Shane O’Hanlon is a Consultant Geriatrician (Surgical Liaison and Cancer Care), Royal Berkshire Foundation Trust and Macmillan Cancer Support.
As a geriatrician who works with surgeons every day, I was intrigued to see what Atul Gawande’s latest book had to say – apparently it was all about what happens in later life. But was it just a misguided attempt by a surgeon to write a book on geriatric medicine?
Gawande has been a general surgeon and a professor at Harvard for over a decade. During that time he began writing for the New Yorker, and is now well known in patient safety circles for his successful books “Complications” and “The Checklist Manifesto”. He is seen as a sensible writer who doesn’t shy away from talking about his own mistakes. This humble approach also pervades “Being Mortal”, which considers how healthcare treats the old and dying, and asks “What really matters in the end?”
At the heart of Gawande’s book is his learning experience. He freely admits that he didn’t know what geriatricians do: despite the geriatrics clinic being one floor below his surgery he couldn’t “remember ever giving it a moment’s thought”. He lays bare his prejudices about older people – the “patient on a downhill” who is no longer interesting. It’s the same widespread ignorance that Louise Aronson has recently written about in the Lancet. But Gawande realises his mistake, and the book is an engaging journey of discovery through an area that he ends up finding very impressive. In fact he is extremely positive about what geriatricians do – perhaps more than any other surgeon has ever been!
Gawande’s book works, not because it idolises the specialty of geriatric medicine, but because he channels people’s stories to demonstrate the rights and wrongs of caring for older people. It’s what makes it interesting and authentic, and gives the book a warm heart. Funnily enough, when I went to see him speak at the book’s launch, he was accused of being overly scientific and evidence-based in his writings – his strength is in telling us about people, but he seems to like to justify what he says with data. But importantly he gets these people – for example when he incisively takes us through how a couple who were both progressively deteriorating cherished the meaning they found in the very simple acts of helping to provide care for each other, and being there for one other.
He covers an impressive breadth of ideas here, explaining frailty, palliative care, rehabilitation, and the tension between our desire for autonomy for ourselves but safety for our loved ones. His research is excellent, and he offers insights that draw parallels in ways that never strike the average health professional. For example he cites Goffman’s description of nursing homes as “total institutions” – where groups of people live all aspects of their lives in a single place, organised by central authority, with forced activities, cut off from society. This description chilled me as it reminded me of personal accounts that I heard from survivors when I was volunteering in a concentration camp memorial site. He also retools Maslow’s hierarchy, arguing persuasively that it changes with age. And he makes a great point that we have no good metrics for how well we assist older people to live, yet we know exactly how much weight they lost and how many times they missed medication.
He does miss a trick, such as too swiftly bypassing examples of paternalism he encounters without really delving into why we tolerate such behaviour (e.g., why are people who do not uniformly cooperate with care labelled “feisty”?). I also think he deals too briefly with palliative care during the book, without really getting into the meat of the specialty. He even questions whether it will be needed in future… This despite his realisation that when his father became ill, his doctor never got the conversation round to what he really cared about or what his priorities were for the end of his life. It’s genuinely touching to see his very personal description of how he and his family dealt with a terminal illness. I understand his hope that one day all doctors will apply the same sensitive, caring approach that palliative care specialists practise – but I am realistic enough to know it will never happen. I would have preferred if he used the opportunity to reinforce how much palliative care can help people who need it and emphasised that it is still not widespread enough.
Overall there is enough here for most geriatricians and other health professionals to either learn something new or have your practice challenged; whether it be the history of how nursing homes came about; reflecting on how to rebalance autonomy versus safety; or what happens when huge numbers of animals are released into a continuing care setting! He was kind enough to dedicate and sign a copy for me, and it’s going straight to the surgeons I work with! That will be its true test.