As a trainee physician I spent two summer spells working as a general practitioner on the coast in Devon in southwest England. After morning surgery I was given a list of patients to visit at home, mainly with minor illnesses and injuries, but always included among them were a few ‘chronics’. On one occasion I saw an older woman whose mobility was gradually getting worse and who had numerous other health problems. I discussed her care with the ‘senior partner’ and the conclusion was to request a domiciliary visit from the local geriatrician. The geriatrician and I met up at the patient's home; he advised me what to do and the patient improved. This type of joint approach saved the patient a difficult journey to see the consultant at the hospital and was (and still is) one of the few sources of extra payments for those consultants who work full-time for the National Health Service. Incidentally, the general practitioner for whom I worked had written a book on this subject that included details of the etiquette. For example, having seen the patient, the general practitioner and the consultant should withdraw to the bathroom to discuss the problem, and it was the former not the latter that reported the conclusions to the patient.
Domiciliary visits by geriatricians in the United Kaingdom became disfavoured. It was thought that consultants could better spend their time working in the hospital wards and clinics, or discussing the patient's problems on the telephone with their general practitioner. At the same time, community services developed, thus affording the general practitioner the opportunity to call upon diverse specialist nurses and allied health professionals to visit the patient at home both for assessment and for treatment.
In the United States, where the author of this book works, there has been a similar decline in home visiting, which has not been matched by the widespread availability of domiciliary care. Unlike in the UK, however, patients can consult specialists directly without having to be referred by a general practitioner, a practice that the author describes as the classical role of the physician. Indeed this was once true, the hospital or the clinic being reserved for the less well-to-do. The needs of older people were identified by Sheldon in Wolverhampton and Isaacs in Glasgow in their pioneering research into visiting people at home. Both contributed to the development of geriatric medicine in Britain.
The book is about the practice of geriatric medicine in poor, deprived neighbourhoods, but importantly it is also about the author himself. Alfred Stillman was a late convert to geriatric medical practice and trained in the specialty in his late fifties, something that would be impossible in the UK. He works with another geriatrician, a nurse practitioner and a social worker. He spends two-thirds of his time visiting and the remainder on administration, receiving most of his referrals from a local non-government organisation funded by federal government. What came across was his commitment to his patients. He is clearly a friend to many and one of their few links to the outside world. To some his approach may seem old fashioned or even paternalistic, but he evinces one of the most important qualities of professional practice – placing the patient first and a willingness to go the extra mile.
Stillman's portrayal of the lives of older people and how they come to terms with the often challenging environmental, psychological, economic and family situations, as well as with their disease, will be familiar to all practitioners. The ethical and practical dilemmas of coping with funders and providers who work with zero flexibility is also familiar. He describes his successes and failures. He clearly loves his work and the privilege of working with older people. Amongst the key messages he makes is the need to try to avoid stereotyping and the need to understand people's present situation in the light of their previous lifecourse. He emphasises a point which I always make to students, that older people have led interesting lives and have much to talk about.
In England, the Department of Health recently conceived the new community matron. These experienced nurses will case-manage groups of frail, mainly older, people. The theory was that by pro-actively intervening at the earliest stage of a patient's deterioration, hospital admission would be avoided. Evaluation showed that in this task they were unsuccessful, although the patients naturally enough appreciated this service. The optimum way of sustaining and improving the health of this growing section of the community clearly depends on harnessing and linking all the hospital and community expertise that is available in a given locality. The rewards that can arise by such an approach are amply illustrated in Stillman's book. Health and social care practitioners, students and policy makers as well as elder advocates will find this book useful and enlightening.
