The Future of Geriatrics: A Podcast with Jerry Gurwitz, Ryan Chippendale, and Mike Harper

Eric: Welcome to the GeriPal podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, who do we have with us today?

Alex: Today we’re delighted to welcome Jerry Gurwitz, who is a geriatrician and professor of medicine at the UMass Chan Medical School. Jerry, welcome to GeriPal.

Jerry: Great to be here.

Alex: We’re also delighted to welcome Mike Harper, who’s a geriatrician, a professor in the UCSF division of geriatrics and is past president of American Geriatrics Society or AGS and as also current board chair for AGS and like me, a rabid Warriors fan. Mike, welcome to GeriPal.

Mike: Great to be here. Looking forward to the game tonight, even though it’s a preseason one.

Alex: We’ll take any Warriors we can get. And finally, we’re delighted to welcome Ryan Chippendale, who’s a geriatrician associate professor at Boston University and also is the Geriatric Medicine Fellowship director there. Welcome to GeriPal Ryan.

Ryan: Thanks so much for having me — go Celts. [laughter]

Alex: Oh boy.

Mike: This is going to be a problem. [laughter] And Jerry, I’m guessing you’re a Celtics fan.

Jerry: I sure am. [laughter]

Alex: Oh no.

Eric: I see a green jacket on. So we got a lot of talk about today. This podcast came up, Jerry wrote a fascinating article in JAMA on the paradoxical decline of geriatric medicine as a profession, which I think stimulated a lot of conversations. And we thought, hey, we should be part of that conversation and talk about what does the future of geriatrics look like. But before we go into that topic, Jerry, I think you have a song request.

Jerry: And my song request is by Coldplay Fix You. And do you want to know why I chose it?

Eric: I would love to know why you chose it outside of I’m pretty sure Alex is happy to sing a Coldplay song.

Jerry: Yeah, I’m really looking forward to this. This song makes me tear up and sometimes cry. It makes me feel, well at the beginning, makes me feel a bit sad and hopeless. The lyrics, “Stuck in reverse, could it be worse?” But at the end, it makes me feel hopeful. I don’t know if Alex wants to sing this, “But if you never try, you’ll never know what you’re worth.” And I feel like that makes me feel like a geriatrician. And I just want to say one thing. I have never for a moment regretted going into geriatrics. Not for one minute, not for one second. So I want to hear that song. I’m ready.

Alex: Thank you, Jerry. Here’s a little bit, first verse in the chorus for those watching live on YouTube, for those who are listening, you get my prerecorded full version that has Jerry’s requested lyrics.

(singing)

Jerry: You know what? That’s worth a $250 donation to GeriPal. [laughter]

Eric: Who told Jerry to say that? [laughter] I wonder if this is foreshadowing for the podcast. I’m going to roll with that foreshadowing. And I’m going to start off with Jerry. I was going to start off by asking Jerry about why he wrote the JAMA article. It was JAMA, right? Not JAMA IM?

Jerry: It was JAMA.

Eric: But Jerry, when did you start in geriatrics? How long ago?

Jerry: Yeah. I started my fellowship in 1986. I finished my fellowship in ’88.

Eric: And can I ask you, why did you choose geriatrics? Why did you go into it?

Jerry: Probably for the reason a lot of people go into geriatrics, close relationship with grandparents, volunteered to work in a nursing home as a high school student, just felt really good about being around old people and not having a problem with it.

Eric: And then decades of a storied career in geriatrics. And you wrote this article, which probably for geriatricians, they probably have a love-hate relationship with your title, which is the Paradoxical Decline of Geriatric Medicine as a Profession. What prompted you to write this in JAMA?

Jerry: I’m going to give you the brief version.

Eric: Jerry asked us if we wanted the three minute versus 10 minute. Alex is all, give the 10 minute. I’m like give the three minute Jerry

Jerry: The three-minute version. As I was about a year ago, I was hiking in New Hampshire with my son who’s in his thirties. He’s an antitrust lawyer at the FTC and I’m a slow hiker. And to keep me moving, he tries to engage me in conversation. He tries to talk to me, so I’ll walk faster. And he got talking to me about geriatrics. He’s not in medicine, he doesn’t know much about it, but he asked me about the field and why people don’t go into geriatrics. And I talked to him about the low salary, but then I said, well, it’s not totally the low salary because people go into pediatrics and pediatricians have a low salary. I talked about lack of prestige and respect, and I talked about how healthcare system leaders and medical school deans don’t always seem to value the field of geriatrics.

