this well filled home has not contributed to the occasional falls that may be becoming more frequent. The bathrooms lack pull bars. The tub does not have a rubber mat to prevent slipping. And the list of concerns pile up with each passing minute that we were there.
Having been a professional firefighter in my previous life (a mere few years ago), my biggest concern had to do with fire hazards. DH and HH have started eating out frequently because HH started to burn pots, forgetting that she had food on the burner. During our visit, there were several toasters with toast in them. The Smoke detector was mounted in a sub-optimal position and was missing a cover. The problem goes beyond the scope of simple fire hazards or increased fire load due to household clutter. It raises questions about diet and ability to maintain nutrition in the event of a catastrophic problem. Living deep in farm country, the nearest place to eat out is a half hour’s drive away. The roads are not always well plowed or cleared. Driving through the woods, there is clear risk of falling trees and suicidal deer. DH still drives, and it is encouraging that the two get out and about, but also concerning. Still, their continued mobility has kept them in contact with a very important social network that has helped them weather tough times in the past.
Even with these issues, the Hs seem to be living full and fruitful lives. If living well is any indication of health, DH and HH seem the picture of health. As I wrote above, they do, however, have a series of important medical conditions. These are managed with regular medications proscribed over the years. It was unclear during our visit how adherent the Hs were to their proscribed treatment plans. We went through their medications carefully with the Hs. They told us about the amlodipine for blood pressure and metoprolol for the heart. Each time they pulled out a bottle of pills, we nodded knowingly and took careful notes. To be honest, it was less important to us what they were taking so much as that they knew what they thought they were supposed to be taking and why. At one point DH pulled out a bottle of Cipro and said it was for his heart. HH quickly corrected him, noting that he wasn’t on that one anymore, presumably for an infection that had long since resolved. Individually, they each made occasional mistakes about what they should be using and why. And yet, between the two of them, they seemed to be managing perfectly well.
When asked about ‘chronic illness’, they both said that they were healthy. Their pills told a different story. It struck me as amazing how differently I saw their health than they did. And yet, I could not deny, that they are clearly happy, active, and not in any need of a couple of med students correcting them on what they do or don’t have. I asked DH about his blood pressure and his response boiled down to a very pragmatic ‘it is what it is’. He takes his pills and feels fine. As far as I can tell, he is fine. No amount of hours spent pouring over books or sitting in lecture could have prepared me for that visceral realization that a person’s health cannot be truly measured by diagnoses or pill counts. DH made a joke about not getting all worked up over a little high blood pressure. HH gave him the kind of playful kick that only comes with years of comfortable blurring of individual boundaries, telling him not to tease the med-students.
All this is not to say that I didn’t have concerns about their pills or their chronic conditions, but rather there was no real cause for me to become hypertensive over his hypertension. It helps to know that they have a home health aid stop by once a month to help with cleaning and other regular housework and chores. Their son’s tend to the land and help maintain the garden. To a large degree, the Hs are better off than many other elders in the community.
Of course all the pills and doctor’s appointments are not necessarily easy or cheap. Getting a good sense of these things was difficult. Family manages their finances. DH says that his “financial position is solvent.” If he needs money, he can go down to the bank and get money out and his son manages his healthcare costs. It helps that they are both medicare beneficiaries, which, to a large degree, simplifies their health finances. They commented on caring for a daughter with Down’s syndrome, noting that they did “not know how people do it now adays.” They are aware that the cost of care is out of control. They know that people live with unstable insurance plans that may come and go with employment prospects. They acknowledge that they have done ok with their own health care concerns, but there is something “unfair” about the system as it has been for decades. They alluded to problems that their family has experienced, implying that they see things as getting harder for others. But they are still hopeful.
Having spent time with the Hs, I was blessed to have had the opportunity to enjoy the comfort of their home. Their warmth and generosity made my homework less work than a conversation between friends. What strikes me most is their resiliency as a pair. DH was more whimsical and carefree, but preeminently adaptable. An old Yankee problem-solver, there is no obstacle that he cannot overcome with the help of wife. HH, was more practical than DH, but her own short term memory and attention span were problematic. However it was exactly her practical approach to the world and concrete thinking that grounds DH and gives him the strength to tackle the obstacles that face them. What worries me is how intertwined the two actually are. Alone, taken out of context, they look like frail seniors slowly losing the capability to manage. Together, I can still see they young man and woman who fell in love at first sight.
