A personal physician or care manager for everyone

‘The problem is that medicine divides people into separate specialisms,' according to specialist in geriatric medicine, Rudi Westendorp, who will deliver the Dies lecture on 8 February. He advocates an integrated system of healthcare and a coherent approach to the human body. Professor Westendorp: ‘We are pushing the limits of the added value of medical specialisation.' 


Overlooked

Westendorp explains what he means by that 'chopping up into separate specialisms' and gives his diagnosis of present-day medicine. 'In the fifties, sixties and seventies we made enormous advances in specific specialist fields. We solved many health problems, but it has not resulted in breakthroughs in complex issues. This is the current state of affairs in medicine, and it reflects what is taught. We are talking here about such areas as nephrology, high blood pressure and optical diseases, but integrated medicine is overlooked.'  

Life course perspective

As a result of the increased tendency towards separate specialisations there is a centrifugal motion, Westendorp points out. The cohesion between all the different elements seems to have been lost and our elderly citizens are the ones who are suffering most as a result. 'We have to put a new safety net in place. I would call it geriatric medicine. We have to move towards a turnaround in our life course perspective. And that also means a turnaround in the way we practise medicine.' But we are not that far yet. This is why Westendorp offers an executive programme for managers in healthcare and a postinitial master's for newly qualified doctors at the Leyden Academy on Vitality and Ageing. The first of these has been going for some time and the second will start in September. Both programmes teach on issues that are not yet available at any of the existing institutions, which makes it unique.  The brochure of the postinitial master's programme (pdf) for newly-qualified doctors.


Water-tight partitions

In the master's for newly qualified doctors a primary focus is on the biology of the ageing process, an area closely related to Westendorp's own evolutionary-focused research. In addition, the master's concentrates on medicine for the elderly and the social perspective of old age. 'Even the partitions between - and within - traditional specialisations such as geriatrics and gerontology are watertight,' says Westendorp. 'I want to show that you can achieve added value if you put all these aspects together.' He is not overly concerned about where his students end up. 'This issue is the same everywhere in the medical world. Opthalmologists only see old people, and the same applies at a certain point in time to specialists in internal medicine and the GPs, too. This is because the major medical problems of youth and middle age have largely been resolved.'

Added value

Nonetheless, Westendorp would be the last person to deny that specialisation has led to an increase in life expectancy. He draws a graph to illustrate his point. 'You can image with young people that added value increases with the increase in investment. But at a certain point you reach a ceiling. For old people, too, the added value increases, but it reaches an optimum level and then declines. If the majority of the medical problems are in the young category, you know what you as a soclety have to do: invest in specialist care. But if the reverse is the case, we have to see that added value doesn't decline as a result of specialist care.' 

 

Solution

It irritates Westendorp to be asked what he sees as the solution for this problem, although he recognises it as a valid question. 'The first part of the solution is that we need to recognise that this is the way things are. And we're not doing that yet. I am expected to find a solution, while people don't even see the problem yet. You have to be able to recognise when you have reached the optimum added value for a patient. Then you have to make a decision about what you will and won't do after that. That's not so difficult. You might find, for example, that you and five other specialists are treating a particular patient, then you need to combine forces.  Old people recognise this; they spend the whole week visiting one healthcare worker aftre another and they wonder what they, as a patient, get out of it.'

Quality

Somebody then has to take command, in Westendorp's view. 'It has to be a doctor who takes on this role for the patient: a kind of 'personal physician'. He listens to the patient, sees that not everything is achievable, and makes choices on the patient's behalf. And for people who are no longer able to guide the physician themselves, an non-medical care manager has to be appointed.' For Westendorp, the quality of care is paramount: 'I believe that professionalising care leads to inferior quality. It's better if you can leave a dementia patient in his own home with his partner, and it's more cost-effective, too. That's a useful side-effect, but my prime concern is improving quality.' The care manager should be able to recognise and express the problems, and also has to be a good organiser. The first role is something the family can easily take on, in Westendorp's view. 'But to get anything organised in healthcare, you often need the support of a professional. In the Netherlands, that can easily be the GP.'  

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Health, prevention and the human life cycle

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(2 February 2010)

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Last Modified: 10-02-2010