Geriatric Rotation / Clerkship: How to Survive It

This was my last core rotation for third year. I had this right after my psychiatry rotation. I don’t think most medical schools will require you to rotate through geriatrics. I suspect that my school made this rotation a requirement because:

  • It prides itself as one of the top 20 medical schools in the US for geriatrics.
  • The geriatric department gets funding and want to justify why it should continue to get funding.

Politics just does not go away, especially when money is involved.

With that being said, if your school does not force you to do a geriatric rotation, you can skip this article. (Although if you do so, you’ll miss out on some engaging stories.)

Alright, let’s get on with the stories then …

The American Geriatrics Society (AGS) consider “old people” to be 55 years old or older. For you baby boomers out there, how do you feel about what? Personally, I think 50’s are the new 30’s. Anyways, most of the patients in this specialty will be much, much older than 55 years.

My Experience with Geriatric Rotation

The rotation spans over 4 weeks. I spent 1 week in my school’s outpatient clinic, 1 week in the hospital, and 2 weeks in a nursing home.

There isn’t much to say about the medicine aspect, because it is quite straight forward. Show up. See Patients. Go home. But I will tell you why my experience in the outpatient clinic and nursing home confirmed that I do not ever want to be employed as a doctor, and why I would rather start my own practice. In addition, I met my first malignant gunner.

The Scared Doctor

The first day of my rotation, I met a worried, stressed-out, and fearful doctor. He was afraid that he was not busy enough — that he was not seeing enough patients for a day. Normally, not having enough patients is a good thing. The less patients you see, the less work you have to do, and the more you get to lay back and chillaaaaax.

However, that is not how it works in the outpatient clinic. Yes, the doctor does get a salary. But he also has a quota to meet. He must see a certain amount of patients every year to justify his pay. If he misses the quota, there is a possibility that the administrators would lower his salary for next year. And he could not afford to live on a lower salary.

You see, he just got married, bought a house (mortgaged to the hilt, of course), and had an unplanned baby. He has a family to support. He has a mortgage to pay. He’s basically screwed.

Looking back, there are a couple things the first doctor did wrong:

  • He became a geriatrician. If you want to become a doctor for old people, you generally need a 1 – 2 year fellowship. So that means you will endure an extra 1 – 2 year of low pay. And for what? After fellowship, you’ll make the same same amount or less than a primary care doctor, which is already on the bottom of the totem pole in terms of pay.
  • He started a family. He can’t just worry about himself anymore. He must worry about others. He has to make enough to satisfy the wife and to feed the baby. He is desperate for money, which results in a whole lot more power for the employer.
  • He bought a house. Assuming he made a hefty down payment, he has quite a bit of equity in the property. So he cannot just walk away from it. This means is he rooted in the area and has a limited amount of prospective employers. This translate into more power for the current employer.
  • He agreed to the quota. If I was to negotiate an employment contract and wanted a stable salary, I would have demanded the quota not apply to me. I seriously doubt that if the doctor exceed the quota, they would pay him more money. So why should he be penalized if he cannot meet quota. In medicine, it is apparently quite common for others to transfer their burdens to the doctor (i.e. insurance companies increase administrative burdens to the doctors who want to get paid, employers forcing doctors to meet numbers to justify their pay).

I thought that if you were a salaried doctor, you would not have to worry about quotas. Making numbers is for the bossman to worry about. Unless you are in sales, It is very rare for an employee to worry about bringing in enough money, simply because it is out of his control.

I asked another doctor if it he had a quota as well. He confirmed that he too had to make quota. I think this is more and more common, especially in the Northeast where the doctor-to-population ratio is higher than any other part of the US.

My response to all of this is:

I don’t need your money. I don’t need the government’s money. I don’t need the insurance company’s money. And I don’t need the prospective employer’s money. I’ll get my own money by practicing medicine my own way. I’m setting up my own shop.

My First Malignant Gunner

I’ve been lucky throughout my third year of medical school. I have not met a malignant gunner until my geriatric rotation, which is at the end of the school year. Yes, there were gunners in my other rotations, but they were the nice ones and did not try to be the best at my expense.

Well, this malignant gunner was the type of person everyone loved to hate. He was a total suck-up to the attending. He asked for information that other students found and presented it as his own. He bossed other medical students around (but he left me alone). Oh yeah, he was arrogant as heck.

I called him TH, which stands for TryHard. Because he … Tries. Too. Hard. Frankly, there was no reason for him to try so hard because a) he was a fourth year student who already matched into a residency program and b) he doesn’t even want to do geriatrics. I later confirmed with other fourth years that TH is indeed, in fact, a douchebag  (yes, the vaginal irrigation type).

So the day he stepped into a small puddle of diarrhea, I tweeted:

Seeing a gunner step in diarrhea on the hospital floor. I laugh on the inside. @LifeofMedstudnt #lifeofamedstudent

— Alex Ding (@AlexDingDO) April 14, 2013

As a side story, a few of my fellow classmates were assigned presentations by a fourth year medical student. Not by an attending, not by a resident, not even by an intern, but by a fourth year. Haha … what a joke. Safe to say, my peers were pissed off. Who does he is? I originally though that TryHard was the person who assigned the presentation. (I later found out he wasn’t it.) I was ready to tear him a new one butthole if he tried to pull that stunt with me.

How to Get Through Geriatric Rotation in One Piece

Overall, this was a very benign rotation. The attendings and residents were all really nice.

If you have this rotation at the end of the third year like I did, it really is just the same song and dance. Come in. Talk to patients. Write notes. Present to the doctor. Go home.

Make sure you know the Beers Criteria and you should be golden. Print this out and carry it around with you.

I actually crammed for the shelf exam by studying the weekend before. And I suspect I did quite well. Since there wasn’t a geriatric section in any of my review books, I basically used my class notes from my second year’s geriatrics course.

Books for Geriatrics

You don’t need a book for this rotation. And if you go to my school, the department will lend you a book: Geriatrics at Your Fingertips.

Geriatrics at Your Fingertips

I would not recommend you buy this book unless you are doing a fellowship or if you plan to treat lots of old people. Think of this book as the Pocket Medicine for geriatrics. It will guide you on how to diagnose and treat. Everything is in outline format.

You really should not have any problem with this rotation.

This article is part of the How to Survive Medical School series. Click on the link if you want more tips and hints about surviving academic hell.

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