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Bob Mauterstock

What is Your Financial Advisor Doing For You?

A few months ago I had the privilege of attending a weekend retreat sponsored by Money Quotient (moneyquotient.org), a non-profit organization focused on assisting financial advisors to take a life-centered approach to financial planning.

My visit opened my eyes to the possibility that financial advisors don’t need to concentrate entirely on their client’s rates of return, asset allocation and retirement income targets to succeed. They can actually work with a client to discover their values and priorities and create a financial plan aligned with their life goals.

You may have noticed that a number of so-called robo-advisors are popping everywhere. They claim that they can manage your money effectively using computer algorithms. All you have to do is complete their simple questionnaire and transfer your funds to them. For a fraction of the cost of traditional advisors, firms such as Betterment (www.betterment.com) and Wealthfront (www.wealthfront.com) will select a portfolio for you and manage it daily using tax-efficient strategies with their computers.

Many of the major firms such as Schwab, Vanguard and Fidelity are now offering these low-cost services to be competitive (Schwab’s service is free).

Investment management is now becoming a commodity.

So now is the time to ask yourself a simple question, “What is your financial advisor doing for you?” Is he/she just managing your money? Or are they providing other services to meet your needs? Financial services industry consultant, Bob Veres, in his new book, The New Profession, has predicted that the traditional financial advisor who focuses his practice on building assets under management and charging a fee based on the total may soon start to lose market share.

Veres states that “Professional Financial Planning is reaching the evolutionary stage where the individuals who genuinely care for and about their clients are capturing the public’s mindshare and market share.”  In the future, your financial advisor may look more like a financial coach or financial therapist.

In recent advertising, the Hartford Funds took out a two-page ad describing their support of financial therapists. They state,” A new kind of financial advisor is helping couples deal with issues that bridge the interpersonal and financial spheres.” In the ad the Hartford states that “we believe in something we call human-centric investing, an approach that seeks a deeper understanding of investors and how emotions, experiences, life stage and psychology affect their views of investing and financial advisors.

If you are looking strictly for an investment manager, perhaps the robo-advisors will best meet your needs. Or at least you will be able to reduce the costs of your investment management fees if you approach your existing advisor. But if your are looking for a more comprehensive partner who will integrate your investments with the rest of your life, it is time to look carefully at what your advisor is doing for you.

Perhaps, as Money Quotient states, it is time to look for an advisor who is “putting money in the context of life.”

Reverse Mortgages are Back and Better Than Ever!

Reverse mortgages have been around for a long time. It’s a method that an individual can use to convert the equity built up in their home to a credit line or an income for as long as they remain in the home as their primary residence, without the burden of monthly mortgage payments. But up until recently the fees to establish one were very high. As a result, financial planners (including myself) did not recommend them to clients. In many cases our broker/dealer firms prohibited us from even talking about them.

But recently I met with Bob Tranchell, a senior VP at the Federal Savings Bank. Bob is a specialist in reverse mortgages. He explained to me all the changes that have occurred with reverse mortgages in the last few years. In 2010 and 2013 the federal govt. revised the Home Equity Conversion program (HECM), reduced its costs and made it more secure. Bob showed me how the reverse mortgage could become a very effective tool for aging baby boomers to give them security during their retirement years.

It is estimated that 87% of baby boomers will own a home in retirement, but 68% of them will still carry a mortgage. Research shows that the foreclosure rate for individuals between ages 65-74 increases by 920%. Often seniors who have a reduced income after retirement cannot maintain the payments they made while they were working.

In addition boomers may face the dangers of being in the sandwich generation. They might have to help their aging parents financially at the same time they have to support their children with student loans and no job. A Merrill Lynch survey indicated that more than 60% of boomers are considered the family bank, handing out funds to their parents or adult children.

Let’s look at an example of how a reverse mortgage can help a retired boomer. If he or she is at least 62 years old he can take out a reverse mortgage on the value of his home up to $625,000. The percentage available is based on his age, the appraised home value, the lender’s margin and the 10 year LIBOR rate (an interest rate index established by the federal government.). The 62-year old will have access to 52.4% of the home value or $327,500.