And at the end of this conversation, he said a couple things to me. One was very surprising. He said, “Dad, did you ever think maybe the problem is you, maybe you have not proven or shown the value of geriatrics and maybe to some extent it’s your fault.” And then he said, the second thing he said is, “You really ought to write about this.” And yeah, that one thing led to another and it took me nine months to write a thousand words. I’ll just put it that way. And a hundred versions.

Eric: Jerry, I was curious how you decided on the title.

Jerry: Yeah, I wanted a title that would be, you could read the title and you’d completely understand what I was going to write about. It just is very apparent and there are lots of clever titles. And I tried to do that in the past where you see the title of an article like this in JAMA or a New England Journal and you’re not sure what the person’s going to even say. And I didn’t want it to be that way.

Eric: So the paradox decline, that means the first part is there is a decline. And you write in your article, “The accumulating evidence suggests that the profession of geriatric medicine has fallen into decline.” I wonder when you write that, what evidence is there to support that proposition? And then we’ll talk about the paradoxical part.

Jerry: Yeah, I did not have all the evidence when I started writing the article. So things started, I wrote what I felt, I read what others had written. I tried to figure out who my audience was and could I say things differently than people like Jack Rowe or Tom Yoshikawa or Chris Castle or Mary Tenneti. But I left a lot of blanks. But as I was writing the article, to be honest, things started falling into place, not necessarily in a good way for the article, but in a bad way for geriatrics, frankly. So the data relating to the number of geriatricians in this country, salaries in comparison to hospitalists or primary care physicians. And finally the big thing was the match. The match numbers came out and they looked as bad as they ever had for a long time. So everything, there’s writing the article and the topic of the article, and in some ways I see things as two separate things, but the article fell into place when those blanks were filled in with numbers.

Eric: Go ahead, Mike.

Mike: Jerry, I was going to say it’s interesting. I think probably of all the articles written in geriatrics over the last five or 10 years, I would imagine yours has been read by more geriatricians than just about any of them. And I think it was forwarded to me within a day of it’s being published. And I think my reaction was a big shoulder slump. I really felt, because I just read the title at first, and I know you said that you knew exactly what you’d be writing about. And then as I was reading, you made a lot of really good points that I certainly agree with, particularly around lack of LCME and ACGME requirements and certainly the diminishment of some of the ACGME requirements. But then I started to think just looking at the pipeline was kind of a narrow way to think about the profession.

And then we can argue, not argue, we can certainly debate the numbers. I think we should probably talk about some of that later in the podcast about whether that number really is a true reflection of where we are in terms of a pipeline. But I was really thinking about where we’ve come as a profession over the last, well, I’ve been doing this for now for I guess 25 years, but certainly since we became a certified profession, it’s really pretty remarkable. So I started to think about it in that context. And while I think we all continue to worry about and want to figure out ways to attract more people to geriatrics, I think that’s really critical to what we do. I wanted to think about ways to talk about the profession and the field of aging and care of older adults a little bit more broadly and sort of saw what we’ve done over that time period as much more of a success.

Eric: Mike, and when you say that, what kind of successes are you thinking about?

Mike: So kind of a number of things. I mean, the most recent thing, I guess things we could talk about is the whole age-friendly movement. The fact that we have I think something like 3000 health systems that are at least now somewhat certified and moving to a higher levels of certification. Another big one, and I think this is one of the things Jerry lamented in the article was the fact that Beson scholarships are now going to non geriatricians. I view that almost the complete opposite, as much more of a success of what I think one of my colleagues ophthalmologist that in Texas says mission transfer. We were never going to have all the geriatricians that folks had forecast, whether it was 25,000 in 2025 or 30,000 in 2030, we were never going to get there. We were always going to have to be successful by helping to bring in be a big tent organization or big tent field and bring in folks from other specialties.

