From a lens of peril, the shortage of geriatricians is a perfect storm for healthcare of older persons. Individually, each crisis—the aging of our largest population, the shortage of physicians in general, the lack of comparable pay for geriatricians and the disinterest of medical students to go into geriatrics—is alarming by itself. Combined, they create a critical situation that’s been discussed with a sense of urgency since at least 2002, with national headlines asking why is there a shortage of geriatricians and online medical forums wondering if advanced training in geriatric care is worth it? 

From a lens of opportunity, however, the ongoing plight offers a chance to explore geriatrics fellowship programs and the future of geriatrics specialists.

1. Overview of fellowship programs

Geriatricians begin their medical careers as internists or family medicine physicians. Geriatric psychiatrists are first certified in psychiatry. As cognitive specialists, they’re required to complete a one-year, accredited fellowship after residency to command the unique qualifications and training needed to care for people 65 and older, often who have the most complicated medical and social problems.

Geriatrician and geriatric psychiatry fellowships follow strict medical education requirements outlined by the Accreditation Council for Graduate Medical Education (ACGME). At the forefront of geriatric education are Stanford Medicine, located south of San Francisco, CA, and St. Louis University School of Medicine in downtown St. Louis, MO. Both have distinguished fellowship programs for geriatricians and geriatric psychiatrists that date back to the 1980s. Graduates of geriatric programs go on to work as clinicians in various care settings, educators, scholars, researchers, administrators or quite often, a combination of these fields.

2. Behavioral health fellowships

The Geriatric Psychiatry Fellowship at Stanford is led by program director, Dr. Parnika Saxena, a geriatric psychiatrist with an embracing open-door policy and a growing wall of Post-it notes with praising comments from previous fellows. The program sponsors J-1 visas and includes clinical rotations on multiple services, including geriatric inpatient and outpatient psychiatry, didactic instruction and research training. 

Offering insight into what geriatric education encompasses, Dr. Saxena explains Stanford’s program in relation to ACGME guidelines:

  • For patient care, we look for evidence you’re able to interact with patients effectively, gather essential information, understand psychotherapy, function in different care settings, adequately prescribe medication as well as when not to prescribe and can liaise with other specialists.
  • There’s an extensive list for medical knowledge, but in general, we ensure our fellows are able to assess and understand psychiatric complications of different illnesses and train you to be a psychiatrist in nursing homes and older care facilities.

We also cover how certain medications have an increased risk of side effects, and psychiatric conditions can sometimes manifest in non-psychotic patients. 

  • For communication skills, we cover working with patients and their families from a wide variety of backgrounds. We train how to translate the info the patient gives you and how to explain what’s needed in a way they can understand. 
  • As geriatric psychiatrists, being mindful of transference—the unconscious act of shifting one’s feelings, emotions or attitudes based on what the patient might have said, done or experienced—can’t be emphasized enough. Developing deep feelings to a person’s past trauma or experiences is a very human response. It’s understandable we might feel strongly. 

As psychiatrists, it’s very important we recognize if we’re having these feelings. One person might feel empathetic by something that was said. Others might feel disgusted. In either case, we can’t let that impact the patient’s treatment.

We also train fellows to be aware of how their unique personality may not be a good fit for every patient. If you’re seeing 20 patients and their families a day—100 patients a week, 400 in a month—it’s not out of character for anyone to not get along with everybody. 

There are certain things you can’t change. We teach the things you can change and to acknowledge what you can’t. We show the need and helpfulness in getting feedback and having different perspectives.”

  • The program also teaches fellows how to keep up with learning. We encourage practice-based learning and train fellows to be clear on what they do and don’t know and how to keep abreast of new information. You’re trained to interpret new evidence that comes in, know your own limitations and how to apply the learning. We also make sure you know when to get your own counselor.
  • Being professional is also a part of training. Are you committed to ethical practices, not just with patients but also with colleagues? We ensure you understand the system at large. For example, the limitations and advantages of different care settings, and how patient care gets impacted in each. 

“Training and feedback happens in a dual format,” continued Dr. Saxena. “There’s on the spot feedback, where we might say something in the moment. For example, attendings might see an interaction or notice the fellow should have followed up on something. We might jump in and say “I wanted to add something” or we discuss when we step away from the patient.  

“Other feedback is provided during weekly mentoring or coaching sessions. After that, we look for evidence of improvement.”

3. Medical geriatric fellowships

Dr. Julie Gammack directed the Graduate Medical Education program at St. Louis University School of Medicine for nearly 10 years. A board-certified geriatrician, Dr. Gammack has been named Best Doctor in St Louis several times in a row by St. Louis magazine. We asked her how SLU’s geriatrics fellowship program helps fellows develop or improve the core competencies needed to be a board-certified geriatrician. 

“With our trainees,” she begins, “we  observe them administering a number of functional and cognitive screening tools during OSCEs, which stands for observed, structured clinical exams. These simulations prepare them to accurately conduct  assessments on clinical patients using these same tools. To ensure trainees have mastered the geriatric assessments, we review their findings and provide feedback after they leave the patient room.

“As health care providers, we’re mandatory reporters. Patients 65 and older are a vulnerable population for whom we have to report if we have concerns about abuse and neglect. Teaching that level of communication, professionalism and compassionate approach to people who are sort of blasé, may be harder. We compensate by giving you tools that make it easier to have these conversations and not feel like you have to sort of wing it. 

“We impart to trainees the importance of what makes older adults different, giving them a greater understanding of why this population faces challenges that many younger patients don’t. That’s part of what we do in medical education. We help health care providers to function better in their role with older adults by giving them the knowledge and tools to do the job.

“To some extent, we also address billing and coding as a part of fellowship, because the practice of medicine—the business of medicine—is part of healthcare. 

“Caregiver burnout is also something we talk about. In fact, the geriatric education center has a tools and resources posted on caregiver burnout and well-being. As geriatricians we’re definitely conscious that patients, caregivers, family, loved ones and neighbors sometimes carry a burden of care that can be overwhelming. 

“Medical and behavioral health geriatricians work closely together. Our geriatrics lectures and educational programming is thus very multidisciplinary. We understand that the issues of older adults are often cognitive, so working with behavioral psychiatry is a standard practice for us. The training programs are very closely aligned.”

4. The future of geriatrics specialists

As for why geriatricians are the high demand, “Geriatrics is a growing field,” explains Dr. Saxena. “It’s no longer niche. More places require double-board certification and hospitals are recognizing they need specialists to help them. In fact, most hospitals I’ve been in have a geriatric division. Smaller, community organizations might also recognize the need but may have a hard time paying for it. Additionally, more people are seeing the value in getting the extra training. For many primary care physicians seeing mostly older adults, as well as those who want academic work and who do research, a geriatric fellowship makes sense.”