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Triple board-certified physician in adult and geriatric psychiatry and addiction medicine, and the founder of The Aging Parent Coach Barbara Sparacino discusses her article “Why caring for a parent is hard for doctors.” Barbara shares the personal struggle of navigating end-of-life care for her own parents despite her extensive professional training. She explains the “prophet in your own country” paradox where family members often dismiss medical advice from their own relatives. The conversation explores the heavy guilt and self-doubt that arise when the professional detachment of a doctor collides with the emotional vulnerability of a child. Barbara highlights the importance of setting boundaries to protect the parent-child relationship and offers advice on extending grace to oneself during this difficult season. Discover how stepping back from the physician role can actually be the greatest gift you give to your aging family.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Barbara Sparacino. She is an adult and geriatric psychiatry and addiction medicine specialist and founder of the Aging Parent Coach. Today’s KevinMD article is “Why caring for a parent is hard for doctors.” Barbara, welcome to the show.

Barbara Sparacino: Thank you so much for having me, Kevin. I really appreciate it.

Kevin Pho: All right, so before we talk about your article, just briefly share your story and journey, and then we will jump right into your KevinMD piece.

Barbara Sparacino: OK, thank you. I am a psychiatrist, and I went into psychiatry knowing I was going to do geriatrics because I have always been interested in older adults. When I was in medical school, I was the “Geri Whisperer.” I would somehow calm down folks who were delirious. Then, as my career took over, I started doing more adult work than geriatric work. With the pandemic, I saw that there was a need because there is a dearth, unfortunately, of geriatric psychiatrists. I felt it was kind of a lapse on my part to not really be practicing geriatric psychiatry during that time.

So I started a micropractice. I started seeing that psychiatrists, and I do not know if physicians in general, but psychiatrists are really trepidatious about older folks. There were psychiatrists who refused to see patients over the age of 65. As a geriatric psychiatrist, I have to tell you that no one is old until they are over 80.

I was finding it a little crazy, so I started seeing patients. I started seeing how challenging it was for families to really adapt to now being caregivers and now being responsible. There was this trend I was hearing about “parenting your parents,” which I found a little bit off-putting and abrasive. We will never parent parents. The power differential never changes. I do not know anyone who goes home and is with their parents and remains a fully functional adult. Somehow we always regress even a little bit.

I started really delving more into geriatrics and into helping adult children. That is how I kind of veered off into the coaching part of helping families navigate this. That is really where the focus of my career has been recently. It is trying to help families navigate this because we have such a high number of caregivers. Most of the care is being done at home. Twenty-nine percent of the population of caregivers is just like me, the sandwich generation, which is in between high-need parents and then high-need children. High-need children are not necessarily underage either because we have some generational issues going on there too.

That is how I have come to be in this place in my career. I am about 15 years out of residency. I guess I am mid-career at this point, which makes me feel a little old. But really, I am finding new ways to contribute as a psychiatrist and as a physician, and then also finding it kind of leaking into my personal life.

Kevin Pho: Your KevinMD article is very relevant for a lot of parents, like you said, the sandwich generation who have to take care of our own kids as well as our aging parents. Your KevinMD article is “Why caring for a parent is hard for doctors.” For those who do get a chance to read your article, tell us briefly what it is about.

Barbara Sparacino: It is really born out of what is really happening to me. It is about how there is a saying in Spanish that we can’t be a prophet in our own land. We are never respected as the wise one in our own family. I think this is very true, especially for physicians. For the most part, I think people come to us when they need help. We are the free advice, the free medical advice, or the free prescription.

But in moments of contradiction, sometimes we lose the authority in our family because we are just the family member. I think this is especially true with our parents. It is very challenging for them to see us as an authority figure. We ought not be either because we lose a lot of the clinical perspective. This is why we are taught in medical school that we shouldn’t really treat family. We should have some distance because we need the distance for clinical perspective.

That is what I was talking about. We have so much knowledge and so much information, and we help so many people. Sometimes when it comes down to it and it comes to helping the people we love the most, we somehow find ourselves incapable. It can be very bewildering and it can be very disorienting. That is really what I was speaking to. I do not have the same authority.

My mom was recently hospitalized after a fall, which resulted in a fractured knee, which then resulted in surgery. Then that went on to her having some cardiac issues. Then that went on to her having Takotsubo cardiomyopathy and being in the ICU. It was difficult for me to navigate that. It just reinforced why I do what I do in my career because I thought: “If this is hard for me, how do people who do not have the savviness or the expertise of the medical landscape do it?” It can be crazy-making. It is kind of trying to straddle both worlds of being a physician, having the knowledge, and still just being a caregiver, a care supporter, and being a good advocate for our parents. That was the tenor of the article.

Kevin Pho: As a physician, what are some specific issues that being a physician within a family that you have versus other non-physician caregivers?

