The Gerontologist Copyright 2002 by The Gerontological Society of America

Vol. 42, No. 6, 835–842

Primary Care for Elderly People:

Why Do Doctors Find It So Hard?
Wendy L. Adams, MD, MPH,1 Helen E. McIlvain, PhD,1 Naomi L. Lacy, PhD,1
Homa Magsi, MD,1 Benjamin F. Crabtree, PhD,2
Sharon K. Yenny, RNP, MS,3 and Michael A. Sitorius, MD1

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Purpose: Many primary care physicians find caring for some time to come (Manton & Vaupel, 1995). Cur-
elderly patients difficult. The goal of this study was to de- rently, people aged 65 and older account for 30–40%
velop a detailed understanding of why physicians find pri- of primary care physician visits (Schappert, 1999;
mary care with elderly patients difficult. Design and Stafford et al., 1999; U.S. Bureau of the Census,
Methods: We conducted in-depth interviews with 20 pri- 1996). As the rapid aging of the population continues
mary care physicians. Using an iterative approach based toward its projected midcentury plateau, general in-
on grounded theory techniques, a multidisciplinary team ternists and family physicians will be called upon to
analyzed the content of the interviews and developed a provide primary care to an increasing volume of el-
derly patients. At present, many of these physicians
conceptual model of the difficulty. Results: Three major
are unwilling or unable to do so. Surveys of primary
domains of difficulty emerged: (i) medical complexity and
care physicians show that between 30% and 50%
chronicity, (ii) personal and interpersonal challenges, and limit the number of elderly patients they admit to
(iii) administrative burden. The greatest challenge oc- their practices (AARP, 1995; Cykert, Kissling, Lay-
curred when difficulty in more than one area was present. son, & Hansen, 1995; Damiano, Momany, Willard,
Contextual conditions, such as the practice environment & Jogerst, 1997; Geiger & Krol, 1991; Lee & Gil-
and the physician’s training and personal values, shaped lis, 1993; Lee & Gillis, 1994). To meet the primary
the experience of providing care and how difficult it care needs of the aging population, researchers and
seemed. Implications: Much of the difficulty partici- policy makers must understand and respond to this
pants experienced could be facilitated by changes in the phenomenon.
health care delivery system and in medical education. The There have been surprisingly few attempts to deter-
voices of these physicians and the model resulting from mine the reasons physicians limit the number of el-
our analysis can inform such change. derly patients in their practices, and results have been
inconsistent. Studies have focused on concerns with
Key Words: Primary health care, Health services Medicare fees and documentation requirements,
for the aged which clearly are sources of frustration for physicians
(Cykert et al., 1995; Geiger & Krol, 1991). However,
frustration with Medicare seems to explain only a
America is in the midst of a major demographic small part of physicians’ willingness to provide care
shift that will have repercussions for health care for to elderly patients. In one survey of primary care phy-
sicians, 65% reported that low Medicare fees were a
very important problem in their practices, but this did
not predict whether or not they limited the number of
We are most grateful to all the physicians who donated their time for Medicare patients they accepted (Damiano et al.,
the interviews. We also thank Jeff Susman, MD, Kurt Stange, MD, and 1997). Some demographic variables are associated
Lynn Meadows, PhD, for their helpful critiques of earlier drafts of this ar-
ticle; John Creswell, PhD, for methodologic advice; and Linda Ferring for with practice limitation, including primary care spe-
manuscript preparation. This study was approved by the Institutional Re- cialty (Lee & Gillis, 1993; Lee & Gillis, 1994), urban
view Board at the University of Nebraska Medical Center.
Address correspondence to Wendy L. Adams, MD, MPH, Department of location (Cykert et al., 1995), and type of practice
Family Medicine, University of Nebraska Medical Center, 983075 Nebraska (solo, single specialty, or multispecialty; Cykert et al.,
Medical Center, Omaha, NE 68198-3075. E-mail: [email protected] 1995). Studies have generally not measured psycho-
1Department of Family Medicine, University of Nebraska Medical Cen-

ter, Omaha. social or practice level variables that might contribute

2Department of Family Medicine, Robert Wood Johnson Medical
to physicians’ perceived need to limit geriatric prac-
School, University of Medicine and Dentistry of New Jersey, New
Brunswick. tice and no previous qualitative studies have ad-
3VA Nebraska–Western Iowa Health Care System, Omaha, NE. dressed these issues.

