Clinical 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.