Search for Geriatrician Identity: Mary Tinetti, Helen Fernandez, Jerry Gurwitz, Ken Covinsky

Eric 00:13

Welcome to the GeriPal Podcast. This is Eric Widera.

Alex 00:17

This is Alex Smith.

Eric 00:18

And Alex, we are going to be talking about geriatricians. What’s our identity? Before we jump into that topic, who do we have on the podcast to join us?

Alex 00:27

We have an all star lineup today. Eric. We are delighted to welcome back all returning to the GeriPal Podcast, Mary Tinetti, who’s a geriatrician researcher at Yale. Mary, welcome back to the GeriPal Podcast.

Mary 00:43

Great to be here.

Alex 00:45

And Jerry Gurwitz, who’s a geriatrician and researcher at UMass Chan Medical School. Jerry, welcome back to GeriPal.

Jerry 00:53

Hi everybody.

Alex 00:54

Helen Fernandez, who’s a geriatrician, palliative care doc and educator at Mount Sinai in New York City. Helen, welcome back to Geripal.

Helen 01:04

Thank you. Really happy to be here.

Alex 01:06

And Ken Covinsky, geriatrician researcher at UCSF. Ken, welcome back.

Ken 01:10

Great to be back. Thank you.

Eric 01:13

So you know, the way this topic came up is that we got a lot of JAGS articles recently about defining geriatrics, the geriatrics identity, and a couple other cool ones that we’re gonna be talking about in this podcast. But before we dive in this topic, we always start off with a song request. Mary, do you have the song request?

Mary 01:31

I do. I was hoping you would do the Streets of Minneapolis. Bruce Springsteen.

Eric 01:36

Why did you choose this song? Mary?

Mary 01:39

So I did my training in Minneapolis and I fell in love with that city. And I was so proud and not at all surprised at the heroics and what they did this winter that no one else has done and they’re kind of…Minnesota is kind of the quiet place where people just do the right thing. That kind of reminds me of geriatricians. Minneapolis has finally got its place in the in the sun. And I hope we do too.

Alex 02:07

That’s great.

Eric 02:08

Wonderful.

Alex 02:08

Here’s a little bit of the protest song.

Alex 02:15

(singing)

Eric 03:29

Wonderful song. Thank you, Mary, for that request. Okay, let’s talk about. So recently there are multiple JAGS articles during American Geriatric Society. Congratulations, Alex, by the way, for your co chief editor of jet. What’s the actual title?

Alex 03:47

Co editor. I can’t say it. Co editor in chief with Deb Saliba. Yeah. Really excited about this new position.

Eric 03:54

Congratulations.

Alex 03:55

Really grateful to Joe Auslander for all the work he’s done and the lessons I’ve learned from him.

Eric 04:00

So, Jerry, you wrote an article in Search of Geriatrician identity. Mary, you also wrote an article recently published this year on Mainstream or Extinction? Can Defining who We are save geriatrics 10 years later? I’m going to start off with you, Jerry. First of all, like, why do you want to write an article about geriatric identity?

Jerry 04:22

Yeah, thanks, Eric. A number of years ago, I read this piece in JAX and it was titled the Unknown Profession. A geriatrician, Jean Campbell, wrote it with a number of her colleagues. And what I couldn’t get out of my head and still can’t, is this video that was attached to that article. And really encourage anybody who’s listening to this podcast to access that video. And what the authors did was to interview people on the street and ask them, what is a geriatrician?

And the answers were related to Ben and Jerry’s ice cream, gerrymandering, being on a jury, whole bunch of other things, nothing to do with geriatrics. And I mean, I found it funny and hilarious, but I also found it a little disconcerting and sad. And so I encourage anybody who’s listening to watch that video. Many others, especially Mary, have written about geriatrician identity over the years, and I felt like, well, it was time to give it a shot. So that’s why I wrote the article. Just summarize briefly. I talked about four different identities from different perspectives. And the first identity, which we’re all familiar with, is the complexivus, and that relates to the fifth M. Multi complexity.

That’s intuitive to every one of us, but frankly not so much to the public or our colleagues. The second one, I basically, I think I made up this name, the Healthful Longevitist. And that’s maybe a more optimistic perspective on aging. Increasing health span, promoting healthy aging, resilience, well, being something we all want to associate with. The next one is the syndromist, to some extent. It’s a bit of a more recent phenomenon. That’s the geriatrician who develops this subspecialty level expertise relating to a single syndrome, a single condition. A common example right now is the brain health specialist.

