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The road less traveled

September 2009

by Sheila Hotchkin

As graduations go, it was low key: About a dozen graduates, joined by professors and well-wishers, gathered in a lecture hall one weekday morning this summer. Remarks were made and certificates distributed before everyone hurried back to work.

Pomp was in short supply, but passion was evident. The graduates - each of whom had completed training in geriatrics, palliative medicine or chaplaincy at The University of Texas Health Science Center at San Antonio - spoke with great enthusiasm about their work.

"I personally chose geriatrics because I feel like seniors are very wise," said Neela Patel, M.D., one of three graduating fellows in geriatric medicine. "I want to make the end of the journey very peaceful, comfortable and happy for them."

And their professors were thrilled to see them entering these professions.

"There are unbounded opportunities for people who want to go into these fields," said Michael Lichtenstein, M.D., M.Sc., chief of the Division of Geriatrics, Gerontology and Palliative Medicine.

The "oldest old" - those over 85 - are the fastest-growing segment of the U.S. population, according to the President's Council on Bioethics. Their numbers are expected to more than quadruple between 2000 and 2050, going from 4 million to 18 million. Meanwhile, the number of doctors who specialize in treating the elderly isn't growing and may be declining.

One reason is pay. Geriatricians earn much less than other specialists. They even fall short of their primary care colleagues, despite training at least one year longer.

"It's paradoxical. It's frightening to students. And, of course, it's a major factor keeping students from going into the field," said Jerald Winakur, M.D., a clinical professor of medicine and associate faculty member in the Center for Medical Humanities & Ethics.

Dr. Winakur recently authored a book, "Memory Lessons: A Doctor's Story," on his experiences as a geriatrician who witnessed his own father's struggle with disability and dementia.

As Dr. Winakur notes in his book, geriatricians face another inescapable truth: There is no triumph over aging. While many medical specialties focus on saving or prolonging lives, a geriatrician's day might involve explaining why a medical procedure would take too great a toll on an aging body, finding strategies to cope with a patient's loss of function or helping a family decide when the time has come for palliative care.

Yet, despite the challenges, a 2002 survey found that geriatricians have the highest job satisfaction of any medical specialty.

Many geriatricians appreciate the intellectual challenge of treating multiple conditions in a patient while taking into account the differing capabilities of an aging body, as well as a patient's environment.


  Photo of Dr. Gerald Winakur and his father, Leonard Winakur
Dr. Jerald Winakur, pictured left with his late father, Leonard, draws on his experiences with his father's disability and dementia to interest students in the field of geriatrics.
A geriatrician might ask whether a patient is eating properly, needs help with medications and can keep up with grooming They are interested in whether patients can accomplish tasks with multiple steps, like cooking a meal or paying bills. They want to know who helps that patient.

"Geriatricians are in this counterculture, asking different questions," said Liliana Oakes, M.D., co-director of the Health Science Center's geriatric fellowship program.

Many young doctors who are interested in geriatrics were greatly affected by a loved one who went through a difficult illness or dementia. That was the case with Dr. Oakes, who describes how her grandfather would disappear for hours after going out to buy bread. "It didn't occur to us that it was a disease," she said.

For certification in geriatric medicine, a year of training is required. The Health Science Center fellowship offers an optional second year for those interested in teaching or research. It typically accepts three fellows a year, but has taken up to five.

Among the program's strengths are its strong focus on cultural aspects of aging and tremendous interaction between fellows and their counterparts in other disciplines, including palliative medicine and geriatric psychiatry, dentistry and nursing.

Nationwide, the number of geriatric fellowships has grown, but the total number of applications has not. In contrast, the Health Science Center attracts a few more applicants each year.

"I think outreach to our own students and residents has been more and more successful," said Laura K. Chiodo, M.D., who was the program's first fellow after it came into existence in 1987. She took over as director of the program a decade ago.

The John A. Hartford Center of Excellence in Geriatrics Education at the Health Science Center not only provides support to fellows but also exposes medical students and residents to geriatrics. And the Health Science Center is one of three universities involved in the Medical Student Training in Aging Research (MSTAR) program, in which medical students spend eight to 12 weeks during the summer conducting aging research.

"It takes a special person to come into geriatrics," said Sandra Sanchez-Reilly, M.D., palliative medicine section chief and co-director of the San Antonio MSTAR program. "Identifying them early is the key."

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