Barbara Sparacino: I think it is the amount of knowledge. We know that children of pediatricians or ER docs tend to underestimate or overestimate things. Very rarely are we kind of right on the spot. We may minimize things that other people might take more seriously. So that can be a bias in that sense because we often see things that are a lot more serious, and then we just may minimize this.

I see this frequently in children of physicians who come in with cognitive issues. Everybody tells me with cognitive issues that it has been about a couple of months. When I get into the nitty-gritty of it, it is usually three to five years that the deficits have started showing. This was true even with myself. By the time I gave my grandfather a MoCA, the Montreal Cognitive Assessment which has been famous recently, he had scored moderate dementia and he was still living independently. We had no idea, and I was already a geriatric psychiatrist at that point. I acknowledge that even myself, there is this lens of seeing competence where it may not be present.

Also, I think the emotionality is different. Learning how to deal with the sense of vulnerability and helplessness is hard. We are usually team leaders. We are usually the ones who are at the forefront of decision-making. We are the ones who are kind of leading care. But when you find yourself in the passenger seat or even the back seat, kind of having someone else dictate care however appropriate it is, it can be disorienting. I think it also depends on medical specialty. I will say there is a bias when trying to insert myself or assert some authority. I wonder if as a psychiatrist I have the same respect for my colleagues on the other end. It can be challenging on that end as well because you don’t want to rock the boat. You don’t want the team to think that you don’t trust them.

Kevin Pho: So how do you balance that? How do you thread that needle? Like you said, you are sometimes wondering whether the colleagues who are caring for your parent how they see you, but you do want to sometimes ask questions and sometimes assert yourself. So how do you balance that tension?

Barbara Sparacino: I think one of the best ways is to be rather transparent and candid. Of course, there are physicians who are more accessible and more approachable than others. But being candid helps. I say: “Look, this is my parent. I am a physician. I understand that my role here is not as a physician. I know enough to get me in trouble. I want to be a source of information for you and clarity for you, and I want you to be able to speak effectively with me.”

I was able during this hospitalization to do that rather effectively with most of the physicians and clinicians because it is not just physicians I am speaking with. I am speaking with nurse practitioners and PAs and all the other health care workers. I think being transparent is key. Identifying for the physician or the care team that I know my role helps. I recognize my role and I may offer insight from my perspective, especially when my mom was delirious at one point, so of course I jumped in with that.

Being transparent involves vulnerability and also a little bit of the death of the ego in that sense of not being overbearing. I think one of the great things about most physicians is that we know what we don’t know. We kind of know when to say: “This is out of my wheelhouse.” I want to be a good facilitator and communicator to be able to translate things for my parents sometimes. At the end of the day, I want to facilitate communication and I want to facilitate adherence to things. I want to make sure that they get the best care without stepping on toes and being abrasive or overbearing because that is not helpful. I know we have all worked with families like that who think they are being helpful and all they do is make you have to take a deep breath before you come in the room.

Kevin Pho: In your article, you also talk about the dynamics between you and your siblings, you being a physician, and that sometimes changes and makes awkward the dynamics you have with siblings. So talk more about those dynamics for those physician caregivers in relation to some of their siblings.

Barbara Sparacino: I am an only child biologically, but I have so many stepsiblings, so I have a very florid family in that sense. Luckily in my family, I have been able to default to be the point person mostly because of age, being the eldest daughter, and because of my practice. But I do see that a lot of times again it is communications and inadequate, unrealistic, or unvoiced expectations.

People do not know what their roles are. People do not know who point persons are. One of the things when I am treating someone as a physician is I always tell them: “Look, pick one point person. I am not going to talk to everybody because I can’t play telephone.” Beyond having too many patients, it is also like telephone. So you pick one point person. But many families don’t know how to do that or don’t do that preemptively. So there is not one person in charge of communicating with the physician. We have piecemeal information, which can be very disruptive and dysregulating to the family when they don’t know good information.

I think one of the strengths of being the physician in the family is that you can be a good interpreter. I had my friend the other day whose father was in the hospital, and she was telling me about how they “diuresed” him. She asked: “Did they use that word with you, ‘diurese’?” She had to look it up. She is in advertising, nothing medical. So I think that is the strength.

But there has to be trust that you are going to be giving accurate and complete information, not holding things back and not trying to assert yourself as a position of power, but just being really a facilitator. I think it is important in families when there are siblings who are willing to show up. That is the other problem. There are ones who show up and ones who don’t show up. Typically in these situations, when someone shows up, the loudest person is the person who kind of gets their way, which is not always effective or efficient.

Having different point persons and different responsibilities helps. You can say: “Look, I am the point person for health care. You are the point person for financial responsibilities or decisions.” Having assigned roles so people don’t feel left out or feel helpless or discarded is important because many times it is just about wanting to be of service and help and have information and not just feel left out. People feel like you are taking over. There is always another thing of people asking: “Oh, what do you think we’re not as smart as you because we’re not understanding this?” It is not about that. It is about just navigating the language. For the vast majority of people, if you hear doctors talking about something, they get dizzy with the abbreviations and the acronyms. You may not understand what is going on, or you may think you do because there are a lot of words that are used in medicine colloquially that don’t mean the same thing.

