Finding Joy and Meaning in Practice: Caring for Older Adults in Dermatology

Today, like most days, clinic is busy, and by midday it is running a few minutes behind. A sip of water or restroom break seem like a faraway dream as one patient sits in an examination room and the next is expected to arrive within a few minutes. It feels like the only logical next step is to take a deep breath and see who is waiting in the examination room: an 85-year-old male with pruritus. Behind the door sits a gentleman with kind eyes behind large frame glasses resting atop his hearing aids. Beneath the gown is busy skin that has undoubtedly seen a lifetime of sun. Next to him sits his cane, a newspaper, his caregiver, and a plastic bag full of creams and ointments.

Most dermatologists have met this patient and many more like him. In a fast-paced, high-volume dermatology practice, seeing an older adult on the schedule can evoke various emotions. Older adults are often perceived as complex and requiring more time than younger adult counterparts. Their skin can be painted with a multitude of pinks, browns, and everything in between. They may move more slowly and be less limber than when they were young, leaving the provider to perform a dance composed of supporting patient movements while back bending and crouching to inspect each part of the body. They can be hard- of-hearing, have a difficult time reading small labels, have several medical comorbidities, and may need written instructions to help them remember what to do when they leave the office. Each of these things can layer on top of one another, increasing the provider’s perceived burden of thoroughly delivering care given an already full schedule. Moments like these can compel us to step back and remind ourselves of why and how we choose to practice medicine.

Although caring for older adults can feel challenging in a system poorly equipped to meet the complex and nuanced needs of this population, caring for these patients can still be tremendously rewarding. Moreover, their care can offer perspective that enhances our experience as dermatologists and as people. In this piece we wanted to explore a few common themes of how caring for older adults is, in its own virtue, able to bring joy to a dermatologist’s practice.

Practicing the Art of Medicine
In his essay “Teacher and Student,”¹ William Osler states that “the practice of medicine is an art, based on science.” In the face of countless algorithms that prompt us on how to diagnose and treat numerous diseases, it may start to feel like we are no longer the artist but a spectator. With the loss of the paintbrush, practicing medicine can begin to feel mundane in its repetitiveness. Caring for older adults, however, feels like a challenge to reclaim our paintbrushes. Older adults often require us to step outside of the day-to-day algorithmic medicine to shift our focus to caring for the person rather than the disease. These nuanced differences and needs invite us to reconnect with our medical knowledge and physician-ship skills. This can create a profound sense of gratification as we are challenged to connect medicine with the humanistic spirit.

Partnership, Trust, and Advocacy
Geriatric dermatology is one of the purest forms of patient-centered care. In most cases, older adults have a clear sense of what matters most to them in their health care goals and tend to have straightforward expectations. This allows providers a unique window into each patient. Prioritizing those critical and personal goals can be incredibly rewarding for a provider, leading to a more fruitful relationship where the patent is motivated and appreciative.

For older adults with multiple comorbidities and medications or socioeconomic constraints, it becomes an opportunity to use team-based care to collaborate with primary care providers, including geriatricians, who are thoughtful practitioners whose expertise stretch beyond our training within dermatology. Geriatricians engage patient experiences in effective and meaningful ways, allowing us to partner in creating a plan of care. Team-based approaches are also optimal when advocating for our patients and is another tool to navigate the complex needs of this population. By bringing unique skill sets to the table, each team member provides helpful resources that may prove beneficial. This extra step of advocacy can help patients feel like someone is on their side looking out for their best interest, further strengthening the partnership between patient and provider.

Gratitude
Geriatric patients can be some of the most grateful patients we see in clinic. They frequently have the composure to listen intently, and when they place their trust in our hands, it is often with a sense of genuine appreciation for the care we provide. Perhaps one of the most exceptional forms of gratitude older adults possess is appreciation of medical partnership. Many conditions associated with aging are chronic, thus the partnership between patient and provider is critical to ongoing and continuous care. This understanding can lead to a recognition that we see them as a person living with a disease and that we see their struggles in the context of being human, rather than treating them as the disease itself. Furthermore, older adult patients are often appreciative of having someone be present and sincerely listen to their experience with illness, which can become the first step in healing.

Perspectives of Life
With age comes wisdom, or at least a lifetime of experience. As physicians, we dedicate ourselves to a lifelong course of learning, and caring for older adults offers a unique opportunity to learn from those who have lived. Older adults are living history. They are people who come from all kinds of backgrounds, overcome profound hardships, and accomplished amazing things. Many continue to make a significant impact through mentoring or volun- teering, or they are still working, showing us that youth is perhaps a mindset rather than a particular age range. Listening to our older patients can put our own lives into perspective. They can inspire us to deal with setbacks in life with greater equanimity. They can help us reassess what is important in life. They can remind us to take time to not just mindlessly live through life but to truly experience it.

A Calling in Care
Comprehensive care for older adults remains an underserved need in the current health care system. By appreciating the offeings of this population, we can begin to welcome the joys that come with caring for them. An older adult’s busy skin represents a lifetime of stories and experiences. Working with older adults is an opportunity to step away from repetitive algorithmic medicine to reconnect with our medical knowledge and develop empathetic partnerships that can help put our lives into perspective. In a busy clinic, sometimes we need a moment to remind ourselves of our why to guide us in how we choose to deliver medical care. Sometimes, an older adult can remind us, too.

1. Osler W. Teacher and student. Dis Chest. 1957;32(4):377-387. doi:10.1378/chest.32.4.377