Geriatricians

[ThinkTooMuch]

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is the problem only salaries?

 

[eyesarecool]

Basically slaving away an extra year for experience and a shot at geriatric academia.

 

[dragonfly99]

Not at all.
These patients are harder to take care of that other patients, due to often having multiple medical problems and being on multiple medications, etc. Also, a good number have physical problems such as hearing loss or physical disabilities, and/or dementia, which makes it take longer for each visit (i.e. if you have to repeat things in a loud voice, go over a really long medication list, and explain a lot of stuff very slowly to the patient). But that does affect the bottom line of how many patients you could see (and thus bill for), as it would be really hard to stay on schedule in your clinic and see anywhere near the number of patients/day that you would see if seeing all ages.

It can be rewarding to take care of this population. Some have a lot of good wisdom to pass along. However, some are just old and cranky

I imagine it could also be depressing, because a lot of your patients will die off.

Personally, I like taking care of a mix of different ages, and wouldn't want to practice solely geriatrics. If you do, you could do so with just a 3 year IM residency (or even family practice). Part of the reason geriatrics fellowships are not popular at all is that you are basically doing an extra 1-2 years of fellowship to do the same thing you could do with 3 years of IM residency...since we see a ton of >60 year old patients in internal medicine, particularly while doing inpatient IM but also in our clinics.

 

[asmallchild]

I forget where the study was listed but it is worth nothing that geriatrics consistently ranks as one of the most rewarding specialties out there.

 

[dragonfly99]

You're talking about a poll that was taken measuring happiness of docs polled from different specialties. It was one study, though. I have to say it's likely a function of the personalities of geriatricians (they tend to be kindly and somewhat saintly and to feel they have a calling). I guess the hours are all right, too, if you are an academic geriatrician (likely have house staff to admit all your patients after hours).

 

[Geri_Gal]

The salary is a huge problem.

The patient population is *very* rewarding to care for. Patients who live to 80+ years have made good lifestyle choices and generally adhere to medical therapy. The patients say "thank you" and are genuinely glad to visit you.

I find that the academic geriatrician's approach to medicine is fundamentally different than the disease-centric approach that most subspecialists and even general IM docs have. The geriatrician focuses on the patient as a whole, and is mindful of the patient's social environment in addition to the many complex comorbid illnesses the patient may have. The patient's goals of care must be taken into account when prescribing multiple meds to treat diabetes, HTN, CHF, CAD, etc. and there are no rigid clinical guidelines to follow. The end of life issues are often not so depressing, as death is natural in this age group. The patients are often prepared for this and the focus can then be on how these patients die (e.g. with hospice, deciding not to be admitted to the hospital, aggressive symptom management).

It is a shame that geriatricians are not compensated more for the work that they do...as it isn't simply about renally dosing meds and referring to social work. Critical care physicians can bill for their "critical care time"; geriatricians would benefit from "geriatric care time".

 

[Zock]

Not at all.
I imagine it could also be depressing, because a lot of your patients will die off.

Personally, I like taking care of a mix of different ages, and wouldn't want to practice solely geriatrics. If you do, you could do so with just a 3 year IM residency (or even family practice). Part of the reason geriatrics fellowships are not popular at all is that you are basically doing an extra 1-2 years of fellowship to do the same thing you could do with 3 years of IM residency...since we see a ton of >60 year old patients in internal medicine, particularly while doing inpatient IM but also in our clinics.

I disagree wholeheartedly with this sentiment. General IM docs and Family Docs are not good geriatricians by virtue of their 3 year training. The focus is totally different. General IM is disease based, cure based, and fights death. Geriatrics looks more at syndromes, functional status, and quality of life. Death in this population (much like GeriGal said) is not the enemy.

