[The following clinician guest post is by Dr. Magda Lenartowicz, an internal medicine resident in Saskatchewan, Canada. Thanks Magda!]
I am an internal medicine resident
interested in Geriatrics. No, scratch that, I am a resident GOING to be a
Geriatrician. In fact, I was an undergraduate student in Gerontology before
medical school, and I have had an interest in the care of older adults for as
long as I can remember.
interested in Geriatrics. No, scratch that, I am a resident GOING to be a
Geriatrician. In fact, I was an undergraduate student in Gerontology before
medical school, and I have had an interest in the care of older adults for as
long as I can remember.
I am also Canadian, and you will not find
one single “eh” in this entire diatribe. But I digress.
one single “eh” in this entire diatribe. But I digress.
In the past year, I have had several people
question my resolve – “why would you possibly want to do Geriatrics?” And, I
have had my share of the not-so-subtle comments suggesting my interest in
“bowels and bladders” is not real medicine.
question my resolve – “why would you possibly want to do Geriatrics?” And, I
have had my share of the not-so-subtle comments suggesting my interest in
“bowels and bladders” is not real medicine.
Ok, I am a big girl, I can take some
ribbing.
ribbing.
I choose to take this behaviour as an
opportunity to think about what my answer to this question really is. Not just the off-the-cuff indignation I
sometimes feel, but the real reason I am so driven to do this. The top two points that have come up so far are:
opportunity to think about what my answer to this question really is. Not just the off-the-cuff indignation I
sometimes feel, but the real reason I am so driven to do this. The top two points that have come up so far are:
a.)
I find Geriatric medicine to be complex, fulfilling, and one of the few
opportunities in modern medicine to practice a truly holistic type of medicine
(taking into consideration mental, physical AND social health),
I find Geriatric medicine to be complex, fulfilling, and one of the few
opportunities in modern medicine to practice a truly holistic type of medicine
(taking into consideration mental, physical AND social health),
and b.)… well, this is going to take a bit
more of an explanation.
more of an explanation.
I work in a province that has ONE, that’s
right, ONE board certified Geriatrician. There are several family practitioners
with additional training in the care of the elderly, but even they are not
enough. The province has a million people (yes, the entire province), of which
about 15% are over the age of 65, which means there is one Geriatrician for a
population of 150,000 – that’s not workable even if you only reduce this to a
subset of those over 80. This is farm country, and there are many very hale folks
over the age of 80 still living on farms. There are also many folks with
varying degrees of cognitive and functional impairment living independently on
farms. That is slightly more worrisome.
right, ONE board certified Geriatrician. There are several family practitioners
with additional training in the care of the elderly, but even they are not
enough. The province has a million people (yes, the entire province), of which
about 15% are over the age of 65, which means there is one Geriatrician for a
population of 150,000 – that’s not workable even if you only reduce this to a
subset of those over 80. This is farm country, and there are many very hale folks
over the age of 80 still living on farms. There are also many folks with
varying degrees of cognitive and functional impairment living independently on
farms. That is slightly more worrisome.
We do not have a Geriatric Assessment Unit
anymore – the 10-bed unit closed in 2009. Yes, you did read this right. In a province
with one Geriatrician and all those older people there is no place for older
adults to go. There were not enough doctors and others to sustainably staff the
unit. So now, our older folks stay in hospital, or if they are lucky, get moved
to the transitional care unit where they wait for long-term care. Those of my
patients who are elderly and cognitively impaired, but have no medical issues,
have absolutely nowhere to go. Those who DO have real medical issues have
nowhere to go once they have overcome their acute issues. Well, there is our
Geriatric Rehabilitation Unit, but it is very specific in what it offers and
again, does not have enough spots. So the worry becomes – will my older
patients succumb to a hospital-acquired ailment and die there, even though a
quick hospital discharge to an APPROPRIATE step down unit would have been
better? I think about this often.
anymore – the 10-bed unit closed in 2009. Yes, you did read this right. In a province
with one Geriatrician and all those older people there is no place for older
adults to go. There were not enough doctors and others to sustainably staff the
unit. So now, our older folks stay in hospital, or if they are lucky, get moved
to the transitional care unit where they wait for long-term care. Those of my
patients who are elderly and cognitively impaired, but have no medical issues,
have absolutely nowhere to go. Those who DO have real medical issues have
nowhere to go once they have overcome their acute issues. Well, there is our
Geriatric Rehabilitation Unit, but it is very specific in what it offers and
again, does not have enough spots. So the worry becomes – will my older
patients succumb to a hospital-acquired ailment and die there, even though a
quick hospital discharge to an APPROPRIATE step down unit would have been
better? I think about this often.
