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www.PharmExec.com
Pharmaceutical Executive DECEMBER 2015Patients and Practice
As big Pharma leans in to seek the source
of that reputational booster called patient
“centricity,” Pharm Exec decided to turn
to other parts of the health system for
some honest advice. We found it from
a leading physician in geriatric medicine
with additional support from a cat named
Oscar–whose instinctive expertise in
compassionate, end-of-life diagnostics is
both free and non-patentable
By Cameron Sharp
T
hough he comes from a family of pediatri-
cians, Dr. David Dosa, a health researcher
and Assistant Professor of Medicine at
Brown University Medical School, chose
geriatrics. He realized early on that there was a
coming healthcare crisis for the elderly demo-
graphic. As the US population ages, there will be
an unprecedented demand for end-of-life care and
services for the elderly from a system that’s largely
unprepared to meet it
It’s his ability to maintain simultaneously a gen-
eral and a focused perspective regarding the issues
of geriatrics and the practice of medicine overall
that makes Dosa an interesting physician to profile.
More importantly, he brings the clarity of an
accomplished, best-selling writer to emphasize the
human element that drives everything we face in
healthcare. Very much alive to the general trends
that make the aging population such a challenge
to our collective mandate to promote good health,
he still knows the importance of providing a level
of care tailored to each patient.
Dosa cites this belief as the biggest takeaway
from his book,Making Rounds with Oscar: The
Extraordinary Gift of an Ordinary Cat. The staff
at the nursing home in Providence, Rhode Island,
where Dosa served as a consulting physician con-
sidered Oscar a typical unfriendly, self-possessed
cat until they noticed that he had the peculiar habit
of cuddling up next to those patients whose deaths
were imminent. Although there may have been a
physiological reason for Oscar’s behavior—one
theory is the cat could scent the biochemicals
released by ketone cells in the terminally ill—the
sheer human effect was most prominent, giving
comfort to the dying as well as family caregivers
and staff.
As he studied Oscar during his time at the facil-
ity, Dosa took this idea to heart—and realized that
The Healing Art
in Medicine

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www.PharmExec.com
DECEMBER 2015 Pharmaceutical Executive Patients and Practice
sometimes the best thing a physi-
cian can do for his patient is just
to be there and listen. Dosa
articulated this view in a July
2007 article published in The
New England Journal of Medi-
cine, and subsequently in his
book, which was on The New
York Times bestseller list for
eight weeks and subsequently
published in 20 languages world-
wide.
A deep appreciation for the
patient as a human being gov-
erns how Dosa practices. When
asked about his work with vet-
erans and with the elderly, he
explained that it was the wealth
of individual experiences that his
patients share with him that
makes his work meaningful.
“I’m a storyteller, and I like to
listen to stories; I love hearing
from people. As I said in my
book, I like the life well-lived
and I like the stories that people
have to say.”
For Dosa, doctors are not
merely scientists. A med student
who has memorized a textbook
but can’t talk to her patients sim-
ply cannot do her job fully.
Doing the difficult thing and
taking the time to learn about
your patient is just as much a
part of the task of administering
care, Dosa stresses. Fostering
communication is more than just
an enjoyable aspect of his work,
however. He believes that spend-
ing time reaching out to others
to talk and to listen will be the
saving grace of geriatrics as a
clinically relevant profession in
medicine.
Specific elements of the
health delivery and financing
system that make it unable to
properly handle geriatric
patients are simply an indica-
tion of larger social issues and
deficiencies. Dosa believes that
the healthcare system is in the
process of reorienting itself
towards a greater focus on
holistic care and patient well
being across the board, not just
in geriatrics. The 2010 Afford-
able Care Act (ACA) reform
necessitates new healthcare
models because science has been
demonstrating that the way we
currently provide care—the fail-
ure to rely on biomarkers to ren-
der treatments more precisely,
an overreliance on standardized
institutional procedures, and
silo thinking among physicians,
administrators, and other ser-
vice providers—is not good
enough.
Currently, one of the biggest
problems Dosa sees in geriatrics
is that doctors are paid to per-
form a specific service, regard-
less of quality or whether it is
even necessary for the patient’s
health. Cardiologists order
EKGs, radiologists perform
scans, and physical therapists
conduct physical therapy all
because the care delivery system
promotes this kind of specializa-
tion and pays doctors to provide
acute care within their field of
expertise—even when it might
be better not to.