Geriatrics, when done properly, is much more than General IM for the 65+ population. It's about knowing how to skillfully manage patients with 8 different conditions (including memory loss), having an exquisite understanding of pharmacology and drug interactions, knowing when to be aggressive and when to let go, managing interdisciplinary teams, truly understanding patient compliance issues and constantly working to uncover barriers to self care, appreciating the difference between the young old and old old, understanding that one thing such as dehydration/fecal impaction/poor oral hygiene/broken hearing aids, etc can lead to a cascade of dependency and death and vigilantly looking for these things that other docs overlook. It's also about social issues, knowing how to break bad news, knowing how to empower your population their families and caretakers, home visits (never underestimate those), and learning how to bridge the gap from the clinic or hospital to the home or nursing facility. It's about taking care of the entire patient and realizing that without considering the whole (including environmental and social factors) your patient will not fair well.

A success to a geriatrician means regaining functioning--loss of function and independence is what most people fear more than death. A geriatrician roots for increased independence, walking, dressing, bathing, preventing falls, and staying out of nursing care for as long as possible (while knowing when it is needed.) When death comes (as it will eventually do to everyone) a geriatrician is not sad if they have done their best to ensure the highest quality of life possible. Geriatricians have a different purpose than most other medical fields. They are charged with quality of life, whereas most other fields are charged with preserving life at all cost. To those who think like a geriatrician this is a beautiful and freeing thing, and to those who don't they wind up viewing the geriatrician as feeble minded, slow to act, and "a bad doctor."

Think about it, in threads "what are they looking for in med school interviews," a common response is, "someone who I would want taking care of my grandmother." Meaning someone who sees the patient as a human being...geriatricians are special because they take up that call as a challenge. They are the ones who (God willing) will be taking care of all of our grandparents, parents, and even us someday. As the population ages and people begin to experience the strain of taking care of older parents/grandparents I'm hoping the general perception about geriatricians in the medical population will change. They are greatly needed, and when properly trained, are phenomenal doctors.

 

[dragonfly99]

I was not saying that I don't like geriatricians. I was saying that I personally would not want to take care of solely elderly patients, because I personally like to take care of different ages of patients, and that I personally like to be able to "save" at least some of my patients. Knowing what you like and dislike, in terms of an occupation, is important to picking a medical specialty or subspecialty. I agree that in general it is not as sad when an older patient dies, especially if they were "ready to go", so to speak, and had a reasonably good quality of life up to the end.

During my residency, my resident clinic was at a VA, and I would say that >>50% of my patients were over 50, and a large number over age 65. It is definitely true that when people get to a certain point in life, the goal is to minimize function and not necessarily to do a bunch of cancer screenings or "disease fighting" per se. Some level of geriatrics training has been incorporated into internal medicine training (is required for all residency programs) as well. Ours included geriatrics clinic, as well as learning about drug dosing in elderly patients, etc.

 

[efex101]

There would be no amount of $$$ to lure me into geriatrics. I am now at my place of residency seeing mostly those above 80 and to be honest it is way tough. Many do want comfort care more of a palliative approach, but many want ALL type of over the top heroic medicine that will in no way benefit them, but they still push which is their right. Also, dealing with families can be a gargantuan effort. Good to know there are other folks out there willing and wanting to take care of these folks, but these are by far in the minority....

 

[dragonfly99]

I recently read a letter to the editor of a major medical newspaper from an internist who sees geriatric patients for a living (he must be at least middle aged, so I'm sure there was no geriatrics fellowship when he trained). He basically said that because of Medicare reimbursements being flat, his income has stayed the same x 15 years and it got to a point where last year he had to dip into savings to pay his office expenses. He figured out that to make money and pay his expenses, etc., he would have to see 6 patients/hour. That might be possible in a practice that is a mix of young, healthy people and occasional geriatric patients, because some of the younger folks will be there for a URI and you can see them for 5 minutes. However, that is totally impossible with geriatric population. It would take 10 minutes just for them to get up on the exam table and for you to review their medication list.

I agree w/the above comment, too, about the aggressive care wanted by some families and elderly patients...just because they are 80 doesn't mean they are mellow and won't want "everything" to be done if they start getting sick and are hospitalized.