What Makes Geriatrics so Stimulating for This Doctor?

Session 110

Geriatric medicine is both stimulating and satisfying for Dr. Shannon Tapia. We’ll talk about housecalls, mortality, and the importance of having a sense of humor.

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Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points.

[01:20] Interest in Geriatrics

Having a father who’s a geriatrician was Shannon’s first exposure to medicine. Growing up, medicine was different back then but she got to witness how it was being a physician.

She liked the cognitive aspects of medicine. She could do procedures but she just never really got stoked about it. Being exposed to it early on and realizing how cognitively challenging geriatrics is, she was essentially drawn to it.

Shannon compares geriatrics with being the Sherlock Holmes of doctors. Aside from a huge kinetic variability if they live long enough, they also have a lifetime of choices.

'A lot of their symptoms don't present like your typical textbook and they have cognitive issues themselves so they can't really fully express how they feel.'Click To Tweet

With geriatric patients, many of them could be suffering from dementia and other cognitive issues, making it difficult for them to express how they feel. So geriatricians have to get a collaborative history from their family and know the environment. 

Shannon finds this to be very interesting, challenging, and satisfying. Half the time, it’s med side effects from the specialists. They throw a med at them which they should never have been on.

You will also realize there’s not an answer so you need to be working with the patient and their family. It basically covers all aspects of medicine. You have to be constantly thinking of options and navigate it with your patients and their families.

[05:00] Types of Patients

The majority of 30-50-year-olds are rare diagnoses but most of them present pretty similar cases. They come in and the doctor asks appropriate questions and they give an accurate history for the most part. This excludes people who are actively psychotic.

In the older population, you have to expand your differential in what they say because a lot of things present differently. They have dampened immune systems. They have neuropathy and they don’t feel pain in the same way.

'The physiology is a lot different so you constantly have to be thinking almost about everything and narrowing it down.'Click To Tweet

Until you spend a lot of time with your geriatric patients, it’s hard to truly describe the extent of how different it is. You’re essentially dealing with a variety of factors when you’re trying to approach a problem. Then there are a lot more limitations on what the achievable goals are. So you have to reconcile those to arrive at a realistic outcome and that people can be comfortable with.

[07:19] Traits that Lead to Being a Good Geriatrician

Shannon says that having a healthy sense of humor is good. You have to be patient and not afraid to get into the thick of things. You never know what you’re going to walk into half of the time.

Don’t take things too seriously otherwise you’re going to end up missing what the patient really needs and that of their family.

Being empathic and being comfortable with mortality are two other important traits of a good geriatrician. Shannon believes that if you’re not someone who can stop doing things to people, you should not be a geriatrician.

There’s this mentality in medicine where doctors intervene when there’s a problem and they’re going to fix it.

As patients get older, the only truth is we all die. There’s always more we could do but you have to be able to step back. Think about the quality of life and prognosis for the patient if you did it. How would it look like not only after they recover but also in two years down the road?

'Have a 'big picture' approach and not just focusing on the immediate problem.'Click To Tweet

Essentially, you have to take it one patient at a time and take their goals and preferences at a time. Have your opinions but separate yourself from that.

Moreover, there’s a lot of misinformation even for geriatric patients and their families as to what’s achievable in medicine. You have to get to know both the patient and their family. Be honest with them about what you think and whatever intervention they’re considering.

If it’s a treatment situation, you have to be able to take their goals and translate what the realistic prognosis would be for them, knowing what their wishes are. That’s not easy always because there’s a lot of misinformation about what the medical community can achieve at a certain point.”

[11:00] A Typical Bread and Butter Day

Shannon explains how geriatrics is struggling in terms of how they’re under Medicare plans. But it’s a cognitive field. It’s not a procedure that they can always do and can rack up reimbursement for. 

Especially if you’re in private practice, it’s really hard to pay off your student loans and do it well. 

Unfortunately, there are very few private practice geriatricians anymore because it’s tough and the pressures in the private practice world are hard. Not to mention that there are only a few great academic institutions that have great geriatric support programs. 

'If you're seeing patients every ten minutes, you're probably doing a crappy job of geriatric medicine.'Click To Tweet

Shannon describes her typical day as being different from an academician. It’s basically different depending on what realm you practice in. If you’re in academic geriatrics, you’re going to do a mixture of geriatric consult service at a hospital you’re affiliated with. You will be on service with heavy clinic and lots of didactics.