So now we have geriatric emergency departments. We have the new geriatric surgical verification process where they’re, I think now eight or so level one geriatric surgical centers with 40 more somewhere in that process of becoming certified. So I kind of look at it in that context less about us thinking about how do we build the guild of geriatric medicine and more about how do we continue to advance the care of older people. And I sort of feel like we’ve made a lot of progress in that area.

Jerry: Let me respond to that and it would be good to have Ryan respond to what I say right now. So I actually wrote this to sort of as a rallying cry, as a call to action, but I didn’t want only geriatricians to read it. I wanted everybody to read it. And I would say initially the response to me was so gratifying. I heard from so many people at all levels of their career who were really taken by what I said and understood, and the responses weren’t negative at all. But then I realized who I wasn’t hearing from, I did not hear from the CEO of my organization, my healthcare organization. I didn’t hear from my dean. I didn’t hear from my Chair of Medicine. So I realized I was sort of in this echo chamber of people who were responding positively, but the people that could do something about it who I wanted to care about it weren’t saying anything to me.

Now I’m going to give an anecdote that I want Ryan to respond to. So a couple weeks after it was published, I took a trip to a medical school in the western part of the country and I was visiting to think about their geriatrics research program, and they had a geriatrics evaluation clinic. I’ll end this story quickly, I promise.

And I met with the clinical pharmacist who worked in that clinic and she told me, “You know what? We don’t have a geriatrician. The medical school has no geriatricians.” And I said to her, well, they had a geriatric nurse practitioner. I said, “Do you feel like you need a geriatrician and a geriatric evaluation clinic? Do you think geriatricians are indispensable?” And she said, “No, I don’t think we really need one.” And that made me think really, really hard about the world, about our country, about our medical care system and how it feels about geriatrics, not geriatrics, but the profession realized I wrote about the profession of geriatric medicine. I was not saying that there haven’t been advances. I was talking about our profession.

Eric: Okay, Ryan, going to turn to you now. All this weight now is on your shoulder. Everybody’s saying respond. When did you start Fellowship Ryan? How long ago?

Ryan: I started in 2011. Graduated in 2013, did a two-year clinician educator track.

Eric: And can I ask, why did you decide to go into geriatrics?

Ryan: Actually, a very similar story as to Jerry. I was very close with my grandparents growing up, and then I actually was exposed to geriatrics as a pre-med student at Yale New Haven Hospital as one of the volunteers and Dr. Sharon Inouye’s initial help trial and had a fabulous role model Dr. Verano, who I wanted to be. And then throughout my medical training that was my North Star. I explored other things, but I felt like I consistently gravitated toward the care of older adults.

And like you, Jerry, have never regretted that a day in my life and have dedicated my career as a clinician educator, now a fellowship program director, but I’ve also been a clerkship director in the past. I was a Chief Resident to really having others, whether it be medical trainees or interprofessional learners that I’m training see that beauty.

Eric: And can I ask, what was your initial response to Jerry’s article?

Ryan: So I am an eternal optimist. I will say that. And I read everything with a lot of excitement and vigor. And my initial reaction was this is a call to action. And actually a lot of chatter with my national colleagues initially we felt that same way that we can’t necessarily dispute these numbers. I mean, I’m a fellowship program director and every year when ERAS opens on July 17th, 18, 19, I cross my fingers and pray that those applications show up on my front door. And so I feel like I live, at least in terms of some of the hard number demographics on a year to year basis.

Eric: I’m just going to push you on that because I feel like I can dispute those numbers because if you look at the number of active geriatricians, yeah, we kind of peaked at 10,000 because we had a bunch of people who grandfathered in and they didn’t re-certify afterwards. And since then we’ve been like mid 7,000. So it’s kind of I would say leveled off. If you look at the number of geriatricians being trained every year, I would say that number actually leveled what’s changed? Just the sheer number of programs. So every year we get more programs who decide that I’m going to do start a geriatrics fellowship program. So the percent filling is decreasing, but the total number has actually been pretty darn flat. Like this year, 287 geriatric fellows started in 2023, which really isn’t a big change over the last 10 years.