For now, they are healthy, regardless of what the diagnoses or pill counts say. They have the resources they need and have maintained a home that should be the envy of us all as we age. Could they use more support? Probably. A quick search of their local council on aging shows that there are many more services available to them than they are using. They could use a hand organizing the home and their keepsakes. It would help to have a standup-shower with anti-slip mats instead of a tub with a chair and a step stool. More regular visits from a home health aid would probably serve them well, but it’s hard to convince an old Massachusetts Yankee to make such drastic changes to a home that was built by hand and over generations of living well. Still, we will try, and these are on Dt.Ts list of goals.
Out of context, one might easily mistake either of these two for a frail senior citizen at the last stretch of life. And yet, seen side by side in the home they built together, they seem vibrant and full of life. HH still gives DH the occasional coy smile from the corner of her lips as they spoke about how they started their family. Standing next to his wife, DH’s pride and joy makes him look like the kind of tree that one seeks out when trying to escape the heat of a midday summer’s sun.
Their story as a family is full of both the joys and hardships of life that one expects from a life well lived. DH built their home with his own two hands and they have been there ever since. They were active in their church for many years and their faith continues to give them strength. The oldest daughter, S, was born with Down’s Syndrome. As though stepping into the past, they speak lovingly about the daughter who was born as a “mongoloid” and passed when she was sixty. However, there was no sadness there. “She lived a good and happy life, and in the end it was time,” Mrs. H noted warmly. Another child, one of their sons, had passed away in Vietnam during the war. Four other siblings remain and have full and healthy families of their own.
To this day, they continue to draw strength from their family. Two of their sons live within a mile of the family home. One of them lives just across the street. My colleague, another student from BU, and I flipped through photos of grandchildren and great grandchildren. The close family unit has had immeasurable benefit to the Hs. Some things that we take for granted are often not as simple for our seniors in the community. Who shovels the walk for a couple of 90 somethings after 3 feet of snow suddenly falls in a small, rural, Massachusetts town? What happens when the power goes out? Many of these concerns can be life threatening to our elders who live alone at home.
This becomes more complicated when the slights of many years translates to chronic illness. Mr. H has had prostate cancer, high cholesterol, hypertension, episodes of acute renal failure, and diabetes. Mrs. H has had to deal with hypothyroidism, hyperlipidemia, and cardiac conduction problems, to name a few. And yes, there is an element of dementia for both the Hs. With all this, it would seem a miracle to most that these two manage to stay in their own home.
To some degree, any health care provider would want to know how they have managed to do so well and stay in their family home, when this is such a struggle for many families across the country. There is no simple answer. One important point is that there are stages of life beyond 55. A senior citizen is not simply that alone. Early in their lives, the community played an important role in mitigating hardship. As active members in their church, it is clear that their church community was central in helping them transition to retirement. The Hs speak with pride about their charitable work with the church after retirement. Mrs. H worked as a home health aid before retiring. To some degree, she carried skills learned in her professional life that she could apply to her community work with the church. For both, community work through the church was full time work after work. The payoff was a community of like-minded people who looked after the Hs and met their social needs during this transition in their lives.
When the years passed and they could no longer keep with the hours, the favor was returned. The church helped with some basic services and there were people to check in with the Hs. This was not limited to DH and HH, but extended to their children as well. We often forget that the work to maintain the lives of the ones we love is more than a full-time job. Through it all, the Hs children have been pivotal in maintaining the health and well-being of DH and HH. But they have not always been able to do it alone.
Like any old, country, Yankee home, the Hs home rolls over with the spirit of reusing anything that passes the threshold. There were old desk lampshades that were made out of teacups and pumpkin pine whittled from scrap. The old tractor that used to sit in DHs field now sits across the street in his son’s. When a tree falls in the field, that old tractor gets started up and the tree is hauled to the house, chopped up, and offered up as firewood. Nothing is discarded, nothing is wasted, and everything is used. Even uneaten food is prepared as bird-feed or fertilizer. The home may seem cluttered from the glance of an unindoctrinated eye, but there is no real clutter there. What isn’t actually used directly, reflects multiple generations of precious keepsakes. The Hs are not so much hoarders, but the heads of a household consisting of multiple generations of lives well lived.
And yet, there is reason to be concerned. Old throw rugs that lack the luster they had when new now present trip hazards. Hand-made bookshelves stay precariously upright based on a balance that has developed over years. As they navigate their home with the adept steps of a well-rehearsed ballet, one cannot help but worry that the warmth and life of this well filled home has not contributed to the occasional falls that may be becoming more frequent. The bathrooms lack pull bars. The tub does not have a rubber mat to prevent slipping. And the list of concerns pile up with each passing minute that we were there.
