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How often have I been asked over the past 30 years, "What is a geriatrician"? I cannot count the times and the ways that I have tried to answer this question. But clearly, even as the field has grown and matured, the public continues to have at best a vague idea of what a geriatrician is and does and why. In this essay, I attempt to capture the essence of my various attempts to respond to this query (e.g., 1) from my friends and neighbors, who still do not understand what I do. I hope that my answer is factually informative while emphasizing that the real magnetic force binding me to the field is my love for the patients we serve, each with an old lives tale to share. I am a geriatrician. I specialize in the medical, psychological, and social care of old people. How old is old? Perhaps 75 for starters, 85 as an average, even 90, 95, 100, and older. I like old people. I love old people. I enjoy their stories. I respect and admire them. They inspire me. They have survived the trials of youth and middle age. They have learned from those trials and all of their experiences. They have so much to teach me about life and what's important. They have given so much and have so much to give. How do you get to be a geriatrician? First, 4 years in medical school to become a doctor, of course. Then 3 years of residency to become an internist or a family doctor, a generalist skilled in diagnosis and treatment of the vast array of medical problems of adults. Finally, 1 or more years in a geriatrics fellowship to become a specialist in the management of the special problems of old people. This is tremendously challenging, because in old folks, multiple coexisting chronic and progressive diseases are the rule, and simple self-limited problems or cures are the exception. In addition, those diseases commonly interact to produce an atypical or nonspecific presentation, making any specific diagnosis obscure. The limited reserves and resiliency of the old person increase the risk of weight loss and malnutrition, dehydration, and bad reactions to drugs and medical and surgical procedures. The complex web of these factors frequently produces one or more of the geriatric syndromes that perhaps best define our specialty: confusion, falls and fractures, urinary incontinence, depression, and dementia, to name just a few. Perhaps my most typical patient is the old-fashioned picture of frailty, a man—or more often a woman—who lives on the razor's edge between independence and triggering a tragic cascade of diseases, disabilities, and complications that all too often prove irreversible. So, as a geriatrician, I am by definition an expert in subtlety and complexity. I am acutely aware of the interaction between physical, psychological, and social factors that affects the lives of each of my elderly patients. Because the care of my patients is so demanding and so complicated, I often work with family members and other professionals who contribute to the care of my patients and try to orchestrate the best care as their primary physician. Our team includes nurses, social workers, rehabilitation therapists, psychological and spiritual counselors, and frequently others. As a geriatrician, I have also come to terms with the reality that most of my sick old patients are unlikely to recover completely. Hence, by training, by temperament, and by experience, I am skilled in continuing and long-term care. This includes palliative care of patients in their last illness, that is, care focused on preserving their comfort and dignity throughout their final days or months. Because the training of doctors in geriatrics and the science of aging lags so far behind the oncoming wave of baby-boomers who will soon begin to experience the challenges of old age—a product of long-standing ageism in health care and society in general—I am most likely to practice my profession in an academic health center. There, as a teacher and researcher, I can best transmit my special knowledge and skills to the next generation of physicians and other health professionals who will care for those aging baby-boomers. My inspiration and my passion will always come from my older patients. One day I hope to be like them; when that day comes, I hope that my doctor will be a geriatrician.
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