Mike: In fact, Eric, that number is actually slightly better than recent years. So that’s the problem with when we decide to use certain numbers. So that match number, one, that the fill rate doesn’t, the number that really matters is how many people are in programs on July one. And that’s what we don’t get until September when we do that survey. And the other thing I would add is if you look at the number of board certified geriatricians, it’s grown as far back as I could see since 2019 where we were at 6670 and we’re now at 7413. So again, the numbers are really, I don’t know what they tell us. I think what you say is right is we’ve basically been stable for probably close to a decade in terms of the total number of geriatricians

Eric: You can argue though that while the total number is actually maybe increasing a little bit of active geriatricians, the total demand has continues to way outstrip the total number.

Mike: Totally agree. But I think the idea that we’re losing numbers is not actually accurate.

Jerry: So I’ll just interject there. I was among the first group of people who took the board certified exam in 1988. A lot of people took it over those few years, subsequently. I am 67 years old, so that cohort is aging out. We’re not seeing it immediately, but we’re going to see it without question in terms of board certified geriatricians, because that was a big bolus.

Eric: We lost those people a long time ago. You can actually see the curves. So you had this initial kind of big uptick and then there was a big, big drop and it’s kind of leveled out. If anything slightly increasing. Again, I think it’s hard because we can pick data points. I think we can see what the curve is. I think nobody’s in disagreement that the numbers are not adequate to meet the demand that’s out there.

Jerry: The other thing is the perception of geriatrics as a profession, and that’s why I worry about the difference between the number who matched and the number who eventually pursued a geriatrics fellowship. I think those matching really wanted to go into geriatrics just as the people who went into cardiology really wanted to match into cardiology. They really did and they did. The additional numbers I think clearly helped the field, but there’s something, there are stories in that additional number of people.

Mike: Ryan, I think you wanted to finish your point there. Go ahead.

Eric: Sorry for interrupting, Ryan.

Ryan: Oh no, that’s completely fine. A couple of things actually that have come up since then is that what I was saying is I agree that when I’m crossing my fingers, it’s not necessarily saying, will I get applications? It’s about making sure that I get enough quality applications that I’m going to fill my program with folks who are really dedicated to geriatrics. And I will tell you that has not changed a bit. If anything, I feel like every year the quality of the applicants that I’m receiving, at least at my home program, is improving of folks that are really mission driven and want to serve older adults. So I’m much more of a quality person than a quantity person. But from the conversations that we have at ADGAP every year, the numbers worry us.

Alex: What’s ADGAP for our listeners who may not be familiar?

Ryan: The Association of Directors of Geriatric Academic Programs, which is the fellowship program director group within AGS. Did I get that acronym right, Mike?

Mike: Yes. Yeah. Association of Directors of Geriatric Academic Programs. That’s right. It is sort of a mouthful.

Eric: You talk that we talk about this every year. So I did fellowship in 2005. I started going AAP meetings because geriatric fellowship programs directors used to go there. So I went in Mike’s place for a couple times, and I think the first one was in 2007, and I just remember year after year, ADGAP always talked about, “Oh, the numbers are so bad. Oh, woe is us. Everything is so bad.” You can look back to an ACP paper in 2001 saying that the only way geriatrics survive is that we have to do this, and this doesn’t feel like a new conversation. Go ahead, Mike.

Mike: I became a fellowship director in 2005 and I remember having these same conversations nearly 20 years ago. So the pipeline issue has always been sort of there, a sort of Damocles over our shoulder that we’ve continued to worry about and we need to, I’m not saying we shouldn’t, we absolutely need to continue to attract more people to the field. I don’t think there’s any debate about that. I think the question is where we’re at today, how significantly different is it than we were a decade ago, two decades ago in terms of where we are as a profession? So that’s the only I think point that I would sort of bring up.

Eric: How does it feel like for you, Ryan, since 2011, you’ve had different roles?

Ryan: Yeah, I would say that it’s fairly stable in terms, so I’ve been program director for five years now, and I have not seen a major decline in those five years. When I matched, it was pre-match, right? It was before we were part of the NMRP. Which the national… I forget the acronym.

