New-in-Practice, Geriatric Medicine; Care of the Elderly – McGill University – McMaster University – University of Toronto
My name is Elizabeth Niedra, and I’m in my first year of practice as a Care of the Elderly physician in my hometown of Toronto, Ontario.
I currently work in a variety of settings, including a hospital-based community outreach program, a primary care home visiting service, an inpatient rehab hospital and long-term care.
I completed my residency in Family Medicine at the University of Toronto in 2017, followed by a year in the Care of the Elderly Enhanced Skills program, also at the University of Toronto, in 2018.
I have a Bachelor of Science degree, Major in Physiology and Minor in International Development, from McGill University. I received my Medical Doctorate at McMaster University’s Michael G. DeGroote School of Medicine in 2015.
Why I chose Care of the Elderly and this location.
Family Medicine Care of the Elderly was a natural specialty choice for me for many reasons.
First, I grew up in an Eastern European culture that places high value on sharing with and learning from older adults; with this at heart, I feel a great sense of adventure and well-being; spending my days talking with and learning from my community’s diverse seniors.I also have always enjoyed the complexity and art of Geriatric medicine. In this field we care for some of the most medically complex patients, but the human factors of quality-of-life, goals of care and the logistical trials of living as an older adult all make for very creative and challenging work to find patient-centred solutions.
I chose Family Medicine as my avenue to geriatric care as I have interested in the community-based prevention and ongoing care of geriatric syndromes; also, because I love checking on newborns, counselling on preventative health and caring for whole families, too! I choose to work in the mostly home-based setting as I love the colour and humanity that can be found within the homes of our city’s elderly, and I think it’s an invaluable way to understand the social context within which our patients age.
Finally, working in home care means I can commit to caring for some of the most frail and vulnerable patients in our healthcare system, who have extreme difficulty accessing healthcare elsewhere than the ED. With this, I feel my work is meaningful in a systems-based approach to reducing the cost of caring for older adults, and most importantly, helping seniors age in place, in their own way.
What does a typical day of clinical duties involve?
How did your residency program prepare you for practice?
Overall, my residency and fellowship program prepared me well for practice. This was thanks to an emphasis on working with vulnerable populations, finding creative solutions to problems in under-resourced areas of the healthcare system, and of course, expert training in geriatric medicine.
A particular strength of my residency program was its site at St. Joseph’s Health Centre, which serves not only a considerable elderly population but also a very socio-economically diverse patient group, with careful emphasis in the program on caring for vulnerable patients, harm reduction, social determinants of health and advocacy.
Electives in Geriatric Medicine here in Toronto from early in my residency were extremely helpful in confirming my interest in this field and deepening my knowledge base prior to my fellowship. The fellowship program itself does an excellent job teaching expertise in Geriatrics and its subspecialties, including Geriatric Emergency Medicine, Palliative Care and Behavioural Neurology; a level of specialization difficult to achieve with residency alone.
Additionally, as a small program (in Toronto at least) I found my program directors extremely open-minded and flexible in customizing the fellowship experience to each of our specific goals for practice. This made it feel like a really useful prep year to pick up any additional skills I felt were critical to my specialized practice goals (For example, more training in small procedures for home visits).
In terms of other electives, I found both Emergency Medicine and rural/remote electives to be very helpful preparing me for home-based practice; it feels much easier to prevent emergency visits when I have a nuanced understanding of the scope and practice of the Emergency Department. Furthermore, rural/remote electives prepared me excellently for relying on clinical skills and resource-limited workup to manage clinical issues.
Unfortunately, I received very little formal practice management training; the exception being some didactic teaching on billing. I find this is an area that is generally under-taught in medical training, regardless of specialty.
Did you seek any resources outside of your residency training to help you prepare for practice?
In preparing for the end of residency and practice, I did use several supplemental learning materials I still access regularly and find very helpful – particularly medical review podcasts; I can listen to them while driving and doing other activities. This means I can get a lot more CME into an average week.
