Geriatrics....what's the big deal?

[Faebinder]

I don't get it...

Last two interviews I went on both had many attendings hyping how much they love geriatrics and geriatric fellowship this and geriatric fellowship that...


What gives? Why even do a fellowship in geriatrics instead of straight out of residency to a geriatric population?

Am I missing something here from the big picture?

*Something else is puzzling but not surprising... there is no extra money in Geriatrics.. heck it pays less than average according to many salary lists I have seen.*

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[deleted6669]

outpatient geriatrics= job security.
fp is uniquely positioned to control this area of practice. the internists want the hospitalized trainwrecks, fine. you guys are better at KEEPING them out of the hospital in the 1st place.....

 

[Faebinder]

outpatient geriatrics= job security.
fp is uniquely positioned to control this area of practice. the internists want the hospitalized trainwrecks, fine. you guys are better at KEEPING them out of the hospital in the 1st place.....

I understand... but it doesn't answer the question.

Why fellowship? Why not straight out of residency? How is that 1 year going to make the difference.

 

[deleted6669]

I understand... but it doesn't answer the question.

Why fellowship? Why not straight out of residency? How is that 1 year going to make the difference.

any added credential makes hospital boards and employers more impressed with your cv. you might as well ask why do a fellowship in anything.
an fp doc with an em fellowship has an easier time doing em and getting credentialed for procedures
ditto fp docs with ob fellowship
ditto sports med
ditto faculty/resident education

if you can get the job right out of residency go for it. if it is a competitive process in a desireable locale beef up the cv.

 

[elizabeth5863]

I understand... but it doesn't answer the question.

Why fellowship? Why not straight out of residency? How is that 1 year going to make the difference.

Hi Faebinder,

I actually love geriatrics and am thinking about getting a geriatrics fellowship, so I'm a bit biased obviously.

So, for people interested in becoming faculty at a residency program someday, it is marketable to do a fellowship. Some people happen to enjoy sports medicine, women's health, adolescent health, obstretics and others like me, happen to enjoy working with the geriatric population. Although it is important to have breadth in family practice, most faculty members and most family doctors in general have a particular field in fp that they are really good at/interested in.

Although not all residency programs require that you need to get a fellowship to become faculty, it helps to be an expert in an area. More and more people are living longer these days and being able to take care of the elderly and their chronic medical problems is important.

If you're not interested in becoming faculty or going into academics, I agree that it is not important to do a geriatrics fellowship (or any type of fellowship at all).

Hope that answers your question

P.S. As for the money, sure... you don't make as much and work hard as a geriatrician but working with the geriatric population is a very satisfying field. Geriatricians that I've met in general have been very satisfied with their careers (First Aid for the Match also says so).

 

[McDoctor]

I don't get it...

Last two interviews I went on both had many attendings hyping how much they love geriatrics and geriatric fellowship this and geriatric fellowship that...


What gives? Why even do a fellowship in geriatrics instead of straight out of residency to a geriatric population?

Am I missing something here from the big picture?

*Something else is puzzling but not surprising... there is no extra money in Geriatrics.. heck it pays less than average according to many salary lists I have seen.*

Yeah, I don't get it either.

I was fairly active in vollunteer work in the geriatric community before medical school and during medical school as well. But I find I don't like practicing geriatric medicine. The geriatricians I've seen have to see a high volume of patients to make it lucrative, so they end up barrelling through the nursing homes and assisted living facilities seeing patient after patient so quickly that they never really establish any meaningful doctor/patient relationship. And the paperwork and regulations associated with extended care facilities is just mind numbing.

I think people who do these fellowships still find themselves hamstrung by the limitations associated with medicare coverage and regulations associated with extended care facilities. Academically, it might make sense to recommend specific modalities of therapy (PT, OT, Speech Therapy, Music Therapy, whatever...), based on unique expertise in geriatrics, but you are still going to be limited by what medicare will pay for and the level of staffing and flow of care at any given nursing home.

Academically, it might make sense to prescribe a particular psychotropic medication. Having a geriatric fellowship under your belt, you may be uniquely qualified to assess the risks and benefits of this particular psychotropic better than anyone else. But you are still going to get the standard hatemail from the P&T commitee of the nursing home recommending a "therapeutic wean" off the medication.

So I don't see the point. Unless you want to go into teaching or faculty development, there is no real-world value in a geriatric fellowship, IMO.

 

[Faebinder]

Yeah, I don't get it either.

I was fairly active in vollunteer work in the geriatric community before medical school and during medical school as well. But I find I don't like practicing geriatric medicine. The geriatricians I've seen have to see a high volume of patients to make it lucrative, so they end up barrelling through the nursing homes and assisted living facilities seeing patient after patient so quickly that they never really establish any meaningful doctor/patient relationship. And the paperwork and regulations associated with extended care facilities is just mind numbing.