Mike: National Residency Match Program, lots of acronyms. [laughter]

Eric and I, we have scars from those battles as well.

Ryan: So it was pre-match, it was a different feel, but I think there were similar conversations happening at that point in my training as well.

Jerry: Yeah, I guess I want to add that this is something that I’ve heard more recently, like “Jerry, this is old news. You’re just saying the same things that people have said for decades and people have written about for decades.” And I think, Mike, you’re correct about that, but I wasn’t writing this for you. I wasn’t writing this for you. You didn’t need to read my paper. I was writing this for the 30,000 people who weren’t geriatricians who read my paper.

Mike: That’s actually worth maybe, sorry, Eric talking more about is, and I agree with you, I knew that’s why you published it in JAMA. I knew we were not the audience. The question is, like you said, the disappointing part is you hadn’t heard from your COO or so. What do we do to create that sense of urgency within our health system? And again, I think there are shoots where there’s some promise, but I was curious, Jerry, did you have thoughts about that? What is the next step to follow on from your call to arms as Ryan said?

Jerry: Yeah, so I’m going to make a comment and then I’m going to ask Ryan to respond to it again. So at any rate, yeah, I did show this article to somebody who’s a national leader in geriatrics for more than one prior to submission. And one of the things was, “You’re telling us stuff we already know”, and also, “I’m going to critique you in that you didn’t provide any solutions.” And when I wrote the article, I’ll be honest with you, I did not have any solutions. I’m not sure I do right now, but I’ve talked to other people since I’ve written the article. I’ve talked to, I don’t know if you know Houman Javedan from Brigham and Women’s Hospital. And he said to me something like, he’s sick of hearing people say there will never be enough geriatricians.

He said, people use that as an excuse to not do something. That’s what leaders of residency training programs do. That’s what CEOs do, that’s what Deans do. And he said, we should really advocate more and be more aggressive. For example, should you be able to be an age-friendly healthcare system if you have no geriatricians? Should you be able to have a residency training program or a medical school with no geriatricians? Should you be able to qualify for a guide program with no geriatricians?

I don’t think you should. I really don’t. However, there’s this attitude out there. I didn’t believe in myself that we can do this. We can train medical students and residents about geriatrics without geriatricians. We don’t need you guys. We can change healthcare systems and improve the care of older adults without geriatricians. Now I really struggle with that attitude.

Eric: Well, Ryan, I’m going to turn to you since Jerry said he wanted you to respond.

Jerry: I do. I do. Because you are the future.

Ryan: Well, I will say I struggle with that attitude as well. I mean, I do think that we have to be at the table and leading these initiatives with the expertise that we have. And I am very inspired by the pipeline that we’ve been able to create through the past few years. And I’m even more excited about, I think future opportunities to tap into that pipeline so that we have enough people at the table to be part of these conversations and lead these initiatives.

Eric: Any examples of that?

Ryan: I think traditionally, and I still see this every year in my applications, programs like the MSTAR program, intergenerational activities with med student learners and older adults like Alzheimer Buddy Programs or Adopt a Grandparent. Those kinds of things are consistently opportunities that I see in applicants. But I think newer initiatives, and I’m going to have a shameless plug here because I’m a co-founder and director, but a platform like GERI-A-FLOAT, so for those of you-

Eric: What’s GERI-A-FLOAT?

Ryan: For those of you that aren’t familiar, GERI-A-FLOAT stands for Geriatrics Fellows Learning Online and Together it was created amongst the COVID pandemic in 2020 when all of the fellowship rotations were shutting down.

Eric: Can I just add it? That was one acronym that came off your tongue very easily.

Ryan: Did you like that? Yes, I own it. I made it. I didn’t make it. My co-founder, Maria Duggan, I’ll give her all the credit for that. I’m not an acronym person if you couldn’t tell. GERI-A-FLOAT initially was made for fellows. And our target population of learners is still fellows, but we have medical students and residents and pre-med students and faculty and folks from all over the world join us for these bi-monthly online virtual meetings. And let me tell you, and Eric, you’ve been on some of these calls before. The energy is infectious. There are truly so many incredible learners and professionals out there that are passionate about geriatrics. And that’s what gets me excited for our future, is being able to interact with those individuals and attract them early and keep them hooked, I think is one of Jerry and my story. Both of us, we were attracted early and we were kept hooked into the field and that there’s some magic in that.