Eric 06:52

Yeah, dementia care brain health specialists. We see a lot more geriatricians involved now with these new mabs for amyloid drugs.

Jerry 07:02

The syndrome is. It’s weird because it can sometimes obscure inadvertently or sometimes even purposely, the geriatrician identity. It’s a little interesting in that way. And finally, I’ll finish up the contextualist, and that’s a geriatrician that we’re all familiar with, who masters a particular clinical setting, a model of care, home care, Snithus, ACE units, pace. In some ways it’s analogous to the hospitalist. And the beauty of being a geriatrician is we can embody any or all of these identities. You can embody more than one. The challenge, I think, for all of us is that we don’t hold a patent on any of these identities. And as we try to claim any of them, we can be easily outnumbered and outmaneuvered.

Eric 08:01

Helen?

Helen 08:01

Yeah. I was reflecting one, on your article, Jerry, and two, the video. Um, and it really kind of provoked me. Last couple of days I’ve been doing my primary geriatrics role. Saw about 15 patients, have a lot of charts to finish up, and a medical student with me. And I asked them, I did that on the street, in the office kind of interview, and I asked them, and some were longitudinal patients, some brand new patients, some recent. And I asked them, you know, what do you see my, you know, my role, who am I to you?

And several answers reflected on the fact that you see me as a whole person. You listen, you think, what’s important, what’s my priorities, my preferences? And you frame really what’s most important around that. And the medical student is like, this is the first time that I’ve had an opportunity to see one of my faculty members or trainee to step back and listen to a story and really listen to that and then frame the plan around that, not interrupt every two seconds. Yes, we have a little bit of luxury of time, but we definitely have much more complexity. And for the student, it was like before I walked in here, I was pre charting. I was seeing 30 problems with 15 medications. I didn’t know where to start.

And I was scared, honestly. Tell you, I sent you the email on Sunday night saying, how am I going to pre chart and what am I going to do? And I think that it’s almost going right to the customer, the consumer, the patient, and getting from Them. Those ideas of who we are. Um, so, Jerry, you helped me. You helped me define.

Eric 09:57

Do you see your. Do you see yourself as one, mostly one of those identities, the complexivist, the health longitudist, the syndromist or the contextualist?

Helen 10:07

I would say sometimes. Well, it depends on the situation. It depends on who I’m seeing in front of me. Most days, probably the complexivist, but sometimes I see a Spanish of. Of patience. But I would say maybe I lean myself more on the complex side.

Eric 10:28

Ken, where do you fall?

Ken 10:30

You know, I mean, I’ve been reflecting on this, and there’s a. I’ll. I’ll admit to a little bit of angst that I have even about what we’re doing right now, because.

Eric 10:40

Why.

Ken 10:41

Okay, well, here’s why. So, like, on the one hand, you know, it’s really. There’s a lot of value within a field of, like, thinking about how a field, what a field does, how we have the most impact. And I think there’s, like, you know, both of these articles were wonderful, and really, I think, a lot of food for thought, I think, within the field. I’m not sure I want to talk too much about this to people outside our field, that. Because I worry that our field, like, maybe a fifth identity is. Identity is. We spend so much time talking about what identity is. And, you know, here’s the crux, though.

Eric 11:21

It’s like, we spend a lot of time saying, also, woe is me.

Eric 11:28

We’ll get to that. We’ll get to that.

Helen 11:30

Okay.

Ken 11:30

Can I give you another truism, though, that I think gets missing in this discussion is like, I am so proud to be part of this community. I mean, geriatrics is an amazing discipline, and the people and the stuff people do in our field are wonderful and amazing. And it’s like, you know, when we went to medical school, we had to say why we wanted it to be doctors. And I admit later that, like, I had no idea what I was getting into at the time. And when I’m in, this is why now I know geriatrics is why I wanted to be a doctor.

And you know that, you know, and I just think, even think, like, you know, the four of you, you know, like, where else. Like, you know, you guys are all superstars, and, like, where else do you get to sit, like, with such superstars? I could, like, spend the whole podcast bragging about each of you, and, like, I sometimes wonder, like, should we be bragging more and exemplifying us by the wonderful stuff we do, you know, I

Eric 12:31

was just at University of Toronto, and I had a chance to meet with Samir Sidha, who is just this. I don’t even know how to describe in that you just feel energetic about geriatrics after you talk with him for a half an hour. Like, is just the things that they’re doing at University of Toronto. It covers all of these different identities, and it’s really pushing the field forward. It’s not who we are, it’s who we kind of want to be and the amazing things that they’re doing.

