Internal medicine, geriatrics, hospice and palliative care

It was upstate New York in the small town of Batavia, situated halfway between Buffalo and Rochester and known for turf farms and its harness racing, where Robert Burns grew up. He credits his mother, a nurse by education and training, for kindling his interest in science.

“I was intrigued by the stories she would tell when she came home from work,” Burns remembered. “Nursing was different then… she might work as a pediatric nurse one week, then rotate to cardiac care or ICU,” so her vibrant accounts of experiences at the 85-bed St. Jerome Hospital painted a broad picture of patient care. It was a time when few men entered the nursing profession, yet his mother’s influence would inspire his choice of medicine as a vocation.

“I think my choice was medicine all along…the thought of family practice, a small town practice in NY state someplace – that was my goal and trajectory going into medical school,” he recalled. But that vision changed.

One of Burns’ most influential and respected mentors was Evan Caulkins, MD. Caulkins is a rheumatologist whom Burns met his first year of medical school at State University of New York in Buffalo during a VA summer fellowship in geriatrics. Caulkins’ practice of medicine had evolved to geriatrics and it was during Burns’ fellowship that he became acquainted with Caulkins’ commitment and the engagement of his dedicated cadre of physicians and colleagues. That exposure fundamentally changed Burns’ trajectory to geriatric medicine.

The intrigue of geriatrics?

When asked what it was about geriatrics that attracted him, Burns laughed, “Evan (Caulkins) is one of those people who could sell ice to Eskimos.” Burns was inspired by his passion and interaction with physicians and fellows. “It was a very rich environment…”

It was 20 years later when Burns was attending a medical meeting that it became clear that Caulkins had one of the most influential geriatrics programs in the country. “Evan had a significant and long lasting impact on the field,” he claimed.

Why did the upstate New Yorker pull up stakes and migrate to Tennessee? “One of the things that happened when I was in Buffalo is that I met my wife, Linda Nichols,” said Burns. She had completed a doctorate in anthropology and had taken her first job at the VA. He knocked on Linda’s office door one day. “Were you looking for me?” he inquired. “‘Come on in,’ she said.” And the rest is history.

It was serendipity that prompted a post-wedding visit by Burns and his wife to Memphis to see her parents. Before they returned to New York, she was offered a research position at the VA in Memphis. They agreed to make the move.

Burns spent the next 10 years at the University of Tennessee where he completed his training and devoted almost 10 years, climbing the ladder both academically and administratively, serving as chief, division of geriatrics and program director of the geriatrics program at UT, and associate chief of geriatrics and extended care at the VA. When the VA made a decision to end its role as a long term care facility in 1997, Burns made the leap to private practice.

Beginning his 15th year in private group practice, Burns said, “It (Geriatrics Group of Memphis) is all integrated. We do primary care… and then we take care of patients in six nursing homes.” Burns is the medical director of St. Peter’s Villa, Memphis Jewish Home, Graceland Nursing Center and Crossroads Hospice. He and his partner, Sonal Mehr, MD, also see patients at Ave Maria Nursing Home, Quince Rehabilitation Center and Wesley Highland Nursing Home.

A typical day in the life of Robert Burns is rarely like the one before it.

“My partner and I split up the nursing homes. We are in the office three days a week and the other two we are traveling around doing home visits, nursing home visits, assisted living visits and (consulting) at Crossroads Hospice,” said Burns. They meet weekly with the hospice team at Crossroads, accompanied by residents in training and a few students.

Burns’ passion encompasses geriatrics, dementia and caregiving, so dementia is of great concern. “It is a very common disease and is becoming more prevalent. People are living longer and the biggest risk factor is getting older. For those 85 or older, the rate of dementia is 30 to 50 percent…that’s why we see so many.” 

He agrees that “…early dementia is the worst because people are cognitive they are losing their memory. Three things patients fear most are: stroke, cancer and dementia,” he continued. “Because everyone knows someone who has dementia, they know the direction they are headed and they are scared.”

Caregivers Program

Burns has been involved with REACH (Resources for Enhancing Alzheimer's Caregiver Health) for over 10 years, originally as the local PI of the NIA/NINR funded study. It was a national pilot study – “a psychosocial behavioral intervention to reduce burden and depression among family caregivers of those with Alzheimer’s disease or related disorders” – based at the VA, which his wife and colleague turned into a national program for caregivers.

“Family caregivers are doing a tremendous amount (of work),” Burns said. Whether managing things at home or from a distance, it is a struggle. “Trying to approach this problem in a comprehensive way…is what we try to focus on.” The REACH program is available for veterans, as well as an individual caring for a veteran or a veteran caring for someone.

“You must give caregivers better skills to take care of the recipient as well as skills to manage their own health better – the frustration, stress, anxiety, sleeplessness – if you don’t focus on both, it doesn’t work,” said Burns.

Additional resources

“In taking care of geriatric patients, there are no easy answers to anything,” said Burns, “…and the solutions for problems don’t necessarily come in bottles or procedures.” One program is the CMS approved Statewide Home and Community Based Services (HCBS) Waiver, designed to provide an alternative to nursing facility care. Additional resources can be accessed for eligible individuals who would otherwise have to be in a nursing home. “The goal is to allow them to be as independent as possible as long as possible,” he added. Assistance with case management, personal needs, and other services allow the caregiver needed relief and respite.

Eligibility requires a qualifying lower income and a daily living deficit. For those over the income limit, services are still available but are charged to the estate and collected after death.

Does the Patient-Centered Medical Home model offer promise?

“One of the problems we have in geriatric care is this huge fragmentation of care,” Burns lamented. “I think if there is truly a medical home for older adults, it is a great idea. At the same time, whoever they are getting their care from needs to be calling the shots…” Specialists tend to focus on their area and may not have the holistic approach. The best person to make those decisions is the geriatrician, internist or the family practitioner who has managed that person’s care for many years. Otherwise, fragmented care results in more procedures, medication, more of everything. “Ten minutes of conversation on the front end may prevent this...” Burns hears seniors say that they don’t want to spend the rest of their lives in doctor’s offices. He is sympathetic. “It is time to put common sense back into medicine.”

“Medical homes have a great ability to deliver better care only if we are going to do things differently from the way we do them now,” said Burns. “The second part of that is, they have to pay people to think. The incentives in medicine are to do more things rather than sending somebody to take 20 minutes to solve the problem…”

Burns feels that his greatest achievement is running his practice “…delivering the kind of care that I believe in. We don’t compromise our integrity,” he said. “We have integrated everything and we practice a patient-centered approach.”

The surprise ending is that the doctor is an aspiring playwright. A continuing education course taken in Hawaii and a class taught by Howell Perre set Burns on the pathway to playwriting. He picked up a Master of Arts in Theatre from the University of Memphis so he could “do it right.” A New Year’s resolution prompted his entering a contest this year for writing a play, “Catch and Release,” landing him a stage reading.

Another passion he shares with his wife, Linda, is his love for a trio of rescued “street dogs,” all girls, two of whom were at their master’s feet for this interview, politely checking out the writer.

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