The Unknown Profession: A Geriatrician

Abstract

The term “plastic surgeon” is oddly uninformative, although it seems likely that most people know what plastic surgeons do. How well can a sample of individuals encountered on the street describe what geriatricians do? To answer this question, we strolled through downtown Baltimore’s Inner Harbor, armed with a video camera and picture identification cards to ask the following question: “What is a geriatrician?” Two of us (PA, JY), from the Johns Hopkins Division of Geriatric Medicine and Gerontology, surveyed a convenience sample of people aged 18–80. To further enhance this survey, a video of the interviews was produced (available in online version of article). We entered this exercise having recently joined the ranks of geriatricians—prepared to improve the health and quality of care of our elderly patients. Our naive excitement at entering this noble specialty was trampled by the reality that virtually no one we interviewed knew what a geriatrician was. Answers like, “somebody who works for Ben and Jerry’s ice cream” were amusing but at the same time typical and sobering. This simple survey reveals a distressing gap in the public’s knowledge of the field of geriatrics and the need for better understanding of its importance to public health and individual health. After all, if people do not know what a geriatrician is, how can they support the growth of geriatrics or seek care from us?

Dr. Ignatz Leo Nascher proposed the term “geriatrician” in 1909, yet geriatrics has been a certified medical specialty for little more than 20 years. Currently, 105 medical schools have an identifiable geriatric academic structure.^1–5 Nevertheless, with the shift in interest of medical students away from primary care and closely related subspecialties, geriatricians continue to be rare. There are only approximately 7,000 geriatricians nationwide,⁶ with fewer than 350 physicians entering geriatric medicine fellowship training annually.^4,7

In 2008, there were 1.07 geriatricians per 10,000 elderly residents (aged ≥65) in the United States.⁶ The scarcity of geriatricians may explain why patients coming into our geriatric medicine clinics for their first encounters are often uncertain about what to expect and what we do as geriatricians. Furthermore, most patients who could benefit from the care of a geriatrician never see one. Based on our experience and these statistics, we wondered whether individuals in the general public knew what geriatricians do.

In an attempt to measure the extent of general public awareness and ignorance of our specialty, we surveyed a convenience sample of people aged 18–80. On a windy winter (February 27, 2012) afternoon, we strolled around Baltimore’s Inner Harbor and interviewed people who were visiting this popular public space. We explained the purpose of the interview and obtained consent and permission to videotape and record their replies to the question “What is a geriatrician?” The video has been uploaded to video S1.

RESULTS

Interviews were conducted with 82 individuals. The responses demonstrate a striking lack of knowledge about what a geriatrician is.

Responses can be categorized into two groups; those who had heard of the term “geriatrician” and those who had not. Eight of the 82 people we interviewed (10%) were able to answer correctly. The rest of the participants stated that they had never heard the term “geriatrician” before our question.

We encouraged all participants who were unsure of the term’s meaning to make a best guess about what a geriatrician does. Nine more participants were able to guess correctly, and two of the nine acknowledged that they were guessing by associating the prefix “geri” with “elderly” and then, by analogy with the term “pediatrician,” guessed that a geriatrician was a healthcare provider for elderly adults. We received a variety of replies. Several respondents thought that “geriatrician” had something to do with fish or salty water, possibly because our survey was conducted at Baltimore’s Inner Harbor. Others believed that it had something to do with gerrymandering or a jury and the law. For those who recognized its relation to health, several suggested that it was a form of a therapist or a dietitian. The most common response (38%) was that a geriatrician was a nutritionist for older people. The range of answers spanned law, health, oceanography, pop culture, the food industry, and even politics.

Even potential recipients of our services demonstrated notable unawareness of the term “geriatrician.” Past or current caregivers of older family members were unfamiliar with the term. Even the older adults we surveyed did not recognize the term “geriatrician,” nor were they aware that there exists a medical specialist who focuses on the care of elderly adults.

Closer to home, our survey showed lack of knowledge of the term among critical collaborators including nurses and a premed adviser. The only straightforward and correct answer came from a physician.

DISCUSSION

The near-complete unfamiliarity with the term “geriatrician” of a convenience sample of individuals suggests a shocking lack of public awareness of our field. That the term “geriatrician” was conflated with “nutritionist” or had something to do with nutrition may imply an association that needs further evaluation. But is it all in a name? This seems unlikely. For example, “pediatrician” is unlikely to be confused with “foot specialist” though one could imagine a person who has never encountered a pediatrician making that mistake. Perhaps, then, the problem is simply a lack of personal encounter. If so, then neurosurgeons should have the same problem, because there were 4,388 practicing in the United States in 2010, or one for nearly every 70,000 in the population,⁸ but we doubt that it is simply a numbers problem or that the video interviews would have been nearly as amusing had we asked, “What is a neurosurgeon?” In any case, if we need greater numbers of geriatricians to get the word out, we will not achieve that soon, as we struggle with dropping recruitment.

Several major differences make neurosurgery a far more recognizable subspeciality. First, neurosurgery is an older field. Second, people generally require neurosurgery because something unfortunate has happened to them. In many cases, substantial or full recovery from a potentially crippling illness is possible, and early death is often avoided. Patients need geriatric care, in contrast, at least in part because something totally unavoidable has happened to them (inasmuch as they are still alive); they have lived long enough to age. This is not something a person recovers from. Inevitable death is often accepted. For good geriatricians, success includes aging, illness, and death. Third, “exploits” are always valued more highly, at least in predatory and warlike societies, than is “uneventful diligence” such as raising crops or children.⁹ Undergoing and performing neurosurgery have elements of an “exploit.” Caring for a frail, vulnerable, sick elderly person is the quintessential “uneventful (if all goes well) diligence.” If pay scales are reliable indicators, Veblen is right again. Fourth, anyone in the Inner Harbor could need a neurosurgeon (or an orthopedist or ophthalmologist) in the near future. There is nothing distant or unbelievable about this. Young and middle-aged people may well be less able to imagine receiving care from a geriatrician than a surgeon. Fifth, much of geriatrics remains confined to academic institutions because reimbursement mechanisms are so unfavorable to those receiving fees for “uneventful diligence.”

Whatever the explanation for the results of this unscientific but striking survey, the nearly uniform inability of the interviewees to define a geriatrician requires discussion, further study, and a remedy. Improving the health care of older people is too great to simply ignore what is probably a widespread lack of knowledge of what geriatricians do.

This study began as an outgrowth of innocence and enthusiasm by two geriatricians embarking on a career to improve the health of elderly adults. The findings were sobering; geriatricians toil in an unknown field. Our name has not been heard. The beneficiaries of our services—older adults and their caregivers, and even some of our colleagues—are unaware of who we are and what we do. This ignorance probably represents the “tip of the iceberg,” and the extent and depth of this incompletely appreciated speciality. Our impression should be confirmed through a scientific survey; the remedy probably requires investment, perhaps through social marketing. If ignorance exists, understanding why and how best to remedy it is urgently needed and would be a major public policy and public health service.

EXPERIENCE THIS SURVEY WITH OUR INTERVIEWEE

To further enhance this survey, the authors produced a video of the interviews. This can be accessed online in the supporting information section.