Adding life to years

As a young intern at Boston City Hospital (now part of Boston Medical Center) in the early 1970s, Leo M. Cooney, M.D., experienced the standard of medical care for elderly patients firsthand, and he describes his impressions from those days in a characteristically unvarnished fashion.

“The thing that struck me was that we did a terrible job caring for older people,” says Cooney, now the Humana Foundation Professor of Medicine at Yale. “During my internship and residency I was lectured daily about very exotic diseases. Nobody talked about bedsores and dementia and delirium and osteoporosis and all the things we saw every day.”

But one bright spot was a program at Boston City in which a team of nurses made follow-up visits to nursing home residents who had been treated at the hospital’s clinic to ensure that the programs and therapies doctors were trying to implement were carried out. “I was fascinated by that, and I went out eight or 10 times with the nurses to those nursing homes,” says Cooney, who cites the program as instrumental in his decision to pursue geriatrics.

After a fellowship in rheumatology at Boston University Medical Center, Cooney, a member of the School of Medicine’s Class of 1969, was encouraged to come back to Yale by his medical school mentor Robert H. Gifford, M.D., professor emeritus of medicine, a rheumatologist who was then section chief of general internal medicine.

Cooney’s charge was to build a program in geriatrics on the firm foundation of the Continuing Care Unit (CCU), founded in 1968 on the eighth floor of Yale-New Haven Hospital to provide comprehensive care for acutely ill elderly patients.

The first job on Cooney’s plate was convincing skeptical medical residents that a clinical rotation in the CCU, established by Samuel O. Thier, M.D. (then chair of the Department of Internal Medicine, now professor of health care policy and medicine at Harvard Medical School), could be both educational and enjoyable.

“My third day here, the chief residents were trying to ‘sabotage’ Sam’s efforts by combining the rotation with the coronary care unit,” Cooney recalls. But Cooney turned the situation around, saying with some pride that “three years later, I got the house staff’s teacher-of-the-year award.”

In his teaching, Cooney stresses what he and his colleagues in Yale’s top-rated geriatric clinical research programs consider the three most basic objectives of geriatric medicine: clarifying patients’ and families’ goals of care; sustaining patients’ highest levels of physical and cognitive functioning; and safeguarding patients’ independence and autonomy.

Goals of care are a highly personal matter, says Cooney, particularly in older patients who may take several medications for their many chronic diseases: “Is your highest priority your comfort, or being in your own home, or maintaining as much cognitive function as you can—or is your highest priority how long you live?” So-called “disease management algorithms” fall short in this population, he says. “I’m not going to treat your multiple diseases by an algorithm. I’m going to look at you, and say ‘OK, let’s talk about what you’re interested in.’ ”

Cooney says that working in geriatrics is “the most gratifying thing I do,” but he worries that today’s best medical students are not specializing in geriatrics, even as those 85 and older have become the fastest-growing segment of our population. The only solution, he says, is a “good sell” of the field’s rewards, and “the best way to sell is to have very good people do very good work.”

Cooney, who turns 65 in November, has no plans to retire anytime soon. A bred-in-the-bone baseball fan, he says with a laugh, “I watch the student evaluations very closely. When they start to say, ‘He can talk about the Red Sox, but he doesn’t seem to know what’s wrong with the patient,’ I’m outta here!”