Occasional Paper |
Whither geriatrics? Do we need another Marjory Warren?
Centre for Health Care of the Elderly, Camp Hill Veterans' Memorial Building, University of Calgary, Canada
Address correspondence to: Colin Powel, Tel: 902 473 8603; Fax: 902 473 4867, Email: phobbs{at}is.dal.ca
Keywords: past and future of geriatric medicine, frailty, elderly
It is an honour to celebrate the founder of geriatric medicine with you. I thank the Society for its invitation to deliver this lecture. I am grateful to my colleagues at Seniors' Health in Calgary for time to prepare and deliver this lecture. My objectives are that by analysing the application of Marjory Warren's principles to current geriatric practice, we are able to incorporate this analysis into future planning for the specialty.
May I remind you of Marjory Warren's contribution to our specialty (Table 1). You will remember all this was developed in a pre-World War II workhouse. I strongly recommend that you read her original papers [e.g. 1] and the excellent summary of her work[2]. The challenge for us today is: do we need to re-state her principles, or revise them, or conceivably, replace them? I suggest we are not here to replace her principles, but certainly, to refine them in our current world of medicine of which she would have had no inkling.
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Old people have changed. When I first began training as a geriatrician, it was generally agreed that old people then exhibited ‘high toleration and low expectation’. This may still be true of the over-80s but, of course, when you and I are in our 80s, we shall have high expectations and will not put up with any nonsense. To use today's jargon, the provider-patient relationship is dramatically changing. After the single-handed general practitioner, multi-disciplinary teams were established, which in turn evolved into interdisciplinary teams, and we now witness the development of professional joint practice, perhaps most clearly epitomised in the legislated relationship between the nurse and medical practitioners. A further exciting progression will be the consolidation of ‘partnership with patients’, first promulgated by Tudor Hart and his colleagues in south Wales over 40 years ago [3]. Grimley Evans has drawn our attention to the diminution of ageist policies, but sadly, ageist behaviour in health care remains [4].
Marjory Warren may have started with a view to serving all elderly people, but we now focus our attention on the frail, older adult. I have discussed the relevant literature elsewhere [5]. In my view, the foundational paper for this discussion is that of Rockwood et al. [6]. I draw this reference to your attention, because its authors comprised four geriatricians and one gerontologist: all Canadian. They emphasised that a balance is perturbable, and hence, readily upset. The balance was between a patient's assets and deficits (Figure 1). Note that there are interactions both within and between each column and row. This framework also provides a useful checklist to confirm the ‘comprehensiveness’ of one's own comprehensive geriatric assessment. Following this model, for a given patient, the assessor should be able to identify specific assets and deficits and the actual and potential relationships between them. Frailty exists when the deficits outweigh the assets, or when they are in precarious balance. This definition of frailty is applicable to about 15% of the over-65s, and about 45% of the over-80s. These frail, older adults appear throughout the health care system: both in institutions and in the community.
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Our group at Dalhousie has popularised the slogan: ‘facing up to frailty’. The health care system needs to become ‘frail-friendly’, i.e. one which expects a substantial number of its subjects to be frail, older adults, and therefore, provides appropriate care which includes emphasising the prevention of hospital-induced problems. This is the very antithesis of the commonly encountered rejection of old people. A perhaps unexpected advantage is that this approach can restore the health care professional's pride in her or his work. For example, one can promote the nursing home as the ‘ICU for the behaviourally disturbed person with dementia’. A nursing home's staff should be the source of such expertise. In a frail-friendly organisation, particular attention is given to communication with patients and their families, to a physical environment which does not aggravate disability, to staff behaviours which facilitate rather than frustrate, and to a pro-active dynamic which anticipates and predicts problems. A frail-friendly service is thus, expert at recognising and alleviating fear, anxiety and pain, impaired function and immobility, and atypical cognition and affect. All this with the important proviso that older adults are a heterogeneous group: ‘one size does not fit all.’ At this point in this lecture, you may quite properly comment: ‘so what, we have heard nothing new; we all do this anyway.’ Nevertheless, a few weeks ago, the BBC website, reporting on Age Concern's campaign: Hungry to be Heard, proclaimed that: ‘Nurses are too busy to monitor food’. Here are some wise words from a recent elective fellow in Geriatric Medicine at Dalhousie, Darrel Rolfson: ‘the identification of someone as frail needs to be used to alert health care providers to their special needs, not to assign them to inferior care’ [7]. This warning echoes Sir John Grimley Evans' ‘aggravating ageing’ [8].