Vol. 42, No. 6, 2002 835

 Though data are sparse, there are suggestions in high proportion of elderly patients. Subsequently, we
the literature that primary care physicians find elderly selected physicians practicing in the vicinity of Omaha,
patients more difficult to treat (Damiano et al., 1997). Nebraska, from a database maintained in the Chan-
This may have to do with medical training. In a na- cellor’s office at the University of Nebraska Medical
tional survey, only 60% of general and/or family Center comprising demographic information about
practice physicians and 50% of general internists felt all physicians practicing in the state. We used a max-
that their formal medical training did a good or excel- imum variation sampling strategy (Kuzel, 1999), in
lent job of preparing them to manage care needs for which we selected physicians from the list by gender,
frail elders (Cantor, Baker, & Hughes, 1993). Another age, and specialty to compile a sample representing
survey of primary care physicians in Virginia found both men and women, internists and family practi-
that fewer than half thought their current geriatric tioners, and a wide age range. We approached physi-
knowledge was adequate (Perez, Mulligan, & Myers, cians by an introductory letter followed up by a tele-
1991). Characteristics of the health care system may phone call. In all, we contacted 141 physicians to
also contribute to physicians’ willingness to provide recruit the 20 participants.
care to elders. In a survey of Canadian family physi- Demographic and practice information about par-
cians, respondents endorsed poor reimbursement, ticipants is shown in Table 1. Of the 20 participants
time pressure, and inadequate community resources recruited, 19 were White and 1 was Hispanic. Eight

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all as sources of frustration in caring for older patients were women. Ages ranged from 32 to 70 years. Three
(Pereles & Russell, 1996). Although these studies sug- respondents limited the number of elderly patients
gest potential contributors to physicians’ limitations they accept into their practices; all three were busy in-
on practice with elderly patients, a detailed under- ternists with a high volume of elderly patients. In this
standing of the problems physicians encounter in ge- article, a code letter has been randomly assigned to
riatric primary care and a clear direction for change identify participants.
are sorely needed.
Given the paucity of data in this area, a research Procedure
approach that allows in-depth examination of physi-
cians’ perspectives is needed. To gain a deeper, more Two of the authors (W. A. and H. M.), both phy-
detailed understanding of the key issues, we conducted sicians, conducted in-depth interviews (Crabtree &
a qualitative study that explored how physicians view Miller, 1999) with the participants. The average in-
providing primary care to elderly people. This article terview lasted 50 min, with a range from 30 to 120
focuses on the theme that most consistently pervaded min. Participants appeared to respond in an equally
the interviews: the increased difficulty of primary care open and forthcoming way to both interviewers. We
with elderly patients. We present a conceptual model, examined interview content for systematic differ-
developed from these data, which suggests vital areas ences in responses to the different interviewers and
to be addressed to ensure that primary care of elderly were unable to detect any. We were also unable to
people meets current and future needs. detect any systematic differences between the re-
sponses of the two participants who were previously
acquainted with the interviewer and the others, who
Methods were not. The interview questions were broad and
open ended. We invited the participants to relate
Design and Participants
personal narratives regarding experiences with geri-
We conducted a qualitative in-depth interview atric primary care with the initial “grand tour”
study with a diverse sample of 20 practicing general question: “Please tell me about some of your expe-
internists and family physicians. The first two respon- riences taking care of elderly people.” We then
dents were physicians known by one of the authors to asked them to relate both satisfying and frustrating
have busy internal medicine practices with a relatively experiences. The existing literature suggests certain

Table 1. Characteristics of Participants

Internists Family Physicians

Characteristic (n  10) (n  10)

Age, mean (range) 44.9 (32–69) 49.5 (35–70)

Years since board certification, mean (range) 14.1 (2–37) 14.7 (4–26)
Female, % 60 90
Urban location, % 90 70
Practice 65 or older, mean percent (range) 57 (25–100) 32.8 (15–65)
Size of group solo practice: 1 solo practice: 2
2–5 physician group: 5 2–5 physician group: 2
5 physician group: 4 5 physician group: 6
Do nursing home practice, % 60 70
Nursing home medical directors, % 40 10

