Dr. Ben Rosenstein

Dr. Ben Rosenstein on the Importance and Rewards of Geriatrics in Family Medicine

10 minutes
Why specializing in older adult healthcare is more vital than ever

Ben Rosenstein, MD, MA, completed his family medicine training at the University of Minnesota St. John's Hospital Family Medicine Residency Program. He completed his Geriatrics Medicine Fellowship at the University of Wisconsin School of Medicine and Public Health. He has deep interest in primary and specialty care of older adults in multiple settings as well as health and aging policy initiatives. As faculty with the St. John’s Hospital Family Medicine Residency, he practices in outpatient, inpatient, and long-term care settings. He is a HRSA Geriatrics Academic Career Award grant recipient. He is using this award to enhance geriatrics education across the University. In this interview, Dr. Rosenstein discusses what he enjoys most about geriatrics as a specialty, how the field has evolved over time, and his plans for the future.

What drew you to geriatrics?

Throughout my training, I felt there was an area of need. We are caring for lots of older adults, and, in various ways, maybe not doing the best job of it. I included myself in that, feeling like I wasn't as capable as I should be.

I wanted to specialize and have a better handle on care of older adults. Especially during residency I strongly felt that way when seeing patients in the hospital. That’s where you see the adverse effects of being hospitalized and the greater impacts these have on older adults. I felt like I was at a loss of how to better manage that.

Geriatrics, for me, was and is a good combination of primary care and other medical interests I have. A lot of us that go into family medicine, or internal medicine for that matter, are very interested in complexity. My background is in engineering—I like hard-to-solve problems. Geriatrics takes complexity to another level when you add in not just medical history, but then geriatric syndromes and social contexts that come into play.

Geriatrics captured a lot of my other interests too. I was very interested in dementia and movement disorders, so geriatrics really highlighted my interest in neurology. Earlier in my career, I was actually thinking about doing palliative medicine for a while. I switched gears because I wanted to maintain more of that longitudinal, primary care—a little bit more outpatient-focused. Also, there are certain elements of care for older adults that seem to stimulate me more than palliative medicine alone, whether that be dementia or delirium evaluations and management. I do practice a lot of palliative care, but I also enjoy the other areas of medicine that are a little outside palliative medicine.

All of us in family medicine have an interest in an underserved population of some sort. For me, it’s older adults. They are an underserved population in many ways. I’ve enjoyed being able to do some advocacy regarding the care of older adults. It combined a lot of interests.

How has your understanding of caring for older adults evolved?

As I've gotten more experienced through my own practice, the amount of internalized ageism I'm trying to counter is quite high. I think it's evolved a little bit in how I try to manage that kind of work with older adults. When I was doing my geriatrics fellowship, I would care for the oldest, most frail, most complicated older adults who faced other elements of ageism.

I still do care for the most complex of older adults, but in my family medicine clinic I'm seeing older adult patients who are relatively well; they might have just a few issues going on. So I’m seeing more of the full breadth in terms of taking care of more well older adults in addition to my most complex older adults. But, being relatively well, they may have preconceived ideas that represent internalized ageism, and it’s really extensive.

Another thing that's evolved is I always knew that we needed to focus more on care of older women. And I am seeing that now more than ever.

What do you wish more people considered when it comes to geriatric care?

Almost all of us in family medicine are going to care for people with various cardiac conditions, but not all of us are cardiologists. In a similar way, almost all of us will take care of older adults, but we're not all geriatricians.

It’s a unique specialty—not organ- or system-based, but population focused. It trains a different thought process. It brings in different diagnostic tools and differential libraries. There may be things that are a little more common in older adults that, through specialty training and practice, I see more frequently and can look out for that maybe somebody else wouldn't, especially related to geriatrics syndromes. There's a certain approach in the care. We are trained in how to approach the complexity and handle it without being scared.

Also, there's really no such thing as a normal older adult. I have 75-year-olds I see in the clinic who maybe have hypertension and that's it. And I've got 75-year-olds in the nursing home who have advanced dementia and need care for everything. Older adults are probably one of the most varied populations out there. If you think about ages 65 to 105, that's quite the span of years, and there's a lot of variation in there. There's no normal; if somebody is 85, their age alone doesn't necessarily tell you much in how to best care for them.

With all of that, something people should consider—especially if they are considering going into geriatrics—is it's not boring.

On that note, what advice would you give students who are considering geriatrics as a specialty?

One of the things to think about when somebody's looking for a career is what makes it interesting and fun. What do they find enjoyable? One of the things I enjoy as a geriatrician is I think (and of course I’m biased) it's one of the most cognitively stimulating specialties out there.

In my role, I'm very independent. I'm in the nursing home essentially by myself. I'm doing a lot of specific things myself as one of the only outpatient geriatricians I know of. But at the same time, it's very collaborative. I work with a nurse practitioner, and we support each other well within the geriatric service arm. I often reach out to the geriatrics pharmacist and ask for their input. We talk about geriatrics being a team sport. So while my work is very independent, it's also very collaborative.