I think people who do these fellowships still find themselves hamstrung by the limitations associated with medicare coverage and regulations associated with extended care facilities. Academically, it might make sense to recommend specific modalities of therapy (PT, OT, Speech Therapy, Music Therapy, whatever...), based on unique expertise in geriatrics, but you are still going to be limited by what medicare will pay for and the level of staffing and flow of care at any given nursing home.

Academically, it might make sense to prescribe a particular psychotropic medication. Having a geriatric fellowship under your belt, you may be uniquely qualified to assess the risks and benefits of this particular psychotropic better than anyone else. But you are still going to get the standard hatemail from the P&T commitee of the nursing home recommending a "therapeutic wean" off the medication.

So I don't see the point. Unless you want to go into teaching or faculty development, there is no real-world value in a geriatric fellowship, IMO.

So far no one stated a single advantage other than academic... and to be honest if someone wanted to go into academic... there are specific fellowships for that. I applaud people for doing for doing what they love.... I just don't get it, especially since medicare sucks for payment in most states, it becomes like they almost dont want you to treat geriatrics.

 

[deleted87716]

Why even do a fellowship in geriatrics instead of straight out of residency to a geriatric population?

The only doctors who don't treat the elderly are pediatricians.

If you truly enjoy treating the elderly, and want to focus on that in your practice, you might want to consider a geriatrics fellowship so you'll be better at it (or slightly more marketable) than the average doc. That's pretty much the only reason to do it.

 

[elizabeth5863]

Well, who would you want to take care of you, your parents, and your loved ones when they get so old that they can barely even walk, feed themselves, have dementia and multiple complex medical problems? A family practioner, general internist, or a geriatrician?

I've worked with fp docs in rural communities who have patient populations that were 2/3 geriatrics and I've worked with multiple geriatricians. Sure, the fp doc can take care of older folks but the care provided by a geriatrician is generally superior. Just like 'kids aren't like adults,' geriatric pts aren't like the avg. adults either.

We are all going to get old someday and so will our pts. We all have to deal with end of life issues. Many of us, our pts, even our family will end up in nursing homes or assisted living facilities. A geriatrician is specifically trained in providing care for the elderly and treating the entire person.

As for money, who says that geriatricians have to practice only geriatrics??? I'm planning on practicing full spectrum fp (except OB). We can still make a decent living. Money isn't everything and if you have a passion for something, why not learn about it in depth as opposed to learning it superficially? We're in medicine because we're life long learners. As for wanting a geriatrics fellowship, geriatric pts in general are harder pts to manage so I want training in it to provide excellent care as opposed to providing mediocre care.

As for going thru nursing home pts quickly, most doctors are able to do that b/c they get updates about their pts almost every day. The fp doctor I worked with gets phone calls and reports from nurses almost daily. You're only required to see pts once a month in a nursing home. Many of them may be demented and can't even talk to you. The nurses who are there everyday know them well so you mostly have to do the physical exam and ask a few questions. I spent a month doing a geriatric elective and geriatricians can go through things quickly and still provide good care.

As for the post stating that geriatricians see their nursing home pts so fast that they don't even establish a meaningful patient-doctor relationship, that is totally false. These pts have been there for a long time and with CONTINUITY of care, you get to know them over time. You know what their problems are and what needs to be done. You see them monthly and sometimes even more than monthly over many many years. Since you know them already, visits don't have to be as long.

 

[piggie]

i am not an advocate of overeducation

 

[Faebinder]

i am not an advocate of overeducation

Especially when the value of overeducation is questionable. Sorry everyone pro Geriatric fellowships... I am just voicing my concern.

It's like saying you need a hospitalist fellowship to become a hospitalist.

This is not the same as saying you need a Sport Medicine fellowship to practice sport medicine... or an OB fellowship to do c-sections.... or a critical care fellowship to do critical care.

I dont know.. I guess I will wait till I experience this more in residency... but I have a gut feeling that my opinion wont change.

 

[sophiejane]

It's also a credential thing. If you are going to practice in a saturated market and would like to add some nursing homes to your practice, having a geriatrics fellowship under your belt will likely make you more attractive to administrators.

Otherwise, I think if you see plenty of geriatrics in residency (and most will), you should be fine.

 

[elizabeth5863]

I think it boils down to doing what makes you happy and passionate about your field. We've been in school for so long, it's nice to be simply done with training. One downside of doing a fellowship is having to get recertification every several years - in addition to taking tests to continue practicing fp.

 

[deleted87716]

One downside of doing a fellowship is having to get recertification every several years - in addition to taking tests to continue practicing fp.

Not to nitpick, but...

