As our journal turns 30 and gerontology comes of age, I thought it would be interesting to ask two elder statesmen, Graham Davison and Tony Broe, to reflect on their careers in geriatric medicine. Both have been geriatricians for over 30 years and have had distinguished careers as clinicians, teachers and mentors. Graham (and Jonathon Baskett) recruited me into geriatric medicine by showing me that dealing with difficult old people and teaching students can be fun. Tony, as Professor of Geriatric Medicine at Sydney University, fought to enshrine geriatric medicine as a compulsory clinical rotation for all medical students. Now when our home-grown interns ring up from ED (Emergency Department) they talk about ‘evidence of delirium’ and not just ‘acopia’. I sent Tony and Graham a set of questions online and in their answers you will find a lot to reflect upon, not only in regard to our achievements as a specialty but also about the way forward.
Dr Graham Davison, from Auckland, is a retired geriatrician who worked with the Auckland District Health Board.
Why did you choose geriatric medicine? Did someone in particular influence you? As a medical registrar, I loved the diagnostic tussle of clinical medicine, but also needed a social challenge, and this came with a talk from Ron Barker (one of the fathers of geriatric medicine in NZ (New Zealand) and later Director General of Health), in a lecture to registrars on demography. It was the squared population pyramid that captured my interest – I thought ‘there's a challenge there!’ After MRACP (Member Royal Australasian College of Physicians) I went to London with an open mind, but quickly followed in the footsteps of my close colleague and friend Jonathon Baskett. I worked at St Thomas' with Terence Picton Williams and for shorter periods with Prof John Pathy in Cardiff and psychogeriatrician Sam Robinson in Edinburgh. I then returned to a career-long post with Auckland District Health Board, where I was greeted by one physician as a ‘super social worker'! Picton Williams' two main principles for aged care were pertinent: that is, ‘the physical, social and psychological causes of morbidity in older people are inseparable’ and ‘home is the place to grow old in’. I must say that home visits in the housing estates of South London's Brixton made Auckland look fairly straight forward!
Has geriatric medicine been a good choice? One can over-romanticise or defend a career choice, but I've not regretted it – I liked the wide variety of work setting up a department and working in a team. I enjoyed the challenging medicine and careful physical examination. And the tussle to find the remediable amongst the multiple problems in older age. There was never room for boredom with the mix of hospital and community work (especially home visiting), and teaching.
My particular interest has been in attitudes to ageing. I used popular lectures on sexuality and on driving to illustrate the myths and complexity of ageing.
I loved ‘difficult’ older characters and the ethical dilemmas they posed. There were events familiar to all geriatricians – court appearances to persuade Mr T to have antibiotics for spinal osteomyelitis, and rescuing a grandmother dominated by a knife-wielding addict grandson who led her regularly to the local ATM.
The highlights were the privilege of being involved at the start of a specialty and seeing younger colleagues become excited about the care of older people. I also helped set up the NZ Association of Gerontology and the first continence nurse position. I am proud that the hospital care of older people in Auckland has remained totally on a base hospital site and that community and hospital care is fully integrated under one management umbrella.
A small personal regret was missing out on a sounder research experience in my training.
How has geriatric medicine changed over 30 years? When I began, the care of older people was provided by a handful of pioneers who had transferred from other specialties and worked in isolated long-term hospitals – in Auckland it was the huge Cornwall Hospital which had been the 39th US army hospital in WW2. Now we have a large dedicated team of career geriatricians who provide high standards of care in base hospitals and recognize the important interfaces with general medicine, orthopaedics and psychiatry. There has been a huge growth in home care, reducing the need for rest home care. Older people have benefitted so much from advancing technology – especially quicker, easier and more comfortable procedures.
The next 30 years? I don't know. Will Alzheimer's disease be ameliorated? What opportunities will accompany the rise in the numbers of centenarians and Asian, Pacifica and Maori elders? Will there be new ethical dilemmas, such as wealthy baby boomers purchasing longevity with expensivepharmaceuticals and organ replacement? Long-term care of our most vulnerable older people is where our specialty began – will public companies continue to reap dividends from this care?
Is geriatric medicine a good career? It is a great career for those with a heart for people. It will always be challenging and changing, with no chance of boredom, and plenty of scope for individuals doing their own thing. I'm pleased that my son has taken a special interest in older people in his area of Clinical Psychology. He has even taken over my sexuality lecture!
Have you any tips for young geriatricians? Always keep focused on the frail older person as the core territory of our specialty and not be side-lined by the younger sick. Family is central – give strong clear advice to patients and their families, and then listen and modify management accordingly. Enjoy enthusing about ageing, but acknowledge it's not a picnic. Hearing impairment is common – a pocket talker is an essential piece of equipment (‘geriatrician's stethoscope’).