Which also makes me think about your article, Mary, is this. You wrote an article 10 years ago, and you wrote another Jags article, looking back. Um, so the title, Mainstream Air Extension. Can Defining who We Save, who We are save geriatrics 10 years later. Can I ask you, Mary, why did you decide to write this? What was the article first you wrote 10 years ago?

Mary 13:21

So 10 years ago, I was. I was really focusing on kind of a lot of things we were talking about right here. We’re not getting respect. Nobody knows who we are. And I was anxious at that point. I’d been in the field for 30 years, and for 30 years we’ve been having this conversation. And as I was writing that article, I realized, well, wait a second. Does it make a darn bit of difference to anybody but ourselves, what we’re called and what we do? What matters is, are our patients, are older adults getting the kind of care they need?

And I just really realized how important the concept of geriatric principles are. Doesn’t matter who’s practicing them. It’s the geriatric principles and. And the. Helen, the people you talked about, both the. I think most of those people you had in your clinic, they’re not going to be geriatricians. But if they learn all those things and all those. And a lot of those principles, Jerry, or what you had in your. In your article. So it’s. It’s. And realizing that even before my article ten years ago, a lot of the things, interdisciplinary teams, patient safety, that all came out of geriatrics and doesn’t really matter that we got credit or not. And 10 years later, I’m kind of having that same angst.

But I will tell you, it’s much more important to me to think that our very complex patients, whatever we want to call them, are getting the care they need by all of their health professionals. And then do. See, in my article, I highlight a little bit. There’s been a fair amount of success in the past 10 years. Not, you know, we’re still having all the other problems in our own identity, but I think the care of older adults is getting a little bit better. A lot of challenges remain, which I’m happy to talk about if that comes up.

Jerry 15:12

Your articles are. Both articles are positive, but they have a little edge to them. And there’s one, I don’t know which article you said, basically, stop whining.

Helen 15:29

Way too much time whining.

Jerry 15:31

Can you expand on that a little bit? Stop whining.

Helen 15:37

I’ll give you an example, which I told Eric about many years ago, 17 years ago, I was in this National Healthcare Leadership Fellowship policy, and we were doing a visit to the Chief of staff office in D.C. of the speaker of the House. And it’s an interdisciplinary, all different specialties. I was the only geriatrician. I walk in, we introduce ourselves and what we’re practicing, and the staff or the chief of staff for the speaker of the House. When I said geriatrician, he said, are you going to talk to me about how you’re underpaid and you work too much? I didn’t even open my mouth besides saying my name.

Eric 16:22

The very first time me and Helen met, I think was in San Diego at AGAP retreat, back when we had those retreats. And a lot of that. What I remember from that retreat was that, like, complaining about how we’re underpaid, how we’re like, there’s not enough of us. All of These arguments, which 20 years later we still hear over and over again. Which also reminds me of one of my favorite, like the geriatric identity. When I think about it, I also think about the New York Times article that highlighted Elizabeth ekstrom that said Dr. Ekstrom, who spends her days focused on complex medical needs of older adults, is like the Central African okapi, a species that’s revered, rare and endangered. She is a geriatrician. I didn’t see that in any of your articles, by the way,

Alex 17:16

But I

Eric 17:17

liked Mary’s article, too, because it talks. I mean, it does have extinction in the title, but it talks about some of the amazing things that we’re doing as a field, including building the geriatric capacity for other fields. And I also think we’re not highlighting some of the amazing things, which I want to turn to Helen because, Helen, you just published an article.

Helen 17:41

Yeah.

Eric 17:41

So today. Was it yesterday?

Helen 17:43

I think yesterday.

Helen 17:45

Thank you, Alex. Yeah. I mean, this is an exciting article. We’re talking about a new training program where it’s taking either internal medicine residents or family Medicine pre matching to a residency as well as the fellowship. So you have a four year longitudinal relationship with geriatrics and so you have both clinical exposure, mentorship projects and it allows some time in that fourth year, your fellowship year to do projects related to geriatrics. And this is really, we started with, not the best year to try to start this in 2020, but we did.

And we got three institutions to come together and start these new ACGME approved residency fellowships. We’ve grown now just this month we got six new programs approved. We have a total of 20, which I have to say that’s a huge uptick in programs because it’s commitment from categorical to your fellowships to come together. We will have in 2027, 47 graduates and we’re just going to grow. This is going to become a common pathway out of this training. We’ve gotten residents who did a chief year, so they’re seeing dense leaders.