You only need to retest if you want to maintain ABFM board certification or your CAQ (only available for fellowships in geriatrics and sports medicine). You don't need to retest to continue to practice medicine unless it's a condition of employment. Board certification is not required by law in any state. State medical boards do have CME requirements in order to maintain licensure, but that's different.

 

[ntubebate]

I'm a strong advocate for two types of special training:
Peds and Geriatrics.

I love them while they're in utero and I don't mind yanking them out but after that I'm more than happy to hand them over to a peds MD.

As for the elderly, I'd love to limit my population to no one over 70 w/o GYN issues. That'd make me a very happy man.

Alas though, being FM trained I deal with it all. I just don't enjoy EVERY aspect of my job; but the good parts make up for all the crap I hate.

ntubebate

 

[RuralMedicine]

Faebinder---In my experience most geriatric fellowships are research oriented more than clinically. If you have interest in academia or research it can be a route to go. If you are just interested in providing good care to your 80+ patients I'd favor selecting a strong FM or IM program to train in and being a conscientious and compassionate provider. You may hear about it a lot at interviews because the faculty consider it a "drawing point" for their program. It may be if you are interested in the fellowship or it may be a draw if the clinical faculty are strong.

Well, who would you want to take care of you, your parents, and your loved ones when they get so old that they can barely even walk, feed themselves, have dementia and multiple complex medical problems? A family practioner, general internist, or a geriatrician?

I've worked with fp docs in rural communities who have patient populations that were 2/3 geriatrics and I've worked with multiple geriatricians. Sure, the fp doc can take care of older folks but the care provided by a geriatrician is generally superior. Just like 'kids aren't like adults,' geriatric pts aren't like the avg. adults either.

I think there are far greater physiologic differences between children and adults than younger and older adults. I think most well trained internists or FM doctors should be trained sufficiently after residency to deal well with geriatric patients if the choose to make the effort. [Many physicians really do not want to make the effort especially with some of the financial disincentives and that is ok too.] Perhaps if you did FM in a very low inpatient volume program then you would need additional training. But I would think that selecting a residency program more consistent with your career goals would be more efficient anyway. As someone who trained at an institution with a strong geriatrics fellowship I'd personally send older family members to several other IM faculty before any of our geriatrics attendings. Our geriatrics attendings were certainly nice but honestly the best "geriatrician" in the city was an old internist. He used to claim that he and his patients grew up together. He was a good guy I miss being able to take care of his patients when they required inpatient care. They adore him!

We are all going to get old someday and so will our pts. We all have to deal with end of life issues. Many of us, our pts, even our family will end up in nursing homes or assisted living facilities. A geriatrician is specifically trained in providing care for the elderly and treating the entire person.

As for money, who says that geriatricians have to practice only geriatrics??? I'm planning on practicing full spectrum fp (except OB). We can still make a decent living. Money isn't everything and if you have a passion for something, why not learn about it in depth as opposed to learning it superficially? We're in medicine because we're life long learners. As for wanting a geriatrics fellowship, geriatric pts in general are harder pts to manage so I want training in it to provide excellent care as opposed to providing mediocre care.

I would be very surprised if all FM programs had superficial exposure to geriatrics. That certainly wasn't the case in the Med-Peds program I trained in so I'd be very surprised if it was the case for ALL FM programs. If experience in the geriatric age group is very important then I would think applicants would seek that out in the programs they ranked as most desirable.

As for going thru nursing home pts quickly, most doctors are able to do that b/c they get updates about their pts almost every day. The fp doctor I worked with gets phone calls and reports from nurses almost daily. You're only required to see pts once a month in a nursing home. Many of them may be demented and can't even talk to you. The nurses who are there everyday know them well so you mostly have to do the physical exam and ask a few questions. I spent a month doing a geriatric elective and geriatricians can go through things quickly and still provide good care.

As for the post stating that geriatricians see their nursing home pts so fast that they don't even establish a meaningful patient-doctor relationship, that is totally false. These pts have been there for a long time and with CONTINUITY of care, you get to know them over time. You know what their problems are and what needs to be done. You see them monthly and sometimes even more than monthly over many many years. Since you know them already, visits don't have to be as long.

My experiences in two different communities are unfortunately very different than yours during your rotation. Personally I do not do ECF care because I do not have the time to do it well and do not want to run a "nursing home mill". I'm starting to get pressure from patients to start so I'm looking into it but I really do not think it is feasible. You certainly can do it well, but in my experience the providers who are not doing it well are not doing it well because they do not devote sufficient time or priority to the task not because they failed to do a geriatrics fellowship. If I think back to the physicians who we hated to get nursing home patients from when I was a resident a top five comes to mind. Of that top five four of them had done a geriatrics fellowship. It wasn't their lack of specialty training that tripped them up. In many cases their lack of overall adult medicine seemed to be a problem but it was never clear if that was true lack of knowledge or just not caring.