It’s hard for academic institutions to do long-term care providing. It’s a whole different set of private regulations that tend to be challenging in an academic setting.

As a private practice geriatrician, your day is variable depending on whether you’re clinic-based or when you’re doing house-based care.

When Shannon’s new job starts, her practice will be in one geographic area with the goal to see 10 patients a day. Four will be in one assisted living facility and the other four from another assisted living facility, and then two independent homes within the same geographic region.

'Being a geriatrician, it's bad for your patients if you don't write something more than just the click boxes.'Click To Tweet

Moreover, Shannon has done some expert witness and chart reviews. There is so much chat vomit in terms of what they’re required to put in the medical records. So much of it is just completely useless information.

[14:50] Doing House Calls

Before Shannon moved to Denver, she used to do direct primary care house calls. She was fortunate in her geriatrics fellowship to get good exposure to it. The problem with geriatric fellowships is they’re hugely variable. Some are more research-focused, some are more clinical. Shannon did it for a year but it was clinically focused on every level. 

While Shannon loved her fellowship training, she also saw how bad what you walk into could get. But part of why she loves doing this is that because of the patient population they serve. Just because you’re Medicare age does not mean you need a geriatrician. It’s really based on your physiology and the individual patients.

'For the majority of patients that really need geriatricians, going to their home is actually what's best for them.'Click To Tweet

Shannon explains that doing house calls could be best for the majority of the patients. This way, you also get to figure out what’s going on with them. Whether it’s physical debility or even a mile cognitive debility, getting them to the doctor is a huge deal. This also gives Shannon as their physician so much more information.

Plus, the relationship you’re able to build with them goes to another higher level. Being invited to their home, you kind of become part of their family. There is a much more intimate relationship with your patients. There is a lot more trust involved.

Whereas just receiving patients in your clinic and you only have to go on the face with what they say that they’re taking their medicines or they’re eating. But it’s different when you walk into their homes and see how they’re taking their medications. So you get this unique perspective when you get to go to their home.

[17:45] Work-Life Balance and Geriatrics Being a Low-Reimbursement Field

Shannon says there’s a potential to have a very good work-life balance as a geriatrician but it depends on how much money you need for your life balance. Again, it’s a low-reimbursement field. So if you are one of those people that wants to take extravagant vacations, it is not for you.

As a single mom and not having to be tied to an office, Shannon says this is really huge for her. When you’re doing house calls or going to a long term care facility or nursing home, there’s a timeframe. There’s that flexibility of time that comes with having children but still being able to go out and do clinical work.

The only challenge is the documentation requirements that put a lot of pressure on you so you end up taking more work home.

Medicare sets the fees even for private insurances. So everything in medicine is all based on trying to figure out how much they’re going to pay you and how many RVUs (relative value unit) you’ve got for a visit. The way the system works out is that time gets very few RVUs unless you do a ton of volume. But procedures get a ton.

It’s inherent that it’s highly cognitive and diagnostic but it’s not like you should be ordering tons of tests because usually, those tests are bad for the patients.

'It's a low-reimbursement field unless you do high volume.'Click To Tweet

People who do nursing home care sometimes do pretty well because they can do high volume as they’re able to see a ton of people in one place.  Also, the reimbursement system is different in nursing homes than in an assisted living or even in house calls.

In nursing home care, how reimbursement works is that it’s not just face-to-face visits but it works like at a hospital where it’s billed for all the time you spent on the patient. If you’re in an outpatient clinic or in a house call, your time is all face-to-face time with them. 

[21:35] The Training Path

You can either do internal medicine or family practice to become a geriatrician. She was originally going to do internal medicine. Then she had great mentors in family medicine that told her that geriatrics is really an outpatient field and that if your patients are in the hospital, it’s not good. Because of this, Shannon wanted to go to a field that emphasizes outpatient and she got a sense in medical school that family medicine did this. So she decided to do family medicine the last minute.

After residency, you have to go through either a one or two-year fellowship thereafter. Whichever one you choose, you have to take both boards. 

Since she did family medicine, she would have to take a family medicine board every ten years and the geriatrics board. She also has to do a ton of things that family medicine requires that are focused on peds and women’s health, which are not related to what she’s currently doing.

