What a major shift from being in the ER to the geriatric clinic. I remember on my first day in the clinic, I was surprised by how few procedures were performed and how much time the physicians would spend with each patient. At the beginning of my rotation, I was with some other PA and medical students that had 1 week of geriatric clinic as part of their internal medicine rotation. Looking back now, I am grateful that York’s PA program had set aside Long-Term Care as its own 5-week rotation because I’ve learned that treating geriatric patients can be very complex and it’s crucial for healthcare providers in any setting to know how to properly manage these patients, taking medical and non-medical factors into considerations. 

What I liked about this outpatient clinic was that I was part of the patient’s care from the beginning through to discharge. In the ER, a lot is happening, and I often didn’t see the entirety of the patient’s visit. The nurses were so quick that even if you stepped away for a couple of minutes, all the ordered treatments or procedures would be done by the time you came back. In this clinic, I was able to call the patient back from the waiting room, take their vitals, participate in the history and physical, assist in any tests or lab work that needed to be done (ex. venipuncture, EKG), and then observe the discharge process by the nurse. For patients that got their bloodwork done in the lab on a different floor, I would offer to walk them there if they needed extra help. Being the only student there, it allowed for more personalized attention and there was enough time in each visit for the physician to guide me in how to conduct a proper geriatric assessment, interpret physical exam findings such as spinal cord deformities and specific gait patterns, and finally how I would manage the patient. By the end of the rotation, I became very familiar with the flow of the office and how the providers worked; I could even anticipate what the physician’s next steps were going to be during the visit and offer my assistance. Though the procedures offered in the clinic were few, it allowed me to focus on further strengthening my skills in the procedures that they did do such as venipuncture, EKG placement, and IM injections. I was eager to perform EKG placements because I didn’t get the chance to perform that many in my last rotation. I learned from different staff members their techniques in placing the leads and in making sure the machine was getting a good reading. I would then analyze the EKG lead with the provider. In addition to the procedures, I was able to get a better grasp on interpreting lab work results and diagnostic tests, which are areas that I felt a bit weak in and still need improving on. I was fortunate that the physician had the time to sit down with me, thoroughly go through the patient’s scans with me, and answer all my questions. He assured me that it comes with time to feel comfortable with scans and to try and review as many scans as I can. Before each patient, I would try to test myself by reviewing the diagnostic scans before looking at the radiologist notes. I was also asked to interpret the scans during the visit.  

An important skill I learned in this rotation was having a great deal of patience and understanding of another persons situation. Questions asked to the patients would often need to be repeated multiple times, and many patients were not compliant with their treatment regimen, denied referrals, or failed to follow up with other specialties. It involved a lot of investigation as to why they were not taking their medications or had cancelled their follow up appointments. I feel that a similar compassion and patience will be especially helpful when working in the pediatric setting. Being at the hospital can be especially scary and anxiety provoking for both the patient and the parent, so it is important to approach the situation with as much compassion as possible. Additionally, taking the time to educate on the condition and clear instructions on the treatment plan is appreciated by the patient and establishes a strong trusting patient-provider relationship, from what I have observed. I’ve found that the teach back method greatly helps. There were a handful of times that the patient would be nodding with everything we were explaining in the visit, but when asked to repeat it they couldn’t. I’ve also found that writing down what medications should be taken in the morning or evening, once or twice a day, for the patient helped. 

Two areas that I found myself weak in and would like to improve in was medication side effects and neurological conditions. There was a huge emphasis on knowing drugs and their side effects, especially because the elderly are at an increased risk for polypharmacy and are more sensitive to side effects of certain commonly prescribed medications such as anticholinergics. I found it particular difficult at the beginning when the physicians would ask me questions about treatments, and I would get it wrong because I didn’t know the dangerous effect they could have in geriatric patients. To become more familiar with these drugs, I would often refer to the Beers Criteria and I would read about common drugs I saw prescribed (mechanism, side effects, and use in the geriatric population). Pharmacology class during didactic year was a lot of memorizations in a short amount of time, but with this rotation, I was able to associate the drugs with the patients that was being treated, allowing me to make better connections to remember. Neurologic conditions were also an area that I found I was not strong in and had to review throughout the 5 weeks. I couldn’t confidently say that this weakness or balance issue indicated issues in this part of the brain. In between patients I would review the basics of the brain, its connections, conditions associated with deficits in different areas, and the presenting symptoms.

One of the most memorable patients that I had was a 77-year-old woman with a PMHx of poorly controlled hypertension, heart failure, and severe anemia, who I had seen several times over the course of my rotation. She was referred to the ER for being in hypertensive urgency after stopping all her medications due to swelling in her whole body but had left without treatment because she didn’t want to be left alone without her husband. She was admitted to the hospital a couple of weeks later for symptomatic anemia. After being transfused with 2 L of packed red blood cells, she left AMA because of a mean staff. I think this highlights the danger in patients not being adequately educated on the severity of their condition and risks/benefits of their treatment, along with the importance of treating all our patients with care and empathy. When we were reviewing her medications, we asked her what she knew about her condition and if she knew how each medication was helping her. She couldn’t answer most of the questions or her answers were not correct. After much explanation and use of the teach back method, she agreed to restart some of her medications. She said how she was treated in the geriatric clinic was significantly better than anywhere else and she only wanted to be treated by the outpatient geriatric physician. The way we treat our patients has a significant impact on their view of the healthcare system and seeking further treatment. If they are not treated well, it can be detrimental because a lot of patients may decide they would rather sacrifice their health than interact with the hospital staff.