As part of a lifestyle and aging series, we’re working with renowned photographer Terry Lorant to showcase inspirational leaders in the industry. Each month, we’ll feature one or a few inspirational member(s) of the Amazing Care Network community who is using his or her voice to empower others in the collective aging experience. Read, in their own words, what the Amazing Care Network’s efforts mean to them.
This month, we’re proud to feature Dr Bob Uslander, “Dr. Bob,” has been practicing medicine for more than twenty-five years, currently as a concierge physician leading a team of holistic practitioners serving the elderly, those experiencing complex illness and end-of-life. He is dedicated to helping people live with joy, and without fear and struggle, at any stage of life, and especially in the face of challenging or terminal illness. To Dr. Bob, there is no group of people more deserving of and desperate for this type of care, than those facing these challenges, and the people who love and care for them.
While his training was in emergency medicine, his career has evolved toward taking care of the elderly and those nearing the end of their lives. Since 2003, he has focused on creating and working with practices and programs that help the elderly and clinically complex members of the community receive excellent health care. In 2003 Dr. Bob created Sierra Housecalls Medical Group to provide medical care to the homebound and elderly members of his Northern California community. In 2004, he helped form Seniority Life Care at Home, a provider of non-medical in-home care for seniors, which allows them to remain in their own homes more safely and independently. He was a founder and past president of Sierra LifeNet, a non-profit organization dedicated to meeting the needs of the frail elderly, including the operation of a local Adult Day Health Care program.
Dr. Bob is a member of Amazing Care Network and has been a guest speaker at our ACN teas. Below we share Part 2 of a Q&A with him, for insights into his world of concierge palliative care and how the new California “Right to Die” legislation has affected his practice, Integrated MD Care (IntegratedMDCare.com).
ACN: Can you describe the model and team that you are trying to build?
Dr. Bob: The model is in-home, customized, holistic medical care. The core is physician, nurse practitioner, nurse, and a practice director who coordinates and oversees. We’re the core team. We engage at whatever level makes sense for each individual patient and family. We may have a very small presence but availability for them twenty-four seven for any change or any questions or any issues that come up. That may be the only thing that we do. Maybe a nurse is going out to see them once a month and a physician or nurse practitioner goes out once a quarter. But, they always know that we’re here to engage in a full court press the moment they need something, the moment that things change.
But, we’re also able to fully engage for a patient who needs a higher level of support and care. For example, somebody who is in the hospital, and about to be discharged needs a whole host of different services; and we can provide the coordinated effort in that. In that case, we would come in and we would coordinate the home care, the home health, the hospice. We communicate with other physicians or set up private therapy, help coordinate the transfer home, and have our nurses and our team there in the home as much as is needed and for as long as is needed.
The team includes integrative therapists, including massage therapy, acupuncture, physical therapy, exercise, yoga, nutrition, cannabis, and nurse consultant. I have a psychiatrist, a neurosurgeon, and other physician specialists who are willing to come in and work with people directly in their homes as needed. We have patients who want acupuncture, massage, music therapy and exercise and so we coordinate and schedule all those.
ACN: How does your billing work?
Dr. Bob: We do centralized invoicing, so the family and the patient never have to worry about the quality of the services, scheduling it, billing and paying all these different people and providers. It’s a very streamlined process.
ACN: How has the California End of Life Option Act impacted what you do?
Dr. Bob: Hugely. I’ve always believed that people should have choices of how they die if they’re facing a terminal illness. I anticipated that once the option was available in California, that other physicians would agree and support their patients, and they would help them get what they needed. This was not the case.
In fact, it became clear early on that there were patients struggling to find physicians to support them. These were people who were desperate. They had already started doing the research before it became law and were getting desperate because their condition was changing; they were dying.
They saw the bill’s passage as the light at the end of the tunnel. And then after it passed, they would call doctor after doctor after doctor who’d say no. These were doctors who had been taking care of them for twenty years, the neurologist, the cardiologist, the oncologist…nobody would have anything to do with it.
ACN: Do you think that reaction was because some doctors feel that “I’m a doctor and I heal” or because they feared this new law and how to administer the medicine within it?
Dr. Bob: It’s multi-factorial. First, probably the most significant reason is because they were working for groups or facilities that wouldn’t allow them to. Initially, hospitals would say we have to develop policy around it and until then, just say no. Or, some places said we will do it but then they didn’t know what to do or how to do it and the doctors who were being requested were uncomfortable because they didn’t understand the law. They didn’t realize they were protected against liability. They thought it was going be too much time, which it often would be. Then there are some who are morally opposed.
However, it’s changing. Hospitals, like UCSD now have a policy procedure. So, if a patient makes the request, they will be put on this path that includes a consult with a social worker or somebody who’s coordinating the whole thing, and an appointment with an ethicist, an appointment with a psychiatrist, two appointments with an attending doctor, an appointment with a consulting doctor.
Recently, I was with three patients who died the same day. But, the beautiful thing is, we were probably together for an hour plus with each patient before they died. And with their family, there was laughter and jokes and just amazing connection and sharing. Even after they drank the medication and the few minutes before they drifted off, the comments and discussions…it’s incredibly, incredibly gratifying to be able to do that.
ACN: Is there an inherent contradiction between your training and this new path that you’re on?
Dr. Bob: I don’t think there’s a contradiction, I think what it speaks to is that the medical training is wrong. It’s inadequate because it doesn’t really include end of life. If you go to medical school and even residency…throughout all the training you would think that people don’t die, or that they’re not supposed to die, right? Everything is about saving people and about extending life and the bottom line is everyone’s going to die. So, thinking of it as a failure is completely absurd, but that’s how it is. There needs to be a shift in the training so it’s not a contradiction.
ACN: Do you see a shift happening?
Dr. Bob: We’re working on it. There are certainly pockets of people who are helping to get those conversations started. There’s a movement, there’s a tribe and it’s developing. Remember, it used to be that birth was taboo. They didn’t used to have midwives. They didn’t used to allow the father in the delivery room. It was very hush-hush and not talked about.
I think death is similar, and I belief that we’ll get to the point where those discussions are becoming more available. I also think if more people saw the actual event; if more people could hear from the patient, could hear from the family, could see what was happening – it would shift their perspective. Because they may have an image someone sitting there, terrified to take this medication and thinking “Oh I wish I could live but I can’t because of this and that so this is my only option.” But honestly, these people are so ready. They are not fearful in the slightest.
ACN: Finish this sentence. “If more people could understand how positive the last hours of our lives could be…”
Dr. Bob: It could be that way, and it should be that way and for more of us. There are some podcasts on my Integrated MD Care website, http://integratedmdcare.com/. In one of them, a gentleman was getting ready to take the medication in a few days, he had ALS. He was phenomenal guy, a bigtime surfer in San Diego. And then there’s another podcast with his three sons who describe what they went through trying to get him the support to have access to the medication and what they did leading up to it the day before. They had this amazing day of celebration with all the kids, and created a t-shirt that he ended up wearing on the day that he took the medication.
Stay tuned for Dr. Bob’s Part 3 next month!