ETHICAL CAREGIVING IN AGING AMERICA
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Web Posted: 01/18/2009 12:00 CST
By Steve Bennett- Express-News Book Editor
“I didn’t start out to be a geriatrician. I became one because my patients and I have grown old together.”
Dr. Jerald Winakur
“Memory Lessons,” San Antonio geriatrician Jerald Winakur’s new book on what he calls the “art” of doctoring, is “part memoir, part manifesto.”
In it, he probes and palpates, thoroughly examining our current health-care system and its sometimes frightening predicted course over the next couple of decades.
At the heart of the book is Winakur’s glowing compassion, his old-fashioned approach to medicine — he is a country doctor in an urban setting — his strict, often anachronistic belief in the patient/doctor relationship.
“I’m a ‘Marcus Welby’ doctor,” he says, “not an ‘ER’ doctor or a ‘House’ doctor.” For those too young to get the TV-series reference, he explains: “I think that patients need to be treated as if they are your family.”
Finally, the book, immensely readable and thought-provoking, chronicles his care of perhaps his most important patient, who is not really his patient. That is his octogenarian father, Leonard Winakur, a fine, if flawed, man who loved art and birding.
“There have been many wake-up calls about the state of elderly care and their growing numbers, but I think it is only when we are personally affected that the message becomes poignant and critical,” says Dr. Abraham Verghese, author and founding director of the University of Texas Health Science Center’s Center for Medical Humanities and Ethics, who now teaches at Stanford University. “Many of us can identify with Jerry because we have either faced that, or will.”
Along the way, Winakur, 60, tells the life story of a Jewish pawn broker’s son from Baltimore who finds solace and support in what might seem a world away — San Antonio.
All of us need health care. Or we will, someday. And many, many of us are part of the largest group the health-care system will ever have to accommodate: the baby boomers. Just as we must try to figure out “What Are We Going to Do With Dad?” — the title of a 2005 essay by Winakur that became “Memory Lessons” — so will our children.
The numbers are staggering — more than 75 million people older than 65 by 2050, 20 percent of the population. (In 1900, only 4 percent of the population was older than 65.)
And the fastest-growing demographic is the “oldest old,” those older than 85. Once, families quietly assumed responsibility for their old people, caring for them in the home. Today, we look for outside solutions, nursing homes and specialized-care facilities.
Compounding the side effects of our societal evolution is the direction medicine is heading, according to Winakur, who cites the numbers: “There is a deficit of 7,000 doctors in geriatrics now, and in another 20 to 30 years that deficit will be 35,000. So I don’t know who’s going to take care of these elderly folks.”
He surmises it will be physician’s assistants and nurse practitioners.
“Our medical organizations say, ‘Well, the specialist will have to take care of them.’ But I know that’s not going to happen. That’s wishful thinking.
“I think what will happen is that they’ll be taken care of by nurse practitioners and physician’s assistants. And that might be OK if they are overseen by doctors well-trained in geriatric care. But if not, I don’t think those folks, try as they may, have the training to deal with the kind of people we’re seeing now, who are older and older, frailer and frailer, and are on more and more medications. It’s a complex task, and I really worry about what’s going to happen.”
Consequently, Winakur long ago entered into what he calls “the realm of advocacy” for his elderly patients, frequently presenting his case to his colleagues and to his students at the Center for Medical Humanities and Ethics, where he teaches a course called Literature and Medicine with his second wife, Lee Robinson, an attorney and published poet. In this class young doctors discuss Nathaniel Hawthorne’s “The Birthmark” and William Carlos Williams’ “Complaint,” rather than, say, “The Esophagus and Pharynx in Action,” to name just one of the titles on Winakur’s office bookshelves.
“He makes a true effort, through teaching, to inspire the younger generation to value the patient/doctor relationship as highly as the effort to strive for scientific competence,” says Dr. Ruth E. Berggren, the current director of the Center for Medical Humanities and Ethics.
“Without role models like Dr. Winakur, students might tend to opt for the more glamorous or materially rewarding disciplines of medicine (emergency medicine, procedure-oriented specialties and the like). His teaching, writing and role-modeling helps to glamorize the primary-care doctor, the geriatrician, the doctor who takes the time to listen and care.”
“Memory Lessons” opens with one of Winakur’s fondest memories: The gift on his 12th birthday of a copy of Roger Tory Peterson’s “A Field Guide to the Birds of Eastern North America” from his father, along with his dad’s Army-issued binoculars.
Birding has been a lifelong passion of Winakur’s. Once he was “a lister” and states with pride today that he’s seen more than 500 species of American birds, from buntings to warblers.
