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"The Patients Chose Us" (Interview, Part 1)

In this first of a two-part interview, a geriatrician explains why highly skilled training and meaningful patient relationships make her medical specialty such a fulfilling --- and necessary --- one.

 

What's your relationship with aging?

With an increasing population of older adults who require and deserve effective healthcare, it is more important than ever to understand the vital work of geriatricians in meeting their needs. Suvi Neukam, D.O., assistant professor of internal medicine and geriatrics at Oregon Health & Science University in Portland, Oregon, offers valuable insights into how her profession enables elders to not only survive but thrive. (This interview has been edited for clarity and length.)


Why did you decide to be a geriatrician?


I never really had one “Aha!” formative experience that inspired my passion for geriatrics. I was always just drawn to the population. I mean, when I was 22, I spent three mornings a week at a local water aerobics class in Washington, D.C., and was the youngest by 50 years. This felt natural to  Suvi Neukam, D.O. me, but my peers at the time found it odd.


What are some common misconceptions about older adult patients and their medical needs?


When I tell people that I am a geriatrician, it is not uncommon for them to assume that I only “help people die.” Sure, death is a part of geriatrics, but goodness, there is so much more to the field of aging: maintenance of physical function, age-appropriate preventive care, cognitive health, preference-aligned care, medication reduction, care planning, and management and treatment of age-associated conditions such as falls, bone health, urinary incontinence, and delirium. Not to mention there is an entire medical specialty devoted to the final chapter of life: hospice and palliative care medicine.


Another common misperception is that geriatricians, de-facto, “do less.” More accurately, we “do differently.” Geriatricians come to the specialty with strong foundational internal or family medicine training, however, we have additional training and interest in understanding a patient’s values and preferences. We also strive to understand how long it will take the patient to experience a meaningful improvement or risk reduction from whatever we are doing.


Geriatric-minded care is not necessarily about doing less. It is about doing what is right for the patient in front of you, taking into account their values, care preferences, and also the medical nuance of the intervention in question.


In what ways does ageism play a role in their medical care?


If you can believe it, it is from my patients that I most frequently hear ageist remarks. “Dr. Neukam, aren’t I too old for that test?” “They would never offer to do a surgery for me!” “You really think I can exercise every day? I’m too old for that!” “Ninety-year-olds can’t learn to do Zoom."


I encourage patients to not assume that they are ineligible for a procedure, treatment, or medication simply because of their age. Instead of simply assuming they are too old for something, I suggest people ask, “What sort of benefit could I see from this intervention?” “How long will it be before I see that benefit?” and “What are the downsides --- side effects, complication risks, time in the hospital, increased level of supportive care --- to doing this?”

 

Why should older adults consider a geriatrician for their care?


I believe that geriatricians give excellent care to older adults. To begin with, most geriatricians have a special affinity for the older adult population. Many of us would say “The patients chose us.” We truly like spending time with elders, and in my experience, this sincere enjoyment is mutually felt in patient visits.


More practically, we have additional training in many syndromes and situations that are specific to older adults. A 70-, 80-, 90-, or even 100-year-old is quite different from a 20-, 30-, 40-, or even 50-year-old. They are in a different chapter of life with different medical considerations, a different social context, and different existential questions and values.


When it comes to their training and practice, how do geriatricians differ from internists, general practitioners, and family physicians?


Geriatricians are generalists who have completed additional fellowship training in conditions and situations specific to older adults. I joke that there is always more we can do in medicine --- us internists love tests, procedures, data, interventions --- anything to solve the mystery! And, until told to stop, most of us will keep exploring and questioning.


When I have on my “geriatric mindset” glasses, however, I look at care differently. I temper my internist’s urge to solve and fix. Then I focus on how my efforts will benefit the person in front of me. And what is deeply rewarding about this field --- and why I believe geriatricians have an incredibly high job satisfaction --- is that the “right” answer is different for every patient.


What has brought you the most satisfaction in your work?


The rich histories, fascinating stories, pearls of wisdom, and balanced perspectives have certainly kept me content in practice. But what I appreciate now is how deeply rewarding geriatric medicine is. It is rewarding because I do genuinely like my patients and feel so glad when I can improve their lives in a meaningful way.


But it is also rewarding because the care I deliver is different and richer than what I had expected. I cannot emphasize enough how nice it is to feel exhausted but satisfied. What I mean by that is that everyone in medicine works very hard, but I am not sure other doctors feel as proud of the care they give. I am not sure that the medical system is set up well to allow non-geriatricians to feel like they have the time and support to really get to know their patients and give the type of personalized care that makes this job feel simultaneously challenging and exhausting but also rewarding, sustainable, and ultimately worth it.


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