Fellows-in-Training Newsletter

Spring 2002

"What's the Gimmick"?

Aanand Naik, MD
Fellow, Geriatric Medicine
U.T. Southwestern in Dallas, Texas

Last year one of my fellow internal medicine residents asked a curious but compelling question about geriatrics. He simply wanted to know "what's the gimmick with geriatrics?" At first I was a bit taken aback and immediately took to my all too familiar defensive tone when discussing geriatrics. I transformed this frustration into a constructive force by placing a recent editorial by Kenneth Rockwood into the mailbox of all one hundred and fifty internal medicine residents at U.T. Southwestern. Rockwood's editorial expounds eloquently about recognizing the atypical presentation of symptoms, addressing the concerns of caregivers as well as patients, and embracing the complexity of multi-morbid disease in the elderly. This article succinctly describes all the aspects of geriatrics that I love.

Six months into my geriatrics fellowship I finally understood the point of my friend's question and the importance of answering his doubt effectively. Internists with an interventionalist outlook find Geriatrics irrelevant. "Come on, I take care of plenty of geriatric patients in my VA clinic. They have a problem list longer than my arm and complaints that none of us can solve. When they have a real problem like a heart attack the cardiologists can shock them, swan them, and stent them." Generalist, even those with sympathetic opinions, often minimize the role of geriatric medicine. "I'm really glad you guys are around because I don't have time to look over all those medication interactions." The advent of functional assessment and the recognition of geriatric syndromes are real examples of the impact of geriatrics.

These clinical skills add immensely to the armamentarium of internists and subspecialists, and yet geriatrics remains largely a clinical research discipline. Once diagnosed sub-specialists are the physicians crafting treatments for geriatric syndromes. So that is why my friend asks in less articulate terms, just what is the scope and role of a geriatrician in day-to-day patient care?

Urinary incontinence presents in nearly a third of the elderly and geriatricians are best at identifying etiologies and treating easily reversible causes. Symptoms that persist are either tolerated by patients or referred to a urologist or gynecologist. These subspecialists then perform invasive diagnostics and procedure based therapies. However, only rarely does this include surgery. In contrast, when a patient presents to a cardiologist with chest pain or a gastroenterologist with abdominal pain both medical sub-specialists identify etiologies and treat easily reversible causes. If symptoms persist they perform invasive diagnostics and procedure based therapies. Only rarely is a cardiothoracic or colorectal surgeon consulted.

Traditionally, geriatricians are primary providers and largely academic researchers. Sub-specialists are increasingly aware of the unique problems of elderly patients within the context of their fields of interest. This evolution pigeonholes geriatricians as internists with a particular interest in the elderly similar to adolescent medicine. Professionally, geriatricians are usually located within divisions of general internal medicine. Geriatrics training could even be folded into the third year of internal medicine training. For some this is a favorable future. Many young internists, myself included, pursue geriatrics because of an interest in epidemiology and a love of multidisciplinary general medicine. We avoid mastering procedure-based interventions.

But, there is an alternative. Geriatricians can take from the cardiology playbook. Cardiology aggressively pursues all modalities to manage cardiovascular disease. Cardiologists adapt the ultrasonography, nuclear imaging, and angiography procedures of radiology for the diagnosis of cardiovascular diseases. Cardiology borrowed from and improves upon techniques of vascular surgery. Cardiology employed the expertise of electrical engineers to build the subspecialty of electrophysiology. In a similar vein, geriatrics can aggressively pursue all modalities to manage geriatric syndromes. Geriatricians can take charge of geriatric rehabilitation units. Geriatricians can adapt the invasive diagnostic techniques of urologists to treat incontinence. Geriatricians can borrow from rheumatologist, physiatrists, and orthopedists to diagnose, manage, and treat the progressive complications of degenerative arthritis.

So, just what is the gimmick with geriatrics? For now it is an academic field specializing in the elaboration of disease syndromes in the elderly and a supra-specialty improving the primary care and function of patients in a variety of clinical settings. That wasn't so appealing to my friend; he is now a gastroenterology fellow.