He can take these funds as a lump sum, a fixed income for the rest of his life (Tenure), a term payment (fixed payment for a fixed period) or a credit line. The cost of the reverse mortgage is a 0.5% mortgage insurance premium, the loan origination fees and any closing costs. For the $327,500 amount the total costs would be between $6000-$14000 dollars. This can be wrapped into the mortgage. No loan payments are due as long as the individual keeps the home.

Payments that come from the reverse mortgage are received income tax-free. If the individual does not tap into the mortgage, the credit line increases each year based upon the lender’s margin, a 1.25% mortgage insurance premium and the value of the 1-year LIBOR rate. Currently it increases at more than 5% a year! Eventually the credit line can exceed the actual value of the home but the heirs of the borrower are only responsible for the value equal to 95% of the appraised value of the home. The rest is forgiven! They can chose to sell the home or take out a new mortgage and pay back the reverse mortgage.

Let’s assume the 62-year old took out a reverse mortgage for $320,000 and didn’t touch it for 20 years. Based on current rates, his credit line will have grown to $1,200,000 regardless of the value of the home. Assuming he wants to convert the loan into an income at age 82, he’d receive $10,103 per month for ten years and could still keep $300,000 in reserve as a line of credit (which will grow to $569,391 in another 10 years)

The reverse mortgage can also be used to pay off an existing mortgage and eliminate mortgage payments, pay for long-term care or a long-term care policy or assist children or parents with financial needs. It cannot be used to purchase an annuity or buy stock. If the borrower is concerned about leaving a legacy to his or her children, he and his spouse can buy a second-to-die life insurance policy and pay the premium with some of the proceeds from the reverse mortgage. When the second spouse dies, the kids will receive a tax-free death benefit which they can use to pay off the reverse mortgage and own the home debt-free.

The possibilities are endless. I have only touched on a few. Key to the program is that payments are received tax-free, the loan is unsecured and the heirs are only responsible to pay back a maximum of 95% of the home’s value, regardless of how much was taken out. It’s a win win scenario all around!

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Financial Advisors may reprint any articles from The Gift of Communication Blog in your own print or electronic newsletter. But please include the following paragraph:

Reprinted from Bob Mauterstock’s The Gift of Communication Blog. Subscribe at http://www.GiftofCommunication.com  and receive Bob’s Family Meeting Checklist Guide.

Are you prepared to pay for your parents’ long term care?

fressYour mom or dad may have decided to move to an assisted living residence or a nursing home if they need comprehensive long term care. The cost of this care can range from $5000-10,00 per month depending on their location and the extent of care. Unfortunately at some point they may run out of money to pay for these services. At that time they will need to apply for Medicaid, a program jointly funded by their state and the federal government, to pay for their nursing home care.

In order to apply for Medicaid they must select a facility that is Medicaid approved. They must also meet the severe limitations on income and assets established by Medicaid. Medicaid funding has become a major budgetary issue for many states over the last few years, with states, on average, spending 16.8% of state general funds on the program. If the federal match expenditure is also counted, the program, on average, takes up 22% of each state’s budget.

As baby boomers retire at the rate of 10,000 per day dependence on Medicaid is very likely to increase. At some point states may no longer be able to fund these increases. They may be required to implement the filial responsibility laws. These laws could hold children legally responsible for the long term care expenses of their parents. They are on the books in 30 states but have rarely been implemented.

But recently the State of Pennsylvania enforced it filial support laws and found a defendant responsible for his mother’s long term care bill from a skilled nursing facility for $93,000. Other states may follow suit if their budgets get tighter.

What does this mean for you and your family? This possibility makes it increasingly important that you have a conversation with your parents about their plans for long term care. You need to ask them three basic questions.

  1. If either one of them needs long term care do they plan to stay in their home?
  2. If either one of them is incapacitated who do they expect to be the caregiver?
  3. If they need long term care services how will they pare for this care?

If initially your parents respond that this is really none of your business, you should tactfully answer that it may become your business. You can cite the case in Pennsylvania as an example.