836 The Gerontologist

topics important for physician satisfaction that may 1985), with 5 of our participants. In these interviews,
relate to their views on care of elderly patients. If we gave participants written descriptions of the cate-
these did not come up spontaneously, we asked par- gories of difficulty and contextual conditions we had
ticipants to comment on them. We used such prompts developed in the analysis process. In the last member
for reimbursement issues (Cykert et al. 1995; Damiano checking interview, we presented the evolving concep-
et al., 1997; Lee & Gillis, 1993; Lee & Gillis, 1994), tual model, similar to Figure 1 in this article. We then
time pressure (Burdi & Baker, 1999; Lewis, Prout, asked for discussion and feedback. Although not ev-
Chalmers, & Leake, 1991; Linn, Yager, Cope, & ery point of difficulty was important to every physi-
Leake, 1985; Linzer et al., 2000; Mawardi, 1979), cian, all strongly confirmed the importance of the
confidence in addressing geriatric syndromes (Can- increased difficulty and the appropriateness of the
tor, Baker, & Hughes, 1993; Perez, Mulligan & categories of difficulty presented here.
Myers, 1991), community resources for elderly pa-
tients (Pereles & Russell, 1996; Siu & Beck, 1990),
the doctor–older patient relationship (Adelman, Results
Greene, & Ory, 2000; Bates, Harris, Tierney, & Overview
Wolinsky, 1998; Greene, 1993; McMurray et al.,
1997; Roter, 1991), and frailty and death (Kra- Most participants enjoyed their interactions with

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kowski, 1982; Morrison, Morrison, & Glickman, older patients and emphasized that advanced patient
1994). We asked the physicians to describe how the age alone was not problematic. All, however, related
doctor– patient relationship was different with older experiencing increased difficulty in caring for elderly
and younger patients. Other questions did not ask patients, which fell into three major domains: (i) med-
physicians to compare and contrast experiences with ical complexity and chronicity, especially patients’
older and younger patients, but they frequently made vulnerability to adverse events; (ii) personal and inter-
such comparisons when discussing their experiences. personal challenges, including time pressure, commu-
nication problems, and ethical dilemmas; and (iii) ad-
Analysis ministrative burden, including more telephone calls
and paperwork as well as Medicare’s documentation
We audiotaped and transcribed interviews verba- requirements. As illustrated in Figure 1, these catego-
tim. A multidisciplinary team including 2 physicians, ries overlap and interact. For example, a medically
a nurse practitioner, a medical anthropologist, a med- complex situation may lead to nursing home place-
ical sociologist, and a psychologist then analyzed ment, which challenges the doctor–patient–family
these data. We used a three-stage coding process de- relationship and increases administrative burden.
rived from the sociologic tradition of grounded the- Figure 1 also illustrates that the difficulty was expe-
ory (Strauss & Corbin, 1998). In the initial open cod- rienced in the context of the practice environment
ing stage, each team member independently read each and seen in the light of the personal characteristics of
transcript several times and marked key phrases, the physician. Although the nature of the difficulty
terms, or sentences. We then met and discussed the in- was similar for physicians with small and large vol-
terviews in detail, sharing insights from our various umes of elderly patients, it had more impact on phy-
disciplines and assigning topical codes to the text of sicians with a high volume.
the interviews. We grouped these codes into catego-
ries as it became evident which concepts were emerg- The Nature of the Difficulty
ing as keys to understanding physicians’ perspectives
on primary care with elderly patients. As the analysis Medical Complexity and Vulnerability to Adverse
proceeded, we compared the content of each new Events.—Elderly patients were seen as medically more
interview to the existing categories and the coding difficult to care for than younger people. They had
modified accordingly. In the axial coding phase, we more medical conditions, and their illnesses often pre-
developed the categories further and began to define sented atypically. They were more likely to become
the relationships among them and their possible im- seriously ill and were vulnerable to rapid declines in
plications. In the final selective coding process, we de- their condition. Multiple medications and the risk of
veloped the conceptual model that is presented here. adverse medication reactions also contributed to the
We used several techniques common to qualitative difficulty. Participants described diagnostic and ther-
research to ensure that standards of rigor were met. To apeutic uncertainty as well as anxiety about causing
maximize the trustworthiness of our data collection unintended harm to patients. An internist who had in-
and analysis, we continued recruiting participants until herited a large volume of elderly patients from a retir-
no new major themes were emerging (Patton, 1990). ing colleague remarked, “Their problems were kind
In the process of developing codes and interpreting of special compared with the general medical popula-
the data, the diversity of the team kept one point of tion. . . . The thing that impressed me the most is,
view from dominating and biasing the results (Cres- their homeostatic mechanisms didn’t leave much
well, 1998; Lincoln & Guba, 1985). We also routinely room for goof-ups” (Dr. C). Another internist de-
searched for disconfirming evidence in the interviews scribed a patient’s adverse drug reaction: “I thought,
(Patton, 1990). We conducted follow-up interviews, here is something I have done to hurt this patient by
also known as member checking (Lincoln & Guba, giving him this medicine. . . . What other things can I

