Mandi Sehgal, MD

University of Cincinnati College of Medicine

“What I love most about my work are the relationships I establish with patients and their family and the differences I can make in their lives."

During her third year of medical school, Mandi Sehgal, MD, told her classmates that she was interested in family medicine—and got an earful. "You're too smart for that; you should go into radiology," was a typical response. But Sehgal paid no attention. She'd recently finished a family medicine rotation—at a rural hospital so tiny that the only living space available to her was a closet-sized room with a bed on casters—and was sold on the field.

"I did everything at that hospital—I delivered babies and did minor surgery too. It was like Mayberry," she recalls, referring to the fictional hamlet that was the setting for the '60s series "Andy Griffith.”I thought, "Who wouldn't want to do this?""

Shortly before finishing her family medicine residency, Dr. Sehgal looked back at her years of training, realized that many of the patients she most enjoyed caring for were elderly, and announced that she was considering a fellowship in geriatrics. She got an earful again. "My residency attendings said things like, "We teach you a lot about aging." It was kind of looked down on," she recalls. She paid no attention.

Instead, Sehgal went on to complete a geriatrics fellowship at the University of Cincinnati College of Medicine -- which offered her a faculty position as soon as she'd finished.

"I always wanted to teach, so this was great," says Dr. Sehgal, who joined the faculty in 2005, did a part-time faculty development fellowship at the University of North Carolina at Chapel Hill shortly after, and is now both an Assistant Professor in the Department of Family Medicine, Geriatrics, and the Associate Geriatrics Fellowship Program Director at Cincinnati.

In addition to teaching, seeing patients, and working with fellows, Dr. Sehgal does research. She was an investigator in a major study examining how to strengthen geriatrics education and elder healthcare that was funded by a $2 million Donald W. Reynolds Foundation grant. She’s been involved with the Reynolds Foundation-funded Chief Resident Immersion Training in the Care of Older Adults (CRIT) demonstration project, which trains chief residents both to diagnose and treat health problems common to older adults and to better prepare the medical students and residents they supervise to do the same. Boston University Medical College originated the CRIT program and, with the Association of Directors of Geriatric Academic Programs, is disseminating the model nationwide through the demonstration project. The project launched at Cincinnati and four other participating medical schools and has since expanded to include several more.

"I'm busy with lots of different things," says Dr. Sehgal. "And I love what I do."

The American Geriatrics Society caught up with Dr. Sehgal recently and asked her to offer some insights into the field for potential recruits:

Q: You mentioned that you like to introduce your trainees to older adults to dispel misconceptions they might have about the elderly and caring for the aging. Could you talk about this a bit?

A: There's this myth, the Myth of Yucky Older People, and it's important to dispel that by having residents meet and actually spend time with older people. My favorite patient—whom I think about almost every day—was this lovely 85-year-old named Clara, who looked much younger than her years. She was extremely curious, belonged to several book clubs, and was a docent at three museums. So we invited Clara and her friends—there were several and they were all equally dynamic—to a dinner for residents. We were going to do it at the hospital, but Clara wanted to host it at her house. One of her friends came in 3 ½ inch heels and dressed to the nines. She was beautiful. And Clara was leading the show and making everyone feel loved and welcome. The residents were like, "Whoa!"

Q: What are did you learn during your geriatrics fellowship that you didn't learn in residency?

A: During fellowship you learn about the procedures and processes and research guiding the care that you just sort of did in residency. You also learn to provide care that you were never involved in as residents. For example, as residents we just referred people to hospice. In a geriatrics fellowship, there's a whole rotation in which you do hospice work. As residents, we'd transfer patients to nursing homes, but I never knew what happened in a nursing home in terms of providing care and continuity of care—until I did that during my fellowship.

Q: What would you tell a med student or resident who says, "I'm not sure whether geriatrics is for me"?

A: I'd tell them that, ultimately, we're all going to be geriatricians in one way or another. Students in medical school and people like me are facing this Silver Tsunami—this huge increase in the number of older patients. No matter what specialty you go into, you'll be dealing with geriatric patients, unless you're a pediatrician—and even then, you'll be dealing with grandparents!

Q: The typical office visit is about 15 minutes long these days. That doesn't allow for much conversation. Why is it so important to spend time talking to your older patients and how do you find the time?

A: If you sit down and talk with your patients about their lives and values, you can help them better make decisions for themselves. I have this 85-year-old patient who's a retired nurse. She has iron deficiency anemia so the protocol would be to do blood work and then a colonoscopy to make sure there's no colon cancer. But she's 85. Does she really want to go through a colonoscopy? I need to tell her what the guidelines are, and explain the benefits and potential harms and let her make that decision for herself.

By talking with and listening to your patients, you develop relationships with them, and when you do that, they respect and trust you enough to take a trial-and-error approach. That's an approach you often have to take with older patients because we don't really know that much about how treatments affect older people—for various reasons, there still aren't a lot of older patients in clinical trials. You have to explain that, and you have to explain that there are possible side effects from certain treatments, and you have to explain that if the treatment isn't working well, they can stop it.

I really enjoy talking with my patients. And I enjoy listening to their stories. It's uniquely gratifying to have these wonderful relationships with your patients.

Q: In addition to being a good listener, are there other qualities or abilities are important in a geriatrician or would-be geriatrician?

A: I'd say kindness and compassion and empathy. It's important to understand, for example, that the language we talk can be very confusing for patients and their families, as can some of the things we tell them to do.

To teach residents about polypharmacy and what it's like for people taking multiple medications, I bought a whole bunch of pill boxes and candy "pills" and told the residents to be a patient for a week, and to take all of these "pills" as prescribed. Well, none of them were compliant. They got frustrated when they had to put the pills in the box and couldn't make them fit. One person didn't get a pill box—because not every older patient has a pill box--and that was frustrating. This was an incredibly eye-opening experience for the residents. They said things like, "I'll never give anyone a four-times a day dosing, because if I couldn't do it…" This kind of thing teaches them to be more empathetic and cognizant.