Your conversation with your parents may uncover their plans to stay at home if they need care. In that case they need to look carefully at their home to see if it safe for a physically limited person. You may learn that they expect your spouse to be their primary caregiver. This opens up a whole new area of conversation. You also may find that they have significant assets to provide their care or they have long term care insurance.

You will not know the answers to these questions if you are afraid to engage them in this critical conversation. It all starts with three words… “Can we talk?

The 4 Steps of Long Term Care Planning

Planning for Eldercare

The Importance of Planning for Eldercare

According to some sources, 60% of us will need long term care sometime during our lives. It is important for all of us to prepare for that day when we will need to help loved ones with care or we will need long term care for ourselves.

We may prepare financially for unexpected disasters by covering our homes, automobiles and health with insurance policies. But no other life event can be as devastating to an elderly person’s lifestyle, finances and security as needing long term care. It drastically alters or completely eliminates the three principal retirement dreams of elderly Americans:

1. Remaining independent in the home without intervention from others
2. Maintaining good health and receiving adequate health care
3. Having enough money for everyday needs and not outliving assets and income

Yet, it is our experience that the majority of the American public does not plan for the devastating crisis of needing eldercare. This lack of planning also has an adverse effect on the older person’s family, with sacrifices made in time, money, family lifestyles and even affecting the family’s or caregiver’s medical and emotional health.

Because of changing demographics and potential changes in government funding, the current generation — more-than-ever — needs to plan for long term care before the elder years are upon them.

What Is Long Term Care?

The need for long term care arises when an individual requires, from someone else, assistance with medical care, daily living activities, comfort, supervision or advice. This need for care may be caused by an accident, disease process, or frailty. Such conditions may require help with the ability to move about, dress, bathe, eat, use a toilet, medicate, and avoid incontinence.

Also care may be needed to help the disabled person with household cleaning, preparing meals, transportation, shopping, paying bills, visiting the doctor and answering the phone. Oftentimes, long term care in the form of supervision or confinement is needed due to cognitive impairment from stroke, mental retardation, depression, dementia, Alzheimer’s, Parkinson’s Disease and so on. Most long term care is provided at home by family members.

What Is Long Term Care or Eldercare Planning?

For seniors, the terms “long term care” and “eldercare” are synonymous. For younger people, “long term care” is the more appropriate phrase.

For the uninformed family member, eldercare or long term care might appear to be a very straightforward and easy-to-understand process. Unfortunately, the reality is that long term care is very complicated and finding care systems and providers is a frustrating and time-consuming process. There is no one single source to help caregivers find services or solve problems with a simple phone call or a single community contact. For this reason, planning for care requires a great deal of prior knowledge in order to avoid operating in a crisis mode trying to find help when the need for care suddenly arises.

However, knowledge of long term care systems is not enough. Because it can happen suddenly, at any time, you must take action now to prepare for the day when you will need to deal with eldercare for your loved ones or for yourself. This action involves:

Determining the care settings and services you or a loved one most likely would want.
Providing funding for paying the cost of care, especially when government support programs are lacking or require sacrifice of assets.
Completing a survey to determine necessary financial and legal arrangements to be made.
Completing a written long term care planning document to provide instructions to caregivers and to your care coordinator in advance of needing eldercare.
Assigning a care coordinator and determining the role of other family members, friends or advisers involved in caregiving.
Holding a planning meeting and drawing up a written agreement for involvement between all those who are willing to participate in future caregiving for you or a loved one.
We have defined four crucial steps necessary in this process for long term care planning. These four steps will be described below. The four steps are based on the following four concepts:

1. Knowledge and preparation are the keys to success.

2. Having funds to pay for care greatly expands the choices for care settings and providers.

3. Using professional help relieves stress, reduces conflict, and saves time and money.

4. Success is assured through a written plan accepted by all parties involved.

STEP 1-Understanding the Nature of Care, Care Settings, and Government Programs (Knowledge and preparation are the keys to success.)

