The Rewards of Geriatrics
As you think about your friends heading off to work in their sparkling technological subspecialties, it might occur to you that you made the wrong career decision. Not a chance.
True, as doctors go, geriatrics providers are not paid handsomely. Nevertheless, our compensation is generous. We are recognized and respected for the ability to take the broad view, to see the forest for the trees. We enjoy greater variety in our work than most physicians—not only clinically (we see diseases of all organ systems), but also in the humanity we encounter. We accrue confidence in our ability to handle most anything, as we learn to view complexity with aplomb, to balance competing priorities, to comfort stressed families, and to help our patients come in for that final landing. Not least, our patients often pay us with legacies of wisdom. They teach us about the importance of work, marriage, and child rearing, how to cope with loss, what makes life worth living, and how to gracefully bring the curtain down on life. Attentive professionals caring for the elderly can learn from patients how to live and how to die.
What characterizes most specialties is a deep and challenging content domain. Pick a clinical problem or patient complaint, and some specialty in the medical center can claim the last word on the subject—cardiologists for arrhythmias, nephrologists for electrolyte deficiencies, oncologists for tumors. Our geriatrics training did give us new content to absorb, such as unusual causes of dementia, and it did expand what we knew about subjects we thought we had mastered, such as parkinsonism, osteoporosis, and others. But the geriatrician’s real estate is not narrow and deep. In fact, knowing more about the particular medical problems of older people isn’t really our claim and distinction.
Geriatrics is more process than content, more how than what. The approach we learn calls for flexibility, comprehensiveness, and sensitivity. The standard method—eliciting a chief complaint, constructing a broad differential diagnosis, conducting tests to uncover the causative ailment—won’t carry you very far with the old. Among older people, function—the ability to do things for themselves so that they don’t have to depend on others or get parked in an institution—often exceeds symptoms in importance. Weak hearts, lungs, kidneys, and joints may combine forces to create a problem that eludes your search for a unifying cause. Some problems (falls, incontinence, forgetfulness) we have to ask about, because patients assume that these come with getting old, and so won’t volunteer these complaints. Other problems arise from flies in the social ointment. Furosemide, for example, is a wonderful drug for treating heart failure, but if your housebound patient’s son is too busy to get her prescriptions refilled, she’s going to get sick. Geriatrics providers practice low-tech virtues, such as asking about how caregivers manage the pills at home.
In their training years, physicians spend most of their time in hospitals, clinics, and the occasional nursing home. But American healthcare occurs in a wide variety of venues, and no specialist knows more about this spectrum than the geriatrician. We work in private and domiciliary homes, and in the range of institutions (skilled nursing facilities, subacute units, and the like) that cropped up when hospital stays contracted. We are familiar with acute rehabilitation hospitals, with long-term acute care institutions, and with residential hospices. Like other physicians, we know about drugs, devices, and procedures, but more than most doctors, we’ve mastered care venues themselves, their advantages, and their drawbacks.
In addition, because our patients spend a lot of time in sundry care settings, we have learned a lot more about a couple of things that, as residents, we were only introduced to. First, the transition of our patients from one location to the next is a complicated and potentially hazardous endeavor. Geriatricians are necessarily skilled at managing these transitions. Second, many of these venues are doctor-free zones, where our patients’ progress is in the hands of a variety of healthcare professionals (visiting nurses, case managers, physical therapists, occupational therapists, speech pathologists, social workers, and others) whose expertise we have come to prize. From geriatrics training and experience we understand far better how these professionals can help our patients. Often, they can do more to directly help a patient than we do, but that means we have to know to call for their help. Geriatrics professionals also have learned to lead these teams of professionals. Leadership training is a key component of our discipline.
We heard about the ethical precept of non-maleficence in school. Doctors are enjoined not to harm their patients. Non-maleficence in the care of younger patients is not a crushing burden. It entails reasonable attention to medical detail and the avoidance of wickedness. But non-maleficence in geriatric care is a good deal harder and is at the core of our work. Our prescribing, procedures, and hospitalizations all can cause collateral damage, and no patient is at greater risk in the clinical combat zone than the fragile elderly person. Geriatrics providers learn the art of finding that sweet spot, that individualized combination of workup and treatment that optimizes the odds of helping, not injuring, our patients.
Facility with complexity is the geriatrician’s stock in trade. A person with diabetes with poor glucose control might benefit from consultation from an endocrinologist. Another patient with severe congestive heart failure might be helped by a cardiologist. A third with crippling arthritis might feel better in the care of a rheumatologist. Now, picture an older person with all three diseases. She has difficulty sticking to the drug regimen. She doesn’t know that a medicine she takes for one illness might make another worse. If she receives care from three specialists, her health may be at the mercy of these doctors’ willingness to talk with one another and compromise. Primary care providers unschooled in geriatrics may be overwhelmed by the intricacy of her situation, but this patient is the bread and butter of our practice. In geriatrics training we acquire the skills to cope with—even to revel in—clinical complexity, to adopt a reliable method for working with patients like her to set priorities and start on the most important things first.
The geriatrician’s proficiency for negotiating goals with patients and families is paramount when the end of life is visible on the horizon. We learned during training to recognize when we’re faced with this situation. We’ve grown comfortable in talking about these things with patients and with the people who love them. We see how to identify the tradeoffs that have to be made, and how to ask diplomatically whether the extra months of life that arduous therapies may buy are worth the costs. Last, we’ve learned how to recognize the limits of medicine, tell this to a patient, and know that we’ve made a salutary contribution.
So, it’s true we could have chosen a more comfortable corner of medicine. Relative to other medical specialties, geriatrics is not lucrative. It lacks glamour and prestige. It has more than the average amount of loss and death. And its scientific evidence base remains comparatively shallow, since most research studies don’t include the frail elderly persons who make up much of our practice. Nevertheless, geriatrics is as invigorating a field as exists in healthcare. It offers profound professional challenge and opportunities for personal growth as well. Accounting for everything, we’re paid very well.
Dr. Lyons is Associate Professor, Section of Geriatrics & Gerontology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha.