Dr. Mia talks with Dr. Mariah Robertson and Dr. June Howell about seeming contradictions: geriatrics was the lowest filled medicine specialty in the 2022 match yet geriatricians are among the happiest physicians.
2022 Medicine & Pediatric Fellowship Match rate- graph on Twitter
Program for All-inclusive Care of Elderly (PACE)
Home-based Primary Care via Independence at Home (IAH) Medicare Demonstration Project
Editing and transcript by Bear Beat Productions.
Transcripts on www.miayangmd.com.
Opinions expressed are exclusive of Dr. Mia Yang and not reflective of her or guest speaker's employers or funders.
Ask Dr. Mia: Conversations on Aging Well Transcript Ep.5
Welcome to ask dr. Mia Podcast conversations on Aging. Well, this podcast is for educational and informational purposes only and solely as an educational tool for your own use. Dr. Mia is not providing medical, psychological, or nutritional advice. You should not use this information to diagnose or treat any health problems or illnesses without consulting your own medical practitioner. For more information, including transcription, please go to Mia Youngmd.com. That's Miayangmd.com. And now our host, Dr. Mia.
Dr. Mia 00:36
Welcome to Ask Dr. Mia Podcast. So the audience of Ask Dr Mia podcast spans everyone from older adults themselves, loved ones who care for them, as well as health care professionals who may or may not see patients, to physicians, nurse practitioners, physician assistants. And what some of you may not know is that geriatrics is a field that folks can go into after either an internal medicine or family medicine residency. Or if you're an advanced practice practitioner, you can choose geriatric as sort of a specialty to go into. If we're looking just at the physician training part, the fellowship match is an annual process where applicants apply to go into a specialty of their choice, and then based on the number of spots that the program has, they kind of go through a mutual selection process where that's called a match.
And this past year, there has been some data showing that while geriatrics has always never been the most popular specialty, were actually the lowest filled rate of a subspecialty internal medicine. So among all the internal medicine specialties, such as cardiology gastroenterology, of the number of spots that are available to train geriatric fellows or future geriatricians, only about a third were filled and that's really what inspired me to invite Dr. Robertson and Dr. Howell to this episode, really talk about why we think this is going on, and also bring you perspectives from around the country since we're at three different institutions.
Dr. Mariah Robertson 02:23
I'm Dr. Mariah Robertson. I am assistant professor of Medicine in the division of Geriatric medicine and gerontology at Johns Hopkins and serve as associate program director within the Geriatric Medicine Fellowship program and a clinician educator big CBIG E and a huge advocate for home based medical care and geriatrics. Generally, glad to be here.
Dr. Aroonsiri Howell 02:46
Hi, everyone. I'm Dr. Aroonsiri Howell. I am an associate professor in the Department of Medicine at Temple University Hospital. I wanted to put in a little plot that I have actually worked in Thailand and multiple states in the United States. This is actually my third job out of fellowship, and I've never had a problem finding a job where I want to go, so I just want to put that in there. But thank you for having me.
Dr. Mia 03:14
So I'm going to let Dr. Howell go first as to what you think might be some reasons why the fill rate or the match rate for geriatrics is so low.
Dr. Aroonsiri Howell 03:23
Absolutely, and I see it as two big areas that we could work on, and the first area that I want to touch on is the compensation, which is what everyone is talking about on social media when we all found out that geriatrics did not fill the spot this year and that goes along with infectious disease as well, because both of these fields for this year had trouble filling, and both of these fields are one of the lowest paid internal medicine compared to the amount of work that's put in. So I think a lot of people think about compensation a lot as one of the reasons why our field doesn't fill the fellowship spots very well. So that's the first component. The second component, I like to call it, is the moral injury that we have to manage when we work as a geriatrician.
Dr. Aroonsiri Howell 04:15
And it comes in multiple forms, which I'm sure we're going to talk about. One of them is respect from other clinicians that we work with or their familiarity with us and one of the things that we've worked on as Geriatricians for a long time is how to message other people and explain what we do and that's in clear contrast to someone who's a cardiologist who never had to explain why they're there, but as a geriatrician, a lot of times we go into a room, I say, I'm a geriatrician. People are like, what is that? Why are you here? What do you do? So that's a kind of moral injury that we have to deal with often. The other part also is we experience ageism for our patients through our work.
And the pandemic, I think, has made us a lot worse, where we see policies and politicians leaving vulnerable older adults behind, and that results in limited resources for us as geriatricians to kind of use and advocate for outpatient that's top to deal with data, like every day at work.
Dr. Mia 05:29
Yeah, you bring up really important points. We're going to come back to each. Of them as well. Dr. Robertson, Mariah, what would you like to add to that?
Dr. Mariah Robertson 05:33
I completely agree with everything Dr. Howell said. I think that there are many factors at play here that contribute, and those are some of the key ones. I think I always have to reference the data to remember how few of us there are, but there is an estimated one geriatrician per 10,000 older adults in the US. So only about 7300 of us in the US trained in geriatrics and so the exposure that trainees have to a geriatrician can be quite limited. The exposure that specialists outside of academic centers and primary care doctors outside of academic centers have to us is very limited and so I think that does contribute to the lack of understanding of what we do, the lack of access to us in places where learners are learning about the core aspects of medical care of older adults.
Dr. Mariah Robertson 06:24
I think that really does make a big difference. I want to also key into the point that Dr. Howell made about ageism being kind of baked into the health system, baked into our ethos, especially in the US. I feel like fear of addressing aging is something that many people feel and it's sort of across the board throughout health care as well as just in society. And so I often get the reaction that isn't it sad to take care of older people? Isn't that depressing work? Like, I would really not enjoy that kind of idea that age equals sadness, right? Whereas we all know what a gift it is to sit with people in their older ages and so I think that contributes as well, and a lot of what we're doing is breaking those barriers down.
Dr. Mariah Robertson 07:12
Finally, I think we don't brand ourselves well. We're humble as a field. I think we try really hard to hear everyone's perspective at the table, which is a good trait. And also there have been calls to action by many people in geriatrics that we really do need to show that we are contributing a significant amount to the care of older adults that you don't receive in just general training. So I think granting ourselves as people who are experts in aging and frailty and the four or five M’s really does help us and is not something we've traditionally done well.
Dr. Mia 07:45
Yeah, thank you for all those points, Dr. Robertson. And I think the branding aspect is something that this particular podcast is really interested in, sharing the voices of geriatricians and other folks who are in this Asian space to the larger public. There are way too many people who are at the table and or not at the table. Just think of an example of the COVID vaccine distribution, and even on the national stage, there really was no geriatrician. On the COVID task force, there were pediatricians, but no geriatrician, which really, when you look at who is most affected by COVID, who has the most morbidity and mortality, those are older adults. So it is all interrelated, I think.
Dr. Mia 08:35
And I think sometimes our field perhaps also has a lack of critical mass of people to really disseminate ourselves and go into other spaces to show the value that geriatrics brings. Even just the terminology of what's geriatrics versus gerontology. It's a common point of confusion. Unfortunately, that really hasn't changed too much. But I have to agree with everything that you have said in that we are really experts in sort of complexity as well as family centric holistic care and that aspect is very similar to pediatrics and that we're not really just focused on the patient themselves, but we're also focused on their care partners, their family networks, and how this person interacts in their environment, whether it's in the home or in the hospital or everything in between.
Dr. Mia 09:31
And I think one thing that I hope people will take away from this is that Geriatricians are great system thinkers because were trained in all the settings that our patients go through, whether it's home based medical care or skilled nursing facility, rehab, in-patient rehab, hospice, palliative care as well as your primary care, consultative care in-patient care. These are all the different settings that I think complement the baseline level of foundational knowledge that we have within internal medicine and family medicine. So on that note, I think we should maybe talk a little bit about just the exposure to learners and what kind of work that you guys are doing within your educational spaces in terms of sharing the joy of geriatrics and dismissing some of the misconceptions about the field. I'll go to Dr. Robertson first.
Dr. Mariah Robertson 10:32
This is my favorite thing to do in my work as an educator, and I think I mentioned earlier, I'm a house call provider in my clinical work. So I see patients at home, and it is my favorite place to be a learner across different disciplines and backgrounds and different levels of training. Because I think that when you get to see an older adult in their home environment and not in the hospital where we often see them in a gown and looking frail and just sort of not the breadth of who they are as a human, you really do get to expose them to the beautiful aspects of aging. The connections, the community, the family, the four or five M’s in action in somebody's face and I have worked hard on my spiel, but much of it is just them seeing it in person.
Dr. Mariah Robertson 11:17
And what I've found is, especially for our medical student learners, that across specialties, it's been enlightening for them to see a way that you can care for patients that does not have to be in the traditional clinical settings that we learn. Just because training programs have traditionally been centered in hospitals and clinics, because we as trainees make money for the health system, does not mean that's the only way you can practice medicine. And in fact, I think we as geriatricians, as you just highlighted, Dr. Yang, we are experts in practicing in all different settings, across all different places in the community and in the hospital. And so I think being able to take learners out to see that especially early in their training is incredibly helpful for them to imagine a world where they practice medicine differently than maybe others have practiced.
Dr. Mariah Robertson 12:05
So that is particularly fun. And then you had mentioned in the earlier part about the small G versus big G geriatrician. So I also think it's important that we recognize not everybody is going to be the big G geriatrician going to Geriatric Medicine Fellowship. But I love bringing out medicine residents, particularly those who are going into specialties like cardiology or pulmonology or gastroenterology, very specialized fields, to say, hey, this is how we tie in geriatrics to what you do. I encourage you to think about the guidelines in the context of a truly older adult and how that might apply or not and geriatrics their practice. So I love doing that with the surgery colleagues as well. We do a lot of different disciplines, but I think passion, a clear message and just eyes on seeing it in practice has really been my success in getting learners excited about geriatric medicine early and often.
Dr. Mia 12:59
That's amazing. Thank you for all the work you do and just to let people know on the same page about the floor or the five M, that Dr. Robertson mentioned, those are kind of the addressing medications, mobility, meditation, and that could be everything from cognition as well as mood, mental health and then multi-morbidity or multi complexity that's sometimes left out but really captures the type of patients and the different settings that people go through. And then what matters most, which is probably the most important M that unifies all the other M but transition to Dr. Howell, I know a lot of your work has been impatient. So on the other end of home based medical care, plus other amazing work you do, what do you think about letting learners know about the work that you do and increasing exposure?
Dr. Aroonsiri Howell 13:54
I just want to start by saying I cannot agree more with what Dr. Robertson said. Personally, I fell in love with geriatrics because as an intern in residency, somebody took me out on a home visit and that's when I decided I wanted to be a geriatrician. So early exposure to geriatrics outside the hospital where we shine, I think is really important. And now that I'm not in an academic center where there's a big geriatric presence, I was the only geriatrician at where I work for a while until recently. We don't have a big presence. We don't have a very established presence within the medical school or the internal medicine residency curriculum.
Dr. Aroonsiri Howell 14:43
And that's been a work in progress where we start to collaborate with people and show other fields like the surgeons and the internal medicine residents and clinic who may be struggling with dealing with an 80 year old patient with multimorbidity on 20 medications and they're trying and the patient is not doing better and then we stepped in to try to work together with the residents and the peace and experienced care improvement. That's when people start to see our value and come back and ask for more help later. But it's been tough in a place where I recognize that the medical students and the residents, the trainees where I am now did not have the same exposure that I had when I was training at a big place with a bunch of geriatricians. I know that they're just missing so much.
Dr. Aroonsiri Howell 15:38
And part of that really is because there are not enough geriatricians to staff all these medical schools and training programs to provide the exposure, but also our health care system in general is set up where it is doctor centered. We ask patients to come to our clinic and they go to different floors to find all the specialists that they need to see versus if geriatric could become more widespread. The way to care for patients really is to go to them, to go to their house, see where they live, because that's where they spend most of their time, not in the hospital, but in their own home.
Dr. Mia 16:16
Absolutely, and I think all three of us share the similar thread where home based medical care is what really inspired us to kind of take that next step and do a jury fellowship. Dr. Robertson and I happen to have trained at the same place, and as a second year resident at my panel of homebound older adults in Baltimore, and that's where I built a house called Bug and hasn't left me yet. So it's great to hear from Dr. Howell also said that it's just such an impactful experience. Even a half day going out into people's homes can really leave quite a strong impression. And I similarly take some of my fourth year medical students as well as internal medicine interns, out on house calls.
Dr. Mia 17:03
And it's always been an experience where I think they take a lot from because they know that their understanding of the patient as a person is so much richer and more quickly obtained by going into the patient's home and going into that person's life. I guess on a positive note, with the expansion of virtual health and the expansion of home based care, especially with COVID pandemic, I do think a lot of people, both clinically and educationally, are perhaps getting into the space. Where they can see how much better it is for patients, families, as well as clinicians, really to take care of older adults in their own homes or more so, in settings that are not traditionally doctor centric, as Dr. Howell mentioned.
Dr. Mia 17:55
And hopefully we can all work toward a future where more people see the value of older adults as well as the value of geriatrics and to go back to what Dr. Howell said, I think it's impossible for any single geriatrician to change the system. And I know that you did the best you could in terms of inspiring folks who work with you. It's just really hard, and I think that also gets back to why so many geriatricians are concentrated in big medical, academic medical centers where there is a pool of geriatricians, because we want to be with other geriatricians as well, and we want to share the load in terms of clinical care, research and education. And I would say that most geriatricians are finding it challenging if they had to do it all on their own.
Dr. Mariah Robertson 18:44
I wanted to quickly add to that point, though that Dr. Howell, one of the things that I am so grateful to you as an educator is that you expand the spaces of the clinical hospital you're teaching in to. The virtual space like Twitter, where I think you have definitely demystified, shared and touched a lot of people's hearts and perspectives around delirium and hospital care of older adults and how we can do better. So I do think that's another role as an educator and as a geriatrician that we can take to reach learners who may not have geriatrician in their clinical spaces like the Twitter space. Although Twitter, I know it's brought with challenges right now, virtual spaces like that where our voices can be amplified and yours is one that I love to amplify because you have so many important things to share.
Dr. Aroonsiri Howell 19:29
Thank you so much. It's really kind. And not to fangirl, but I love the content that you put out as well because it really excludes the joy of home visit. Just love little pictures that you take. This is in the hallway of the assisted living facility that I was and it's just so full of joy in life and I think you really brought up a good point that we can expand the presence and understanding of geriatrics through social media, which I think it's going to reach more people than what I'm doing on a daily basis right now, where most of the time I reach maybe like a few trainees per day.
Dr. Aroonsiri Howell 20:08
But I do want to say that these AHA moments that we could create with trainees are really impactful because I had a trainee the other day asking me, I have a patient who's like 92, but she doesn't really have any medical issues. Should I start her on osteoporosis medications? Which I understand because based on the number alone, I think the training was hesitant. But we talked about numeric. Age is a factor, but it's not everything. Physiology age is a factor that we should consider and time to benefit and like patient preferences. And we talk about all of these things in a scientific way where the way trainees think traditionally when they don't have exposure to geriatricians is they kind of go by, I think this is too old. I think this is okay.
Dr. Aroonsiri Howell 21:00
I think this is the goal, a one C that this patient should have, but they don't really have a systematic way of thinking about it. But once we kind of walk the trainee through, you don't have to guess. We have a specific systematic way to think about this logically. I think we can create these AHA moments with the trainees where they are like, oh my God, this makes so much sense. Now I feel confident, like, talking to this patient about the recommendations that I'm going to make and I think that's when they see the value of geriatrics because this is how we think and this is how we approach patient care in a comprehensive way.