This step requires an understanding of 12 different living arrangements and four different settings under which care is provided. In addition, understanding the provisions and limitations of government programs is essential because the public generally has a misconception that the government will step in and provide care when the time is needed.

Government programs are limited and according research by the National Care Planning Council (www.longtermcarelink.net), only 16% of all long term care services are provided by government programs. The other 84% is provided free of charge by family members, friends, charity, church groups or volunteers or paid for by private funds.

STEP 2-Funding the Cost of Long Term Care

(Having funds to pay for care greatly expands the choices for care settings and providers.)
Much emphasis is being placed on purchasing long term care insurance or arranging for reverse mortgages in order to fund the cost of care. These are two excellent tools for providing funding but in reality, this approach for planning is not working that well.

After 30 years of being touted as the ultimate solution, less than 2% of the American public and only 9% of seniors own long-term care insurance policies and using reverse mortgages may be a good strategy but in practice, few seniors are using them to pay for care. Our new book definitely covers these two funding options but also addresses at least 30 other strategies that can be used when trying to provide funds to pay the cost of long term care.

STEP 3-Using Long Term Care Professionals

(Using professional help relieves stress, reduces conflict, and saves time and money.)
Long term care services are complicated and provider contacts are fragmented throughout the community. For the majority of Americans, eldercare becomes a frustrating do-it-yourself process. This approach is unnecessary. Using care professionals is the most cost effective and efficient way to provide help for a loved one.

Those people who need help with long term care and use the services of professionals often find they save money over doing it themselves. They also reduce their stress and they free up a considerable amount of their personal time. Another benefit with using professional help, such as a care manager, elder law attorney or mediator, is to help you alleviate or avoid family conflicts that often arise as a result of caregiving.

Hiring professional advisers or providers to help with long term care is no different than using professionals to help with other complex issues such as car repairs, dealing with taxes or dealing with legal problems With their education and training, long term care professionals also bring experience that only comes from dealing with countless hands-on, caregiving challenges.

In much the same way that a three legged stool needs all three legs to be useful, the care planning approach needs at least three key entities in order to be successful. It needs YOU, LONG TERM CARE PROFESSIONALS, and GOVERNMENT LONG TERM CARE PROGRAMS. Our new book describes this team planning approach in more detail and outlines 13 vital professional services necessary for a successful long term care plan.

STEP 4-Creating a Personal Care Plan and Choosing a Care Coordinator

(Success is assured through a written plan; accepted by all parties involved.)
The first three steps in the planning process are designed to give you a wealth of information about long term care. It is important for you to have an understanding of care systems and the resources you can turn to when the need arises. However, knowledge of long term care systems is not enough. You must take some tangible action now to prepare for the day when you will need to deal with eldercare for your loved ones or for yourself.

The final fourth step in the planning process will help you make a care plan. If you follow our instructions and prepare a written plan for you or a loved one, the challenge of dealing with long term care will unfold for you in a more manageable manner. You will experience less stress, have fewer costs, require less time committed and have fewer family conflicts.

Government Programs-Part One

Veterans Benefits to Help Your Parents

The Department of Veterans Affairs provides three types of long term care benefits for veterans.

VA Health Care

The first type is benefits provided to veterans enrolled in VA health care who have substantial service-connected disability. These medically necessary services include home care, hospice, respite care, assisted living, domiciliary care, geriatric assessments and nursing home care.

Some of these services may be offered to veterans in the health care system who do not have service-connected disabilities but who may qualify because of low income or because they are receiving Pension income from VA. These recipients may have to provide out-of-pocket co-pays or the services may only be available to these non-service-connected disabled veterans if the regional hospital has funds to cover them.

Currently, veterans desiring to join the health care system may be refused application because their income is too high or they do not qualify under other enrollment criteria. Increased demand in recent years for services and lack of congressional funding have forced VA to allow only certain classes of veterans to join the health care system.