They become influencers within. They develop curriculum in their primary internal medicine or family medicine residency. They become kind of the spokespeople to make sure that other residents who are not even in the med geri program are getting those geriatric principles. So it’s the non stealth way of doing this.

Eric 19:33

And how many again are being trained in this program? You have some beautiful charts.

Helen 19:37

Yeah, yeah, we have 40, 47 who will finish in 2027 and that’s that. These six new programs are just approved. So each of these programs will have one to two other resident fellows that will be part of it. You know, I think about your first article, Mary. When we thought about kind of where we should be kind of in this elite force. As myself, as an educator, I’m always thinking about new ways of training, new ways of incorporating everybody, getting geriatric principles and also thinking about how we look at fellowship training, how we don’t lose students that are interested in geriatrics and really have a much more longitudinal. And this has made such a huge impact in terms of not just within our institution, but the other 20 that are joining us.

Ken 20:29

Helen, I’m sorry. Go ahead, Eric.

Eric 20:30

Just a shout out to Helen too. This is not her first time. She created pathways for geriatrics, combined integrated geriatrics and palliative care pathways. Helen. I think again, as a field, I think we have to praise people like Helen who are really pushing the boundaries of how we can get more people who are specialists into the field in addition to what Mary was talking about, you know, training everybody else. Go ahead, Ken.

Ken 20:56

You know, Helen, just, I love this program. And it’s like, yeah, it’s just. I’m. I’m. I’m sure there’s another backstory about all the brilliance you had to do to pull it off. I’m interested in learning a little bit more. Sounds like you have your first cohorts and what the people doing this are telling you as to why they want to do this, Because I’m wondering if they have some messages for us as a field as to why at, like, a young age, they’ve decided they want to do this.

And because one of the things I was thinking is on one hand, I’m thinking one difficulty of structuring this is you could sort of say, well, on the one hand, okay, we’re going to develop this training program. Which of Jerry’s four pathways should we emphasize or which aspects of identity that Mary talks about should we emphasize? And I’m also wondering if, like, there’s more central psychological motivations of, like. Like, are the people doing this? It’s because this is the kind of doctor I want to be. This is the kind of professional I want to be, and if there’s something more intrinsic in their motivation that we kind of need to learn about bottle and use to sell ourselves.

Helen 22:07

Yeah, I think that you hit it spot on there in terms of many of the folks that are these resident fellows are graduating. This is the medicine they wanted to practice. This is why they went to medical school. And, you know, many were actually involved in their student interest group in geriatrics or in a research project in geriatrics. And what we heard from folks that didn’t have this and tell me I wish I had this, is that it wasn’t enhanced while I was doing residency. Residency was very focused on, let me get these procedures done.

Let me get good at X, Y, and Z. And not necessarily reminding us of them, of why they went into medicine, so that this helps bring back that joy of why I wanted to go into this field. And I think we’re also seeing some folks really develop, maybe as educators, but also as researchers. Sometimes they go on. Not all, but a few will go on to do even another specialty and join both geriatrics and cardiology. You know, so that’s been kind of neat to see that journey where they’re bringing in those geriatric principles, even to another specialty besides the core.

Eric 23:23

I was just talking to a medical student yesterday who was interested in doing this residency program as a pathway, and it gets, like, them into it early on. Instead of what usually happens is, you know, some internal Medicine program director tries to talk them out of doing geriatrics, which is also a common theme. Go ahead, Mary.

Mary 23:41

Yes. No, what I was going to say is. Helen, just pay a little devil’s advocate. You talked about two things. You talked about this pathway where you have 47 people over I don’t know how many years. And then you talked about the residents and students that come in that probably are hundreds and hundreds. And which of those is really going to have the largest effect of our. Let’s lose sight. It’s not us that matters. It’s how many older adults are touched by these geriatric principles. And, you know, in terms of a multiplying effect, if I. If I had five hours in the day, I’d spend four of them working with physical therapists and social workers and cardiologists and not with other geriatricians.

Eric 24:22

But, Mary, don’t you.

Helen 24:23

Well, I would say that you can do both. I am energizing.

Mary 24:27

Still only 24 hours in a day.

Helen 24:28

I create more time.

Mary 24:31

Well, maybe that’s what we should be talking about.