He is more casual about ornithological pursuits these days, although when asked about the best sighting he’s had at his acreage in Comfort, where he and his wife seek sanctuary and sanity, Winakur responds without a second thought: “A Roseate Spoonbill. There are very few Hill Country sightings of the roseate spoonbill.”
He writes in the first chapter of “Memory Lessons”: “My father has forgotten all he ever knew about birds.”
Born in 1908 to immigrant parents, Leonard Winakur dreamed of being an artist, but his mother removed him from junior high school to work in the family pawn business. He suffered poor health later in life, including prostate cancer and finally Alzheimer’s disease. (First sign? He got lost coming home from Luby’s.)
The second chapter of the book chronicles another key event in the Winakurs’ lives: the destruction of the Baltimore pawn shop during the 1968 rioting after Martin Luther King’s assassination.
“My father, an average man caught up in these tumultuous times, was . . . never able to recover from the losses he suffered in the civil unrest of those days,” Winakur writes.
The entire family, including brother Michael, an architect, ended up in San Antonio, where Winakur came in 1973 for his medical residency at the UT Health Science Center after graduating from the University of Pennsylvania medical school.
“The chamber of commerce should give me a medal for all the people who followed me here,” Winakur says.
For the past 23 years, he’s been practicing his brand of old-school medicine out of an office at the corner of Louis Pasteur and Babcock, designed by brother Mike. (Soon, the growing practice — seven internal medicine doctors have joined the group, and they’ve outgrown the space — will move to a “standard, sterile office building.” “Oh, well,” says Winakur, “to live is to accept change.”)
Much of “Memory Lessons” deals with Winakur’s often prickly relationship with his father and the disease’s effect on his mother, Fran, who has macular degeneration and can barely see. Trips to the grocery store can be an adventure. “You remember Mr. Magoo? Well, she’s Mrs. Magoo,” says her doctor son.
Winakur is not his father’s primary physician. But he consults frequently with Dr. John Galan, occasionally tinkers with his dad’s medications when he suffers from night terrors or rages. And he vows to keep his father out of the hospital, where Alzheimer’s patients can become dangerously disoriented.
Diarylike, “Memory Lessons” chronicles a family’s care for a proud patriarch and the difficult decisions that must be made when, for example, a grandfather refuses to attend his granddaughter’s wedding. Later, when he is shown the wedding photos, Len points to Betsy — whom he once picked up daily from school and cared for with her sister until her parents finished working — and says, “Who is that?”
“I hope these stories will resonate with readers and their loved ones,” Winakur says.
What will restore medicine to its Hippocratic roots? Call it human touch, which is the major theme of “Memory Lessons.”
“The most important thing is to be able to sit down with your patients in the examination room and listen to their stories,” Winakur says. “Eighty percent of what’s wrong with a person is gleaned by listening to his or her story and asking questions. And if you don’t have the time to do that, you are going to miss what’s wrong with them a good percentage of the time. The statistics are that physicians misdiagnose about 35 percent of the time, and I think a big reason for that is they don’t take the time to listen to the story and ask the questions they should be asking.”
Winakur views the physical examination as “a sacred rite.” It is also “a lost art.”
“Nobody knows how to do a thorough physical examination anymore,” he says, managing not to sound like an old crank. “We think we’ll just check the blood and do a CT scan.
“You have to be able to do a thorough physical examination. Not only because it’s the right way to practice medicine and you find things, but it’s another way to bond with your patient. It’s a privilege. To allow me to probe them, touch them, yes, I describe it as a sacrament. But that’s part of the doctor/patient relationship that is getting lost. Part of the examination is paying attention to your patient. It’s a way of being attentive. I’m going to take the time to do an examination. It’s a way of showing up for your patients, and that’s getting lost because we are so dependent on technology. Doctors talk to their patients, they listen to the patients, they examine their patients.”
That, in a nutshell, is “Memory Lessons.” That, and a phrase Winakur frequently falls back on: “Geriatricians worry.”
“Jerry’s approach to writing this book was much the same as his way of caring for patients,” says Robinson, Winakur’s wife, whose poem “Creed” introduces “Memory Lessons.” “He’s thorough, persistent and compassionate.
“He worried over the book, just as he worries about his patients. In the end I think all the worrying has been worth it.”
A public reception and signing commemorating the publication of Dr. Jerald Winakur’s “Memory Lessons” is set for 6 p.m. Thursday at the UT Health Science Center, 7703 Floyd Curl Drive, Room 3.102, next to the Briscoe Library.
A reading and signing will be held at 5 p.m. Jan. 26 at the Twig Bookshop, 5005 Broadway.