Veterans’ Homes

The second type of benefit is state veterans homes. The US Department of Veterans Affairs in conjunction with the states helps build and support state veterans homes. Money is provided by VA to help share the cost of construction with the state, and a subsidy of $71.42 a day is provided for each veteran using nursing home care in a state home. These facilities are generally available for any veteran and sometimes the non-veteran spouse and are run by the states, often with the help of contract management. Most state veterans homes offer nursing home care but they may also offer assisted living, domiciliary care and adult day care.  There may be waiting lists for acceptance into veterans homes in some states.

State veterans homes are not free but are subsidized; however, the cost could be significantly less than a comparable facility in the private sector. Some of these homes can accept Medicaid payments. A complete list of state veterans homes can be found athttp://www.longtermcarelink.net/ref_state_veterans_va_nursing_homes.htm

Disability Payments

The third type of benefits for veterans is disability payments. These include Compensation, Pension and survivors death benefits associated with Compensation and Death Pension.

Compensation is designed to award the veteran a certain amount of monthly income to compensate for potential loss of income in the private sector due to a disability or injury or illness incurred in the service. In order to receive compensation a veteran has to have evidence of a service-connected disability. Most veterans who are receiving this benefit were awarded an amount based on a percentage of disability when they left the service.

However, some veterans may have a military record of being exposed to extreme cold, having an in-service non-disabling injury, having tropical diseases, tuberculosis or other incidents or exposures that at the time may not have caused any disability but years later have resulted in medical problems. In addition, some veterans may be receiving compensation but their condition has worsened and they may qualify for a higher disability rating. Veterans mentioned above may qualify for a first-time benefit or receive an increase in compensation amount. Applications should be made to see if they can receive an award. There is no income or asset test for compensation and the benefit is nontaxable.

Aid and Attendance Benefit

Pension is available to all active duty veterans who served on active duty at least 90 days during a period of war. There is no need to have a service-connected disability to receive pension. To be eligible the applicant must be totally disabled if he or she is younger than 65. Proof of disability is not required for applicants age 65 or over. Apparently, being old is evidence in itself of disability.  Pension is sometimes known as the “aid and attendance benefit.”

Veterans’ service to qualify for Pension would include World War II, the Korean Conflict, the Vietnam Conflict Period and the Gulf War conflict. The veteran did not have to serve in combat but only had to be in the service during that period of time and only one day of the 90 days of service had to occur during the period of war.

The purpose of this benefit is to provide supplemental income to disabled or older veterans who have a low income. If the veteran’s income exceeds the pension amount then there is no award.

Submission of Claims

Compensation and Pension claims are submitted on the same form and VA will consider paying either benefit. Generally, for applications associated with the cost of home care, assisted living or nursing home care, the Pension benefit is a better option.

Pension can pay up to $1,843 a month to help offset the costs associated with home care, assisted living, nursing homes and other unreimbursed medical expenses. The amount of payment varies with the type of care, recipient income and the marital status of the recipient. There are income and asset tests to qualify.

VA claims this benefit is only for low income veterans but a special provision in the way the benefit is calculated for recurring medical expenses (long term care costs associated with home care, assisted living or nursing homes) could allow veteran households earning between $2,500 and $5,000 or more a month to qualify.

There are also death benefit payments associated with Compensation and Pension that are available to surviving spouses of veterans or surviving dependents.

The National Care Planning Council estimates that up to 33% of all Americans over the age of 65 might be eligible for a Pension benefit under the right circumstances.  That’s how many war veterans or their surviving spouses there are in this country. If your mother or father served in the armed forces it is definitely worthwhile to check into the benefits that may be available to them.

Government Programs-Part Two

Medicaid

How can Medicaid pay for your parents’ extensive health care costs? Medicaid is a program jointly funded by the federal and state governments. Each state manages its own program. Medicaid is designed to provide assistance to the indigent. A third of the payments from Medicaid provide payments for the elderly who are in nursing homes. Other funds are provided for those who are disabled or without financial resources. Medicaid does not currently provide any benefits for assisted living or home care. It is strictly for those individuals who are in a nursing home.

In the past, a number of families transferred assets from their parents to other family members to qualify them for Medicaid assistance. Parents transferred their homes, investments, and savings accounts to their children and then applied to Medicaid. Unfortunately, the number of the elderly applying for Medicaid has increased so much in recent years that it has become a very substantial part of most states’ budgets.

