Revival of a Debate – Subspecialization Following MD Geriatrics

There has been much turmoil within the academic geriatrician community in India recently. The Indian Academy of Geriatrics has been flooded with demands that the office-bearers of the society should appeal to the medical regulator of the country for allowing doctors to pursue subspecialization (Doctorate of Medicine [DM]) courses after completing residency in geriatrics. There have been two highly antagonistic schools of thought in this regard, but the problem is probably gray. At the outset, it would be correct for me to state my obvious conflict of interest that I am personally against subspecialization following MD Geriatrics in India but let us still delve into what the opposing lobbies say. Those in favor of subspecialization support their noble cause with the scarcity of employment opportunities for doctors with an isolated Geriatrics training, the lack of public awareness of the subject, and the difficulties in setting up a private practice outside the academic setup – all valid arguments. Some suggest that gaining subspecialist experience in cardiology or neurology would allow them to practice Geriatrics more effectively and drive innovation. Learning, of course, never stops. Detractors say that Geriatrics itself has great subtleties, and subspecialization would lead to the same compartmentalized practice of medicine as now plaguing the subject of general internal medicine, and which may affect pediatrics too in the future, as the country undergoes a demographic transition. The art of seeing the patient in full may suffer. My great personal concern has been whether a geriatrician turned cardiology subspecialist would bother taking a 20-min drug history for an older patient in the private setup, spending the same time needed for them to perform an angiography. While we all uphold the virtues of humanitarian doctorship, the forces of economics are real. Would a corporate hospital setup encourage a geriatrician turned gastroenterology subspecialist to leave an endoscopy procedure to perform a physical gait assessment of an elderly patient with a vague history and recurrent falls? The financials would probably not make sense. It would be useful to ignore personal opinions and try to look at hard data of how many subspecialist doctors are joining general internal medicine faculty positions or choosing to continue general medical practice in India. However, I could not find much on this aspect in a scholarly search. Our general observations over the past decade in medical academics have been a great crisis of teaching faculty in clinical subjects. Medical teaching institutions, graduation seats, and residency positions are on the rise. Cutoffs are often reaching zero percentile to prevent positions from being vacant. It suffices just to appear for a qualifying examination, and one would make it into specialization programs. The same fate lies for subspecialization in the future. Doctors aiming for a final destination of subspecialization may not be motivated enough to make the most of residency training in Geriatrics nor may they be interested in continuing in academic positions where the pay, sadly, is much lower compared to corporate medical practice. The concern of finding enough faculties to run academic geriatric programs is a very serious one, and the absence of a solution may be detrimental to the growth of the specialty. One argument propagated is that the absence of scope for subspecialization is preventing the best medical graduates from opting for Geriatrics. However, there are medical graduates who wish to opt for residency in what in the Indian context is called “an end branch” where further subspecialization courses are not mandatory – dermatology, tuberculosis and chest medicine, emergency medicine, geriatrics to name a few. Opening up the scope for subspecialization may adversely affect the residency prospects of many such medical graduates who look forward to making the most of the 3-year residency training. Residency positions suited to them may be filled up by those wanting to use it as a launchpad to subspecialist training. The problem is more complex because of the wide disparities in the employment conditions, private practice rules, and scale of expansion of geriatrics residency programs in different states of the country. While MD Geriatrics has been around for a long time in Tamil Nadu creating a pool of doctors, the same is not true for the rest of the country. The demands with respect to subspecialization are hence disparate from different centers – those having a surplus and those having barely enough hands as faculty to continue residency programs. However, national-level policies would affect all centers, and hence, there is a need for a consensus call. There have been some issues raised from a social viewpoint – geriatricians have complained that geriatrics wards in medical institutions are often considered “end of life care wards” and are not as glamorous or as well-funded as other departments. My own experience in this regard has been quite mixed, although there are reports of institutions completely preventing faculty in geriatrics from developing in-patient services, preventing faculty in geriatrics from having administrative roles, and such. The responsibility to change the situation lies with the geriatricians themselves; the Indian Academy of Geriatrics can and should play a more constructive role in sorting out problems of individual academic centers. Branching into subspecializations should not be seen as a solution to bypass the ignominy of neglect. In a country where degrees are often considered paramount – a by-product of our education system which promotes a race for marks and ranks, the obvious charm of more and more degrees is irrefutable. Would there still be a clamor for subspecialization if DM courses are geriatrics-specific and not the same as those following an internal medicine residency? Some have sought an easy solution to this debate by suggesting that a majority vote must decide the official stance of the Indian Academy of Geriatrics. What would be the majority stance if a vote is conducted among medical graduate students as to whether qualifying examinations at the end of the semester should be mandatory? What would be the majority stance if income taxpayers were asked to vote in favor or against income tax? Some questions are not solvable by standard democratic means due to associated conflicts of interest, and some decisions are necessarily harsh for the sustained functioning of the greater system. The debate, though reinvigorated, is complex, and there are no easy solutions in sight. Geriatric-specific fellowships are indeed needed for upskilling, but I stay skeptical to a mass opening up of general medical subspecialization courses to Geriatrics residents. Maybe the time for it would come, but maybe there is considerable time to that, in the interest of the development of the specialty of Geriatrics. I leave you with responses from an anonymous survey conducted among fellows, senior, and junior residents in Geriatrics at our center [Supplementary File 1]. Funnily, as expected, many of them disagree with me!