Here’s why geriatrics really shouldn’t be a medical specialty

In medical training, there were very few students or residents who intended to go into geriatrics, a subspecialty of medicine involving the care of older patients and an extra one-year fellowship after an internal medicine or family medicine residency. Future geriatricians got significant side-eye from their peers and superiors. “Bleeding heart,” people would think. “Oh, that’s so cute. She’s frumpy — it’s kind of a frumpy field.” Or: “What’s the point of medical school to end up working harder for less money?” Cardiology or gastroenterology, with their video-game procedures, one-percenter salaries and prestige, were sexy specialties. Taking care of old people? Not so much, and not really better paid than foregoing the extra year of training at $55,000 per year and going straight into private practice as a primary care doctor.

Except by 2050, one in five people will be elderly, and that growth is happening now (between 2010 and 2030) as baby boomers are aging over 65. And today’s graduating doctors have an education that emphasizes the care of patients up to the age of 55. The elderly have the same diseases as young and middle-aged adults, but with more of them. They face higher risks when it comes to drug interactions and surgical complications, and more complex critical care wishes (for example, a 95-year-old may ask not to be put on chemotherapy or resuscitated).

Our medical education, particularly in books and written tests, was lopsided toward single-answer cases (Who always needs a chest X-ray for TB screening? Immigrants who had a TB vaccine as a kid) and inherently interesting factoids about rare conditions (a red eye with nausea and vomiting means acute glaucoma). Of course, all this information is useful and relevant. But we graduated medical school lacking confidence about how to manage pain in a 90-year-old cancer patient. Drug interactions and dosing adjustments for the elderly get short shrift. Family practice doctors often know more about rare pediatric genetic diseases than they do about clearing an elderly female for surgery. How do you balance depression, epilepsy, and pain treatment in a 75-year-old? We were not challenged to answer these questions often enough, and the advice to “be slow and careful” was not enough.

We graduated medical school lacking confidence about how to manage pain in a 90-year-old cancer patient. Drug interactions and dosing adjustments for the elderly get short shrift. Family practice doctors often know more about rare pediatric genetic diseases than they do about clearing an elderly female for surgery.

Much has been written about the fallacy of the 15-minute appointment. Doctors who see older patients have an even harder time with this restriction, given the delays in check-in from a patient who might be slowly trudging with his walker from the parking garage, struggling with confusing instructions, or dealing with disagreements between family members in the exam room. But given our demographic future, this type of appointment will increasingly dominate future physicians’ offices. These patients are not just a temporary inconvenience until the “easy” 20-year-olds come in for their birth control refills.

The idea that older patients will disappear conveniently into geriatricians’ offices once they turn 65 or 70 is just that, an idea. The Wall Street Journal has reported on a shortage of geriatricians. As of 2014, the fellowship positions for geriatrics were the least likely to be applied for or accepted, leaving hospitals with geriatrics funding and no doctors to train. As of 2017, this continues to be the case. Several medical centers in the U.S. have been looking for a geriatrics fellow for nearly a year. Many hospitals do not even have a geriatrician on call to consult on tricky medical decisions or prescribing plans.

The solution is to give every doctor who is not a pediatrician — urologists, primary care doctors, cardiologists —the needed training so they can care for older patients. Geriatric patients should be better represented in test questions and medical books, and training programs with relatively young patient populations should make efforts to ensure that their students know the guidelines for elderly patients and have more of these patient encounters under their belts by the time they finish residency.

Rheumatoid arthritis and myelofibrosis are conditions that require switching to a specialist. Being old should not be.

[Photo by Emilio Labrador via Flickr.]