As a cherry on top, our beautiful new
psychiatry unit has no acute beds for those with dementia. You are welcome to
figure out how this makes any sense. I still haven’t. I have had to assess
patients with dementia, deemed as “aggressive” and surrounded by guards, in our
ED’s psychiatry isolation room. When I talked to the patients, it turned out
the problem was being alone, disoriented, or overwhelmed. The frustration? I
had nowhere to send these people other than home or another tertiary care
hospital bed, a place where few people with dementia do well.
psychiatry unit has no acute beds for those with dementia. You are welcome to
figure out how this makes any sense. I still haven’t. I have had to assess
patients with dementia, deemed as “aggressive” and surrounded by guards, in our
ED’s psychiatry isolation room. When I talked to the patients, it turned out
the problem was being alone, disoriented, or overwhelmed. The frustration? I
had nowhere to send these people other than home or another tertiary care
hospital bed, a place where few people with dementia do well.
Yes, we do have Telehealth. We actually
have a very robust Telehealth network, and one of our neurologists and a team
of wonderful, dedicated folks puts on a very excellent Memory Clinic. Patients
love not having to travel hundreds of miles to their appointments, and when an
assessment occurs, everything is arranged for them in one day. The follow-up
takes place via Telehealth at regular intervals.
have a very robust Telehealth network, and one of our neurologists and a team
of wonderful, dedicated folks puts on a very excellent Memory Clinic. Patients
love not having to travel hundreds of miles to their appointments, and when an
assessment occurs, everything is arranged for them in one day. The follow-up
takes place via Telehealth at regular intervals.
It’s so beautiful, it’s like poetry. Too
bad that funding is limited and not enough of those needing this service ever
get to use it. And I won’t mention home care at all because we don’t really
HAVE true home care visits by Geriatricians.
bad that funding is limited and not enough of those needing this service ever
get to use it. And I won’t mention home care at all because we don’t really
HAVE true home care visits by Geriatricians.
In one word, this is Geriatrics where I
work. Virtually non-existent. Yet we make it work, and the more I become
immersed in the minutiae of elder care, the more I WANT to take on that
challenge. I want to be a Geriatrician because there are so many things that I
can see myself changing.
work. Virtually non-existent. Yet we make it work, and the more I become
immersed in the minutiae of elder care, the more I WANT to take on that
challenge. I want to be a Geriatrician because there are so many things that I
can see myself changing.
So the b.) in my answer is: because there
is a need. Because when I took my oath I promised to be of service, not just self-service.
My city is not the only place with a
dearth of Geriatricians, even large centers do not have enough physicians
interested in Geriatrics to meet the care demands of a growing 75+ demographic.
is a need. Because when I took my oath I promised to be of service, not just self-service.
My city is not the only place with a
dearth of Geriatricians, even large centers do not have enough physicians
interested in Geriatrics to meet the care demands of a growing 75+ demographic.
I’ll tell you what I do love about working
with older folks. I love the ability to make a real difference not just in the
office, but in their life in general. I love being able to take my time, and
really practice my art as well as my science. I especially enjoy working with
dementia patients and their partners in care, as hearing “This worked!” from a
caregiver or seeing a patient becoming less frustrated is one of the best
feelings in the world. And yes, I even love it for the bowelsJ Only fellow gastroenterologists will be able to share the rewarding
“I told you so!” when a delirium resolves simply because I prescribed some
Laxaday.
with older folks. I love the ability to make a real difference not just in the
office, but in their life in general. I love being able to take my time, and
really practice my art as well as my science. I especially enjoy working with
dementia patients and their partners in care, as hearing “This worked!” from a
caregiver or seeing a patient becoming less frustrated is one of the best
feelings in the world. And yes, I even love it for the bowelsJ Only fellow gastroenterologists will be able to share the rewarding
“I told you so!” when a delirium resolves simply because I prescribed some
Laxaday.
I have spent many years of my life being
embarrassed that my “talents” were in the social sciences, and not the “real”
science of physics, and math, and chemistry. I always loved the natural sciences,
but studying just those subjects felt empty unless I could combine them with
classes in medical anthropology, the humanities or linguistics. I hated rote
memorization and woke up when information lived for me, and you only get that
when you learn from people, not from books.
embarrassed that my “talents” were in the social sciences, and not the “real”
science of physics, and math, and chemistry. I always loved the natural sciences,
but studying just those subjects felt empty unless I could combine them with
classes in medical anthropology, the humanities or linguistics. I hated rote
memorization and woke up when information lived for me, and you only get that
when you learn from people, not from books.
So now, that I am a little kinder to
myself, I see Geriatrics as that perfect canvas – being a poor visual artist,
Geriatric medicine allows me to join my patients in the creation of daily
masterpieces, one person at a time.
myself, I see Geriatrics as that perfect canvas – being a poor visual artist,
Geriatric medicine allows me to join my patients in the creation of daily
masterpieces, one person at a time.
[Magda Lenartowicz, MD is a second-year internal medicine resident in Saskatchewan, Canada. She divides her copious spare time between the Prairies and California, the home of her ever-patient better half. You can reach her at mlenartowicz[AT]gmail[dot]com.]
