Perspective
Nursing Home Rounds
How a simple conversation can yield important clues about the health of a patient with dementia.
By William Amundson
Joyce* wasn’t in her room when we went to see her in the nursing home. We found her sitting in her wheelchair between the nursing station and the cafeteria, watching the other residents and staff. Dr. Johnson knelt down beside her and said, “Hello! It’s good to see you today.” Joyce didn’t recognize him, despite his many previous visits. We asked her if we could go back to her room so we could talk to her and examine her. She told us the room was occupied because “they were doing something in the classroom.” Dr. Johnson didn’t seem concerned and started walking toward her room. I followed, pushing Joyce in her wheelchair.
This was my first experience with nursing home rounds. I had spent the morning in the clinic and saw a dozen patients with problems ranging from depression to upper respiratory tract infection. In the clinic, medicine is fast-paced and to-the-point. You ask questions, patients answer them, and your exam is focused. Often, it feels as if the patient is working for you. However, the nursing home is not the clinic.
Like most of the patients we saw that afternoon, Joyce was just getting a checkup. We knew of no particular complaints, and she probably couldn’t have told us otherwise. Once we got to her room, we again told her who we were and what we were doing. She seemed comfortable with us examining her and asking her questions, but I am not sure she ever really grasped who we were or what we wanted to know. Dr. Johnson didn’t seem fazed by this.
He proceeded by taking pictures from the walls of Joyce’s room and asking her who was in them. She was able to answer, for the most part, and then started telling stories about her husband, children, other family members, and friends. At one point, she sneezed and asked Dr. Johnson to hand her a Kleenex “from over there,” pointing across the room to a Kleenex box that was out of her view. Dr. Johnson gave her a tissue, and under his breath said, “Oriented times one.” Seconds later, Joyce remarked that Fridays were always hard for her, earning an “oriented times two” from Dr. Johnson since it was, indeed, a Friday. For almost our entire 15-minute visit, we sat next to Joyce’s wheelchair, chatting about life and listening to her reminisce. The conversation was free-flowing and unguided. Never once did we ask her about a specific medical problem. I found myself wondering when the actual exam was going to start.
When we left the room, Dr. Johnson turned to me and talked about how well she was doing. He has known Joyce for a long time, and although she didn’t remember who he was, he was able to use her behaviors and stories as surrogates for answers to questions he would have asked in the clinic. This nontraditional approach to examining a patient revealed that Joyce was still alert and oriented to her surroundings, still able to recount important moments in her life and tell us about her family, and still functioning in a nursing home setting. We did listen to Joyce’s heart and lungs and examine her feet. However, Dr. Johnson was able to get most of the information he needed just by having the conversation about her life.
The interaction was simple and so different from the regimented interview techniques we learn in medical school. This was truly medicine on the patient’s terms. And it was a reminder that care should be about the patient, not the physician. Unfortunately, clinic medicine is not nursing home medicine. Focused questions have a place, as physicians must do the necessary detective work to uncover and treat problems during a short office visit. We should not, however, disregard the more humanistic conversations that can provide clues regarding concerns a patient may not tell us about. Instead of focusing on how to make patient interactions productive for us, we need to focus on what makes them most productive for our patients. MM
William Amundson is a fourth-year medical student at the University of Minnesota.