Vol. 42, No. 6, 2002 837

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Figure 1. The difficulty of primary care for older people and its context.

do to hurt people? . . . In a lot of ways you’ve got to osis and you can’t do anything about it, or they may
be very careful with things” (Dr. I). be a little depressed, but they won’t take any medi-
Elderly patients often have chronic conditions with cine, and they’re chronically constipated and, you
symptoms that are difficult to control. “In general, know, sometimes those are the most frustrating (Dr. O).
they have more things wrong with them and in gen- Medical complexity also had a positive side. Sev-
eral, they’re on way more medication and in general, eral participants enthusiastically told of satisfying ex-
they don’t feel good most of the time and they don’t periences in which they had made a difficult diagnosis
sleep at night and they are deteriorating . . .” (Dr. P). and helped patients substantially. Regarding a 96-
This can lead to a disinclination to see these patients: year-old woman with an atypical presentation of
Every time they come in something’s aching or hurt-
ischemic heart disease, a family physician remarked,
ing or . . . “My back’s a little sore” or “I’m a little I was able to stabilize her in the hospital, get her feel-
stiff, I don’t have the energy I used to,” “Well, maybe ing good and actually took care of her for another
I’m a little depressed.” Sometimes they get to be those two years or so. . . . She was so grateful that I had
people that you look at the list and go, “Ah-h-h-h, been able to find what was wrong with her, and she
doggone, that name again” (Dr. E). became a very dear patient to me . . . so that was a
really good experience (Dr. J).
Many participants described frustration at their
perceived inability to help with older patients’ Adjusting to the increased prevalence of chronic ill-
chronic conditions. One family physician related, ness and the relative infrequency of cures requires a
change of outlook on the physician’s part. One young
No matter what you do, they hurt. No matter what internist seemed to be in the midst of this process
you do, they get agitated. And no drug exists to stop when she related,
a cognitively impaired patient from falling. You
know, yeah, that’s frustrating. You bet it is. But hey, But then I was thinking, I need to think of it in a dif-
somebody needs to take care of these folks (Dr. L). ferent frame of mind. More of maybe getting them to
understand that this is a chronic problem and what
An internist reported, can we do to make them feel better as opposed to fix
them. (Dr. O).
You know, there are some patients that they’re al-
ways going to have the same problems year after year This may be an adjustment that not all physicians are
after year. They’re not going to be fixed. You know, able to make. Regarding caring for cognitively im-
it’s their back pain from their osteoporosis and scoli- paired patients, Dr. L said,

838 The Gerontologist

 I mean in general, there’s not a lot that medicine can kind of put into the awkward position of having to
do about that. Our interventions are somewhat lim- carry out what they want (Dr. L).
ited, so this just adds to this area of medicine. It takes
a special kind of mind set, a special kind of provider These decisions are frequently emotionally charged.
to grapple with those on a day-to-day basis. “Our culture is so afraid of death, that usually it isn’t
that peaceful. It’s just wrought with being torn apart
Personal and Interpersonal Challenges.—Commu- by just an incredible amount of argument and bicker-
nication barriers, especially those resulting from hear- ing between family members. It’s terrible” (Dr. P).
ing problems or cognitive impairment, contributed to Time pressure was a major issue for participants
difficulties with history taking, treatment, and the with a large volume of elderly patients. “That’s prob-
quality of the relationship. One physician remarked, ably the biggest problem I have right now, is manag-
“[There are] lots of various obstacles to getting the ing my time with the older individuals” (Dr. A). Med-
whole story, getting the truth out and sometimes ical complexity, family involvement, ethical decision
’cause they don’t remember and sometimes they just making, and communication barriers all made caring
don’t think it’s important and sometimes they’re just in for frail elders more time consuming. History taking
denial of what’s really wrong” (Dr. P). Another com- was slower, physical examinations took longer, and
mented, “It’s sometimes frustrating when you’ve got mobility impairment slowed down the flow of office