Having defined whom we serve, I now consider how we deliver this geriatric care. I suggest there are three essential components to the effective delivery of geriatric medicine: teamwork, geriatricians, and relationships. ‘Teamwork’ is a word readily used but rarely practised. Of the several essential components of teamwork (Table 2: Characteristics of teams) I comment on two characteristics. The bedrock of teamwork which works, is the mutual respect that team members have for each other's training and expertise, willingness to learn from each other, acceptance of other members' ideas and in all this, the geriatrician should be the catalyst for doctors, yet they commonly tolerate clinical ambiguity when faced with difficult diagnoses or unclear treatment regimens. However, they often seem less willing to accept hesitancy or uncertainty in a non-medical colleague's opinion [9]. Effective teams display collective responsibility. Mere labelling of a group of health care professionals of different disciplines does not make them a team. A team demonstrates joint accountability for its purpose, approach and outcomes, and in the end the team takes responsibility for its collective actions (‘only the team fails’).
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You will be relieved to know that geriatricians have something to do with the delivery of geriatric medicine: they are the catalysts. As an aside, you will remember that the definition of a ‘geriatric patient’ is one lucky enough to be under the care of a geriatrician. A common premise for teamwork and the role of geriatricians, is that of relationships: firstly, within the geriatric team; then with other health care professionals; and, most importantly, with older adults themselves. Unashamedly, I draw on our experience at Dalhousie University for some examples.
We have developed the role of orthopaedic nurses in the pre-operative and post-operative assessment of elderly patients undergoing both elective arthroplasties and traumatic hip surgery [10, 11]. For the past 8 years, all orthopaedic trainee specialists have spent 1 month on the academic geriatric unit during their 4 year orthopaedic residency. At present, the Canadian cardiology residency comprises 3 years in internal medicine, then 3 years in cardiology. We have arranged that selected cardiology residents will spend 2 months in geriatric medicine in each of their three cardiology years. This is an exciting development for us all as we explore and define what ‘Geriatric Cardiology’ is.
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What's next? |
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 TopNotes What's next? Key pointsReferences |
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How do we refine and build upon Marjory Warren's principles? We have got beyond merely being kind to old ladies (although I readily concede that this is immeasurably better than being nasty to old ladies), and health care without humaneness is an empty shell. We no longer have to justify our specialty's presence and development. Profound change is occurring in health care delivery at present, and this British audience will be far more aware of much of this than I. There are several current examples: the virtual exclusion of geriatricians from the planning and delivery of Intermediate Care (this seems true both sides of the Atlantic) [12]; the potential devastation to be wreaked by ‘payment by results’ [13]; perhaps all this is best summed up in Chris Ham's provocatively titled BMJ editorial—‘Creative Destruction’ [14].
To develop partnership with patients, in Halifax, we identified a Council of Reference who are a group of older adults whom we invited to criticise what we do, clinically, educationally, and in research, and hence refine our activities. All this validates the patient's viewpoint. We both need to encourage patients to speak about their experiences, and also require professionals to listen to them.
