Why geriatric medicine?

Why geriatric medicine? It’s a question I am asked often, often by people who are surprised I have chosen the specialty, or perhaps assume I would prefer to do something else.

I remember being asked my career intentions by a fellow candidate sitting MRCP paces whilst we were waiting for our exam. His reply when I told him:

“Oh. Did you choose that?”

The contempt in his voice was barely disguised. I replied that yes, of course I had chosen geriatric medicine as my number one career choice and outlined the reasons why. I politely asked him what his future path entailed. He wanted to be a neurologist and launched into a passionate speech about his subspecialist interest, where many patients were sadly misdiagnosed – tinnitus. It is still ringing in my ears.

This isn’t the only time I have encountered such negativity. The look of disappointment when the ed reg asks what your day job is, the medical consultant who announces that there isn’t much we can do for bay 8 because they’re all old anyway, the lawyer who asked me why I would do a job which must surely just involve waiting for people to die, the midwife with similar views… My own parents, paediatrician and paediatric surgeon between them, spent an evening with me discussing the pros of nearly every other medical specialty from cardiology to diabetes and neurology.

So, why geriatric medicine?

Geriatric medicine is well suited to those who like “a bit of everything” but also has good opportunities for those who would like to subspecialise. Stroke medicine is a good example of this but there are many others, from movement disorders to syncope. In terms of future hospital specialties, it is well placed to cope with the upheaval facing the NHS – the RCP and a recent feature on the future of hospitals in the BMJ have noted the demands that an ageing population is likely to place on the health service, and a need for more “generalists” well suited to managing patients with multiple morbidities. It is also a good specialty for those interested in management or education, with many consultants having significant roles in both. My own area of interest is undergraduate education and it is a good specialty to build up links in the area.

A previous consultant of mine once described geriatric medicine as “general medicine with kindness.” It is one of the few areas in hospital where you will get to see patients with myocardial infarctions, GI bleeds, sepsis, malignancy, renal failure as well as the “geriatric giants”

It might also be described as “good general medicine, with the patient at its heart.” In many areas of medicine, treatment is protocolised and standardised. When working as a cardiology SHO, I quickly got used to prescribing aspirin, clopidogrel, fondaparinux, ramipril and bisoprolol for most patients with chest pain if their troponin was elevated. Yet what do you prescribe for the 80 year old lady with postural hypotension, falls, chronic kidney disease and a previous GI bleed. What about the 90 year old man with relatively few comorbidities that walks for miles every day? Standard protocols or pathways don’t work in such a diverse population. You have to make an individual decision for an individual patient, where there may not be an “answer” as to what to do. Trying to make the best decision in these circumstances is at the heart of geriatric medicine. Making such decisions and discussing these issues with patients and relatives is what I enjoy.

The patients are great. It goes without saying that you must enjoy talking to patients if you want to pursue a career in this specialty. There are no procedures in geriatrics.  One of our “special skills” is talking. Elderly patients often have interesting stories to tell and I have found talking to them very rewarding. I particularly like the little old ladies who tell me how attractive I am; without fail they all have significant visual impairment!

I have found geriatricians to be among the nicest of all doctors. This might sound fluffy but it is important. Hospitals can be stressful places and it helps if you work with good colleagues. I found, that from a house officer, up until now, that my consultants have taken an interest in me as a trainee and encouraged me in my career plans. I remember one of old consultants from when I was a foundation doctor phoning me a year later via the hospital switchboard of my new hospital on a Friday at 4pm because he wanted to give me some advice on some last minute tweaks for a job application. Another time, I remember doing a ward round with a professor of geriatric medicine. He was due to retire just a few months later but his enthusiasm was undimmed. At the end of the ward round, he turned round to us and said: “Isn’t the breadth and variety of geriatric medicine fascinating?!”

Such enthusiasm is infectious and certainly helped influence me.

Why geriatric medicine?

That’s why.