Geriatric Medicine and the burden of common sense.

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. shutterstock_145815530

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.

3 thoughts on “Geriatric Medicine and the burden of common sense.

  1. I think you also need to use the shock tactics of showing where the obvious common sense option fails, because common sense is often an excuse for ‘lazy sense’: making do, with a solution that fits the service provider and not the patient.

    Example: nurses and doctors giving geriatric patients with early dementia verbal instructions for their own care.

    This probably doesn’t happen where the patient has such advanced dementia that they are practically unresponsive. But in early dementia patients can seem quite sharp with small talk, but lack the capacity to hold on to instructions for more than a few minutes. I’ve turned up at a discharge lounge far from the main ward (e.g. at Oldham Royal), to collect my mother, to find her muttering something about some instructions they may or may not have given her on the ward, and with the discharge nurses unaware of any such instructions.

    It’s not only on hospital wards. If I’m working away then my mother attends clinics on her own, or with a friend or relative. I regularly find that verbal instructions have been given that are not recorded for the patient.

    Your ‘common sense’ is telling that a patient’s nodding compliance and acceptance of your instructions is understood and recorded. That’s as much a failure of your common sense as it is of the patient’s capacity to follow through with a memory or understanding of those instructions.

  2. A though-provoking piece, Ken. I have to start by saying that like many UK Geriatricians, I have been a huge admirer of your work for many years. We have all learned a lot from you and you have provided genuine leadership to our speciality. So I hope you won’t feel that my strong disagreement with your (albeit deliberately provocative) piece is any kind of criticism. The reason I think you are wrong is because we should challenge current values and priorities in our profession (i.e. doctors in general) not just pander to it. Its like saying ” we know all the guys like enhanced women/all the ladies like a many with a flash car, so lets all go for plastic surgery/spend all our savings on an Aston Martin” – instead of “if that’s what they really want, then I don’t want them”.

    There is an unspoken hierarchy in the values of many doctors that goes roughly…

    Rare conditions with obscure diagnostic tests – high status, common conditions easier to diagnose low” (think Dr House)
    Cutting edge treatment based on latest science – high, better understood management – low
    Heroic Individualism – high, multidisciplinary team working – low
    Curative/life-saving intervention – high, helping people remain as well as possible with long term conditions -or die with dignity low
    Organ-based specialities (preferably in hospital, preferably in tertiary referral centres attached to medical schools and research units) – high, expert/skilled generalism based around people rather than diseases/organs (including geriatrics, mental health, primary care, acute internal medicine – low)
    Lots of opportunities for high income – high, salaried public servant with no private practice – low
    Academic clinicians – high (whatever the calibre or extent of their clinical care), jobbing service-delivery low
    Even within research we tend to value basic science or RCTS of therapeutics far more highly than much needed health services research quality improvement, policy work or work on medical leadership

    I would suggest that these values subconsciously underpin many of our priorities as medics including the allocation of funds, the likelihood of people in some specialities having high profile as clinical leaders, the prioritisation of research questions, the ability to attract staff

    But we have got these values completely the wrong way round. The core business of modern medicine is the care of (usually older) people with multiple complex long term conditions – not single organ disease and with frailty or dementia. Allied to this, we require a greater focus on prevention and proactive management and care co-ordination for people with long term conditions outside hospital, more integrated health and social care systems and when people are in hospital ensuring that the services are geared up around older people with complex co-morbidities rather than settings that often make them worse.

    The last thing we should be doing is going along with some “cultural cringe” to the focus on high tech, organ-based, lab-focussed specialisms. We should be saying loud and proud that anyone in the 21st century working with adult patients will spend a large part of their time looking after the frail, the oldest old, those with dementia and those with multiple co-morbidities. And frankly, any clinician coming into the job in 2014 should leave right now if they don’t embrace this. Maybe even start all students or new entrants on a geriatric medicine ward and if they don’t like it wonder about their suitability for the role. Certainly in the UK, doctors are public servants, trained by the taxpayer, paid for by the taxpayer and should be providing a service to the people who actually come through the door, not cherry picking work that they find more glamorous or exciting. (We only have to look at the flight of many organ specialists from acute general medicine or the neglect for many years until recently of hip fracture patients by orthopaedic surgeons, or the relative orphaning historically of mental health or palliative care, or Emergency Department medicine to see the perils)

    Instead, you seem to be advocating pandering to the unhelpful hierarchy of values and priorities “look, look we have bits of kit and fancy software too. We can be just as high tech as the cardiology catheter lab and pacemaker clinic – come and join us”. What we should be doing is selecting and training doctors who want to do the job that will actually await most of them. We can’t all be doctor House. All too often, even in 2014, we encounter students or doctors in training who are either turned off by discussions of issues such as post acute rehab, discharge planning, dementia or frailty or whose whole training has been so single disease pathway focussed that they find it very hard to shift their thinking. This is what we need to tackle rather than using bright shiny baubles and inducements. And of course if they have a good training experience working with a geriatrician we can play our part by turning them on to the speciality. We should also assertively and persistently challenge ageist attitude values and language.

    David Oliver

  3. One more thing, while I am at it. If geriatrics is just “common sense”, how come so may clinicians make such a mess of it and geriatricians and their colleagues in the multidisciplinary team have to spend so much time rescuing frail older people or reversing bad decisions. Either its not that obvious after all, or its easy enough but other clinicians are complacent about doing it well. Either way, blinding them with science ain’t the answer. Its getting them to do the job they are actually paid for, training them properly, supporting them properly and holding them to account when they don’t deliver

    David Oliver

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