This essay was published online on November 21, 2024 in the Journal of the American Medical Association (JAMA) column, "A Piece of My Mind." It will be published in print in December 2024.
Although JAMA would not let me acknowledge my writing groups, early versions were shared witih the Warehouse Writers in Eagle River, WI and the MCW Moving Pens. Thanks to everyone who offered feedback! Thanks also to JAMA APOMM editor, Preeti Nalini, MD, MSJ and to Kathi who caught a typo that everyone else missed. I fixed the typo here but, if you look carefully, you will find it in the online version.
doi:10.1001/jama.2024.22472
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The medical assistant taps her badge on the card reader, unlocking the examination room computer. After locating my name on today’s schedule, Sheila confirms that I am the 69-year-old human version of the electronic patient on her screen. She clicks through the drop downs. “Okay, Bruce,” she says—calling me by my first name, something I never did with patients during my 35-year career as a practicing physician—“any change in your medications?”
“No. No changes,” I reply.
“Any new diagnoses?"
“No.”
“Any pain today?”
“Not really.”
“Have you fallen in the past 6 months?”
“Well...”
I know a bit about falling. Years ago, my wife, Kathi, and I were hiking in the Cascades, making our way single-file along a forested mountainside. The trail was obscured by ferns still heavy with morning dew. I turned to ask her a question but, when I planted my right foot, I missed the trail and my boot slipped straight down the side of the ridge. As I was dropping, I somehow grasped a tree and leaned desperately toward the trail. I felt a snap as I landed hard on the instep of my left ankle with the full weight of my body. We were 2 miles from where we were staying, and I knew I had fractured my left fibula. I cautiously got to my feet and, after gingerly testing my leg, realized I could bear some weight. Kathi found a branch to use as a walking stick, and I hobbled down the trail back to camp, one agonizing step at a time.
Because I was 46 years old and managed to recover completely within a few weeks, my fall on the mountain trail raised no red flags for my health care providers. Now that I am enrolled in Medicare, things are different. Every time I see my internist, surgeon, oncologist, dermatologist, or cardiologist, someone asks me whether I have fallen.
The Centers for Medicare & Medicaid Services (CMS) defines a fall as an “unintentional change in position coming to rest on the ground, floor, or onto the next lower surface.” (1) Because falls can be so devastating to older adults, The Joint Commission prioritizes screening and fall prevention in hospitals and hospital-based outpatient facilities. CMS requires fall assessments at each Medicare wellness visit and gathers data to track the proportion of enrollees who are assessed for their fall risk each year. Documenting whether a patient has been asked about falling is tied to reimbursement. The greater the proportion of patients queried, the better the reimbursement.
Determining whether I have fallen also reflects my hospital’s commitment to science and public policy. Falls are reported by more than 14 million US adults aged 65 years or older annually and can result in substantial health consequences, costs, and even death (2). Unintentional falls are associated with about 90% of hip fractures. A history of 1 or more falls in the 6 months prior to a surgical procedure is associated with postoperative complications, higher levels of posthospital care, and increased 30-day readmission rates. My health system, by identifying and intervening with older adults who have had a fall, improves the odds people like me remain safe, active, and free of preventable injuries.
But have I fallen in the past 6 months?
I actually did fall about 4 months ago. I massage my right knee, still tender after losing my footing while walking on a bridge over a frozen swamp at the nature center. The fall was pretty uncontrolled—arms and legs flailing as I spun down, eventually slamming hard onto the boardwalk. When I was younger, I probably would have stayed upright or at least caught myself before I hit the ground. “Do I tell Sheila about this? Nah,” I decide. “Slipping on the ice probably doesn’t count.”
What about the time playing pickleball when my youthful tennis-playing reflexes kicked in but my aging physical reflexes did not? I got out in front of my feet and ended up sprawled but unhurt on the court. “Do I report that? Eh. No harm, no foul.” And, not long ago, I caught myself when my foot did not quite reach the next step on an uneven flight of stairs. I never ended up on the ground, but I might have. “Do near-misses count?”
