Vol. LXV, No. 32
Wednesday, August 10, 2011
THE ART OF MEDICINE: What makes geriatric medicine special for me is its diversity. There is no average 90-year-old. This allows for the art of medicine to be practiced. Dr. David Barile, founder and director of the New Jersey Goals of Care Foundation, is also director of the Acute Care for the Elderly Unit at the University Medical Center at Princeton.
What do patients want from their doctors? Ideally, of course, if they are sick or injured, help to get well.
If their disease is advanced, however, and a cure is not possible, then what? Or if they are very old with limited strength or chronic health problems that make it impossible to accomplish what they once did, what do these patients want?
Dr. David Barile faces these questions every day. Director of the Acute Care for the Elderly (ACE) Unit at the University Medical Center at Princeton, he is also founder and director of New Jersey Goals of Care, a non-profit foundation whose mission is to align the patients goals and hopes for care with available therapies and treatments.
As a geriatrician, he focuses on older people who are entering the final years of their life, and their goals may change from cure and longevity to more comfort and better quality of life in the time remaining.
When I meet a 90-year-old patient, I first assess his or her condition, says Dr. Barile. Then, the medical prognosis, life expectancy, and the patients personality, preference for care, and goals of care are all taken into consideration.
What are their hopes for the future? Maybe the patient wants to be able to drive again, garden, or live long enough to attend a family event, such as a wedding or graduation. By aligning therapies to achieve a specific patient goal, quality of care and satisfaction with care will improve. We want to achieve the best possible outcome for that patient. This really allows for the practice of medicine the way it used to be years ago.
His experience in geriatric care since 1995 has led Dr. Barile to the conclusion that the above scenario is not typical. One of the fundamental problems in geriatric care is the lack of an individualized approach, he points out. The current model for health care in New Jersey is for physicians to pursue aggressive and curative therapies until the patient has approached an actively dying phase. Not until the physician recognizes this phase are goals of care discussed with the patient or families. This often leaves the patient and family members disappointed in their medical care and sometimes feeling abandoned by their primary physician.
Goals of care have often not been discussed earlier, and elder patients spend their final weeks or months in a hospital setting. During this time, they receive aggressive medical interventions they may likely have forgone had they been asked. Both the amount of time spent in the hospital and the intensity of physician services delivered in the hospital are higher in New Jersey than in any other state.
Many might think New Jerseys aggressive use of hospital services would bring better health outcomes and greater satisfaction with health care, but it has not, continues Dr. Barile. According to the Dartmouth Atlas (which researches variations in health care in the U.S.), health outcomes for New Jersey residents are no better, and perhaps worse, when compared to other states.
New Jersey ranks highest in the nation regarding health care dollars spent on Medicare beneficiaries. Seniors in New Jersey can expect to see more doctors and undergo more tests during their final years of life than in any other state. While this high level of service may sound beneficial, it has actually often had a negative impact on the quality of life for many older citizens who are not consulted about their care.
Dr. Barile points out the factor of ageism among numerous health care professionals. Sadly, many physicians withhold therapies simply based on the patients age without entering into a discussion with that person regarding their treatment goals. This prejudice occurs across the spectrum of medical providers and negatively impacts quality and satisfaction. Very old patients are sometimes denied surgery or entry into an intensive care unit simply because of their age. Without a discussion of goals of care, some physicians will continue either to deliver unwanted or withhold wanted services to the older patient.
Dr. Barile, who is 47, is dedicated to the care and well-being of older patients. It takes a special kind of doctor to spend the time and effort with those who are often the most vulnerable, points out Princeton resident Dr. Pam Barton, board certified in hospice and palliative care, who specializes in home visits to frail older patients in Princeton and the area. She also serves on the board of New Jersey Goals of Care.
Dr. Barile is a physician of uncommon compassion, patience, and sensitivity; qualities essential to the care of those dealing with difficult diagnoses. He has helped the hospital champion the principle of appropriate care for frail elders in our community. Dave has been a most energetic advocate for acute care that is sensitive to the unique needs of the frail and those in failing health.
Dr. Barile attributes his ability to connect and empathize with older people to his close relationship with his grandfather. I think one of the reasons I was drawn to geriatrics is because of growing up in the household with my grandfather, my mothers dad. We played Italian card games, and he told stories. We were very close and spent time together.
In fact, however, Dr. Bariles early years gave little hint of his future career. Born in New York City, he was the youngest son of Michael and Aurora Barile, who had both emigrated to the U.S. from Italy. Older brother Michael and sister Susan completed the family.
We moved to Yorktown Heights in Westchester County, N.Y., when I was 2, recalls Dr. Barile. As a boy, I was completely uninterested in academics. I was good in art, though drawing and woodworking and my mom insisted that I go to college. I didnt come from an academic background. My dad only had six years of education. He came to the U.S. when he was eighteen. Actually, first, my mom wanted me to be a priest, and if that didnt happen, then an artist!
Neighborhood games with friends were common when he was growing up, he recalls. There were a lot of unstructured activities with the neighborhood kids, he remembers. 10 or twelve of us were near the same age. We lived on a dead-end street, and we were always outside.
Dave liked sports, and was on the ski and baseball teams in high school.
The family took trips to California and Canada, and one excursion especially stands out.
Its actually my earliest childhood memory, he reports. I was five, and we were stuck on the New York State Thruway in the family Beetle. My dad and grandfather were in the front; my mom, brother and sister in the back, and I was in the little mini compartment behind the back seat. It was 1969, and there was all this traffic. Everyone was on their way to Woodstock! (the legendary happening in the sixties, when thousands of young people descended on a small town in New York for a weekend festival of music and uninhibited activity).