Patients in end-of-life care
situations are disproportionately
affected by the current system.
“When you ask older folks what
it is that they want in terms of
their healthcare, they want qual-
ity of life,” Dosa says. “They
want to be surrounded by family.
They want to die at home, sur-
rounded by family. They obvi-
ously want to live a long life and
a happy life, but they don’t nec-
essarily want to sacrifice quality
for quantity.
“Unfortunately, our health-
care system rewards doing rather
than not doing. Our healthcare
system rewards treating rather
than not treating, and it doesn’t
Fast Focus
» Dr. David Dosa formerly worked as a consulting physician at a nursing home in Rhode Island,
where his studies of Oscar the cat’s connection with terminally ill patients was the basis of a
2007 article published in The New England Journal of Medicine, and eventually his best-selling
book, Making Rounds with Oscar: The Extraordinary Gift of an Ordinary Cat.
» Now a researcher for Brown University’s Center for Gerontology, Dosa believes that patients
in end-of-life care situations are disproportionately affected by the current healthcare system.
For example, in geriatrics, doctors are paid to perform a specific service, regardless of quality
or whether the service is even necessary for the patient’s health.
» Dosa contends, however, that the system is in the process of reorienting itself towards a
greater focus on holistic care and patient well-being across the board, not just in geriatrics. For
the pharma industry to adapt, he says companies and regulators must move away from what
is easiest or simplest towards what is best. “Sometimes that means that researchers need to
make clinical trials messier and more nuanced,” Dosa cites as an example.
A deep appreciation for the patient as a human
being governs how Dosa practices. … He believes
that spending time reaching out to others to talk
and to listen will be the saving grace of geriatrics
as a clinically relevant profession in medicine

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Pharmaceutical Executive DECEMBER 2015Patients and Practice
reward communication. People
don’t get paid to communicate, to
sit down and ask, ‘What is it that
you truly want?’ I think that that’s
the central dysfunction with our
healthcare system today.”
For Dosa, listening is where the
care begins, especially with elderly
patients where studies suggest that
fewer procedures and tests make
for a better quality of life.
But taking the time to find out
who patients are as individuals is
no easy task, in large part because
individuals are so, well, individ-
ual. It takes time and energy to
nuance how one provides care
around the different traits and
problems of the patient. It’s much
easier to treat the symptom with-
out addressing the larger pattern
of disorder, and even easier to
forget whether this treatment is
in line with who the patient is and
what they want.
Dosa is adamant that this
mindset needs to change.
“Older people have multiple
medical problems and they have
multiple chronic comorbidities,
and that requires a different
approach. It requires that doc-
tors and healthcare systems
speak to each other so that peo-
ple don’t do things to a patient
that are counterproductive just
to conform to a guideline.”
Dosa offered the idea of hav-
ing a “captain of the ship” for
patients suffering multiple
comorbidities as a solution to
this issue. Such a person could
manage the nitty-gritty task of
making sure the patient’s goals
are being met but also making
sure that the patient’s multiple
physicians are in communication
with one another, too.
No longer working in the
nursing home facility with his
feline companion, Oscar, Dosa
sees his role evolving as a teacher
of geriatrics for med students
and other doctors. When asked
what we can do about the rela-
tively few geriatricians com-
pared with the large population
of geriatric patients, he
responded that the solution is
not to do the simple thing by
growing the field of geriatric
practitioners because, to a cer-
tain extent, it’s too late for that.
“It’s more about teaching the
cardiologists and the ophthal-
mologists and the primary care
doctors to pay more attention in
treating their aged patients and
to be geriatric savvy,” says Dosa.
“I view my role, now, as more
in a teaching capacity to make
sure that the next round of urol-
ogists understands what those
urological drugs do to patients
who perhaps have cognitive
impairment, that they are able to
manage patients with chronic
multiple comorbidities when
they do surgery, and that they
understand what it is to treat a
patient with delirium or demen-
tia.”
Dosa believes that for doctors
to have a more comprehensive
understanding of their patients
requires that they have a more
comprehensive understanding—
or at least a greater apprecia-
tion—for the other branches of
medicine. And when doctors are
armed with this knowledge, they
can focus on their patient’s
health holistically, giving them
the outcomes they both require
and deserve, Dosa says.
These new expectations are
not limited to geriatrics, how-
ever. Rather, Dosa believes that
changing expectations among
the population as well as a shift-
ing regulatory environment will
drive change. The federal Center
for Medicare and Medicaid Ser-
vices (CMS) is working on
healthcare quality measures on
which to base reimbursement.
