For two decades, in the middle of my career as an internist, I was also a board-certified geriatrician. It’s easy for me to remember why I declined to renew my credentials in that area. At sixty, I could not face another multiple-choice standardized test. More important, my income did not depend on my added qualifications in geriatrics. Medicare pays a geriatrician the same amount for an office visit that a general internist receives without the credential. The average geriatrician, who trains an additional two years and takes the test, makes less money than the average internist.
What compelled me, then, at age forty, to study geriatrics in the first place? That’s a more difficult question. I had been caring for the elderly, among other adults, for a dozen years, since I passed my internal medicine boards in 1980. In fact, that experience allowed me to “grandfather in” to the field, to sit for the exam without the training fellowship. When the American Board of Internal Medicine and the American Board of Family Practice joined forces to create the geriatric credential in 1988, they recognized that people like me, who had finished our training in the past, would have difficulty interrupting our practice lives for two years. They accepted documentation that we had significant experience caring for the elderly instead of the fellowship.
Ironically, part of my motivation to qualify as an expert in geriatrics was curiosity as to what geriatrics was. I remembered lectures about death and dying from medical school, but nothing about caring for seniors living their lives with multiple chronic problems, walking with canes and walkers. “Don’t grow old,” my patients in my Oakland practice told me. I felt overwhelmed by their thick medical charts, which only hinted at the social issues I encountered routinely, such as loneliness. I hoped learning more about geriatrics would help me navigate these murky waters.
When I took the test, in 1992, I hadn’t, to my knowledge, ever met a fellowship-trained geriatrician. I bought a syllabus and studied alone. My alma mater, the University of California at San Francisco, did not create a division of geriatrics until 1997. UCLA, a West Coast leader in the field, set up their geriatrics program in 1979. That gap of almost twenty years reflects the controversy over the necessity of having a separate field.
The American Geriatrics Society was founded in 1942, so the concept of specialist medical care for the elderly had been kicking around for a while. However, many doctors argued that practicing geriatrics did not involve learning a different body of knowledge. All doctors who treat adults care for seniors; physicians have depended on Medicare for a chunk of their income since 1965, when the health insurance program for the elderly was enacted. Internists and family practitioners did not want new training requirements to block this revenue stream. There is also the question of prestige, or lack thereof. In his best-selling book Being Mortal, the surgeon Atul Gawan-de couldn’t hide his personal distaste for the work, even as he recognized its significance. “What geriatricians do—bolster our resilience in old age, our capacity to weather what comes—is both difficult and unappealingly limited,” he said.
Typically, lay articles about geriatrics (which is the medical specialty, as opposed to gerontology, a broader group of people who study the elderly) bemoan the shortfall of physicians it attracts, compared to the ever increasing population of the aged. Only one percent of physicians are geriatricians. Why, when the need is so great, do so few medical students choose this field? This is no mystery. The mystery is why a hardy few ignore the financial disincentives and the stereotypes of elderly patients to soldier on.
In geriatrics, as in pediatrics, we look at patients through a developmental lens. The difference is that our patients are losing function and becoming dependent, rather than gaining function as children do. One definition of aging is the loss of physiological reserve. We are born with two lungs, two kidneys, a huge liver and brain, and plenty of extra capacity, so that we can get away with smoking and drinking for years. But even abstemious elite athletes lose organ function as they age, just more slowly. This fact is difficult for most of us to accept.
Doctors without geriatric training typically think only in terms of disease, rather than also assessing function. Yes, the patient has diabetes; so do a third of seniors. It’s important information, but it’s not enough to formulate a treatment plan. Does neuropathy prevent him from walking, or does he play pickleball three times a week? Geriatricians believe that the gold standard of care is a comprehensive functional assessment by a multidisciplinary team, including a social worker, a physical therapist, an occupational therapist, and a pharmacist along with a doctor. Unfortunately, this kind of team is difficult to assemble except at an academic medical center or in a large system like Mayo or Kaiser, where the organization can subsidize it. Fee-for-service does not support multiple providers billing for the same time.
When I was board certified, I en-joyed the luxury of serving as the attending physician in a geriatric referral clinic about once a month. Together we measured mobility and balance (there is a “Timed Get Up and Go Test”), strength, and cognition; we assessed the living situation and medication list (ideally with the help of the relative we asked to accompany the patient); and we roughly checked vision and hearing, in addition to performing a standard physical exam. This expansive visit established a baseline, a snapshot of the patient at that moment in time. I dictated a detailed summary of our findings for the referring doctor.
The evaluation took so long that the internal medical residents I taught saw only two patients in an afternoon, and we fed the patients a meal halfway through. Over my career I have worked in several medical groups, but none of them allowed internists extra time for the elderly, and all of them judged physician performance by “efficiency”—that is, how fast we saw patients. To encourage us to love the treadmill, they exhorted us to “work smarter, not faster.” Women doctors tended to resist the time pressure and work more slowly. But we women have been vindicated in the twenty-first century by multiple studies which show that our patients have better outcomes. It takes time to listen.
