Marc D. Rothman, MD

Kaiser Permanente - San Francisco

"Geriatrics is a good example of a field where you can both impact the individual before you and the population at large, which is another aspect that got me excited about it in the first place."

It's hard for Marc Rothman, MD, to pinpoint exactly what led him to pursue a career in geriatrics.

There were too many contributors.

For starters, there was the time he spent with his great aunts, great uncles, and paternal grandmother while growing up. "I loved being around them; they were so good at telling stories and listening," recalls Dr. Rothman, who completed a fellowship in geriatric medicine in 2006 and completed a fellowship in clinical epidemiology and aging research at Yale University School of Medicine. "I know that a lot of people aren't comfortable around older adults but I've always enjoyed them."

Then there was the time he spent—after earning his BA from the University of Wisconsin at Madison—working in a laboratory doing research exploring genetics and longevity. "I got really involved in that and it just dovetailed with my attraction to older people," he explains. The experience prompted him to apply to New York University's School of Medicine.

At NYU, the excitement of studying and working with leading scientists in the medical school's Silberstein Aging and Dementia Research Center was among the experiences that furthered his interest in geriatrics. At the center, he worked on longitudinal research examining risk factors for dementia. "It was exciting to be involved in a study following people over the lifespan," he explains. "That was also my first exposure to multidisciplinary teamwork. Every four years, people participating in the study would spend two days being seen by a team of geriatricians, psychiatrists, radiologists, social workers, and geneticists." Multidisciplinary teamwork is a central element of geriatric care.

Then there were his experiences at Yale, where Dr. Rothman did his internship and residency prior to starting his fellowships. "Early in my internship at Yale I was lucky enough to have the chief of the department of geriatrics as one of my attendings," he says. "At Yale I was exposed to just an incredible group of geriatricians, including Mary Tinetti, Tom Gill, my mentor Terri Fried, Leo Cooney, and Sharon Inouye.” For his three-month research project during residency, he worked with Terri Fried investigating the circumstances in which seriously ill older adults refuse treatment.

At Yale, as at NYU, he found the time he spent with older patients extremely gratifying. "I'd have to say there were a lot of reasons why I was drifting toward geriatrics, but I guess the real reason I chose geriatrics was because of the patient contact," Dr. Rothman concludes.

American Geriatrics Society caught up with Dr. Rothman to talk about charting a career in geriatrics.

AGS: So what's a geriatrics fellowship like?

MR: It's eye opening. In a geriatrics fellowship you get to practice and see patients in so many more settings than in your residency. It's like the doors from the hospital are opened and you realize that there are a million places to practice geriatrics. I was exposed to all sorts of different settings, not just clinics and the ICU and the hospital floors, but also to very specialized, multidisciplinary dementia clinics, assisted living facilities where I got to see patients in daily life, and a wide array of nursing homes, including mega rehab facilities. I also had experience in a geriatric evaluation and management unit—a GEM unit; we had one at the VA. In units like these, you're taking care of dialysis patients, amputees, stroke victims, people with end-stage cancer, all kinds of things. You learn about inpatient hospice, and home-based hospice, and home care. Some of my home-based hospice care experiences were among the most intensive of my fellowship.

I did rotations in a special long-term acute care setting, which was fascinating. It's like an intensive care hospital but also, almost like a nursing home. And I did home-based psychiatric care treatment. I went out with a geriatric psychiatry team to visit people at home.

Fellowship is great because you realize that most of your patients aren't in the hospital—they're out there in the community somewhere. You discover that not only can you do good geriatric inpatient care, but there are all these alternative sites where you can work with patients and truly help them.

AGS: Opportunities for patient contact were central to your decision to specialize in geriatrics. What makes patient contact in geriatrics different from that in other fields?

MR: A lot of other fields are procedure-based; geriatrics just isn't like that. If you really want to spend time with patients—not just 19 minutes—and get to know them and learn about their problems, medical and otherwise, if you thrive on that, geriatrics is perfect.

Older patients often have multiple, interrelated medical problems, including a variety of problems that may present in the same way, and problems that could have any number of causes. Of course older patients are more likely to be taking multiple medications, and so they might have multiple side effects or interactions. So, it's not as though you have a single health problem due to a single factor. Geriatrics isn't cookie-cutter medicine, and that's both an enormous challenge, and, for me, extremely satisfying. You have to be a detective. With older patients, you have to be a detective and get as much information as possible. You need to invest the time to work through the mysteries.

AGS: Has your training opened up any unexpected opportunities or avenues?

MR: Again, because there aren't that many geriatricians around, you get tapped on the shoulder a lot. People are hungry for input from people who know about caring for older people, especially from a medical perspective. Being a doc in the field makes you unique.

One unanticipated avenue opened up for me when someone tapped me on the shoulder and said, "We're putting together emergency preparedness materials for health systems and public health departments—would you do a special module on geriatrics?" I got some training in disaster preparedness and, boom, now I'm one of the few authorities on geriatric disaster preparedness. I've put together a CME course with the emergency management group at Yale on preparing for and responding to geriatric needs in disasters. And I've written a couple of articles about the medical needs of older people during evacuations. So you never know what's coming around the next corner in geriatrics, which is also what keeps the field fresh and exciting.