Helen 24:34

I do. I come from a father who stopped working at the age of 89 as a cardiologist and who. I was just looking and going through his things. He was an AGS member as of 1976, so he believed in that. But I think I’m also working on curricular. And we’re putting in the threads of geriatrics within the curriculum. Right. So it’s touching the curriculum for all medical school so that everybody gets it. So I think you’re right. You have to, you know. Yes, there’s only a finite amount of time in a day, but I think we have to attack this in multimodal ways.

Eric 25:13

And, Mary, don’t you need the geriatrician to. To be there teaching people? Because nobody else will.

Mary 25:20

Yes, you need the geriatrician. And that’s. That was sort of. My point is, as we’re creating the geriatricians, are we training them to see 15 patients a day, or are we training them to train hundreds of people and disseminate the principles to everybody who touches people? It’s not an either or. I’m just sort of, sort of pushing that a little bit to highlight, to get outside of our worry about navel, gazing at our own identity and more. You know, let’s remember what the bottom line is. Getting as many people as possible to get the kind of care that geriatrics has created and studied and teaches.

Helen 25:59

Yeah, I think that’s a great point. I mean, I Think Eric and I just did this whole. How many times did we do it at acp? We did seven workshops. It was like

Eric 26:13

I was delirious at

Ken 26:15

the end of that.

Mary 26:19

Hemp syndrome must take care of you.

Eric 26:21

I. Yeah.

Helen 26:24

And it was super rewarding. It was kind of that expansive way of thinking. Right. That they were really coming to these workshops, really checking into our expertise, bringing in their cases. I mean it was a, it was yes, very exhausting but also very exhilarating.

Eric 26:40

And can I push you on that, Mary? Because there is only so much time in the day, you know, when we think about defining a field, we’re trying to again regulate the term of that field. Kind of what we should be focusing on. Are there things you think we should not focus on when we define geriatrics? Like is it doing primary care, longevity care, like are or is it just, you know, specialized care for the more complex older adult?

Mary 27:09

Yeah, and that’s a great question and it’s not either or. I think there’s always going to be geriatricians that that’s what we want to do is be primary providers. And I actually talk about it in my article. I think that probably they don’t need to be taking care of the healthy 70 year old who has hypertension and, and hypercholesterol. Frankly I think most of that should be self care today anyway. But it’s co, a lot of co management with primary care in places that, where that’s really doable. The home care. This is really, really high complex people. I think about it very much like other specialists look at cardiology. I mean most cardiology is not provided by cardiologists. Right.

Eric 27:52

And you don’t see them having this debate.

Mary 27:54

Well that’s, that’s what my, my, my thing is we need to think more like cardiologists and I, I first I gotta do one quick aside. I really realized when you just start talking about cardiologists when I was on an FDA committee that was talking about statins going over the counter and this one after cardiologist said this is so important and so safe it should be in the drinking water. And this came out the same year as, and it’s about a 30% benefit from statins came off the same year that yet another meta analysis says oh there’s only moderate benefit from multifactorial fall prevention. It only helps 30%. Exact same amount.

Ken 28:37

My goodness, my goodness, that’s fascinating, Mary.

Helen 28:42

Yeah.

Ken 28:42

Mary, you said one thing earlier and that you just implied that it got me thinking and like, like A lot of wise thoughts. It’s almost so obvious that we don’t use the term or we don’t do it. So you kind of said that the index of what we do should be a little bit external to us and that we should simply be asking the question how much does this impact the older patients in our community and how many does it impact? And it just seems like such a wonderful index to validate things.

And I’m wondering, honestly, that’s probably missing from all of medicine is that medicine is becoming so corporate that the patient is often not at the center of much of what we do. But geriatrics is the one to bring the patient back. And I’m just wondering if boiling your point is an important piece of this because I think one of the things that we have to offer the public is that we are the field that really, I mean, I don’t want to say, I mean other specialties do too, but being patient centered is really front and central to our field and thinking about the patient’s full well being.

Jerry 29:57

Ken, can I add on to your question or comment that Mary’s going to respond to? And I’m not sure how to totally phrase this, but taken to the extreme, things like age friendly care, which have the goal that you’re describing, can that sideline the geriatrician? Can that be a impetus toward the geriatrician losing identity? Because, and Mary, you pointed this out in one of your articles where you’re a little, I think you were showing some skepticism about those approaches in terms of the impact on this profession of geriatric medicine. So just adding on to Ken’s observation.