Eric: Yeah, I love just creating the community of people who are passionate about that. I think for a lot of us, we go in with an interest in geriatrics, but it’s usually a person for me, like Rainier Soriano, I still remember the day we were talking. He was my attending when I was a resident, and he said, “Have you considered geriatrics Eric?” Huh? Geri what? And it was really the first time and he said, “I think you’d be good at it.” Those two things. It was perfect marketing for geriatrics. It was the nudge. It was like, oh, I would be good at it. Let me go into it. And it worked. It worked for me. I think for a lot of folks, they may not have those mentors. There may not, like Jerry said, be a geriatrician at their institution, but if you break down the silos, the institutions do something nationally like you’re doing, Ryan, I just love that as far as increasing the passion and community around geriatrics.

Ryan: And really that’s why we’ve kept it going post COVID is because we have seen such a need, both for fellows that are an N of one and a program. There’s a lot of fellowships out there that I didn’t realize because the Boston Fellowships, the Massachusetts fellowships are much bigger, but that have one fellow or two fellows. And same with what we’re learning from the residents and the medical students that are joining. Yes, many of them have AGS chapters at their institutions, but it’s a really small cohort. And like Jerry said, there’s not a ton of role models for them at their institutions. So they join this group and not only are they exposed to like-minded peers, but they’re getting exposed to the experts in the field and it makes them even more excited about going into geriatrics. So again, it’s not the answer, but I feel like creative solutions like this could potentially enhance that pipeline moving forward.

Eric: If fellows or faculty want to join and listen, how do they get on that?

Ryan: You can certainly put it in the show notes, but we have a website. You can just google GERI-A-FLOAT and it will be the first thing that pops up. You can join.

Eric: That’s a great idea. We’ll put it in show notes too.

Mike: So Ryan, I almost wore my GERI-A-FLOAT T-shirt.

Ryan: I should have too. We failed. [laughter]

Mike: So part of the reason I’m hopeful is because of people like Ryan and Maria. I always say her name wrong.

And the energy that they bring to this field, and I’m like you Eric. I was not someone who had early exposure to geriatrics. I went to a medical school in the late eighties where there was no geriatrician. I didn’t meet a geriatrician, didn’t know the field even existed. And then I went to a place where my very first ward attending was a geriatrician, a guy named John Burton. And he asked me questions like, “Why is this patient in bed? Why do they have a Foley catheter?” And in my head the answer was, “Because they’re in the hospital.” That was what I just saw. And then I had the opportunity to really interact and work with a lot of geriatricians, and I really was attracted to the care of older people. I really like the stories and the complexity and all that kind of stuff, but you’re right, there are lots of ways, and that’s why I’m more hopeful of that additional 100 or 110 folks who chose to become geriatricians because there are multiple pathways to doing this.

And we need everybody, the passionate and the ones that come late and say, “I don’t know.” This is an opportunity. Let’s see how it works out. I think we are really good. And once we do kind of get our hooks into people at showing why what we do is fun and valuable and rewarding, which is I think like Ryan and Jerry, I don’t regret a single day that I chose to, I can’t imagine having done anything else in my career.

Eric: Interesting. So Jerry, you also picked the song Fix You, which is both, you said, starting off sad, but ending off maybe a little. Yeah, I got to say reading because I read your JAMA piece multiple times. It felt to me just sad. It felt to me like these are the problems. It felt like death was inevitable and it’s hard. You got a word limit of what, a thousand words? So I realize that. Do you have hope, Jerry? Is this the Coldplay song where you’re crying, then you’re hopeful, or are you just crying throughout?

