Tim Mullaney

Doctors have a lot to learn about long-term care.

“Duh,” you say? Fair enough. But a newly published study and a just released book really drive the point home.

For the study, medical residents took a 10-question test about skilled nursing facilities devised by investigators at the University of California, Los Angeles. They failed miserably. The mean number of correct answers was 4.9. Worse, some of the doctors consistently got certain questions wrong even after training. The lack of knowledge about SNF services and staffing — even the very definition of what a skilled facility is — should be setting off alarms about how well physicians can “assure proper triage of patients and safe transitions,” the study authors concluded.


The only excuse I could think of was that the doctors were still residents, early in their careers. Perhaps with more real-world seasoning, they’ll grasp the SNF’s place in the care continuum, I thought.

Then I read some excerpts from Being Mortal, the new book by Atul Gawande. A surgeon at Brigham and Women’s Hospital in Boston, a New Yorker staff writer, a bestselling author of books on healthcare topics and an expert on matters of public health, Gawande is one of the most visible and impressively experienced doctors in the United States. And in his latest book, he admits that “for more than decade in medical practice, I had not really understood what choices might exist” for a dying patient, other than pressing forward with aggressive last-ditch measures or counseling the patient to essentially “give up.”

“I wasn’t effective in these situations,” he writes. “And it bothered me — as a surgeon caring for patients with problems I often could not fix and then as a son with a father in his 70s experiencing mounting difficulties in his life. So for three years, I researched a book on what has gone wrong with the way we manage mortality and how we could do better.”

The disturbing news to me was how far Gawande could get in his career without a firm understanding of late-life and end-of-life care. The good news is that he took his blind spot so seriously that he wrote this book as a corrective.

The long-term care community can celebrate that someone as high-profile as Gawande has turned his attention this way. His book should spark much discussion and spread the word about the culture change transforming so many nursing homes. He zeroes in on the story of Bill Thomas and his “radical idea” to “treat old people like people,” as the Boston Globe book review puts it.

The book also summarizes the lessons Gawande learned from the “most successful clinicians” who specialize in long-term and end-of-life care he spoke with. I think this could make the book a very helpful resource; it might give even seasoned pros a succinct way of talking about what they do well, and impart valuable lessons to doctors, nurses and other caregivers just starting out. For instance, here’s Gawande’s breakdown of the “few important questions” that “often unlocked transformative possibilities” in guiding end-of-life care decisions, when he and other doctors posed them to patients:

1. What is their understanding of their health or condition?

2. What are their goals if their health worsens?

3. What are their fears?

4. What are the trade-offs they are willing to make and not willing to make?

Read “The Best Possible Day” — an adapted portion of the book published in The New York Times — for Gawande’s moving story that illustrates the power of these questions.

Or read Slate’s excerpt, “No Risky Chances,” which has an equally moving story centered around these questions. I also encourage you to look at the comments — currently approaching 150 — that readers have posted. Some family caregivers have posted about how these seemingly simple questions can be extremely difficult to answer for a variety of reasons, such as the presence of multiple conditions, uncertain prognoses, and impaired cognition. Some commenters are medical professionals themselves, and they have raised some good points and questions, including about the impact of finances on decision making and the premise that a surgeon rather than a different type of doctor is even in the position of facilitating these discussions.

The Slate excerpt ends with Gawande’s call to “refashion our institutions, culture, and conversations to transform the possibilities for the last chapters of all our lives.” The comments are a small sliver of that larger conversation, which long-term care workers, as experts, need to participate in with full-throated conviction.

Tim Mullaney is McKnight’s Senior Staff Writer. Follow him @TimMullaneyLTC.