Age Discrimination, Eppur Si Muove (Yet It Moves)

nine other medications. The promethazine led to multiple side effects, followed by medications to treat those side effects. She was ultimately hospitalized in a catatonic state and bed-bound for 4 months, and it took a year’s worth of recovery before she could interact with her family again. Mrs. Smith’s age is important because the American Geriatrics Society (AGS) recommends against using promethazine in the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Despite promethazine’s effectiveness in its study populations, it should have been avoided in her case. As a medical student, hearing this story terrified me because I would have chosen the same treatment for Mrs. Smith What her doctor and I failed to consider are the effects that the prescribed medication would have on an 83-year-old vs the younger individuals in which its efficacy and safety were tested. After completing my preclinical curriculum, I realized I was not taught how to care for older adults. Our education exposes us to a wide breadth of subjects and fields, but our lectures and rotations lack a dedicated exposure to geriatrics. According to the Census Bureau, the United States had more than 40 million elderly persons in 2010 and will have 70 million by 2029. Despite this increase in the size of this population and its healthcare needs, the number of geriatricians in the country is inadequate and dwindling. According to the AGS, there was a 33% decline in medical school graduates pursuing advanced training in geriatric medicine between 2005 and 2010. Although we cannot reverse this trend and build a sufficient geriatric physician workforce overnight, we can better prepare current medical students for the practice of geriatric medicine that they will assume, regardless of their field. To see firsthand the approach to care in elderly adults and what we as medical students must do to practice it competently, I requested to work 1 month on a geriatrics unit during my internal medicine subspecialty rotation. The approach to care I witnessed was different from what I had seen on other services, even when I had been caring for older adults, and it changed how I will care for elderly adults in the future. One practice I observed is deprescribing, or stopping a current medication. Deprescribing is necessary to combat polypharmacy, which is prevalent, and sometimes dangerous, in elderly adults. More than 36% of people aged 75 to 85 are taking five or more prescribed medications, and almost 100,000 adults aged 65 and older are hospitalized for adverse drug events each year. Although polypharmacy is risky, deprescribing can be dangerous. Appropriate medications extend and improve the quality of life as well. Choosing which ones to discontinue can amount to playing Russian roulette. To address this, Dr. Joshua Uy, a geriatrician on my rotation, taught a tactic he called “the partnership with patients. ” The partnership uses close follow-up to obtain feedback on the effects of deprescribing, as opposed to adherence to an evidence-based algorithm that I have learned on other rotations. This collaborative relationship allows the doctor and the patient to balance risks and benefits and make shared decisions to treat or not in time-limited trials. Combining their knowledge of geriatric-specific guidelines such as the Beers criteria with the partnership strategy allowed Dr. Uy and his colleagues to personalize medical care to each person. Despite the importance of deprescribing and other skills that geriatricians need and interactions that they have with greater frequency, such as palliative care and the dying experience, only approximately 10% of my classmates will complete a geriatrics rotation during medical school. Although most medical students will not become geriatricians, the majority will care for older adults, and it is essential that we learn to do so responsibly. The task falls on medical schools and us as students. Our curriculums should better emphasize geriatric medicine in our preclinical years and should provide more opportunities on a geriatric service in our clinical years. As students, we must take the initiative to pursue clerkships, subinternships, and electives in geriatric medicine. As Dr. William Osler once said, “The good physician treats the disease; the great physician treats the patient who has the disease. ” If those words ring true today, then the future of American medicine must learn to treat the 83-year-old Mrs. Smith and not just her nausea.