Mary 30:50

Yeah, thank you. Those are very simple questions there. So the age friendly, I really like the age friendly obvious part of it right from the very beginning. And I think it is a step towards getting geriatric principles out everywhere. But it’s not enough. It’s broad but not very deep. I think that the way I sort of look upon it is what I think I said in the article, the 4 Ms. Of age friendly versus the 5 Ms. Of geriatrics. And it really anchored by the multi complexity. And I think, you know, to answer, I think it addresses your question a little bit. Ken is again Helen and her students where she didn’t start with, you know, oh gosh, your blood pressure’s a little bit high.

This is this and this she started what really matters most to you and to me it’s very fast. Geriatrics integrates everything and focuses on what matters to that individual. They filter all their cardiac disease, they filter their social factors, everything gets filtered. And the game plan is based on what matters most to that individual. And I don’t know any other field that sort of does that. Do we do it all the time? No. Are we guilty of doing one disease at a time? Yes. But added our aspirational it starts at what really matters.

And I’m just going to throw in a plug for AI because I think AI is going to help us get there. I think AI might if we really take good advantage of it, if the data are there, which they aren’t, because I don’t know about your place, but in our place, the EHR scrubs out anything to do with goals or social stuff because it doesn’t help billing. So a lot of challenges, but I think at its very best, we integrate all of it and come up with an individual plant for each person.

Ken 32:39

Is that really true? Your AI scrubs out what matters?

Mary 32:43

Yes. My goodness, look at yours. Look at yours.

Alex 32:47

Yeah, we’ve heard this repeatedly that AI considers the. The what matters part chitchat. It just cuts it out.

Jerry 32:55

Right.

Alex 32:56

It’s terrible.

Helen 32:57

So we need to build models that will.

Alex 32:59

Yes. Help inform those models. I was at the Society of General Internal Medicine meeting last week and I had been about 10 years. That meeting has grown. I went to the geriatrics interest group meeting and it was twice the size of what it was 10 years ago and about a third to a half of the attendees or trainees, medical students and residents who are interested, enthusiastic about geriatrics. And when we went over, like, what do we want to cover at future meetings?

One of the topics that came up that people were very enthusiastic about was like, why aren’t more people going into geriatrics? And this is a topic that we’ve covered before with Jerry Gerwitz and Ryan Chippendale and Mike Harper on our prior podcasts. And I told them that we were going to do this podcast and there was a lot of excitement about that. So one question for all of you, maybe Jerry first is like, what have you been thinking since that article came out, since we did the podcast? And I also want to point out one more thing, which is that Ken Kavinsky was the distinguished professor of Geriatrics at the Society of General Internal Medicine meeting.

And he gave this terrific talk about geriatrics that covered everything from, like, how we approach patients differently than the disease focused model to like, hospital acquired disability. But the part where he got the most applause was how geriatrics is a terrific specialty to look at people who are most vulnerable, like old age, disability as a women’s health issue, and focus on disparities. And he got a big standing ovation at the end and then got a Cubs jersey with his name on it, which was awesome.

Speaker 7 34:36

Aw.

Alex 34:38

So

Ken 34:41

that’s the best payment I’ve ever gotten.

Alex 34:44

So, before we get to Jerry and his reflection since we last talked, Ken, any other thoughts? Anything you want to tell our listeners from that talk, which was really inspiring.

Ken 34:54

Thanks, Alex. And, you know, it was, you know, the process of giving me a talk really kind of made me think a lot about where geriatrics fits into the big picture, because I was like, you know, my history is as an accidental geriatrician. I kind of became a geriatrician without ever explicitly planning to it. And it’s kind of over time, it’s because of people like you that I was, you know, every time I was exposed to a geriatrician, it was kind of like, whether it was a clinician or a researcher, it’s like, this is how I want to be, and this is how I want to think.

So that it’s. I think the principle that I think, like, all of you are getting at is there’s something really wonderful about. There’s all the stuff we do, but there’s something wonderful about the way geriatrics approaches patients and approaches research questions that is just so eye opening and changes your view of patient care and medicine. And, you know, I.

Eric 35:53

Did you feel like you needed to define what a geriatrician, going back to the podcast topic, did you feel like you had to define what a geriatrician is to get that message across?

Ken 36:02

No, no, I think to get the message apart across, I think I had to define, you know, what a broad impact that way of thinking has and how it just completely. Whether you’re taking care of a patient or whether you’re studying a complex problem, why, it just completely changes and transforms your approach. And as a researcher or, you know, an investigator, it’s just so intellectually fulfilling. And, you know, when I have a consult, it’s just to sort of.

