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By now people who have talked to me about specializations and what I am interested in would have known that I have for the better part of the year been struggling with what to choose. I basically have narrowed down the list to 2 primary considerations-Geriatrics and Emergency Medicine, though it is prudent to say I haven't thoroughly ruled out any others yet.

The people who have spoken to me would usually have been taken aback at my preference for two specialties of apparently polar opposite nature.

This is not the post where I attempt to thrash out my thoughts and come to a conclusion, I suspect it will come but not so soon. Instead, this will be my attempt to coalesce my feelings and reflections on both specialties so that when the time comes, I have these written entries to look back on and aid my eventual choice.

I realize I should have started this when I was in the midst of my Emergency Medicine posting, but it's better late than never. I'll start with Geriatrics first, since ruminations of it are freshest in my mind.

I realised right away when I stepped into ward 8 @ Renci that I had made a terrible mistake, and also what an idiot I was to not have realized it way back earlier. Why put a Geriatrics psoting immediately after an Emergency Medicine one? The abrupt change in pace hit me like a wall. I had little time to adapt when I was ushered into my first ward round. Amazingly, I was still scanning the ward for people to set plugs on (Emed had driven me nuts I tell you, but in a good way- more on that next time).

If you haven't been paying attention to Pharmacology, or like me and most of the general medical student population have conveniently forgotten details like drug interaction and elimination etc, then Geriatrics will drive you up the wall. Each patient has a corundrum of comorbidities, and an accompanying cornucopia of medications. Every ward round is among other things an intense exercise on finely balancing patient physiology against multiple drug effects and interactions. Getting asked "why is the dosage so high? Can we lower this and increase that, take this out and replace it with this other one?" is NOT FUN, as a medical officer and even more so as a sotong student. For the first time in months I was dusting off the covers of my Katzung and flipping through the pages. Even now, 2 weeks into the posting, I can assure you I haven't sorted everything out.

Apart from polypharmacy, there is the effect of multiple comorbidities itself on elderly. We have the triumvirate of conditions drilled into medical students ad nauseum and chanted like a Buddhist scripture at almost every patient's round- hypertension, hyperlipidaemia and diabetes, the "Big Three". Then there are their complications- stroke, ischemic heart disease, pheripheral neuropathy, peripheral vascular disease, etc. There are the other conditions associated with elderly-osteoporosis with fractures of the long bones, osteoarthritis, and the inevitable malignancy. But what burdens both patient and caregiver the most must be the diseases that affect the mind and affect. Dementia and associated psychosis and depression are the most frustrating and energy-sapping conditions in the elderly. But they are also why the elderly are such a sorry lot of people. Imagine having your intellect and awareness and eventually self-dignity and civility slipping away into nothing-death- but then again if you  were the patient you wouldn't feel it, instead your friends and loved ones suffer as your consciousness and their patience erode away slowly and painfully. Watching an old lady cry sorrowfully for her daughter every waking moment was so painful. Witnessing a previously vivacious lady reduced to nothing different from a very old baby-like creature was heart-rending. After 1 week in the subacute ward, I went home and cried.

But within all the burdens, the heartaches, the stresses, lies the beauty of Geriatric Medicine. As many have come to discover, it is worth all the effort to discover. More on my next entry, as I have run out of time. Perhaps you should relfect on what has been written...