One day in geriatric clinic we saw a diabetic patient who was losing weight despite normal blood glucose. He appeared weak and moved slowly. His doctor was convinced that he had hidden cancer, yet repeated x-rays and blood tests were negative. His family brought him food that disappeared, so presumably he ate it. They couldn’t understand why he didn’t gain weight. Neither did we, until we put the tray with the meal in front of him. He couldn’t see. He had trouble finding his fork, cutting the meat, opening the juice carton. He must have thrown away food in frustration. When we lay out the meal and directed him, he ate like the starving man he was.
We looked back in his chart, and sure enough, the patient had diabetic retinopathy, as was clear in the scattered notes from the retinal surgeons, written in cryptic ophthalmology jargon. Glasses don’t help retinopathy, so optometry notes, with refractions, were rare. This patient had received eye injections. His general doctor could have guessed that his vision was not normal. His family could have eaten a meal with him, too.
On the other hand, the patient did not complain about his vision, and his diabetes was well controlled now, though it hadn’t been in the past. Old folks fear that if they tell their family that they can’t see, they will be sent to a nursing home. Patients who are legally blind still want to drive. For the middle class, it is shameful to admit to needing help. The affluent, who employ drivers and maids and cooks, can continue the same lifestyle into old age and still appear “independent.”
Geriatricians, too, speak of patient “autonomy” in hushed tones, as if it were a holy concept. This is the one area where my personal experience as a caregiver diverges from geriatric orthodoxy. Certainly I agree that although we elderly may be disabled, we should not be treated like children. Doctors must respect the psychological loss that accompanies dependency in adults, and must work with both the patient and the family. At the same time, doctors should recognize that maximizing autonomy for the patient is hard work and expensive for the caregiver.
My father had a stroke in 1988. He was in his seventies, a few years older than I am now. He remained paralyzed on his left side although mentally intact. My parents chose to sell their apartment in Chicago and move in with my older sister in Los Angeles. My mother spent most of their savings on a daily caregiver for my father—an autonomous decision. Nine years later, when he died, she came to the Bay Area, where she moved four times in seventeen years before she died at the age of a hundred. She tried independent senior housing, another sister’s house, different independent senior housing (at ninety), and eventually landed in assisted living after a hospitalization at age ninety-five. Her daughters moved her and drove her, bought her clothes and diapers, maintaining the façade of her independence as long as possible; she was the Wizard of Oz, well turned out and mentally sharp, and we were behind the curtain.
Journalists feature the “independent” nonagenarian, but I suspect there are not many people in their nineties who truly accomplish their extended activities of daily living on their own. It’s a lot to cook and clean and shop for groceries (many much younger widowers can’t do any of these: a long-married traditional husband is a helpless creature alone); it’s even more difficult to handle their own finances and house repairs, or travel to the doctor and social occasions. Most of us will need help, and we should not have to pretend otherwise. When an uncle of mine was featured in an article about self-sufficient elders who relied on volunteer community helpers once a week, he admitted to me that they asked him not to mention the paid attendant who came during the rest of the week.
My first years in practice, the 1980s, were dominated by the early AIDS epidemic. As it happened, AIDS diagnoses peaked in 1992, the same year I passed the geriatric boards, but once AZT hit the market in 1987, there was more hope. With the proliferation of new medications, AIDS therapy morphed into a new kind of chemotherapy and specialists took over. We general internists no longer had to focus our continuing education on HIV every year.
After facing the deaths of so many young adults, I was fascinated by the cohort of elderly survivors, like my parents, who had skated through the Depression and World War Two and were grateful to have reached old age, surprised at their own persistence. My mother never imagined that she would reach a hundred. When they were children, before antibiotics and childhood vaccines, they had lost siblings and friends to infectious diseases like measles, polio, and pneumonia. Their parents and grandparents died younger. We Baby Boomers were the first generation who did not routinely face death before adulthood.
In Oakland, we saw seniors from all over the world, a living history. Each war brought new emigrants, from Europe, China, Korea, Cambodia, Laos, and Vietnam. Latino patients hailed mostly from Guatemala and Mexico. The directional signs on the hospital walls were written in English, Spanish, Chinese, and Vietnamese. My elderly black patients had migrated from Texas and Louisiana—as op-posed to Georgia, where my Chicago parents had come from, or South Carolina, the original home of my husband’s East Coast father.
My patients had lived in brutal camps under various names (concentration, re-education, internment) in Europe, Asia, and the United States. So many stories, so much cruelty. One Hungarian patient started every visit with the declaration, “I lost everything twice. Once to the Nazis and then to the Soviets.” She was a good example of the challenge of caring for the displaced elderly. She lived alone and often panicked about her blood pressure, worried that she was about to have a stroke. Unable to negotiate the phone tree at the clinic, she showed up in person, dressed in wool suits and full make-up, making a fuss, demanding to see me immediately. At first the receptionists would try to schedule her an appointment, negotiating her broken English, but eventually I told them not to bother, just to put her in a room right away. If I personally would check her blood pressure and acknowledge her losses again, she was satisfied.
