Geriatrics is considered one of the newest medical specialties because it was not truly studied until the late 1900s. To this day, there continues to be uncertainty regarding exactly what geriatricians do, and older patients are often given fewer resources in clinical settings due to their age or misconceptions about the nuances of elderhood.
Houman Javedan, MD, clinical director for the Division of Aging at Brigham and Women’s Hospital, set out to establish the exact role that a geriatrician plays and redefine the way decisions are made in geriatric clinical care. Here he discusses his development of the Geriatrics Clinical Reasoning curriculum that has completely transformed geriatric care at the Brigham.
Q: What drew you to practice geriatric care?
Dr. Javedan: I initially began as a surgical trainee before I became an internist, but I was exposed to geriatrics in medical school and during my clinical training covering the geriatrics floor at night. I became known as the “geriatric whisperer”—whenever there was a geriatric patient that was difficult, they would always call me. I was very impressed by the integrative approach to geriatrics because when you’re dealing with an older patient, it’s an investigation of truth. You always have to start with a blank slate. The solutions will not necessarily be straightforward, and I enjoy the complexity of that.
Q: How does geriatrics differ from general medical care?
Dr. Javedan: In a younger patient, things are generally driven by one disease process. But an older patient, it could be a problem with multiple manifestations, or it could be multiple different things happening at the same time. The most common presentation in geriatrics is confusion. The breadth of the differential is a simple change of environment, or the patient is imminently going to die. It’s totally different than a younger patient. Older patients cannot tolerate hugely aggressive medical interventions, so you can’t just do every test in the book. You have to find the one that is going to have the greatest benefit because you may only have one intervention that the physiology can tolerate.
A lot of doctors are still trained to think in a disease-based approach, and aging essentially defeats the disease-based approach. If something has an incidence of 100%, it can’t be a disease. The core element of geriatrics is aging physiology and how it interacts with living and with the disease. Geriatrics is about the network, not the nodes—it’s all about integrating things to get the sum vector. There’s aging happening across all these different systems, so we have to figure out how all these systems help each other so that the patient can live.
Q: Could you explain your Geriatric Clinical Reasoning curriculum?
Dr. Javedan: I developed a formal geriatric clinical reasoning curriculum in 2010-11, and what I did was delve into how we teach clinical reasoning. Geriatric clinical reasoning needs to be taught as both analytical and non-analytical approaches. If you’re super analytical with geriatrics, you’re going to suffer because there are just too many uncertainties. The curriculum layers geriatric knowledge onto the basic clinical reasoning that’s done in general medicine. It goes back into true concepts of wellbeing and how you can gently support or nudge physiology into functioning. With how the physiological changes produce different clinical symptoms and affect the disease processes in an older patient, it’s critical that in medical school you’re aware of aging and recognize that what you’re learning may not necessarily apply to the aging population. This curriculum clarifies the clinical cognitive skill of geriatric practice in clinical medicine.
Q: Why did you develop this curriculum?
Dr. Javedan: After I did my geriatric medicine fellowship, I didn’t understand why geriatrics was dismissed so much. Never in history have we had so many people who have aging as part of their reality. Whether it’s public health, medicine, social, or economic variables, we’re living longer. So the way I look at this “silver tsunami” is that none of the ways that we practice medicine has actually been developed in this population. I realized we have to start thinking differently about elderhood and aging.
To this day, there’s a real lack of clarity around what geriatricians do. It’s always viewed as a non-rigorous kind of rotation. One of the reasons I created this curriculum was to highlight the complexity and beauty of geriatrics. People wanted a quick measurement for aging, but geriatricians had discovered that aging happens at a different rate differently in every person.
Q: What impact has this curriculum had on patient care?
Dr. Javedan: For me, it has completely transformed the training of the geriatric medicine fellows, and it’s also completely transformed the way we practice as geriatricians. This has become the norm for us at the Brigham. In the 70s, a small group of people were really the first to look at the aging population with any sort of rigor, and so in some ways, it’s one of the newest specialties out there. This curriculum defines the role of a geriatrician and solidifies the importance of recognizing the complexity of aging in medicine.
COVID-19 was the first time people really needed to pay attention to the elderly, and I actually had a geriatric fellow tweet about how the Geriatric Clinical Reasoning curriculum helped her during COVID-19. When you stop paying attention to what you’re traditionally taught and instead pay attention to physiology, the clinical practice of taking care of older patients will completely transform.
Q: What do you envision for the future of geriatric care?
Dr. Javedan: What I envision for the future of geriatrics is that we not only educate people about aging but that the medical system recognizes its deficiencies around elderhood and the medical care of the elderly. There are so many studies out there that show with geriatric expertise, you can make a difference in this population. This is like climate change: it’s expensive, it’s inconvenient, and it’s going to affect all of us. We have to give this phase of life the resources it needs. All our money goes to procedures, medications, and tests, and this is a population where those three things are not the most valuable. They need more human evaluation. I hope people recognize that you actually need to invest in people with genuine geriatric knowledge and skills to be able to deliver the care that’s needed.