Jerry: Do I have hope? I mean, some of the people that have written to me that are geriatricians end their email by saying, “I hope there’s a geriatrician that will take care of me someday. I worry about that.” And personally I’m worried about that too. Will there be somebody who understands older adults who are complex, who will take care of me? So yeah, I did end it on, I don’t know if, you said you read it a couple of times. I tried to have the last few lines be positive, but also, what resonates in my head? You’ve all read Louise Aronson’s book. I’m sure

Eric: Elderhood, we will have a link to it.

Jerry: Yeah, the quote I had from her book in my paper, and I don’t know, I’m scared to even refer to it at this point.

Eric: What’s the quote? Do you have it?

Jerry: I have it.

Eric: You got it. Okay.

Jerry: Okay. She wrote, “When I tell someone what I do for a living, they usually have one of two reactions. Either they’re faced contorts as if they’ve just smelled something foul, or they offer compliments about my selfless dedication. These apparently opposite responses are actually the same. Both imply that what I’m doing is something no one in their right mind would ever do.”

Eric: Which is really fascinating because you have 12 comments on JAMA to your article. The first one was somebody who grandfathered in. And that one was also for me quite depressing to read ends with, “If you were considering a career with the lowest pay in the most complex patients consider geriatrics, yay.”

But then Rebecca, I think it’s Ellen, I may not be pronouncing that name right. She was actually the one who wrote the 2001 or 2004 ACP article, which also there was a series of articles lamenting there won’t be enough geriatricians. How do we train primary care doctors to do geriatrics? But she wrote this a counter. “I would counter that if you wish to serve the most intellectually interesting patients, if you wish to strengthen your communities by being a resource for those elders and family members whose needs are not met by the traditional system of care, if you wish to form strong relationships with your patients, the families and your communities, if you wish to be part of the solution to reforming our broken healthcare system, then and only then choose geriatrics.” I did love that line. “You’ll not be the richest doctor, but you will be the most satisfied.”

Ryan, I see you’re nodding your head.

Ryan: Amen. [laughter]

Alex: There’s an article coming out in JAGS about where they did a survey. I don’t think it’s out yet, I just looked, a survey of 125 AGS members and 38% that said they felt burnout at least once a week and half experienced high levels of emotional exhaustion or depersonalization. And so I think it’s not all sunny. And of course those high rates of burnout and exhaustion are present across medical specialties. This is not particular to geriatrics and I think geriatricians were particularly hit hard during COVID with the patients they care for, nursing homes and other settings, particularly vulnerable to the harmful effects of COVID and under very stressful circumstances as we’ve talked about on this podcast before.

And so I just wonder what steps when you hear those numbers about rates of burnout and exhaustion among practicing geriatricians, though they may be, and certainly there was another article, I think it was early 2000s that said, among medical specialties, actually geriatricians had the highest satisfaction rating. I wish they would repeat that study now. And I don’t know what it would show, and I hope it would show something similar. But when you hear these concerns about exhaustion and burnout among practicing geriatricians now, who are the role models for the geriatricians of the future, what are your thoughts? What do you hear? How do you react?

Mike: Well, I’ll jump in and say I think one is, again, what is the comparison group? How do we compare it to? The other thing is I don’t think we can know yet. I don’t know that we’re fully reemerged from how we’ve all felt about the pandemic. I think so much of how folks have felt that has sort of overshadowed anything that sort of is asking about those kinds is my sense. And just talking with our own faculty, I think people are feeling better this year than they did last year. I don’t know if they’re feeling pre-pandemic better, but my sense is that things are slow. This has not been sort of revolution, but evolution in terms of how we’ve come out of this. Again, that’s purely just an anecdotal sense.

So it’s not to ignore your question, I think it’s an important one. I think that’s been a trend. I mean, if you look at just medical trainees, the amount of behavioral health issues that seem to emerge, it feels different than I think from a generation ago for a whole host of reasons, whether that’s not to impune social media, but to impune social media, all the effects of things that the stressors are just different now. So I don’t know how to directly answer that question, but I don’t know how much of the pandemic and its overarching impact do we yet know.

Jerry: I would just add that geriatrics is an amazing community. I mean, there’s a closeness amongst us that’s different I think, than any other discipline in medicine. And I do think that we have to start advocating for ourselves. I think we have to be more proactive. I’m glad, Ryan, you took it as a call to action, but I think we can be more assertive, somewhat more aggressive in our demands and make the field better for ourselves and make ourselves feel better about ourselves and our profession. So that’s one thing I feel some optimism about. I definitely do. And I love this community. I love it.

