Who’s visited you? 

By Payal Dey, MBBS, Johns Hopkins Observership Program, with Sonal Gandhi, MBBS, Johns Hopkins Medicine 

I arrived at Johns Hopkins for a six-week observership in hospital medicine, excited to observe clinical decision-making, complex patient care, and the legendary teaching culture. But what stayed with me most wasn’t a rare diagnosis or a technical procedure—it was the quiet, unspoken truth of elder care in a country abundant with resources. 

As someone trained in India, I couldn’t help but compare the settings. Out of the 18–20 patients I observed across both medical and surgical units, nearly all were above the age of 67. What struck me wasn’t just the number, but how many of them were living independently—alone in their homes, managing their conditions, medications, and appointments without daily family support. This was very different from my culture, where aging usually happens within the folds of extended families, in which parents and grandparents rarely live alone. 

I saw patient after patient admitted after a fall—often unwitnessed, with no clear history to explain what happened. In more than 11 such cases, the story was the same: no obvious trigger, no prodrome, no family around to clarify the baseline. And that made even basic decisions difficult. Was it a syncope or an imbalance? Was it medication related? Was there a missed diagnosis? We weren’t always sure. 

What I hadn’t anticipated was how difficult medication reconciliation can be in this population. With polypharmacy being common, and patients often unsure of their full medication list, even experienced clinicians found it challenging to figure out what was still active, what had been discontinued, and what had been duplicated accidentally. The EHR, though powerful, isn’t always foolproof when it comes to sorting out medications from multiple sources of care. 

But beyond the clinical puzzles, I started to notice something else—something that impressed me. 

I saw how deeply embedded therapists are in discharge planning. They weren’t just consulted for mobility—they helped determine whether a patient could go home safely, whether a rehab facility was needed, and what adaptations might allow a return to independence. I watched social workers juggle complex family dynamics, insurance limitations, housing challenges, and even emotional strain. They worked in the periphery of care, holding the patient’s narrative together when everything seemed fragmented. 

A patient encounter that stayed with me was a 78-year-old man with multiple comorbidities who came in after a fall. Over the next few days, he developed acute delirium—likely triggered by a mix of urinary retention, infection, pain, and disrupted sleep. I saw how carefully the team crafted his care plan: managing his constipation and bladder issues, adjusting antipsychotic medications, coordinating with recreation therapy (he loved karaoke), and encouraging out-of-bed activity. But what made the most difference? His wife. Her consistent presence and gentle reorientation did more than any medication. Over time, his mental status improved, and the hospital room began to feel less unfamiliar. 

Another encounter was with an 85-year-old patient who came to the ED with bilateral leg cellulitis. Due to bed shortages, she spent nearly 48 hours in the emergency department. The environment—bright lights, constant alarms, lack of privacy—disoriented her completely. By morning, she was no longer the pleasant, coherent person she had been the day before. She had slipped into a state of confusion and agitation; a clear reminder of how environmental factors can deeply affect geriatric patients. 

And then there was a soft-spoken grandmother, admitted with anemia and a recent syncopal event. She, too, was on a cocktail of medications. But her recovery was striking—she had her daughter and granddaughter by her side the entire time, gently reorienting her, chatting about home, and making the hospital room feel just a little more like her living room. That sense of familiarity, of being grounded in one’s own story, was a powerful medicine. 

In India, I’ve seen how families often shoulder much of the elder care. It’s not uncommon for relatives to sleep on floor mattresses in the hospital room, keeping vigil, helping with feeding, bathing, or just providing comfort. Here in the U.S. that role is often filled by a coordinated network of professionals: therapists, pharmacists, case managers, nurses, and social workers, each working behind the scenes to bring the pieces together. It’s not better or worse—just different. And both systems have lessons to offer. 

What I learned from this observership is that healing older patients isn’t just about treating disease. It’s about treating disorientation, loneliness, and fear. It’s about noticing who is missing from the bedside and finding ways to fill that absence. Sometimes it’s a family member. And sometimes it’s a social worker who finds them a place to go after discharge. And sometimes it’s a therapist who brings music and motion back into their day. 

In a country where older people may be alone, they are not unseen. They are supported by a hidden web of professionals who ensure that care continues even after the medical part ends. That, to me, is the true art of medicine: recognizing that while healthcare professionals can address illness, it takes a community to restore the person. 

This piece expresses the views solely of the author. It does not represent the views of any organization, including Johns Hopkins Medicine.