'If you know you just want to do geriatrics, do internal medicine.'Click To Tweet

In terms of subspecialty, there really isn’t that much. You can do geriatrics/psychiatry but you would have to also go into psychiatry residency.

[24:04] Bias Against DOs

There is apparently no bias against DOs. Geriatricians are badly needed. Unfortunately, there are people who do fellowships just for filler because they can but they don’t really have intention of really practicing the specialty.

'They barely fill 50% of the fellowship spots for geriatrics every year.'Click To Tweet

[25:33] Working with Primary Care and Other Specialties

Shannon wishes to say to internal medicine and family medicine physicians that geriatrics is a specialty. This has been her biggest frustration with some family doctors. There are some that think that they’ve got it all and they don’t need help from geriatricians. But they are trained to recognize a lot of things that can help their patients out.

Geriatricians are very good at recognizing and helping treat dementia, Alzheimer’s, and most vascular dementias. 

They’re actually better suited to treat it than neurologists because they are also generalists in the whole area. They’re able to take a more big-picture approach. They can stay involved with the families and get them connected to the resources they need, more than just do a cognitive evaluation once a year and give them medicine.

For family medicine or internal medicine physicians that have patients that are of the geriatric population or have geriatric syndromes such as Parkinson’s disease and certain types of early-onset dementia, you would benefit from a geriatrician.

'Get a geriatric consult involved. They won't take over but they can really help especially when you have a busy clinic and there's just no way you can address all of those issues.'Click To Tweet

Other specialties they work the closest with include cardiology, ophthalmology, and neurology, and gastroenterology. She also works with nephrology but not as much.

They also work closely with trauma surgeons because so much of the geriatric trauma are related to unrecognized geriatric syndromes. Getting a geriatrician involved can medicate delirium and help the patients get on the right track.

[30:30] Special Opportunities Outside of Clinical Medicine

One opportunity is being an expert witness. Shannon only does defense. There’s a lot of physicians, especially academic physicians that are on the plaintiff side.

For instance, if a geriatric person had a fall in a nursing home and a bad outcome, the family goes and sues. So she does the defense and expert witness if she’s asked to.

[31:45] Most and Least Liked Things

What Shannon wished she knew about the specialty that she knows now is that the system is not great for geriatric patients. And Shannon thinks it’s even gotten a lot worse. If she had to do it all over again, she would still have gone into geriatrics.

She just wished she had known how things would change in the system for the worse. 

For her, it would have been easier to accept things if she knew about it going in, sort of like an informed consent process.

Just like when she didn’t know she had to take the family medicine boards every ten years that doesn’t even apply to geriatric patients. So she was really frustrated about it. And had she known it, it would have been a different story.

'The system is just not great for geriatric patients. It's really bad actually.'Click To Tweet

There’s a disconnect between the general population’s understanding of how the medical system works and how the system actually works.

What she likes the most about being a geriatrician is the patient population. It’s fun to be dealing with people. You get to know them and their families. She likes how these people have a lot of wisdom. If you go into it with a sense of humor, you can have a lot of fun with it.

On the flip side, what she likes the least about her specialty is the system. She really believes how detrimental the system is to the patient population. It’s a growing population and it’s costly. 

Eventually, she wants to get involved in advocacy for changing the system because she really doesn’t think we can sustain the way we do things now.

[37:08] Major Changes in the Field

Shannon admits that she stopped subscribing to the Journal of American Geriatrics Society as she didn’t see it necessary. She doesn’t think there are major changes in the field but she hopes that there will be changes in terms of the system and Medicare. 

'We have a lot of evidence to show that when geriatricians are involved, there are better quality outcomes.'Click To Tweet

On a side note, Shannon also does hospice, which a lot of geriatricians do because of a similar mentality. And she really hopes politics will recognize the need for qualified geriatricians.

[39:15] Final Words of Wisdom

It’s one of the most fascinating medical fields you can go into. You have to constantly use your mind and be an expert at pharmacology and psychiatry in some ways. The physiology is fascinating as well as the pathophysiology. So if you love to think and you love relationships, it’s a great field for you. 

But be aware that everybody is different in terms of their student debt burden and the kind of support systems. That being said, it’s not the field that’s going to make you the most money the fastest.


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