I offer you my personal, albeit partial, SWOT analysis to guide us toward our desired objectives. Our strengths include skilled, enthusiastic, competent health care professionals; provision of geriatric services throughout our jurisdictions; the establishment and development of old-age psychiatry. Different jurisdictions will exhibit different weaknesses. In Canada, recruitment to the specialty is a desperate challenge. At present, outside the province of Quebec, there are perhaps half a dozen internists being trained to become geriatricians (happily, three of those are located at Dalhousie University). The relevant leading factors are: prestige, pay, purpose and preceptor. Although, traditionally, geriatric medicine was low in the medical professions' esteem, recent surveys have shown geriatricians to be generally very happy with their lot in contrast to some other specialties [15]. Briggs and colleagues [16] reported that: ‘Few doctors have regrets about choosing geriatric medicine as a career and these [regrets] were rarely about core aspects of the specialty.’ Unfortunately, but understandably (particularly in this era of high student expenses), remuneration is directly correlated with recruitment to a given specialty: the more interventional, the more highly remunerated the specialty. A principal factor in recruitment remains the moral impetus of a vocation. Often, the prospective geriatrician first sees this in a mentor or preceptor.
Another weakness is what I have termed ‘the spectrum shift’, and this seems to be particularly apparent in England (in contrast to Scotland). By this I mean that as general internal medicine has fractionated into its respective sub-specialties, the ensuing vacuum has been filled by geriatric medicine. In ‘the spectrum shift’ towards acute care, an insidious consequence has been the withdrawal of geriatric medicine from its traditional territory, which included institutional and community long-term care, and the rehabilitation of older frail adults.
Moving to some Opportunities for Geriatric Medicine and Gerontology, one can never underemphasise the role of exercise. Could one have imagined, 20 years ago, that part of the proper management of congestive heart failure would be judicious rehabilitative exercise? In Canada, the ‘Falls’ movement—largely led by nurses—is a practical application of this discovery. I also commend the (then) President-elect when he addressed the House of Lords in 2004, as an example of seizing opportunities. He bluntly challenged their Lordships to recognise and root out ageism (‘although age discrimination is officially against government policy, we see example after example.’). He identified Geriatric Medicine as having ‘special involvement with the frailest and most vulnerable of older people’ leaving other specialties to treat patients who just happen to be old but not frail.
I shall leave you to identify the current Threats to delivering health care to frail older adults, but here is a salutary warning from Rudolph Klein of the London School of Economics: ‘it is impossible to be sure the new model can ever be fully implemented, however seductive its logic may be in theory’ [17]. We must remember in all our plotting and planning that ‘old people have a lot of inside information about ageing’. Do we ask them? Do we listen to them?
This leads me to my most important focus, namely, old people or, being North American: ‘seniors’. Two words stereotype ageing. The first is ‘tranquility’: thus the older person is seen in a rocking chair under a rose-covered arbour, with the sun setting in the west, and he or she is clearly resting after the heat of the day. The second word is ‘inevitability’ where ageing is seen as a time of decline, decrepitude, disintegration, and, finally, death. Neither of these words is an adequate description of the challenges and successes of old age. One must be realistic about ageing, and some, older people. Not all is sweetness and light. There are nice old ladies and nasty old ladies (also true of doctors!). Daily, the geriatrician is challenged by patients with difficult diagnoses requiring difficult management, by patients who have ‘difficult families’ (remembering that if you or I had been treated in the way that many of these families have, we would be doubly difficult). I will say nothing about difficult colleagues. Many old people are also ageist. Some are terrified of the word geriatrics, because to them it means a system which takes away their driving licence, gives them a mental test reminiscent of their school days and promptly puts them in a nursing home where they are ‘drugged out of their mind’. There is a grain of truth in all this.
Whatever the negatives, there are some definite positives. Old people know that they need reliable, effective safety nets for their health problems. Tonight they might suffer a disabling stroke and need a health care system which rescues them. It is always worth reminding politicians in every democratic jurisdiction, that old people both remember and vote. For us in geriatric medicine, old people are our potential political allies (as are their children—‘the boomers’). We must encourage non-frail elders to say to our universities: ‘Why don't you produce professionals who know how to care for us?’ and to the various ministers of health (we have 11 in Canada!): ‘Why don't you employ people who know how to care for us?’