For example, I really enjoy ‘Family Medicine RAP’ and ‘Emergency Medicine RAP’, both of which are US-based review podcasts available for a reasonable yearly prescription fee, but with customized Canadian content.
Can you describe the transition from residency to practice?
I was very fortunate as through my fellowship program, I became very well-acquainted with my future colleagues in Toronto, and as well as the different sites hosting care of the elderly clinical programs. Because of this existing comfort with the landscape and connection to other staff, the transition to practice was much more kind than it might have otherwise been.
Still, initial transition to practice can be challenging. While the scope of your skills and clinical work may not change significantly from fellowship, the new responsibility and independence that comes with practice can feel bit isolating and nerve-wracking to start.
My advice would be to keep mentors and peers close during the transition, and when more senior colleagues offer to be available for questions or advice, be wise enough to take them up on that back-up support.
There’s also a big shift in non-clinical demands on your time when starting practice. Residency administrative responsibilities are replaced by new practice management tasks like billing, team development, teaching, and CME.
New responsibilities requiring new skills which may not be taught as thoroughly in residency, creating another hidden learning-curve look out for.
What are the best aspects of being in practice?
I would say the best aspect of being in practice is the freedom to make the practice of medicine your own.
While I always appreciated the variety of experiences offered by medical school and residency, it’s a remarkable feeling to know you have the freedom to choose the kind of medicine you practice; in terms of all of style, specialty, and setting, now and ongoing for the rest of your career.
It feels wonderful to be able to focus on the parts of medical practice that mean the most to me, day in and day out in a sustainable and long-term routine.
What are the most challenging aspects of being in practice?
While I’ve found my new colleagues very open to support and building collegial relationships, independent practice can sometimes initially lack that “resident lounge” feeling of peer support that is so helpful in training. This is especially true if you are the only new staff at your practice site or are working in a single-physician practice.
In this way, independent practice can feel relatively isolating and unstructured in the initial months. I’ve found reaching out early to build safe relationships with other staff to be helpful in mitigating this; as well as keeping my peers close through social media and phone contact, even if when no longer working in the same specialties or cities.
What is one question you’re often asked about being in practice?
Residents always ask about billing! Especially with regards to home visits and care of the elderly focused practice designation, which are definitely niche areas in terms of working ministry.
Residents have often heard that family medicine home visits are inefficient and unsustainable financially, something that can be presented as a significant deterrent to this style of practice. In my experience though, it’s hardly been the case – home visits can be extremely satisfying and rewarding, with very reasonable remuneration.
Often, the difference is made by practice style and structure, team resources and a bit of billing nuance know-how. I’m more than happy to give trainees the detailed run-down on my practice management, to try and dispel some of the myths around house calls and recruit more allies in this extremely high-needs area.
Is there anything you would do differently in residency now that you are in practice?
Something I realized coming to the end of my residency, which I’m certainly grateful for in practice, is the difference in availability of training and learning opportunities in practice.
While CME opportunities can be abundant, they are sometimes challenging to prioritize in a busy practice week.
I would advise to not take for granted a moment of formal teaching in residency; after you finish training, didactic learning will be a privilege: often accessed outside of already busy work hours, and frequently at an out-of-pocket cost.
Don’t let learning-fatigue get to you, and soak in the training experience while it lasts!
On a more personal note, I stayed in my home city for residency, and while I had a wonderful experience, in retrospect I may have considered training away from home. Now that I’ve transitioned to practice in my home neighborhood, I’m finding very little incentive or reason to move elsewhere for a year or more.
Taking the opportunity to spend 2-3 years outside of my home and comfort zone might have been an interesting way to get a bit more life and travel experience out of my residency years.
What are your colleagues like and how do you interact with each other?
Here’s a biased answer – my colleagues are wonderful, because most people who choose careers in the Care of the Elderly are! Haha!