Another thing for medical students, and especially if residents are thinking about a geriatrics fellowship, is really knowing your why for this. This is not a competitive fellowship—at least if the pattern stays the same. Less than half the spots fill every year, unfortunately. You can practically choose where you want to go.

So even though there's not that same competition you’d find with, say, sports medicine fellowships, the interviewers ask some very deep questions. They're looking for people with passion. By its nature, it’s a small community, so interviewers are extremely interested in learning your “why.”  Being that this specialty doesn’t tend to attract many to it, they are trying to gain deep insight into what brought you to it.

What do you find most rewarding about geriatrics and family medicine?

I enjoy the complexity. I like the number of times I have family members of a patient coming to me and saying, “We don't know who's going to help us manage everything. We’ve got all these appointments. Who's going to manage their heart failure and their kidney disease and their diabetes?,” and I get to say: “That's me.”

With that, one of the things that I didn't really appreciate before—and it's partly the nature of the practice I do with long-term care—is that it’s maybe one of the most cognitively stimulating specialties. I've sort of become my own specialist because I see older adults who are very medically complex. They have multiple chronic conditions, and they can't go see a bunch of specialists because of functional mobility issues or they can't wait months for an appointment. In some ways, I've had to become my own cardiologist, gastroenterologist, neurologist, take your pick.

I still will reach out to another specialist via Epic if I have a question, but I'm getting more comfortable in a lot of areas. I act fairly independently. And that carries into some of my clinical and inpatient practice as well. That, to me, makes it enjoyable. I feel like I can manage a person’s needs well and address their concerns in real time.

This applies to both family medicine and geriatrics: I like that I get to form really strong relationships. For example, the people I see in long-term care: I get to know them and their families very well as I see them frequently for regular and acute visits.

In geriatrics, we often talk about the four Ms, one of those being “what matters most” to the patient. While I couldn't possibly address it every time I see somebody, over time I understand what matters to a person through our conversations. I can bring that to future visits and family discussions as their course changes. At times when somebody goes to the hospital for something, I've called the hospital to talk to the ED or inpatient provider and tell them what I know about the person and what's important to them.

Being able to form those strong relationships and that trust is what I really enjoy about being a geriatrician in family medicine. Now and then my colleagues, including residents, will reach out to me for my input or I will see one of their patients as a consultant for memory issues. That is beneficial because a memory care clinic sees somebody maybe once to evaluate for a cognitive impairment—and depending on what they find, they might see the person again in six months to a year. Whereas if I see somebody, I perform a thorough evaluation, know they have a lot of questions, and ask them to see me again in a couple of weeks to further discuss.

As a primary care geriatrician, I enjoy being able to do that. That is in no way to undercut memory care clinics and the extraordinary service they do. They are booked out a year for a reason. But it's a nice service I'm able to do as a family medicine geriatrician, especially for patients who are not English-speaking, where going to another clinic may be more difficult or just isn't something they are going to do. It provides that familiarity, and I'm able to follow up more regularly.

What does the future of family medicine and geriatric care look like to you? What are your hopes and your plans for your career as you look ahead?

In terms of future family medicine geriatrics, we in family medicine need to take a stronger lead in geriatrics. I don't quite know why we haven’t. It's one of the things that we can and should do, yet we don't really highlight it. That's not to say that everybody should become a fellowship-trained geriatrician—although it'd be kind of cool. We just need more directed training. The current requirements are a little bit lax. It would be beneficial if everybody had greater comfort in caring for older adults in general, especially since memory care clinics book a year out on a good day.

As far as hopes and plans for the future, I've got the Geriatric Academic Career Award sponsored by the Health Resources and Services Administration that supports me doing lots of various projects. I'm working within that to hopefully introduce some validated models of care within the hospital, for example.

I've tried to think about formalizing my role as a consultant in our clinic to create more of a geriatrics assessment clinic. I can imagine a future where every family medicine clinic or every family medicine residency at least has a staff geriatrician that can do some specialty care as well. I'm hoping to continue to do some education projects and some research into geriatrics education and more population-level research that looks into patterns around care partners and needs of older adults who are caring for each other.

One of the things that brought me to geriatrics was its ability to pull in my interest in advocacy. So in the future I may be more legislatively active.

Would you like to share anything else?

It’s important to understand the lack of a healthcare coverage system we have for older adults. Based on what's proposed to happen in a couple of years, there are a lot of concerns there. Much of my practice is in long-term care, and Medicaid is one of the primary payers of long-term care. Any cuts there are a high concern.

Partly this is a reflection of how we don't have a good coverage structure for older adults as their needs increase. That is an area I'm hoping to advocate more for as we come to terms with the needs of our older population. Because all of us are going to need care and some level of assistance as we get older. We need to think about how we, as a society, plan to manage that.

Geriatrics Healthcare Resources for Providers and Learners