In preparation for the Year of the Older Person, in 1999, the Canadian National Advisory Council on Ageing, identified what seniors in Canada wanted from society. This was: independence, dignity, security, participation and fairness. In my own administrative activities, when chairing or leading any kind of meeting, I put these five nouns at the top of an agenda to remind us that these ideals must govern all our discussions and decisions.
Marjory Warren was a determined resilient advocate for old people (and for geriatric medicine). We now also must add association with old people. We add to ‘advocacy for the vulnerable’, both ‘partnership with the informed’ and ‘accountability to society’. I thus append Alliance and Accountability to Marjory Warren's contribution, to reflect our contemporary situation. By Alliance, I mean both partnership with patients and effective relationships with others, both inside and outside geriatric medicine. With respect to Accountability, I commend the work of NICHE—Nurses Improving Care for Health system Elders [18]. Building on Marjory Warren's contributions by adding contemporary insights, we can effectively continue to serve older frail adults.
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Key points |
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TopNotesWhat's next?Key pointsReferences |
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- Marjory Warren's first principles:
- Frailty, teamwork, and relationships.
- SWOTing geriatric medicine.
- Alliance with, and accountability to, older adults.
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Conflicts of interest |
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None
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Notes |
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TopNotesWhat's next?Key pointsReferences |
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An abbreviated version of the Marjory Warren lecture delivered at the Annual Meeting of the British Geriatrics Society on 5 October 2006, at Harrogate, Yorkshire. 
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References |
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- Warren MW. Care of the chronic aged sick. Lancet (1946) i:841–3.
- Matthews DA. Dr. Marjory Warren and the origin of British geriatrics. J Am Geriatr Soc (1984) 32:253–8.[Web of Science][Medline]
- Hart JT, Haines AP. Representation of community health councils in health-centre management. Lancet (1975) i:571.
- Evans JG. Age Discrimination: Implications of the Ageing Process. (2001) London: IPPR Project Age as an Equality Issue, Institute for Public Policy Research, Nuffield Foundation.
- Powell C. Frailty: help or hindrance? J R Soc Med (1997) 90(S32):23–6.[Abstract]
- Rockward K, Fox RA, Stolee P, et al. Frailty in elderly people: an evolving concept. Can Med Assoc J (1994) 150:489–95.[Medline]
- Rolfson DB, Majumdar SR, Tsuyuki RT, et al. Validity and reliability of the Edmonton frail scale. Age Ageing (2006) 35:526–9.
[Free Full Text] - Evans JG. The gifts reserved for age. Int J Epidemiol (2002) 31:792–5.
[Free Full Text] - Naylor CD. Leadership in academic medicine: reflections from administrative exile. Clin Med (2006) 6:488–92.[Web of Science][Medline]
- Freter SH, Dunbar MJ, MacLeod H, et al. Predicting post-operative delirium in elective orthopaedic patients: the Delirium At-Risk (DEAR) instrument. Age Ageing (2005) 34:169–84.
[Free Full Text] - Freter SH, George J, Dunbar MJ, et al. Prediction of delirium in fractured neck of femur as part of routine preoperative nursing care. Age Ageing (2005) 34:387–8.
[Free Full Text] - Black D. Medical aspects of intermediate care. Clin Med (2003) 3:9–10.[Web of Science][Medline]
- Carpenter I. Payment by results, in a nutshell. BGS Newsl (2006) 7:1–3.
- Ham C. Creative destruction in the NHS. Br Med J (2006) 332:984–5.
[Free Full Text] - Hogan DB. Why the surprise? Can Med Assoc J (2006) 174:1746.
[Free Full Text] - Briggs S, Atkins R, Playfer J, et al. Why do doctors choose a career in geriatric medicine? Clin Med (2006) 6:469–72.[Web of Science][Medline]
- Klein R. The troubled transformation of Britain's National Health Service. New Engl J Med (2006) 335:409–15.
- Fulmer T, Mezey M, Bottrell M, et al. Nurses Improving Care for Healthsystem Elders (NICHE). Geriatr Nurs (2002) 23:121–7.[CrossRef][Web of Science][Medline]
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