Restrictions on Qualification

As a result, the federal government has put severe restrictions on qualification for Medicaid. Monthly income limits differ depending on whether the applicant is single or married. For a married couple, the spouse remaining in the community (community spouse) can retain all of his or her income. The community spouse’s income would not be counted in determining the applicant’s eligibility for Medicaid. However, all of the applicant’s income must be counted for his or her long-term care except for certain deductions. These deductions may include a personal need allowance not to exceed $60 per month (less in some states), an allowance for a dependant child living at home and, depending on the community spouse’s income, a portion of the spouse’s income for living expenses known as the Minimum Monthly Maintenance Needs Allowance (MMMNA). In 2008, this amount ranges from $1,711 to a high of $2,610 per month.

If the community spouse’s income is less than the MMMNA, a portion of the applicant’s income may be used to meet that minimum. The balance will go to the nursing home providing care. If the applicant is single, he or she cannot exceed Medicaid income limits and qualify. The limit for 2008 is approximately $1,911 per month but varies from state to state.

Countable Assets

To qualify for medicaid coverage, the recipient’s countable assets cannot exceed $2000. The  community spouse of the Medicaid recipient may keep half of the couple’s joint assets up to $104,400 (in 2008). In any case the community spouse may keep the first $20,880 (in 2008), even if it exceeds half of the couple’s assets. These figures vary from state to state.

Countable assets consist of all investments such as stocks, bonds, mutual funds, checking and savings accounts and CDs. Countable assets also include any personal or real property as well as any art and collectibles.
Non-countable assets consist of personal possessions such as clothing, jewelry and furniture and the applicant’s primary residence. Further, non-countable assets include one vehicle not to exceed $4500 for unmarried applicants (there is no value limit for a vehicle for married applicants). Non-countable assets also include prepaid funeral plans, certain amounts of life insurance and retirement funds which cannot be cashed in because they are in payment status (however the latter will be considered under the income limits).

Based on these restrictions, it is very difficult for most people to qualify for Medicaid unless they have already used up their assets to pay for care. But the income restrictions usually exclude most people from being accepted into the program.

Be Careful With Gifts

The federal government has made it extremely difficult for a family to attempt to transfer assets away from their parents to qualify for Medicaid. The sick parent must apply for Medicaid at the time they wish to enter the nursing home. The government first calculates the family’s assets and income. If these meet the qualifications, Medicaid then checks to see if the parents have made any gifts to their children or others within the last five years. If the parents have made any gifts that delay their qualification for Medicaid, the government uses a very simple formula.  They are very thorough in checking all your parents’ financial records bank accounts and investment reports. Let’s assume your parents transferred $100,000 from their bank accounts to you four years ago and your father has just entered a nursing home. The nursing home then applies for Medicaid to cover his costs.

The Feds then look over his records and determine that four years prior to entering the home, he gave you $100,000. They then divide this gift by the average monthly cost of a stay in the nursing home in your father’s state to determine the number of months your dad is disqualified from getting Medicaid. In Massachusetts, in 2008, that number was $7380. $100,000 divided by 7380 is 13.5. That means Medicaid will not pay for his care for 13.5 months even though he qualifies based on current income and assets.

Gifts of all different kinds can disqualify you. Some families have tried some very subtle techniques to transfer assets from their parents to others. Setting up a joint account with a son or daughter and then removing the parent’s account is one technique that is no longer allowed. Putting a home in the name of a son or daughter or other family member or friend fits into the same category. Purchasing a “life estate” in an adult child’s home by paying off their mortgage is also disallowed.

Use of Annuities

A technique that often worked in the past was for your parents to transfer their assets to an insurance company for an immediate annuity to pay a monthly income. They planned that this would no longer count the lump sum as a countable asset. The state has countered that by comparing the amount of the annuity with the life expectancy of the recipient. If the projected payout exceeds their life expectancy, this difference will trigger a period of ineligibility. Even if the annuity is taken on the life of the healthy spouse, the state will require that the government be listed as the beneficiary of the annuity.