The last century brought a technological revolution, with improved surgical outcomes, more effective medications, and gene therapy. Yet the giddy anticipation of the early days has yielded to a more realistic appraisal of the costs and benefits of the new medicine, just as our happy prospect of “friends” communicating globally for free online has yielded to the reality of data mining and pornography on the internet. Aging has proved to be one of the most frustrating fields for the tech-minded, because we are no closer to a “cure” than ever. You can’t outsmart death.
Geriatricians embrace new technology but insist on retaining regard for patient welfare. Some years ago, a dapper seventy-eight-year-old man, the only person wearing a suit and tie in the waiting room, had an urgent-care appointment to see me at a community clinic. He wanted to stop chemotherapy, and he couldn’t get through to his oncologist. He was apologetic: he had tried, but he was too exhausted to continue. He lived alone, and he took the bus to dialysis three times a week, as well as to the hospital for an infusion once a week. True, he was a stoic guy who didn’t look indigent. But just making conversation, a nurse might have asked how his eating was going, how he was feeling. Both dialysis centers and oncology centers typically have social workers, too. But no one had considered food and transportation for this man, who endured two therapies guaranteed to deplete anyone’s energy reserve.
I don’t know whether this high-tech treatment prolonged his life. I hope so. We should always seek to optimize our patient’s function, along with any therapy; this is a modest, compassionate goal. Yet we have created a system of specialists where it is routinely ignored. The late Paul Farmer, an internist and medical anthropologist, wrote, “For me, an area of moral clarity is: you’re in front of someone who’s suffering and you have the tools at your disposal to alleviate that suffering or even eradicate it and you act.”
Only forty percent of the people who took the geriatrics exam with me in 1992 bothered to renew their credentials in 2002. I did. I treated myself to an intensive course in “Geriatrics and Board Review,” a weeklong class at UCLA. It started on September 12, 2001. The flight I was supposed to take on 9/11 was canceled, but the course was not. When I called, they told me that there were enough doctors registered from the Los Angeles area to allow them to go ahead, and they refused to refund my $800 tuition. I drove the four hundred miles from Berkeley by myself that afternoon and evening, alternating between NPR and Spanish-language radio through the Central Valley.
I stayed with an older aunt, a New Yorker who had reluctantly moved to Los Angeles because of a job transfer. Before I left in the morning and when I returned in the evening, she sat inclined toward the television, rapt and heartbroken. At least I could take her out to eat in the evenings. I never lived in New York. I was horrified but my world hadn’t collapsed—I sat in lectures and workshops all day. At the breaks, we gathered around a TV suspended over the bar, to hear the latest. On September 14, the Day of Remembrance, we listened to President Bush’s speech in silence, crying, then headed back to work. Not so different from a day at the hospital.
Aside from a few East Coast speakers who couldn’t make it, the conference was all I had hoped for. It was the first time I had been around doctors excited about geriatrics, people who had made it their career rather than a side gig, as I had. Thinking back, I realized that without a fellowship I had not developed a network of colleagues in the field. I only knew mid-career internists like me, who had qualified by passing the exam. The geriatricians in Los Angeles did not see the field as “unappealingly limited”: they saw many opportunities to improve the care the elderly received, based on new research and common sense.
Aging is a journey through territory unfamiliar to those of us who enjoyed good health as children and young adults. The wealthy can afford a deluxe bubble of porters and personal guides, but it’s a lot of work for the rest of us to guess the best route, trouble-shoot, and avoid exploitation, especially when we don’t speak the language. It’s planning that is psychologically difficult because we don’t want to reach the destination. The specialized knowledge of geriatrics is as much an approach as a collection of facts.
Gawande concluded that it is the cost of providing care to the elderly without lucrative procedures that dooms geriatrics. By the end of Being Mortal, he champions palliative care, a newer specialty that focuses on pain management and the wellbeing of the patient. “The field of palliative care emerged over recent decades to bring this kind of thinking to the care of dying patients. And the specialty is advancing, bringing the same approach to other seriously ill patients, whether dying or not.” This is the way doctors spoke about geriatrics in the 1990s, suggesting that the new added qualifications exam was proof that the specialty was “advancing.”
Thirty or forty years on, even fewer students are choosing geriatrics. Palliative care is the shiny new thing. Largely hospital-based, short-term and better paid, palliative care is a world away from outpatient geriatrics, where the need to bolster resilience in an elderly patient with chronic diseases often lasts for years, even decades. We old people are not all seriously ill. Arguably, it is the young old, in their sixties and seventies, who can benefit the most from the geriatric approach. We are the ones with the muscle and motivation to maintain with conscious effort the function we took for granted in earlier years.
I have friends who wish they were young again. But many of us recognize, watching our children and grandchildren, that life presents challenges at every age, and maybe we don’t daydream about changing more diapers or working sixty-hour weeks again. We elderly know that we are on the last leg of our journey, the returning train. If the outward journey was to someplace exciting, this one may be more restful and contemplative.
Toni Martin is a physician and writer who lives in Berkeley. Her short story “Hold On” won the Craft 2024 Short Fiction Prize.