If an elderly person were brought to your emergency department for delirium, would you think to diagnose appendicitis? It’s a mystery why older people can suffer a perforated appendix but report no pain, says Ronnie A. Rosenthal, M.D., chief of surgery at the VA Connecticut Healthcare System in West Haven. “Why don’t they demonstrate the same kind of response to intra-abdominal inflammation as young people do?”
The puzzles of diagnosing surgical disease in the elderly and the challenges of predicting how older people will fare in surgery fascinate Rosenthal, an associate professor of surgery. In the past, surgeons didn’t recognize the ways in which older people differ from the young. “We applied the same rules we applied to middle-aged people to older people without ever determining if they were appropriate,” she says.
The field of geriatrics came into its own in the early 1980s, about the time that Rosenthal was finishing her vascular surgery fellowship at the State University of New York Downstate Medical Center. Two decades later, a great deal of basic information about surgical care of the aged remains unknown. With funding from the American Geriatrics Society and the John A. Hartford Foundation, Rosenthal is working to articulate the unanswered questions in geriatric surgery. She is assisting David H. Solomon, M.D., a prominent geriatrician and director emeritus of the UCLA Center on Aging, in constructing an agenda for further clinical research in general surgery and the surgical specialties.
One reason for the late maturation of surgical geriatrics, says Rosenthal, is “there haven’t been that many older surgical patients before. Rapid growth of the older population and advances in anesthesia and other technology have allowed us to double the percentage of operations we perform in which the patient is over age 65.” Two decades from now, she says, one person in five in the United States will be over 65. And the fastest growing group is those older than 85.
Rosenthal, 56, didn’t plan on a medical career. She was determined to be a biomedical engineer. After earning a master’s degree in electrical engineering at Columbia in 1970, she almost landed the perfect job: troubleshooting a prototype ultrasonic cataract-emulsifying device in the operating room. At the last minute, the company president withdrew the offer, telling Rosenthal he didn’t think surgeons would view a young woman as an authority. She remembers thinking: “If surgeons won’t believe me, maybe I have to just be one!” She’d already realized that she was more interested in the “bio” in bioengineering than in the engineering. She applied to medical school.
Once she was in medical school, however, she leaned toward what she considered more of a “thinking person’s” specialty—internal medicine or perhaps rheumatology. Her perspective changed during a surgery rotation treating nursing home patients. When patients arrived with seemingly inscrutable patterns of distress, the surgeons with experience treating the elderly amazed Rosenthal with their quick appreciation of the nature of the illness. Clearly, this was a thinking person’s specialty, too.
She likes the way surgeons think—“the logic of their approach, pattern recognition, putting things together, being able to fix things. It all fit with engineering. And surgeons do. They think, but they don’t just think. They also do.”
Rosenthal has balanced the demands of her work with raising her daughter, Lauren, who started college at Northwestern this fall. Rosenthal says the keys to balancing work and family are to find high-quality, flexible childcare and for at least one parent to make career concessions that allow for time at home.
Lauren was in middle school when Rosenthal took on the job of chief of surgery at the VA, a multi-specialty service with 20 beds. "Having a VA that is integrated into the intellectual community, as it is at Yale, and having this patient population was a perfect combination. If there were only more women patients, it would be perfect," says.
Rosenthal also appreciates the collegiality at Yale. If I have a new idea for looking at a problem or need someone to help design and teach a program in geriatrics “someone is always willing to talk to me about it and think about how to do it. People here are interested in what you’re thinking. They’re very willing to collaborate.”