This effort is being imitated
everywhere in healthcare as a
part of a general effort to reduce
bloat in an unwieldy system bur-
dened by the recent influx of mil-
lions of newly insured patients.
The ACA is incentivizing the
launch of new accountable care
organizations to develop new,
more integrated systems of care.
Dosa affirms that though the
newly insured may have trouble
finding enough doctors at first,
this shift away from fee-for-ser-
vice will be a boon to the coun-
try at large.
Lessons for pharma
And where does the pharmaceu-
tical industry fit into this new
landscape? Dosa affirms that the
industry must be part of this new
landscape, though it may have to
adapt its business model to do
“The notion that the physician is no longer the
driver of decisions in healthcare has been
overstated. Closed formulary or not,
pharmaceutical companies looking to understand
where the gaps are in available treatment options
need to work with those on the ground.”

4. 39
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DECEMBER 2015 Pharmaceutical Executive Patients and Practice
so. As recent studies suggest,
drug therapy must be more ori-
ented towards achieving a larger
health outcome. Dosa sees clini-
cians like himself as an under-
utilized resource to this end.
“The notion that the physi-
cian is no longer the driver of
decisions in healthcare has been
overstated,” he says. “Closed
formulary or not, pharmaceuti-
cal companies looking to under-
stand where the gaps are in avail-
able treatment options need to
work with those on the ground.
No one is in a better position to
understand what’s needed for
the health of patients than the
doctors who work with them.”
These new expectations as
well as the newly insured popu-
lation create a variety of oppor-
tunities. Many needs are not
being met by the current health-
care system, needs for which
many people are willing to pay
out of pocket. Dosa hopes that
business will step in and embrace
this new environment, finding
ways to make it economically
viable.
“There’s certainly a business
opportunity here for an entre-
preneur to come into the mix
and negotiate with government
payers and insurances and help
in this situation,” he says.
First forays into this world
already exist with some regional
HMOs providing compensation
to doctors with the money saved
by performing preventive medi-
cine, shifting to a so-called fee-
for-performance model.
Dosa understands the diffi-
culty that implementation of
these ideas presents, however. It
involves individuals, companies,
and regulators moving away
from what is easiest or simplest
towards what’s best. Sometimes
that means that researchers need
to make clinical trials messier
and more nuanced. Sometimes
that means that physicians will
have to make time to pick up the
phone and call her patient’s
other doctors.
And sometimes that means
taking the time just to be there
and listen to a patient because
there are other and better ways
to care for patients than we do
currently.
“Doctors are human beings.
They have the same hang ups
about death and what we can do
for patients,” Dosa says. “But we
need to acknowledge limitations
and decide, through conversa-
tion and communication, at
what point is being there and let-
ting go more important than
providing treatments for specific
ailments.”
This sentiment doesn’t have
to be limited to doctors, how-
ever. Among government regu-
lators, scientists, and pharma-
ceutical executives, there is
room for all of us to do the dif-
ficult thing and acknowledge
our limitations in order to work
with one another to better the
way we practice care in this
country and the human beings
that live in it.
Newsmaker note
Dr. David Dosa received his
M.D. from George Washington
University in 1998 and his MPH
from the University of Pitts-
burgh in 2003. His book, Mak-
ing Rounds with Oscar: The
Extraordinary Gift of an Ordi-
nary Cat, has sold over 100,000
copies and has been published in
20 languages worldwide. In
addition to practicing geriatrics,
he has performed research in
many areas related to nursing
home care, including pain con-
trol and pharmacoepidemiol-
ogy. The recipient of several
awards, he recently won a
Career Development Award
from the Veteran’s Administra-
tion to study medication admin-
istration in nursing home facili-
ties. Currently, when he is not
busy conducting research at
Brown University’s Center for
Gerontology, he spends time on
his latest work, a book of fiction
about finding love late in life.
Dr. Dosa can be reached at
david_dosa@brown.edu
CAMERON SHARP is
a contributing writer
for Pharm Exec. He
can be reached at
cdsharp19102@gmail.
com
“Doctors are human beings.
They have the same hang
ups about death and what
we can do for patients. But
we need to acknowledge
limitations and decide, through
conversation and communication, at
what point is being there and letting go
more important than providing
treatments for specific ailments.”