In all seriousness, though; I’m grateful to have found a specialty path that is truly a vocation, because it means that most of my colleagues, while diverse in background, share a deep kinship in their values and outlook; both in practice and in life.
After many years of training as the odd-one-out with a passion for caring for older adults, it’s a beautiful thing to have found my people – so to speak – in my care of the elderly field.
I find interactions with my colleagues much warmer and less formal than they might be elsewhere, I think owed to the relatively humanistic and down-to-earth nature of home visiting practice, and the common joy we find in the work that we do.
How do you achieve your CME hours (i.e. do you go to conferences, read journals, etc.)?
I achieve my CME by attending conferences, reviewing challenging cases on CME-accredited online resources, and listening to accredited podcasts like ‘Family Medicine RAP’.
What are your academic interests (e.g. leadership activities, research)?
My academic interests are focused on teaching medical students and residents on the care of the elderly, especially promoting early and holistic exposure to caring for older adults, and dispelling stigma and hidden curriculum that often discourages working with older patients.
I’m also keen to take on work as a physician champion in bridging the gap between routine primary care and the care of the elderly, particularly speaking to expanding support and infrastructure for home visiting work.
What is your work-balance life like and how do you achieve this?
I think to say anyone actually achieves a work-life balance is a perhaps a bit of a stretch. I like to think of it more as a constant flux; my physician identity and personal identity are both meaningful to me and demanding of my time, though unfortunately sometimes (and to varying degrees) in conflict with one another.
Sometimes work does a small takeover for weeks or months at a time, other times there’s more room to learn, grow, and rest outside in my non-physician life. Thankfully, I’m able to ride that wave, I have a partner who – while not a physician – has a similar work dynamic with a fluctuation of long, demanding hours.
We work the balance by supporting each other without judgment in both our heavy-workload and light-workload modes; we make sure even when we’re busy, we’re still getting enough sleep and finding ways to have fun.
My minimum requirements for mental health maintenance are protected sleep hours, semi-regular exercise and some kind of creative pursuit every day, even if it’s just taking the time to cook dinner or singing along loudly while driving to my next visit in the car.
When work is in our favour, I sing in a choir and get involved as a volunteer in my cultural community, and we love hitting the road to cottage country or just a daytrip to a new wildlife hike, to really get outside and find fresh space to breathe.
My advice would be that it’s important to find things that help you unwind and build resilience, but true wellness is much more than developing interesting hobbies or finding time to exercise. In fact, this strategy can often backfire, as it can just add more must-do items to an already full plate, and paradoxically contribute to burnout.
I like to quote one of my favourite poems, The Invitation by Oriah Mountain Dreamer – It matters less how you fill your time, or what well-roundedness mean to you. It matters more just to discover, “What sustains you from the inside when all else falls away”, and learning, on your own terms, what that flame needs from you to stay alight.
That way, you always have a safe place to go to, no matter what is happening in practice or the world outside.
Are there any major differences in your non-clinical life now compared to residency?
I think so, definitely. In some ways, I feel as though my life and non-clinical time is much more my own, which is very liberating.
For example, in planning my next career and family goals, I no longer have the requirements and time constraints of completing a residency program to contend with. What’s more, being off a rotation-based lifestyle makes it much easier to create a stable home life and a routine. This has been a huge relief for my partner and I; as we have already spent a lot of time dating long-distance and through grueling training programs.
As a counterpoint, the privilege of continuity in family medicine can be a double-edged sword in practice. As a staff, I find it much harder to “turn off” my clinical brain and put work away at the end of the work day or on the weekend, as primary care workflow is constant and ongoing and – unlike in residency rotations – I don’t hand over patients and walk away after a day, week, or month on service.
I continue to struggle with learning how to carve-out space for my non-clinical identity and get a good night’s sleep after a worrisome. Speaking to some of my older colleagues, perhaps it’s not a challenge with a quick or easy fix.