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an older person who can’t hear and won’t wear hear- activities. Medicare’s extensive documentation re-
ing aids and you know, you have to shout so loud that quirements and lengthy claims processing also make
everyone else in the building hears everything you say heavy demands on physicians’ time, as do paperwork
to them” (Dr. J). and phone calls from home health agencies and nurs-
Families often became involved in the care of frail ing homes. “[If you see 15 elderly people] it takes
elders. For the physicians we interviewed, this had time. You feel like you’ve done a big day’s work. You
both positive and negative implications. Involved can see 15 young people with sore throats and be
family members increased the safety of medication done in an hour” (Dr. M). In the current health care
use and the home environment. However, their par- environment, where efficiency is highly valued, this
ticipation increased the length of office visits, the presents a major difficulty for physicians. “You have
complexity of the doctor–patient relationship, and to have sheer volume with Medicare patients but
the difficulty of decision making. Friction with fami- Medicare patients also require most of your time be-
lies sometimes arose when it was unclear whose re- cause they need so much, so it’s a hard situation out
sponsibility it was to provide personal care: there” (Dr. I).
You know, I don’t mind dealing with it as long as the
family is going to deal with it too. If they act like it’s Administrative Burden.—Nearly all of the physi-
all my problem to deal with Mom or Dad and figure
cians felt they spent too much time, effort, and worry
out, you know, a solution at home for care and you
know, that’s what’s irritating because that’s not my
on Medicare regulations. Claims were often denied
responsibility (Dr. G). for apparently trivial reasons and resubmitting them
required substantial personnel time. In some situa-
When older patients were unsafe driving or living tions, “The amount of return is less than the effort
alone but wished to continue to do so, the need to bal- made in acquiring the reimbursement” (Dr. Q). Medi-
ance safety and autonomy was sometimes difficult. care regulations seemed particularly frustrating be-
It’s usually a struggle between the family wanting cause they did not seem to relate to the quality of care.
them to move to a more supervised level of care or It has nothing to do with the care the patient got. . . .
out of their home and the . . . parents not wanting to You go through a whole long physical exam of stuff
do that, so it’s usually a negotiating process, usually a that is irrelevant really to the problem at hand, . . .
slow process (Dr. Q). and spend more time on the paperwork than you do
On the whole, physicians found caring for elderly taking care of the patient. And so that’s extremely
patients who are dying one of the most important and frustrating as well as stupid (Dr. M).
meaningful aspects of practice. Most, however, had The threat of legal action from Medicare adds ad-
experienced serious conflicts with family members in ditional anxiety to geriatric primary care:
this area. One related,
You wake up in the middle of the night in a cold
The most difficult thing . . . is just the actual end of
sweat thinking, “Oh my God! The Office of Inspector
life issue when the patient is in the hospital and you
General showed up at my office today and wants to
have a family there, and the family doesn’t get along,
go through every file in my charts!” So it’s sobering to
and then trying to be a mediator within the family to
know what Medicare could do to you and your prac-
get some kind of good consensus (Dr. K).
tice if they chose to. And I’m of the opinion they
Physicians were challenged to examine their values could probably find improper documentation/coding/
and balance them with the family’s. billing in every office in this country (Dr. L).

When you internally feel like a family member is In general, Medicare was seen in an adversarial
making decisions on behalf of the patient that are light, increasing the burden of providing primary care
maybe prolonging the patient’s misery . . . then we are to older patients.

Vol. 42, No. 6, 2002 839

Multifaceted Complexity It eliminates some of the camaraderie, if you will,
with the patient. That’s inevitable” (Dr. L).
In the initial coding process, complexity and diffi- Physicians’ personal characteristics, values, and
culty were noted in all 20 interviews. As we returned training also affected how they viewed geriatric pri-
to the data for the axial coding process, it was evident mary care. For instance, older physicians felt closer to
that participants rarely felt overwhelmed by difficulty their elderly patients:
in one area alone. In every interview, however, there
was a discussion of at least one situation where an el- I’m not exactly young myself anymore and so I guess
derly patient’s medical needs overlapped with psycho- I have a fair amount of good feeling towards the el-
social and/or administrative difficulty. These were the derly. It’s easier for me to identify with somebody
situations in which caring for older patients became who is 75 and has lived through some of the things
seriously problematic. “It’s just that you have a num- they lived through or the depression, World War II,
ber of these things happening all at the same time. raising children, than a very young person with an ear-
Physicians are human. It wears on you” (Dr. N). ring in their nose and ear and their lip and I’m not sure
When considering Figure 1 in a member-checking in- I have much in common with that person (Dr. H).
terview, one participant remarked, Some participants felt a social obligation to care for
This helps me understand why these patients are so nursing home patients, whereas others did not.

