I think the practice of geriatrics depends on where you are in Canada as well. With regards to remuneration, it is on the low end since there really aren't any procedures for that given subspecialty, and the fee scale doesn't reflect all the work and effort and time that goes into one geriatrics consult.
So, if you live in Ontario, you won't make enough money to cover the overhead of your office, if you are practicing primarily geriatrics in the community. That's why most, are associated with hospital based practice, and have inpatient wards (for geriatrics). It gives things a bit of "variety" so to speak.
In Alberta, there is an alternate funding plan (salary), and I think that helps with practicing geriatrics here. There is no rush to get through volume (there will always be lots), the preceptors are more into teaching because they have time, and I think patients get better care overall because they get the time and attention that they need.
Having said that, I didn't love geriatrics because it kind of wasn't internal medicine (or a lot medicine) anymore. I'm in third year of my residency, and not going into geriatrics. I did geriatrics in my third year.
Most patients were all deemed "medically" stable before we saw them. So, there was no adjusting drugs for CHF, HTN, DM and the like, because they were already optimized by internists before we got to them. Plus, I think the geriatricians also refused patients who weren't medically optimized before referral. True, a major bread and butter of geriatric medicine is cutting polypharmacy, but there were times where it was kind of overdone accidentally, and patients went back into rapid A fib and CHF because their meds were cut; and thereby, back to internal medicine to be managed. Sometimes you just have to try to find out. The fact is, patients are on 10 or more meds because they kind of need them. Geriatricians do a great job at cutting polypharmacy... as do general internists.
And a lot of the time, we would be assessing patients, and agreeing that they may have worsening dementia or delirium. We would do a bit of cognitive testing, which I found to be pretty educational for residents. But the major ones were consulted to neuropsychologists to do more detailed screening.
But in the end, I found that often, there was little for us to do, except recommend a few medications (anti psychotics for sun downing, or aricept if it helped at all), and the majority of inpatient and quite a few outpatient referrals ended up transitioning people into long term care... I found that part depressing, because almost nobody seemed to get better or go home for those kinds of consults. They eventually needed to go to long term care facitilities, and that, is often sad for them and their families.
A lot of social issues came up, and it was often the whole family that you were treating; that's the good part. You would talk the the patient, but then, you would not always believe everything the patient tells you, and you would then spend the next 2 hours collecting collateral because that's what is very important in geriatrics. It takes time to do geriatrics, and that's just how long it takes to help these families. There isn't anyway around it, so you have to really love it.
We certainly made transitions better, and that's where they're needed. I think the biggest thing that the geriatrician did was see the big picture and coordinated the plans to help families cope with deteriorating family members into long term care. It is all about the quality of life, and that is so important. I think geriatricians did that the best.
Yes, part of their job is to help keep geriatric patients independent and at home in the community as long as possible. I think that they do do this, with the aid of social work, and home care and such; and many, through family physicians have done that already. But the patients and the families that get referred into geriatrics clinics are really the ones who can't manage at home alone.
There was memory clinic - where you would assess for dementia, and follow up. And I suppose, try strategies to slow the deterioration. It's kind of depressing to watch people deteriorate. Falls clinic was the better one of the things that I did. It was happier in that you could minimize falls and keep people more independent and functional. Involved OT assessment of their homes and such. Again, it's all kind of not medicine, and more OT/PT/SW side of things. The other major bread and butter of geriatrics was dealing with incontinence issues.
The positives: no hurry, nothing acute (ever... because, there's internal medicine for that), can take your time, work with allied health, and keep geriatric patients as healthy as they can be, because aging, is actually natural. There's actually a lot of neurology involved in geriatrics too. You can be hospital or community based. You never have to be on call or come in in the middle of the night. It's a great lifestyle specialty, but it's something that I think you really have to like a lot.
The negatives: nothing acute... and you kind of spend three long and stressful and tiring years in internal medicine before you can match into geriatrics... not remunerated as well as the other specialties.
If you go into geriatrics via internal medicine, you have to know that you will be doing a lot of acute inpatient care during the first 3 years... like 90% of the time. That includes CCU and ICU. It's three years before geriatrics, and can be long and work heavy too. Just keep that in mind, especially if you don't like acute care medicine.
With regards to old people: personally, I don't mind dealing with them. In fact, so many patients that we see in internal medicine are old. They have med lists that are very long, and issue lists that are also very long. That's just normal for internal medicine. It's just a reality that we have to face. But they are our patients, and we're here to see them.
In terms of geriatrics via internal medicine or family medicine:
I only know of one girl who has always wanted to be a geriatrician from day one. She went through internal medicine, and went into geriatrics. I think that she is unique, because in recent years, via R4 match, geriatrics has not been popular at all (like, graduating 0 to 2 geriatricians a year in the country). You can't blame residents, who slave through 3 years of a work heavy residency for choosing other things because they liked it more, had better pay, or other reasons.
And I think it largely has to do with selection of internal medicine residents too - their personality types: hard working, spend many hours in hospitals, care less about lifestyle in order and agree to 3 years of this stuff that we do in the first place, who love acute care medicine, or who love academics, love research, type A, etc. That's a big generalization, but it isn't always about attractiveness of the specialty. Geriatrics, is and should be a very attractive lifestyle specialty (with the alternate funding plan).
Perhaps it's also the residents in internal medicine who aren't that attracted to it because of personality fit nowadays. I know that I love acute care. I get a thrill out of resuscitations that we do, and I feel like I'm fixing something. I know someone else who gets a thrill managing diabetes day in day out because she feels like there is this long term impact that she makes a difference in. Meanwhile, there are those of us, who love rheumatology despite the functional stuff that they have to deal with.
Residents in internal medicine also have more other choices at the end of third year too - like 8-10 other subspecialties to choose from... or to be a general internist if they like that the most.
Out of all of the subspecialties, geriatrics is least like internal medicine than the others, I think. I think that it is closer to family medicine on the spectrum today, and that one doesn't need the acute care training of general internal medicine to be a great geriatrician. In fact, a lot come out from family mediicne with that third year of training after family medicine. And are probably just as good, if not better.
Although, I've only worked with FRCPC geriatricians, so I can't really say in comparison.
I hope that's a little helpful.