Sunday, July 5, 2009

What makes a geriatrician different?

In the United States, there are approximately 300 geriatric fellowship positions. Many of them go unfilled. In fact, less get filled every year. I heard that only about 200 positions are filled. From talking to one fellowship director, many fellows are just killing time until they get another fellowship that they really want like cardiology or heme-onc. Fewer medical students and residents express interest in primary care (1, 2, 3, 4), much less geriatrics. According to the Institute of Medicine's report (Retooling for an Aging America), there were just over 7,000 geriatricians in 2007 (not all of whom went through a fellowship). And at the American Geriatric Society meeting, I heard that most geriatricians are choosing not to recertify as geriatricians. My main point is that every year, there are fewer geriatricians, both new grads and practicing physicians, not more.

So the question is, does this matter? What makes a geriatrician different? Right now I'm working for a group practice of physicians as their hospitalist. There is one patient that I saw there that provides a good example.

An 85 year old female who came in with an intestinal infection, developed pneumonia, sepsis, respiratory failure, a urinary tract infection and renal failure and 45 days later she is still immobile, has a feeding tube and requires 5 L of oxygen. While all her specialists have written that they think she's getting better, no one has addressed her immobility. After 28 days of bedrest, a geriatric patient will have lost 50% of their muscle mass and 75% of their strength. Like an astronaut, she will have a component of low blood pressure whenever she tries to get upright (even in a wheel chair). This patient has been bed bound for 45 days. Geriatricians excel at not only coordinating complicated care, but also thinking about the patient as a whole with an eye towards geriatric syndromes. Things like delirium, pressure ulcers, deconditioning, malignant effects of bedrest are issues that are best prevented. Treatment is very very difficult. Would a geriatrician made a big difference in this lady's hospitalization? Maybe, but it definitely would have given her her best chance for getting out with the fewest complications.

Somehow, I hope to see the state of geriatrics take a turn. I hope to see more and more students choosing to go into geriatrics as a career. I think it is clear that there is a huge need for more professionals in this field who have a passion for making sure that older patients get the care they need and deserve.

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