The Changing Face of Medical Care

The aging of the population has dramatically changed the nature of medical practice in developed countries. We have moved from the former model of isolated medical care for acute illnesses to a model that is starting to address the needs of those with chronic illness. What does this mean to the medical practitioner? Firstly, it alters the relationship between the medical practitioner and her patient; the relationship becomes a cooperative one. Unlike an acute episode of pneumonia in a previously healthy young person, the long-term nature of chronic disease means that patients have to take greater responsibility for their own care. A physician will see a patient with diabetes only intermittently; successful management requires the patient to carefully monitor their own sugar levels and follow the appropriate dietary and exercise regimes. To be successful, a patient must be extensively educated about his/her condition. This is the cornerstone of successful management of most chronic diseases. Although some patients can educate themselves via texts and the Internet, this approach will not work for everybody. The enormous amount of information available (some of it garbage) means that some judgement in the selection of appropriate materials is essential. As well, the patient and doctor have to agree on appropriate goals of therapy. The goals for a 90-year-old man with diabetes might be significantly different from those of a 19-year-old man with identical blood sugar levels. The complexity of this approach means that care is often better delivered via a team of health care practitioners, rather than by a solo practitioner. As an academic physician in geriatric medicine, I would be lost without the dedicated multidisciplinary geriatric team that includes nurses, occupational therapists, social workers, and physiotherapists. One of the challenges our health care system now faces is how to ensure that primary care in the community can also be delivered in a multidisciplinary fashion.

As well as this general change in the nature of medical care in modern societies, the very diseases we are treating are changing their faces. Fifty years ago it would have been considered lunacy to have clinics devoted to cystic fibrosis in adults, or adult congenital cardiac clinics. Our success in treating certain diseases in early life, means that we are seeing for the first time, substantial numbers of patients who are aging with diseases such as cystic fibrosis or cardiac malformations. This is particularly evident in the population with end-stage renal failure. This cohort is expanding at an incredible rate for two reasons. Patients survive longer with better dialysis techniques and supportive care, and we are starting older patients on dialysis more frequently as the benefits become more evident. I am proud of the fact that a Canadian, Professor Dimitrios G. Oreopoulos, has been one of the most prominent individuals in the field of geriatric nephrology.

The article on HIV in the elderly, by Dr. Brian Conway, appearing in this issue of Geriatrics & Aging, is another fascinating example of this trend. Why are there elderly people living with HIV infection? I think there are two reasons. Modern drug regimes for HIV have been incredibly effective, so we will see more and more people infected with HIV living into old age. However, the statistics Dr. Conway quotes preceded the common use of highly active antiretroviral therapy. Simply put, this means that older people are quite sexually active and run the same type of risks as younger sexually active people do! And this series was compiled before the introduction of Viagra. It reminds us that we do not evolve into a different species simply because we grow older. The aging of the population might have increased the number of frail elderly, but it has also resulted in an even larger absolute increase in the number of fit and vigorous elderly who are as prone to various maladies as younger adults--from sexually transmitted diseases to trauma. So please read the article carefully, and promise to caution your patients to practice safe sex.

We have a wonderful selection of articles in this issue, but because of space limitations I will just mention a few here. To highlight the newly published 6th edition of the Canadian Medical Association's guide, 'Determining Medical Fitness to Drive', we have an article emphasizing the physician's legal responsibilities. For CMA members, a free copy of the guide can be obtained by calling the CMA at 888-855-2555 or 613-731-8610 extension 2307. We have a broad selection of articles on virology: influenza vaccination for patients and healthcare workers, antiviral therapy for influenza, and an article by Dr. John Conly on Herpes Zoster. We have two articles on another important infection, tuberculosis. We also have highlights from the recent World's Alzheimer Conference in Washington D.C., and hope to have more in our next edition.

Enjoy this issue.