Mike: Jerry, that point’s a, I think, really important one, which is I think historically the things that work against us as geriatricians as it feels out you’re right, is the great community we have. We tend to demure. We tend to not want to take credit for things we do. We are not very good self-promoters I would say, as a profession. That’s not our nature. It’s not why most of us went into this field. And yet I think all of us, we all have to have leadership roles in that, whether it’s in our own institutions or in our communities and saying, this is why you need us. This is why your health system is going to not serve your community, will probably not be as successful as profitable without adopting some of the things that we do. And I think places that are going to be successful will have geriatricians and leadership roles. I think that’s going to be really, really critical.

And developing that pipeline of leaders is really also an important thing that we have to focus on, that people have the skills when they’re called upon to do this kind of work, that we are at least taking some aim at that as well.

Eric: And in our last couple of minutes, Ryan, I’m going to turn to you. When you think about the next several years, let’s say one to five years out, what are you most excited about right now in addition to GERI-A-FLOAT to help with some of these issues, whether it be from a clinical, education, policy?

Ryan: I think a lot of energy right now, at least what I’m feeling from, again, that generation coming behind me, the current fellows and those that are junior faculty that coming out of the pandemic are extremely interested in the intersection between aging and the other social and structural determinants of health. So racism, ageism, classism, sexism, all of the intersections and how that impacts the health outcomes of older adults. And there’s a lot of energy around that. And because of that, what I’m seeing is an attraction of folks that might’ve not thought about geriatrics initially, but see the vulnerability in our patient population and actually are getting excited about projects and initiatives in our field. And I would say part of the work that I’m doing in medical education is around that area because I work in a health safety net hospital and it makes sense for some of the teaching that I’m doing. But seeing that national movement I also think is really exciting. And again, it’s like another wave that we could potentially capture for increasing that pipeline.

Eric: Great. Mike, how about you? What are you most excited about, hopeful for, optimistic about?

Mike: Yeah. So maybe I border on Pollyanna, but I’m pretty bullish on where we’re going for the reasons I think I talked about earlier. For me, I’m kind of immersed in this geriatrics for specialist initiative within AGS. And I see tremendous amounts of enthusiasm and leadership among these champions, whether they’re an orthopedic surgeon or a rheumatologist who recognize that their fields need to adopt an age-friendly approach, and to think about their patients differently. Does every basal cell cancer need to be removed? So asking questions and developing the knowledge base. So I’m pretty excited for this idea that we want to continue to grow the field of geriatricians, but continuing to bring more people into the fold. And I think we’ve been very successful, and I’m optimistic we can continue to do that.

Eric: Yeah. It’s great to see all the surgical literature around geriatrics and frailty and prescribing and deep prescribing. That gives me a lot of optimism. Jerry, how about you? What are you optimistic for?

Jerry: Yeah, the thing that gives me the most hope are the medical students that I interact with or the residents that I interact with that are interested in our field, that are committed to geriatrics. And they give off so much energy for me and make me feel so good. There just aren’t enough of them. There aren’t enough of them.

Eric: What excites me about the med students is when I was a med student, I never heard of ADLs or IDLs and we just gave a talk to first or second year of med students. I forget which one, Mike, but they were able to name them off. Wow. I was like, holy smokes. What a difference 20 years makes. It’s been 20 years, but I think it is infusing, and that excites me. So I think there is a little bit of things, things are fixing. I didn’t really get the name right. I was trying to add fix you to that, but then I just lost it. Not enough coffee in my system.

Alex: (singing)

Eric: I should have just stuck to the lyrics. Jerry, Ryan, Mike, thanks for joining us on this GeriPal podcast episode.

Mike: Great to be here. Thanks for inviting me.

Jerry: Thank you.

Ryan: Thanks for having us.

Eric: And to all of our listeners, thank you for your continued support. We will have additional details on our show notes. Just go to GeriPal.org. And again, thank you very much for your support.