I think the best way is to have a plan before these emergencies happen. I have been talking to my parents about health care proxies and all these things for about 10 to 15 years now. I try to update it every couple of years to make sure we are on the same page. I ended up having to be the health care proxy for my mom when she was found incapacitated because of the delirium. I was glad that it was very well articulated by her that I was the proxy. So things were simpler. Even with my stepfather, things were simpler because everybody knew their role and nobody was feeling overbearing.

I think it is better to have a plan in place so we are prepared. When we can identify things that we can do and ways we can help, even in the not doing, it is much more effective than feeling clueless and out of control and helpless. At the end of the day, what we want to do is really protect our parent and also not drive ourselves crazy in the bargain because I don’t know anyone who has time to spare.

Kevin Pho: So you are the aging parent coach. Obviously, you have that coaching practice specific to this topic. Now, for those other caregivers who may be listening to you, what would you say are one of the top tips that you can share with them to help ease some of these situations?

Barbara Sparacino: I think the number one tip for caregivers is that you can’t give from an empty cup. Caregiving can encompass so many things. I think people often misconstrue caregiving as the person actually providing the service. As opposed to everything else in life, there are different layers. I have caregivers who live in another country and a parent lives here. So caregivers can mean a lot of things. If you feel responsible, if you are making decisions or you are helping them make decisions, then you are a caregiver. It does not necessarily only mean the physical caregiving.

I think that the best thing you can do is prioritize yourself and your mental health because we do know that there are high rates of this. I think one-third if not half of caregivers suffer with symptoms consistent with depression and with clinical depression. It can be overwhelming. They have higher rates of stress, higher rates of burnout, and higher rates of compassion fatigue.

Again, it is not like people are doing this in a vacuum. They still have to maintain their lives, maintain their other relationships, and still prioritize the things that they want to prioritize while also trying to help the folks that they love and want to provide caregiving for. So I think being very mindful of boundaries and being very mindful of what you are capable of giving irrespective of somebody else’s expectations of you is important. It is so much healthier than trying to constantly chase this idea or this notion of what a perfect child is or what a perfect caregiver is.

I think depending on cultural backgrounds, there are different expectations for how much you are going to be responsible for your aging parent. We have cultures where your parent is expected to move in with you. And you have cultures where your parent is expected to go to a nursing home. All the way in the middle, things are fluctuating. We don’t have as many intergenerational homes as we used to where people would age in place because everyone aged in place.

I really think having really prioritized your own self-care and having a good outlook or a good blueprint for what caregiving looks like for you and what you are willing or able to do will be very beneficial for being an effective, loving caregiver for your parent. Hopefully you will outlive your parent and you still have a lot of living to do. Also, remember that as we navigate this transition with our parents, our children are watching how we navigate this. So what we are modeling is how we potentially expect to be treated by our children. Not to add more pressure, but that is the truth of it.

Kevin Pho: We are talking to Barbara Sparacino. She is an adult and geriatric psychiatrist, addiction medicine specialist, and founder of the Aging Parent Coach. Today’s KevinMD article is “Why caring for a parent is hard for doctors.” Barbara, let’s end with some brief take-home messages that you want to leave with the KevinMD audience.

Barbara Sparacino: I want everybody to know that the vast majority of caregivers are under the age of 50. So they are also in the sandwich generation. When it is your parent, you are not practicing medicine. You are practicing love under pressure.

I want folks to realize, and I want fellow physicians to realize, that while they are still a physician in this role, they are much more vulnerable emotionally without their lab coat on. And that is OK. I think showing that vulnerability, especially to your colleagues, will be helpful for everyone because we are all in this together. All of us have had parents. Hopefully folks’ parents are still living and healthy, but we will all go through this at one point.

I think being supportive of one another and being compassionate helps. Also, if you see a fellow physician struggling with this, maybe approach it from this perspective of knowing that they are also navigating being not in control. We have upwards of 7 million patients living with Alzheimer’s this year in this country, and that is just the tipping point. Those are just the ones that have been diagnosed. That is not even taking into account all the other medical comorbidities. So we have a long road ahead of us.

The good thing is that we have ways of making sure that our parents’ wishes are respected, their autonomy is maintained, and that our relationships are maintained with them. I also want to remind folks that again, let’s not consider parenting our parent because they are always our parent. We just fall into this new role of trying to help them maintain that autonomy as they age. Once they are gone, that is when our vertical authority is gone. I think that is when people finally feel like adults. I hope to stay a non-adult for as long as possible.

Kevin Pho: Barbara, thank you so much for sharing your perspective and insight. Thanks again for coming on the show.

Barbara Sparacino: Thank you so much for having me. Appreciate it.