In the Tax Relief and Health Care Act of 2006, the government made it clear that they are eliminating all the loopholes that families can use to qualify their parents for Medicaid unless they are truly destitute. Medicaid has become a very large part of each state’s budget and they know that they must control its growth in the future.

What we want in a doctor

Many of us are frustrated by our interactions with our doctors. They often seem rushed and only focused on tests and medication. Rarely do we see a doctor who just sits back and asks “How are you doing?”  Dr. Thomas Graboys was such a doctor. In his book “Life in the Balance” he describes what he seeks in a doctor now that he is sick himself with Parkinson’s disease. I thought it would be very beneficial to share his words with you.

Illness interrupts (book excerpt: Life in the Balance)

Thomas Graboys, MD

A few days before a regular six-month appointment with my neurologist, John Growdon, in late 2006, I was asked what, if anything, I would like him to do for me that he wasn’t doing already. My answer was quick and sarcastic: “I’d like him to call me every month to ask how I’m feeling,” I snapped, as if a busy doctor with hundreds of patients in his care would have time for that.

But the more I thought about it, the more I realized that my glib remark cut close to the truth. I want to be on his radar screen. I want him to be thinking about my case, not just when I am in his office, but when he reads about new treatments and new insights into Parkinson’s and Lewy body dementia. I want him to be turning my case over in his head once in a while, and I want to know that while there is nothing that exists today to reverse my dementia, he is thinking from time to time about how to make my life better.

When I saw Growdon a few days later, I asked if we could increase the frequency of our regular consultations from every six months to every three months, to which he readily agreed. Why? For the simple reason that the Parkinson’s path is taking me through very unfamiliar and forbidding territory. I want a guide — someone I trust who knows the medical terrain, someone who has been down the path with others — to be there in spirit and in mind.

I want someone mindful of the pitfalls, the traps, and the forks in the road. It may well be that little will change in my clinical condition over three-month intervals, but I don’t want to see Growdon every three months merely to size up incremental changes in my symptoms or to tweak my medications; I also want the comfort of his presence and to know that every once in a while we can, in [former New York Times literary critic Anatole] Broyard’s words [written while dying of prostate cancer], brood over my situation together.

In my own practice, I developed a keen sense of just how deeply appreciated and how profoundly comforting small acts of kindness and mindfulness can be for the patient and his or her family. Dropping in on a hospitalized patient at the end of a busy day, not to check the chart or to do a quick exam, but just to say “Hello, I just came by to see how you are. Is there anything you need?” Calling a patient at home a few weeks after their annual visit to see how their new diet and exercise program is progressing.

Writing a letter of condolence to the family of a patient who has died (a sorely neglected necessity, in my view). These small acts say to the patient and the family, “I know you ache, I know you suffer, I know you are in pain,” and allow doctor and patient to meet on the common ground of their mutual humanity.

I am not a surgeon, but when a patient of mine was scheduled for surgery, cardiac or otherwise, I always tried to pay a social visit in the hospital the night before, or tried calling them at home if they weren’t yet hospitalized. I can’t prove it, of course, but I believe such a visit or call decreases operative mortality. Such social calls were invariably welcomed and comforting. There is no way to measure the curative and healing power of such a bond between doctor and patient, but I am utterly convinced of its salutary effect.

It is also hard to overstate the importance of the doctor’s literal laying-on of hands. Years ago I had a patient, Mrs. H, who had been hospitalized with terminal gastric cancer. It was her cancer, not her heart disease, that was threatening her life; but every day, as I rounded with my medical students and stopped to examine Mrs. H, I routinely listened to her heart. One day, under pressure of time, I forgot; and as I turned to leave, she said, “Dr. Graboys, aren’t you going to listen to my heart?” I was embarrassed and flustered in front of my charges and immediately struck by the fact that although she knew her heart was not her major problem, she needed and wanted the reassurance of my touch.