I mean, the example you just gave Helen, you know, they’ve seen lots of doctors, but to start the conversation with, you know, tell me how things are going and what things are going well in your life and what matters. And the point of, like, it’s not just touchy feely, it’s. It completely transforms how you take care of the patient. And, you know, it’s like people say it takes more time, you know, no, it doesn’t. It takes a lot less time because you now know what’s important. And, like, the 20 problems become just a few problems because only a few of them really matter. So, you know, just. It’s a way of thinking that’s just utterly transformative. And I kind of wish we could get that across more.

Eric 37:17

Jerry, your thoughts?

Jerry 37:20

Yeah. Well, I’ll just say first of all that figuring out the identity issue is not the answer to this geriatrician shortage problem. So they’re two different things. I think the identity thing is more for us who are geriatricians, how to think about ourselves and maybe brand ourselves, but it’s not the answer. Mary knows that I love her quotes, so I’m going to quote her freely. And she wrote, trying to increase the number of geriatricians by lamenting the shortage hasn’t worked in three decades. It has probably discouraged promising candidates. We now, and I’m going to underline this, we now have 40 years of failure.

So I perseverate on this a lot, way too much. And I’m trying to stop myself from perseverating. And this is going to be a little abstract, but I’m going to paraphrase something I heard my rabbi say in a sermon recently, which had nothing to do with geriatrics. Okay, Nothing. But I’m paraphrasing. Let’s paraphrase. Vibrant professions have big dreams, while dying professions rehearse nightmares. So I’ve been perseverating about that thought because what does it mean for our own profession and how we think about it and go forward?

Ken 39:07

Wow, that’s wise, Jerry.

Eric 39:09

Yeah, I love that, too. I always felt like, and now I’m one of the older geriatricians out there. And I think about it does feel like I just remember me and Helen 20 years ago thinking about this. Like, why is everybody so down on geriatrics? That was 20 years ago. And now, like, I’m that person talking about this. And you have newer people in the field who are energetic. You have people like Samira, who I talked about, who is energetic. You have people like Ellen.

Alex 39:40

We will have a podcast, we’re planning one, with some of the younger people who are really energetic on social media. Have thousands, hundreds of thousands of followers, millions of hits. I bring them on.

Eric 39:50

I gotta ask Helen. I’m asking you, Helen, because I’m going to go back to this idea. Do we have to define geriatrics? Do we have to define what our identity is? I hear from most of you, Jerry, correct me If I’m wrong, there was no one answer to your. Like, you didn’t say that you should be all this or that or that.

Jerry 40:05

No one answered.

Eric 40:06

No one answered. Mary. I’m hearing the same from you, Helen. You go to any palliative care fellowship, at the very start, they’ll have one lecture talking about how do we talk about what palliative care is? How do we define palliative care? How do we define it to our patients? Every palliative care fellowship has that. There are CAP C guidelines on how we should talk about what palliative care is for your fellowships that you create and that you are part of. Is there a similar session on geriatrics defining it? Should there be?

Helen 40:38

I don’t think there should be. I think you need to know the principles. You need to know what’s important. But I don’t. I don’t see that spending the time. I think that’s spending the time and so much time in terms of talking by identity is really helping us. Right? I mean, I think you. Going back to what you said, that woefulness is really. I think I want, you know, flip the coin. And that’s why I’ve been trying to, for the last 25 years of like, really thinking about different ways of looking at this and how to integrate those principles more widely with still thinking about the workforce, with still focusing again. I don’t think we need to have those lectures.

Eric 41:18

Jerry, what do you think about that? Should we spend more time defining who we are? You wrote a paper on this.

Jerry 41:24

I think that we need, as geriatricians, we need to. I mean, how can we live like this? We have to be able to describe who we are and what we do. And we haven’t done a good job of that for over 40 years. And Mary’s pointed it out. She says we keep coming back to this. One answer is, let’s stop talking about this once and for all. And many famous geriatricians have said that the other way of thinking about it is, let’s keep trying to figure this out.

Eric 42:04

Yeah. Mary, what do you think? Can we even define it?

Mary 42:08

I don’t think we can define it. I mean, I think we. You know, there’s a general. There’s much more consensus about it than I think we’re. We’re implying here today, anyway. I think we all agree that it’s about complexity. It’s all agree. We all agree it’s about what matters to that individual. We all agree it’s integrating medical care, social care. I don’t think we have to get beyond that much. No. And last thing is that, is that we’re not getting a lot of people into, into geriatrics. But I’ll tell you, they’re the smartest and the best. We’re still getting good people. To me, that’s, that’s the answer we’re getting. If we’re getting the best, the good people, I think we’re doing okay.