Later, Dave enjoyed visiting his sister who had moved to New York City. She really exposed me to good music and also critical thinking, he observes. I liked movies, too, especially old movies, which my mom introduced me to.
His father took him to baseball games, including the Mets and the Yankees. My favorite team was the New York Mets, and Willie Mays was my favorite player.
In fact, his admiration extended to individuals, including celebrities, of great diversity: for example, Jim Thorpe and Fred Astaire. As a boy, I admired both of them. I was really impressed with Jim Thorpes ability to do a lot of things well. And Fred Astaire was all about grace and movement.
After graduation from high school in 1982, Dave attended the State University of New York at Purchase, planning to study art. It had an excellent visual arts and performing arts department, he reports. And, then one day, everything changed. It was my second year, and I took an elective anatomy course. That was it. Then and there, I decided I would be a doctor!
This wasnt a total bolt from the blue, he notes. There had been a few signs leading up to it, I had always had an interest in healthy living, personal health, and biology.
So he switched to a biology major, and transferred to the University of California at Santa Cruz, where he graduated in 1990. He says his parents were happy for him, but not sure whether to take his decision seriously, given his previous lack of interest in academics.
Nevertheless, he followed through, attending Eastern Virginia Medical School in Norfolk, and his interest in geriatrics surfaced early. After graduation, he trained in internal medicine at Beth Israel Medical Center in New York City for three years, and then received a geriatrics fellowship for two years at Mount Sinai School of Medicine, also in New York.
I was very influenced by Rose Ann Leipzig, director of the geriatric program at Mount Sinai, explains Dr. Barile. She had such a tremendous influence in developing my passion for geriatric medicine.
After finishing his fellowship in 1999, Dr. Barile, who is board certified in hospice/palliative medicine, geriatric medicine, and internal medicine, obtained his first position in general medicine and geriatrics at St. Vincents Hospital in New York, where he also served as an assistant professor at New York Medical College at St. Vincents.
Previously, he had met and married Nicole Schrader, a native of Germany. I had met her at Beth Israel when she was a medical student. I was at St. Vincents for a year, and then Nicole got a residency in ear, nose, and throat at Temple in Philadelphia. I then got a position at Drexel as assistant professor at Drexel University College of Medicine, teaching medical students and residents.
In 2005, they moved again, when his wife received a facial plastic surgery fellowship in New Brunswick. That was when we decided to come to Princeton, says Dr. Barile. Its a great place, and I first started working at the medical center as a hospitalist, overseeing cases. When a patients own doctor doesnt come to the hospital to see them, a hospitalist oversees the case. By default, it was mostly older patients.
I was also responsible for the medical and geriatric rotation for medical school students and residents. In addition, I served as director of Palliative Medicine Services, which I continue to do today.
In addition to his other work, Dr. Barile is assistant professor at the Department of Medicine, UMDNJ School of Medicine. He is also author and editor of numerous medical publications.
As Director of the Acute Care of the Elderly Unit at the Princeton Medical Center, he oversees cases, as well as providing geriatric consultations at the hospital. He also sees patients on site at Merwick and Princeton Windrows.
Dr. Barile is happy with his move to Princeton, a congenial place not only for his practice but for his family his wife and two children, six-year-old Maxine and four-year-old Fabian. He also enjoys riding his bike to work!
I like the cultural diversity in Princeton and we have a wonderfully diverse group of friends. It really is a special place. There are so many opportunities. My wife and I attended the recent Dave Brubeck concert at McCarter, and also the Arts Council Gala.
Dr. Barile has taken up the guitar in his rare free time, having lessons, in fact, from Dr. Pam Bartons son. Dave and I are both Borough residents, with similar interests, says Dr. Barton. Over the years, we have exchanged plants in our gardens and shared more than a few laughs. Its a small town. We see each other biking around town as well as at hospital meetings.
I had always wanted to take up a musical instrument, and I have been learning the guitar for a year. I have lately been studying with Caroline Mosely, adds Dr. Barile. Now, a friend and I will be going to guitar camp in Ohio (with spousal consent!) to work with acclaimed guitarist Jorma Kaukonen.
In addition, the family will travel to Italy this summer, and they go regularly to Germany to visit his wifes family.
His work engages him fully, and he strives to focus the medical professions attention on the goals of the patients. He spends a good deal of time lecturing throughout New Jersey on the Goals of Care and older patients unique needs.
My work is especially meaningful to me because it transcends decision-making. Its really human rights and patients rights, he says. Older patients need an advocate. This is about protecting vulnerable older people. And it is about empowering older patients, physicians, and health care teams to make treatment decisions based on the goals of the patient.
Yesterdays and Tomorrows
Dr. Barile is intent on adding a hospice facility in Princeton. Princeton needs a residential hospice, a home-like situation separate from the hospital where patients can go in their final time, and have a place, a sanctuary. I envisage a facility with 4 to 10 beds.
Working with patients who now have more yesterdays than tomorrows is not always easy. Understanding, compassion, and patience are essential. But you get back so much, he points out. These people have a history, and you get a lot personally. It is very rewarding to help these patients through a crisis. So often, medicine seems to abandon older patients at this time.
And, helping patients to achieve their goal has become his own goal. My mom told me when I was a youngster, You should always have a goal. That wasnt the case for me then. But now that I have a goal and goals, I see that they are achievable; you can accomplish something.
Medicine changes constantly today, especially with the rapidly advancing technology. With it can come a certain impersonality. There is no doubt in Dr. Bariles mind, however, that it is important to have empathy with patients. Attention to the whole person, to that individuals hopes and fears is the basis of Goals Of Cares mission and it is surely Dr. Bariles mission.
Goals of Care website: www.goalsofcare.org.
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