Geriatric Medicine

It might have been a miserable start to the day in the heart of downtown San Diego. A heavy rain had soaked the large homeless population congregating near the intersection of Third Avenue and Ash Street as they waited for a free breakfast to be served at the First Lutheran Church on the corner. Bodies were sprawled in damp sleeping bags on the terrace above the church, where another line had formed for the free medical clinic that opened at 9am. Weaving through this disarray came a few more people, older than most, moving gingerly as they took the few chairs available outside a closed door at the end of the terrace.

All at once, nearly everyone on the terrace rose as the pastor's voice rang out. Below, on the church patio, a couple was getting married, and people leaned over to see the pregnant bride and groom beaming in a sudden shaft of sunlight. Even as the clinic opened, people were cheering and clapping for the newlyweds. Within minutes, though, the crowds dispersed as medical students from the University of California, San Diego (UCSD) began ushering their patients in, while the senior citizens left their chairs to lie down on massage tables in the acupuncture treatment room – another free service, provided by the Pacific College of Oriental Medicine (PCOM), San Diego in conjunction with the Third Avenue Charitable Organization (TACO).

Aside from the outdoor wedding, this is the scene on most Friday mornings when I arrive shortly after 8am with Jo Douat, the PCOM clinic supervisor. I am a volunteer at the acupuncture clinic, where I formerly worked as a PCOM intern. It is not idyllic, yet there is a strong sense of the ideal about it – never mind the imperfections. If that sounds like a paradox, it is. Because here we all are – church volunteers, medical and dental students, acupuncture interns and the organizations behind them – trying to offer health where there is illness, food where there is hunger, relief where there is suffering. The physical backdrop is fairly rudimentary, ambient environmental controls are minimal and the budget is not lavish, but to a large extent it works.

And here's something else – everyone seems to appreciate it. Our acupuncture patients, by their own account, depend on their treatments. Most come weekly and would do so more often if they could (there is also a clinic on Wednesday mornings and a clinic not restricted to seniors on Monday nights). Many have been coming for years. They seem to benefit from the regular treatments, says Douat. He has been at the clinic, aside from a brief sabbatical, since its inception in 1998, so he knows some of the patients very well. And he has noticed something intriguing.

"You know, we haven't had very many people dying," he says. "We have had a few, of course, but not really that many that we know of. We haven't really tracked that, but I only know of three or four patients that have died. But not really that many compared to what you would expect. I think we actually have helped keep them alive. They deal better with life."

As Douat says, no one's been tracking the statistics. But there is research showing that elderly people do better, and live longer, when they have strong social support. And there is an abundance of evidence linking emotional disorders such as depression and anxiety to other conditions which may affect longevity.

Christine Cronin supervises the clinic on Wednesday mornings. She has only been there for about a year, but her observations are in line with Douat's. "I've had patients tell me repeatedly what they love about seniors' clinic is, 'You actually touch me,'" she says.

Cronin describes the clinic as a "support system" for people "who are losing more than they're gaining." "I can't tell you how many people say, 'I think I'm the last of all my friends', she says. "And I've had seniors tell me they can't count on families but they can count on seniors' clinic. The breaks are hard for them. It's stressful for them to know that we're not there for a couple of weeks."

Providing a social support service is a valuable thing, but what about our medicine, our hard-earned knowledge with all its benefits? Douat lists the common patterns treated. "We see a lot of blood deficiency and people with blood stagnation problems. You see a lot of qi stagnation, for instance you look at backaches or digestive disturbances. Spleen qi deficiency where people don't digest that well. And the kidney deficiency which is more like jing deficiency, where so many things are breaking down."

As to the benefit of acupuncture for this group, he says, "With the needles, it's contact and such. You put the needles in and they relax and they fall asleep. So we can control the pain. We can control hormonal responses so they're happier. In terms of the medicine, the simpler the better. They have very many problems so 'we want to address everything' – that's probably not a very good tactic. A good tactic would be to be very focused and precise in the treatment."

One of the greatest challenges of geriatric medicine is the intractability of the patients' conditions. For the most part, they're not going to be cured. Rather, the goal is to alleviate the problem – whether the distress is physical or mental. Douat says, "You're battling entropy. Those are the challenges: can we slow down the process of aging and reduce the pain and the anxiety regarding death and dying? There's also the challenge that old people don't respond so fast. Aging is a chronic problem."

The clinic benefits more than the patients themselves, though. There are specific ways in which students gain. And there is another sense in which the clinic provides a model of Chinese medicine working in a community.

The Free Seniors' Clinic was founded in 1998, the same year that TACO – an offshoot of outreach programs offered by the First Lutheran Church - was established as a non-profit charitable organization. Leaflets were delivered door-to-door at the senior housing apartments surrounding the church, and the patient population soon swelled. The swell has never ceased. There is no advertising, says PCOM clinic director Greg Lane, who adds, "We have more demand than we can supply."

The clinic operates on a tight budget, with PCOM donating its staff, administration and supplies. Yet it is "a really critical component of our clinical training," Lane says.

He describes what students gain from the clinic. "Seniors have a whole host of different things that are going on with them that you don't necessarily have access to in your day-to-day life as a younger person or even younger practitioner," he says. "You wouldn't necessarily know some of the challenges, some of the issues that a senior would have, or what they're capable of doing - their desires, their dreams and hopes and wishes, as well as just their health conditions."

Lane firmly believes that the profession of Chinese medicine can gain from having a presence in other medical and social settings – such as proximity to the UCSD clinics. "I think it's imperative that we are operating our practices side-by-side," says Lane. "It's critical that we have that type of exposure, and the more we do that the more familiar we become to these other healthcare providers. The more patients see that we're side-by-side, we become an equal partner in the healthcare paradigm and not just some mystical kind of adjunctive quackery that people just don't understand."