Eric 42:50

Yeah. You know, I just want to highlight one other article that came out which was by, I think it’s pronounced Richard Stefan and Ankar Patel on geriatricians as a primary care providers in payvider programs. A strategic solution, really focusing on like if we had a limited supply of geriatrics, like should we be do primary care, does it even work in a fee for system system or is it really like PACE programs, these quote unquote pay vier programs that we need to, you know, really focus on? Ken, what do you think about that?

Ken 43:22

No, I think it’s a great question. And you know, I think there’s a, there’s a bifocal argument here. Like when I think about the stuff in the, in that article, Eric, and you know, the models that you described, Jerry, and the various approaches to care that you described. Mary, you know, I think if you’re like running a geriatrics program and you have a budget, those models become essentially important because like, how you spend your budget and utilize your resources is very fundamental to Mary’s question as to how we have the biggest impact and help our patients the most. And I think it’s inside baseball to the rest of the world.

And I don’t think that. I think we need to talk more about our vision and the impact we have and honestly brag more about how good we are than the rest of the world and leave the inside baseball card and also the whining about resources, you know, outside those discussions.

Eric 44:18

One more I’m going to ask quick lightning round, but before I do, Helen, I was a fellowship director for 10 years and I felt like, I don’t know what it was, but I could see our fellows as they start in the year and the end of the year, it was like, not a geriatrician, not a geriatrician. And then at some point, like, it’s like, it’s not like a magic something that happens. I’m all, oh my God, they’re such a great geriatrician. Like I like for 10 years I’ve couldn’t figure out, like, what was that thing that all Of a sudden, they are the identity of a geriatrician. Do you see that? I mean, you’ve been doing this for a long time. Does that sound similar?

Helen 44:54

Yes, it does. It does. And I think. I think the other piece, besides kind of the whining and complaint, is also that I don’t think that there’s spaces where we should be that we aren’t, and spaces that we are in that we don’t show enough. Right. And I think that that’s where I see the fellows when they start thinking about the next steps of where they want to explore their career paths. It’s fun to see that. That all of a sudden they’ve learned all this and now they want to kind of, whether it be in education administration or research, but they’re leaning in, and we need to give them the role models to say this is a potential and sponsor them in order to have those career paths.

Eric 45:37

Okay? We can only control what we have a control over. So if you had a magic wand, if you could use that magic wand on one thing our field of geriatrics could do differently or should do more of. What would you use that magic wand on, Jerry?

Jerry 45:50

That’s a tough question. I’ll say something tangential to that. Okay. I’m looking at all of you, and this profession has been so good to all of us. I mean, both career wise and personally. I think we couldn’t have done better for ourselves. And how can we give that feeling to those who are going to follow us?

Eric 46:16

I love that.

Jerry 46:16

How are we going to do that?

Eric 46:18

Pass the excitement on? Mary, what’s your magic wand?

Mary 46:22

I would get rid of the chief complaint and have every encounter saying what matters most to you? What’s your very specific goal that you want me to help you achieve?

Eric 46:32

And that’s almost the truism for geriatrics as a field. Get rid of our chief complaint and just focus on what matters most to us. Ken.

Ken 46:40

Oh, wow. I’m just trying to. I want to spend an hour thinking about what you just said. Mary what I would say is I feel that I’ve been allowed to enter a secret club. You know, that I didn’t intend to enter by being a geriatrician, and now I could see doing nothing else. And now I want to think about how I tell people in training that it’s a secret club, but you can enter, too. You have an opportunity, and there’s nothing that’s going to make you happier or be more awesome.

Helen 47:18

Helen I would say I would love to impart some of the wisdom I’ve learned with interacting with the great leaders and do some leadership training to help the trainees, the younger generation, to really pivot high because they can, they can achieve so much if we, we give them the right tools to do that.

Eric 47:39

Wonderful. And that leads us into the song.

Alex 47:46

(singing)

Eric 48:57

Mary, Ken, Jerry, Helen, thanks for being on the podcast.

Helen 49:01

Thank you for having us.

Jerry 49:03

This has been great.

Eric 49:03

And thank you to all of our listeners for your continued support.

This episode is not CME eligible.

For more info on the CME credit, go to https://geripal.org/cme/