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hard. It’s OK if they just have difficulty in one of these
It’s not that much fun but I just feel like it’s something
areas, but when there’s more than one, and especially
that I have to do for society, part of my job. I could
in that area (pointing to the model) where they have
never do that as a full-time job or even have a larger
all three, the difficulty is exponential, or logarithmic
practice in a nursing home (Dr. G).
or something (Dr. B).
The Practice Environment.—Certain aspects of the
Contextual Conditions practice environment facilitated or hindered caring
for elderly patients. The volume of older patients in
The three-faceted difficulty presented above oc- the practice had a major impact on how the difficulty
curred within the context of the practice environ- was experienced and whether the participant was lim-
ment. There was also a context of personal and inter- iting or was planning to limit the number of new el-
personal factors. For instance, a complex medical derly patients. Physicians with a high volume of older
situation that occurred within the context of a long- patients found it more difficult to incorporate their
term doctor–patient relationship was perceived dif- complex care into the usual flow of work. One inter-
ferently from a complex medical situation in the con- nist who had recently cut back her practice related,
text of a new relationship. Various constellations of
these contextual conditions shaped the experience of The patients are so complex and they take so much
providing care and how difficult it seemed. In Figure time sometimes and they have side effects from med-
1, the larger circle represents this context. ications and phone calls, that yeah, you get over-
whelmed. It’s just not physically, humanly possible. It
just isn’t. You would need to have a smaller patient
Personal and Interpersonal Factors.—All participants population to do a good job (Dr. P).
found elderly patients more grateful and appreciative
than younger patients. Some also enjoyed hearing The roles of office staff members and their relation-
their stories and experiencing their wisdom. For ships with the physician and each other also affected
many, this mitigated the difficulty of their care. how well they were able to cope with a high volume
I enjoy taking care of elderly patients, mostly for the of elderly patients. One geriatrician remarked,
personal interaction with them as opposed to their “[Nurses] can make you or break you. I mean, if they
medical problems. I would look at the medical care of left, I’d have to leave” (Dr. A).
those individuals to be a little more cumbersome than Community resources were generally perceived as
younger people from an operational standpoint. It’s inadequate. None of our participants had ready ac-
harder to do things, more difficult. But the interaction cess to social workers in the office, so arranging home
with the individuals is more rewarding I would say health care, adult daycare, and other community ser-
(Dr. Q). vices added to the difficulty of primary care.
When patients are severely cognitively impaired, You know, there’s no one place, no one clearing house
on the other hand, the limited relationship often made that you can go for those kind of services. You just
the care seem meaningless. One internist related, have to kind of make a patchwork quilt almost of
The very severe cognitively impaired people, . . . I that. It’d be nice to have someplace where you can
don’t find any particular satisfaction in taking care of have one phone call . . . and say, here’s my patient’s
them. Whatever was . . . the essence of their humanity needs, what can you provide for us? (Dr. C).
is long since gone and I’m tending to a body, which Caring for patients in nursing homes was generally
has no hope of recovery and it’s hard for me to get
regarded as difficult and unpleasant. Prominent diffi-
real excited and enthusiastic in that setting (Dr. B).
culties with nursing home care included the logistics
A family physician said, “You have to tell them the of providing care, communication with nursing home
same thing every visit. And they don’t remember you. staff, and dysfunctional regulations.

840 The Gerontologist

 Their regulations are ridiculous, you know, especially care system (Kottke, Brekke, & Solberg, 1993; Wag-
the one where they have to call you if somebody ner, Austin, & Von Korff, 1996). This study vividly
scrapes their elbow. Nursing home visits usually demonstrates the real impact of this mismatch on the
aren’t the most stimulating . . . and you have to sift daily practice of medicine. In so doing, it strongly
through charts that you’re not familiar with and supports the need for health system change. The recent
where anything is and I don’t know (Dr. G). Institute of Medicine report, Crossing the Quality
Although caring for frail elders is difficult and time Chasm, calls for efforts to improve health care by ap-
consuming, Medicare reimbursement is lower than proaching it as a “complex adaptive system” (Institute
private insurance. Low fees did not contribute to the of Medicine, 2001). To effect positive change in such a
difficulty of geriatric primary care, but clearly influ- system, it is essential to recognize which elements can
enced how physicians responded to it. change and which cannot. The three-faceted difficulty
at the center of our model must be regarded as a fixed
If you told me that I had to run this place on the basis
of what I get from Medicare, I would have to tell you
element of the system. Caring for chronically ill elders
I couldn’t do it, which is kind of sad, because they is and will remain complex and time consuming. There
claim that they’re bankrupt and everything. Where in is great potential for positive change in the context in
the hell are they spending their money? They sure which care is delivered, however.
ain’t giving it to me (Dr. F). Our results suggest potential for change in practice