Dr. Mia 21:35
Yeah, and I think all the work that you do with each individual trainee, then that creates a ripple effect where that person can share with the patients they treat as well as other people that they come in an interaction with. So that seed of the love for Geriatrics, I think it's going to be carried out in other settings as well, many years down the line potentially because I still remember certain interactions I had in medical school and training that still stay with me today. Great, well, let's transition a little bit and talk about the level of flexibility or how Geriatrics could be a field that is sustainable in healthcare, which I think is a moral injury, as Dr. Howell previously mentioned, is working in a system that is not well designed for our older adults.
Dr. Mia 22:26
And all the systems racism, ageism, sexism combined can really wear people down. How do you kind of manage all the societal issues that we come in contact with on a daily basis in our work lives along with the potential benefits that we are in Geriatrics to potentially provide? Dr. Robertson, you want to go first?
Dr. Mariah Robertson 22:51
I feel lucky everyday that I get to wake up and do the work I do, truly. And I was someone who I came to medicine a little bit older and had done other work before medicine and in residency I had a neighbor who is a burn out, which I think a lot of us do, particularly when you care a lot and have a lot of empathy and you want to make a difference and all these are really weighing on you as you try to do that. And what I've found for myself in joining geriatrics just immediately in fellowship, I was like a light bulb went off. That this is a space where I can make a difference and I can advocate and I can also feel like there's an impact in everything I do day to day. Not everything I should say.
Dr. Mariah Robertson 23:33
I don't think any job is perfect, right? And there are parts that are hard in every job. But I feel such joy in the work I get to do and I feel that because I think I know that I add value to the health system and I add value to the care that my patients receive, and I think that's the future of medicine. If we're all being honest, we can't sustain this healthcare system the way it is right now in a fee for service approach to care and a care that's transactional rather than focused on actually improving a person's life and their quality of life and adding value to the system.
Dr. Mariah Robertson 24:05
And so I think we are getting to see the way medicine should be practiced, we have to practice it the way it really should be done, which is thinking most about how we center what we do around what matters to a person. And when we do that, we really do center care that is focused on them and not on outcomes that are not relevant to them. So I think the value based piece of what I get to do, the fact that I get to go out and see people in their homes and actually feel like I'm making a difference for them where it matters most to them, really bolsters my day to day and my joy also helps me center kind of advocacy is huge.
Dr. Mariah Robertson 24:39
What I do and what I care about and I think this work I get to do is all about shining a light on the inequities that exist and care of older adults across bases in the healthcare system. And that is empowering for me to be able to say, like, here's a picture or here's a story or here's an example of how we're failing as a healthcare system, the older adults in our communities, and how these are stories in human and lives that we're getting to see on the regulars that you all should know about, obviously be identified, but in a way that allows people to see that this is important. So, yeah, that's what bolsters me and also what I think is exciting about Geriatric, also say the balance is nice.
Dr. Mariah Robertson 25:18
I chose to choose one clinical space, for the most part for what I do for my work, and I do some in-patient attending with residents, which allows me to sort of keep my finger on general internal medicine in the inpatient space. But a lot of people in geriatrics that I know have many different settings they practice in and many different days of the week, which they love. One day's nursing home, one day's primary care clinic, maybe another day they do some house calls, they teach. There's just a breadth of spaces and settings and ways of caring for older adults in the healthcare system in Geriatrics that can make it exciting and diverse and fun all the time. I will just add a plug for house call medicine, which I have to do in geriatric medicine so that my patient barely wakes before 9:30.
Dr. Mariah Robertson 26:02
And so I often get to take my kids to school and I often get to pick them up at the end of the day if my visits are finished. And that, to me, is such a delight as a person with children who could never do that in training. Not to say the work isn't hard and that there aren't parts that are challenging, but that little delight of some days a week, being able to take my children to school and then go out and take care of patients and do a really important job is amazing.