For older adults, reporting falls has both real and imagined consequences. For the final 18 months of her life, my highly functional 90-year-old mother was in a senior living apartment a few miles from our home. Out of an abundance of caution, she always carried her phone in the pocket of her house coat. One evening, she took a spill in her living room and could not get up. She called. “Come help me,” she said.
“Did you call the office?” I asked. “They’re right down the hall.”
“No, of course not! If I ask the front desk for help, they’ll notify the paramedics who will likely load me on a stretcher and take me to the emergency room. When I am released,” and here she repeated the often-shared rumor that circulates among the residents of her facility, “they’ll kick me out of my apartment and move me into assisted living or the nursing home. I don’t want that! Just come over and help me up, okay?”
Thankfully, she was unhurt, yet based on CMS guidelines, her fall should have triggered an assessment and a comprehensive evaluation of her health and environment. We talked about it, but she was adamant. At her next clinic visit, she folded her hands, looked the medical assistant straight in the eye, and said, “No. I haven’t fallen.” For her, there was too much at stake.
I am beginning to understand my mother’s hesitation. Whenever I reveal a new symptom, a deep furrow appears in my physician’s brow, and I end up undergoing a battery of tests and scans. Without fail, each laboratory report and imaging study uncovers some other fresh finding of uncertain significance, which leads, of course, to more tests and scans. If I admit to a fall, I might find myself scheduled for a home visit, ophthalmology consult, neuropsychiatric evaluation, balance testing, physical therapy assessment, geriatric clinic appointment, serial electrocardiograms, a stress test, and/or brain imaging. It would be daunting.
My reflexes are slowing, my joints are less flexible, and inclines make me nervous. I will never again water ski or play softball. I sit at the side of the bed for a few seconds before standing. Before I get down on the floor with my grandkids, I plan exactly how I will get back up again. Gravity has become the enemy.
“So, have you fallen in the past 6 months?”
I look down. “Well...no. No falls. Steady as a rock.”
I really do not like deceiving her.
“Okay,” she says while grabbing her equipment. “Let’s check your vitals.” I roll up my sleeve, proffer a finger for the pulse oximeter, and hold the digital thermometer under my tongue.
“Ohh. Your pressure’s a bit high. I’ll check it again before you leave.”
Sheila slips out the door. I sit in the quiet examination room breathing slowly with my eyes closed, trying to will my blood pressure back to normal.
Every “Have you fallen in the past 6 months?” encounter reminds me of being a kid again and facing Mom when she asked, “Did you eat the last cookie?” We both knew I had eaten the cookie, and I hoped she was not paying attention as I brushed crumbs off my shirt and wiped chocolate from my chin. Even though there was never any doubt my deception would eventually be discovered, I was not ready to deal with the consequences. Not yet. Please.
It is good that I am repeatedly asked if I have fallen. At some point, an unexpected slip or spill will terrify me, and Kathi will finally convince me I need to own up. Despite knowing the good intentions, public health implications, and reimbursement realities behind this simple question, however, I will, for the time being, continue lying to both Sheila and to myself.
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Section Editor: Preeti Malani, MD, MSJ, Deputy Editor.
Corresponding Author: Bruce H. Campbell, MD, Department of Otolaryngology & Communication Sciences, Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI 53226 (bcampbell@mcw.edu).
Published Online: November 21, 2024. doi:10.1001/jama.2024.22472
Conflict of Interest Disclosures: None reported.
Additional Contributions: I thank my wife, Kathi, for allowing me to share our story and my colleague Mark Lodes, MD, for editorial input.
References:
QEP pocket guide: distinguishing a fall for J1800. Centers for Medicare & Medicaid. Accessed October 24, 2024. https://www.cms.gov/files/document/pocket-guidedefinitions-coding-section-j-fall-items.pdf
Colón-Emeric CS, McDermott CL, Lee DS, Berry SD. Risk assessment and prevention of falls in older community-dwelling adults: a review. JAMA. 2024;331(16):1397-1406. doi:10.1001/jama.2024.1416
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A simple question