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organization, health care policy and medical educa-
The mismatch between patient needs and the level of tion. In the area of practice organization, a number of
reimbursement generates a conflict between the phy- interventions to facilitate primary care of chronically
sician’s role as healer and his or her role as business ill elders have been proposed and a few have been stud-
person or employee. ied (Boult, Boult, Morishita, Smith, & Kane, 1998;
You owe it to your employer to be as productive as Leveille et al., 1998; Schraeder, Shelton, & Sager,
you can but you also owe it to your patient to be as 2001; Netting & Williams, 2000; Wagner et al.,
helpful as you can and sometimes the two masters 1996). The participation of nurse case managers in
can’t be served at the same time (Dr. C). primary care practices, for instance, has shown bene-
The imbalance between the time required and reim- fits in elderly patient mortality and physician satisfac-
bursement sometimes leads to physicians limiting tion (Schraeder et al., 2001). As yet, however, such in-
geriatric practice even if they enjoy it. terventions have met with very little acceptance by
health care organizations or third party payers (Boult,
In the real world, communication takes time, whether Kane, Pacala, & Wagner, 1999; Wagner, Davis,
you’re communicating with an elderly person who Schaefer, Von Korff, & Austin, 1999). None of our
has a delay between the time that you give them a participants had access to such personnel. Perhaps the
question and the time they give you an answer, or greatest interpersonal challenge our participants ex-
those that can’t understand or deal with complex
perienced was the expansion of the doctor–patient
questions. . . . It takes longer to take care of patients
like that. You superimpose upon this slow reacting relationship to include family members and other
patient a worried . . . family member who has a num- caregivers. Programs that facilitate communication
ber of questions. . . . It adds more time to the office between families and staff in the nursing home setting
visit and the way Medicare is paying us for office vis- have shown great promise (Pillemer, Hegeman, Al-
its. From an economic standpoint it just does not bright, & Henderson, 1998; Specht, Kelley, Manion,
make sense to take care of old people (Dr. C). Maas, Reed, & Rantz, 2000). A similar intervention
to enhance doctor–patient–family communication
could be extremely helpful in the primary care setting.
Discussion
Regarding health care policy, participants con-
This study, using face-to-face interviews with prac- firmed that Medicare documentation requirements
ticing physicians, gives an in-depth look at the difficulty are onerous and fees too low. Simplification of docu-
involved in providing primary care to elderly patients. mentation requirements and increased reimburse-
The voices of these physicians and the framework we ment for complex nonprocedural care would clearly
propose for understanding the difficulty they de- facilitate caring for elders. Participants also found the
scribed can inform future efforts to meet the health infrastructure of support services inadequate and dif-
care needs of our aging population. On the whole, ficult to access. Policy directed at improving commu-
participants enjoyed interactions with their elderly nity resources to meet the needs of chronically ill el-
patients, but the high prevalence of multiple medical ders would also be extremely beneficial.
problems and declining physical and cognitive func- Changes in medical education could have impor-
tion among these patients gave rise to interacting tant impact on physicians, who are themselves modi-
medical, interpersonal, and administrative difficulty. fiable elements of the health care system. On the
Physicians struggled to deal with the difficulty in a whole, participants felt confident managing specific
practice environment that was not set up to provide illnesses, but lacked confidence in dealing with geriat-
the support and resources these patients needed. ric issues, such as vulnerability to adverse medical
We are by no means the first to recognize the mis- events and cognitive impairment. They experienced the
match between the chronic care needs of our aging greatest difficulty when the medical problems over-
population and the acute orientation of our health lapped with interpersonal challenges and administrative

Vol. 42, No. 6, 2002 841

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Leveille, S., Wagner, E., Davis, C., Grothaus, L., Wallace, J., LoGerfo, M., et
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