Dr. Aroonsiri Howell 26:25
I really agree with what Dr. Robertson said. I think one of the biggest problems in US healthcare right now, and there have been a few New York Times articles talking about this, is the commercialization of healthcare in the US. Where not just for profit, even not for profit hospitals are trying to make more and more money at the expense of patients and doctors and nurses. We're asking healthcare professionals to take care of more and more patients in a shorter amount of time with less resources just to increase the compensation of hospital CEOs and healthcare network CEOs, all at the expense of vulnerable people. And I don't think that's only with geriatricians, right? That's everyone in the healthcare system, surgeons, internal medicine, doctors, everyone. And it seems like it's only getting worse, especially after the pandemic.
Dr. Aroonsiri Howell 27: 19
And I hope that we hit an inflection point, we're moving away from this. But right now, based on how politics works, it seems very hopeless, I guess. But the great thing about Geriatrics is that it's a great deal that helps counter that kind of burn out from people trying to push you to do more with less. Because like Dr. Robertson said, when you feel that you make a difference with the one patient that you see, and I think that helps limit the burn out because even for me, when I'm down and I'm burned out and I was told to do more with less, I go back to see the patients and that's what brings us joy and that's what helps us get through the day.
Dr. Aroonsiri Howell 27:59
The other part about how geriatrics can help with physician burnout in general also is that we can work as part of the PACE programs, PACE stands for Program for All Inclusive Care for the Elderly. And I've had a lot of geriatrician colleagues who kind of move on to the PACE programs because they don't want to deal with the burn out from being pushed to see more patients anymore and the PACE program is really great because it's patient centered. You go to the patient and you treat them where they are, but also it's a capitation rate program where you get a certain amount of money from Medicare and that's it for the year. So there's a high incentive to provide quality care and not just increase the volume so you can build more.
Dr. Mariah Robertson 28:44
Completely agree. I think one of the things that's a challenge is that it is academic. Centers are behind on this and I think we have the most learners and also are kind of moving at a snail pace in comparison to a lot of venture capitalists and other groups outside of academia who see the value in value based care, see the cost savings and who can expand exponentially when they're not beholden to academic health system. For example, And so I think one of the things to bring it all back is that we need to find ways to expose our trainees to these options in these models, even if they're not affiliated with our academic centers, making it still something that we encourage their exposure to. So they can see pace in their communities.
Dr. Mariah Robertson 29:28
They can see home based medical care, even if it's not affiliated with their academic institution. And they can understand that this is a way that they can practice medicine that is joyful, that is not deeper service, where you have to burn and churn through 30 patients a day to make money. And where you also provide value added. And I actually feel like a weight is lifted to know that truly the models that work are not physician centered, but our team centered, where we value all the members of the team. I think traditionally in medicine, it's always centered on the physician. And that's just negating the skills that so many other team members bring that allow for better care, more comprehensive care.
Dr. Mariah Robertson 30:06
And seeing that in geriatric, seeing that in models like capable, for example, where there isn't even a physician involved, those things can help learners really see the breadth of what's out there for the care of patients, but especially older adults. So I think it's an exciting time. Maybe also you can link in the show notes the independence at home demonstration program just because that shows this is a Medicare demonstration project to see if there are cost savings affiliated with doing more value based, home based medical care. And it's unbelievable how much money was saved and also how much better care was received.
Dr. Aroonsiri Howell 30:38
I want to put in a plug that the two happiest doctors are pediatricians and geriatricians. And I think that payment systems change based on politics. But if we're looking towards the future and we're looking towards things that are practicing in a way that brings us joy and practicing in a way that brings quality, because in the end, I do hope that's what we as a country pay for. I think geriatrics is a great field if you are looking for the long term and not just for right now.
Dr. Mariah Robertson 31:15
I love that so much. It's so true. I just think it's hard to bottle and sell the joy of geriatrics. I wish that I could, other than just exuding my joy when I can. But I will just say that aging is a gift and caring for individuals who have lived long lives is a huge gift. And every day I get to sit in here, the secrets to longevity, the secrets to a well lived life, and to sit with the joys, the challenges, all of the many layers of it. And it feels like a secret that I get to be a part of every day and that is something that I think we need to demystify and to make sure people understand. It's such a gift. And it's such a gift to care for our aging population. And I hope more people can see that and appreciate it in the future.
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