As I reflected on the experience later, I also realized that Mrs. H. had interpreted my actions as a commentary on her condition. My failing to listen to her heart that day signaled a loss of hope in her situation. If I could no longer be bothered to examine her heart, it meant the cancer was so serious that it had rendered her heart problem irrelevant. Conversely, by examining her heart, I had been signaling hope that she was not succumbing to her cancer.

Similarly, a doctor’s words — as my mentor, Bernard Lown, [MD, renowned cardiologist and Nobel Peace Prize winner] has written — can maim or they can heal. The physician who offers nothing more than impeccable clinical judgment can, nevertheless, draw the cloak of illness tight around a patient with carelessly chosen words.

Too many times, patients have come to me and said that another cardiologist described their heart as a “widowmaker” or a “time bomb.” The stress and anxiety thus induced by the doctor can turn him into a prophet. Words that allay stress, words that allow room for hope — not false hope, but hope — can allow the patient to shift the burden of worry onto the physician.

So I know what I look for in a doctor.

Protect your parents from fraud

Young@Heart

Last night I had the privilege of watching a movie entitled Young@Heart. It is a documentary showing a group of older people (average age 80) who get together with a chorus director (Bob Cilman) and form a chorus which sings such contemporary hits such as “Every Breath You Take”, “Yes I can,can” ‘I got you” and many others. The  movie is absolutely heart warming as it shows these elderly folks rehearsing two to three times a week to prepare for a concert, some leaving their hospital beds  to get to rehearsal.

While crying, laughing and dancing as I watched the DVD, I realized something very important was being shown to us. When old people have a purpose, a passion, they live longer, more satisfying lives. Steve Martin, one of the chorus members (not the comedian) said it well. “If you stop moving you will become a target”. During preparation for the concert two members of the group died, but the chorus continued on, dedicating their efforts to their fallen friends. And even those who passed on, up to their dying day, were trying to make it back to rehearsals and sing.

This is a strong lesson for us and our parents. What are your parents’ passions? Encourage them to stay involved in the activities they love and even find new ones to explore. Hopefully they will happen upon an angel like Bob Cilman, the chorus director of Young@Heart who nurtered the members along the way to enjoy and expand themselves. It’s not such bad advice for each of us, no matter what our age. Follow your passion. Stay involved and grow a little every day.

I encourage you to watch Young@Heart. Better yet, watch it with your parents. You will all be inspired.

Caregiver = Angel

Approximately one year ago I learned what it was really like to be a caregiver and the receiver of care. In December of 2007 I had ankle surgery and was told by the Doctor that I couldn’t put weight on the ankle for six weeks. As a result I was confined to a wheelchair and a walker ( I had a terrible time using crutches) I needed help taking a shower, getting into the bathroom, couldn’t negotiate stairs and generally had a difficult time taking care of myself.

I was home and away from work for over a month. During that period of time my wife had the primary responsibility of taking care of me.  I learned how frustrating it was to be relatively helpless. But more important than that I realized the pressure I put on my wife to take care of me. Every time I needed something I expected her to be immediately available to get it for me. I often found myself calling out her name ( sometimes yelling it) and waiting for her to arrive to fulfill my request. One time when she was in the basement washing clothes I yelled her name for a good twenty minutes. I thought she had left the house and gone somewhere,  I panicked.  I found that I often became irritable and grumpy when it took her more than a few minutes to respond.

Our caregiving experience only lasted about 30 days. I  imagined what it would be like if Mary had needed to take care of me for months and even years. Then I thought of some of my client families with one spouse debilitated by a stroke, Parkinson’s Disease or dementia.  And of course you know who the caregiver is 90% of the time. It is a wife, daughter or daughter in law. How many of us men would have the stamina and patience to take care of a spouse or our parents?

These women are angels. They take better care of their parents and husbands than themselves. But unfortunately this takes a toll. They often have to leave the workplace to take care of a family member. As a result they often lose income, retirement benefits and seniority inside their company. But worse than that they often suffer physically from being a caregiver. Stress and physical exhaustion takes it’s toll, often making them sicker than those they take care of.

We must take care of these angels, our wives, daughters and daughters in law. Because we know that they would take care of us.