Having been a professional firefighter in my previous life (a mere few years ago), my biggest concern had to do with fire hazards. DH and HH have started eating out frequently because HH started to burn pots, forgetting that she had food on the burner. During our visit, there were several toasters with toast in them. The Smoke detector was mounted in a sub-optimal position and was missing a cover. The problem goes beyond the scope of simple fire hazards or increased fire load due to household clutter. It raises questions about diet and ability to maintain nutrition in the event of a catastrophic problem. Living deep in farm country, the nearest place to eat out is a half hour’s drive away. The roads are not always well plowed or cleared. Driving through the woods, there is clear risk of falling trees and suicidal deer. DH still drives, and it is encouraging that the two get out and about, but also concerning. Still, their continued mobility has kept them in contact with a very important social network that has helped them weather tough times in the past.
Even with these issues, the Hs seem to be living full and fruitful lives. If living well is any indication of health, DH and HH seem the picture of health. As I wrote above, they do, however, have a series of important medical conditions. These are managed with regular medications proscribed over the years. It was unclear during our visit how adherent the Hs were to their proscribed treatment plans. We went through their medications carefully with the Hs. They told us about the amlodipine for blood pressure and metoprolol for the heart. Each time they pulled out a bottle of pills, we nodded knowingly and took careful notes. To be honest, it was less important to us what they were taking so much as that they knew what they thought they were supposed to be taking and why. At one point DH pulled out a bottle of Cipro and said it was for his heart. HH quickly corrected him, noting that he wasn’t on that one anymore, presumably for an infection that had long since resolved. Individually, they each made occasional mistakes about what they should be using and why. And yet, between the two of them, they seemed to be managing perfectly well.
When asked about ‘chronic illness’, they both said that they were healthy. Their pills told a different story. It struck me as amazing how differently I saw their health than they did. And yet, I could not deny, that they are clearly happy, active, and not in any need of a couple of med students correcting them on what they do or don’t have. I asked DH about his blood pressure and his response boiled down to a very pragmatic ‘it is what it is’. He takes his pills and feels fine. As far as I can tell, he is fine. No amount of hours spent pouring over books or sitting in lecture could have prepared me for that visceral realization that a person’s health cannot be truly measured by diagnoses or pill counts. DH made a joke about not getting all worked up over a little high blood pressure. HH gave him the kind of playful kick that only comes with years of comfortable blurring of individual boundaries, telling him not to tease the med-students.
All this is not to say that I didn’t have concerns about their pills or their chronic conditions, but rather there was no real cause for me to become hypertensive over his hypertension. It helps to know that they have a home health aid stop by once a month to help with cleaning and other regular housework and chores. Their son’s tend to the land and help maintain the garden. To a large degree, the Hs are better off than many other elders in the community.
Of course all the pills and doctor’s appointments are not necessarily easy or cheap. Getting a good sense of these things was difficult. Family manages their finances. DH says that his “financial position is solvent.” If he needs money, he can go down to the bank and get money out and his son manages his healthcare costs. It helps that they are both medicare beneficiaries, which, to a large degree, simplifies their health finances. They commented on caring for a daughter with Down’s syndrome, noting that they did “not know how people do it now adays.” They are aware that the cost of care is out of control. They know that people live with unstable insurance plans that may come and go with employment prospects. They acknowledge that they have done ok with their own health care concerns, but there is something “unfair” about the system as it has been for decades. They alluded to problems that their family has experienced, implying that they see things as getting harder for others. But they are still hopeful.
Having spent time with the Hs, I was blessed to have had the opportunity to enjoy the comfort of their home. Their warmth and generosity made my homework less work than a conversation between friends. What strikes me most is their resiliency as a pair. DH was more whimsical and carefree, but preeminently adaptable. An old Yankee problem-solver, there is no obstacle that he cannot overcome with the help of wife. HH, was more practical than DH, but her own short term memory and attention span were problematic. However it was exactly her practical approach to the world and concrete thinking that grounds DH and gives him the strength to tackle the obstacles that face them. What worries me is how intertwined the two actually are. Alone, taken out of context, they look like frail seniors slowly losing the capability to manage. Together, I can still see they young man and woman who fell in love at first sight.
For now, they are healthy, regardless of what the diagnoses or pill counts say. They have the resources they need and have maintained a home that should be the envy of us all as we age. Could they use more support? Probably. A quick search of their local council on aging shows that there are many more services available to them than they are using. They could use a hand organizing the home and their keepsakes. It would help to have a standup-shower with anti-slip mats instead of a tub with a chair and a step stool. More regular visits from a home health aid would probably serve them well, but it’s hard to convince an old Massachusetts Yankee to make such drastic changes to a home that was built by hand and over generations of living well. Still, we will try, and these are on Dt.Ts list of goals.
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