Prof Kenneth Rockwood is Director of Geriatric Medicine Research at Dalhousie University, Canada and serves on the International Advisory Panel of Age and Ageing journal.
I’ve been teaching geriatric medicine for about 25 years. During that time, my attitude towards the common sense of geriatric medicine has changed. At first, I saw it as a great blessing: it was easy to let people know what they needed to do. Then I began to see it as a challenge: an audience could sit through a diverting 40 minutes, but in the end not be persuaded that they have learned anything. “Nothing to that – it’s all common sense”. Now I see the common sense of what we do as a foe, and one that we should conquer.
At heart we are all Anglicans, we don’t like to change, even when it is clear that we must. And while it takes more than exhortation to bring it about, medical practice does change. Geriatric medicine has changed. Even so, routine medical care – especially routine hospital care – has not changed anywhere as much as it needs to do to care for an ageing population. Our patients get sick the only way they know how: it is not up to them to read UpToDateTM. People who care for older adults need to read Brocklehurst. We just need to make it more technical.
So how do geriatricians help them learn the lessons of our trade? Usually we answer this by trying to be accessible, engaged and to lead by example. We aim to get across how what we do meets patients’ needs. But I’ve come to think it is a mistake to leave it at that. We must sex up the message.
Many disciplines do this though technology and gadgetry. We have this in some domains: thrombolysis in stroke is one example. Some disciplines wear special clothes and caps that look good on television. Others promote the impenetrability of their basic science, hoping that some of the mystique will be transferred to them.
This last I wouldn’t entirely rule out. “Inflammaging” for example is about as technical as things get. On the other hand, all that counter-regulation of response mechanisms makes it easy to get lost oneself and the translation of it is never as satisfyingly clear as, say, the Frank-Starling mechanism. And the name is clumsy.
For my part, I think that we have a shot at tarting up our pitch through with the mathematics of frailty. The ideas are straight forward, the graphs give pretty pictures that are easy to understand, and the notion can be understood well enough with just a few hours of YouTube videos (search “Poisson distribution” to start is my advice). The clinical lessons are surprisingly clear and relevant. This makes easy the old trick of taking your audience out into the swamp (and that you can blame on the “demographical imperative” – I mean, it is an imperative after all) and then leading them back to safety.
So I say, enough of common sense. No more calling for the obvious and needed to be done. Goodbye to plain language. Stop with this “take a proper history, examine skillfully, see if the patient can walk, find out how the family is holding up, set proper goals, review medications” and all that. It is holding us back. Let’s stochastic things up a bit (or least interleukin them) and see how far that gets us.