What are you doing now? I am fully retired from clinical practice and busy observing my own ageing through curious geriatrician eyes. I attend journal clubs and the annual geriatrician's national retreat (a NZ icon) to keep in touch with colleagues and the evolving medical care of older people. I am giving ageing lectures to health science students. I have always been involved in music and singing and playing my church organ – I have organised the restoration of this historic John Avery organ built in 1779 and pretty much the oldest in Australasia. Some years ago I helped set up a housing trust for mentally ill people and remain a trustee. I have a special interest in literature and am now co-editing a literary page in the AJA.
Professor Tony Broe, from Sydney, has worked at Concord and Prince of Wales Hospitals and currently runs a research program at Neuroscience Research Australia (NeuRA).
Why did you choose medicine as a career? I got into medicine more by accident than design. My first choice was archaeology and I enrolled in Arts at Sydney University in 1954; however the professor promptly died and the course was ceased pro tem. I switched to anthropology, which seemed pretty close (at least alphabetically). While I enjoyed the anthropology course it didn't grip as a career – so I applied for an Arts/Medicine scholarship – giving me nine great years as a student, graduating in Arts in 1957 and Medicine in 1963.
Why did you choose geriatric medicine? Was there someone in particular who influenced you? Once again fate took a big hand. To finish the last three years of Medicine with a growing family, I took a NSW Public Service Cadetship. This meant a five-year bond to work in Western Sydney at Lidcombe Hospital, then a special Hospital for the ‘Aged and the Indigent’ complete with 2000 ‘Home Section’ beds. Lidcombe was Sydney's ‘Salpêtrière’ for people with unusual dementias and rare neurological disorders and this, together with good mentors, set me towards a career in geriatric medicine and then neurology.
Lidcombe was staffed by a team of interesting doctors with remarkable backgrounds. They included two physicians who had a big influence on Australian Geriatric Medicine and my career and on that of other budding geriatricians. Frank Ofner was a refugee from Yugoslavia; a dermatologist who was obliged to retrain in Australia. Frank was a brilliant scientist who taught me basic research principles and supervised my early research efforts. Sid Sax was a South African physician who was a refugee from Apartheid and employed at Lidcombe; he became the first NSW Director of Geriatrics among many achievements. Sid was an outstanding clinician, a mentor in social medicine and promoted my plans for a Fellowship in Geriatrics in Glasgow in the 1970s. In Glasgow another great mentor, Francis Caird, inducted me into epidemiological research with the Glasgow Kilsyth Study of the Neurology of Ageing. I went on to complete neurology training in the US and came back to Lidcombe as a staff specialist – and a neurologist at RPAH (Royal Prince Alfred Hospital) – until I happily gained the Chair in Geriatric Medicine at Concord Hospital.
Has geriatric medicine been a good choice for you? Geriatric medicine was a top choice. Having worked in a few different areas – general medicine, neurology, rehabilitation, geriatrics – I can safely say that geriatrics provides the most interesting varied and stimulating career anyone could have in medicine. While it is not for the faint hearted, with a heavy load of acute and emergency medicine and general medicine, and a commitment to rehabilitation, community care and administration, it is a deeply satisfying specialty. But you have to enjoy working with older people and see them as the salt of the earth.
Tell us about the highlights. What achievements are you most proud of? What was your greatest administrative coup? I took to geriatric medicine in the 1960s like the proverbial duck to water and loved the process of setting up and running the first Geriatric Unit and community services from Lidcombe for Western Sydney – particularly domiciliary visits in an old FJ Holden with Jeannie Rowe, our hospital ‘almoner’. What am I most proud of? The geriatric trainees and PhD students I have supervised. The achievements I relish most are the health care and research systems that last the distance when I have moved on: local district Geriatric Services for Western Sydney in the 1960s; district Geriatric Services for the rest of Sydney (with Ted Cullen and Helen Felton) in the 1970s and 80s; the Concord Centre for Education and Research on Ageing (CERA) in the 1990s; the ASETs (Aged care Services in Emergency Teams) in the 2000s; and the Ageing Research Centre in Aboriginal Health at NeuRA – as my retirement plan. What was my greatest administrative coup? Persuading the POWH (Prince of Wales Hospital) Department of Surgery to give Geriatric Medicineone of its surgical wards, making the aged care system work better for everyone's benefit.
Any regrets or downsides? I sometimes regret my middle decades spent as a general neurologist, although I applied that knowledge-base to my research on behaviour, brain ageing and dementia. Clinical neurology was too remote from patient care, too cut and dried, too repetitive – with the same problems presenting year in and year out. So it was a pleasure to return to the complexities of geriatric medicine and aged care at Concord Hospital in 1985.
How has geriatric medicine changed over the last 30 years? How would you like to see it develop in the next 30 years? Over the last 30 years Australian geriatric medicine has grown enormously in size, in confidence and in status within the health system – taking on more and more basic hospital roles. In general ‘frail’ older-old people are treated with dignity and respect in our hospitals and young geriatricians I find are the cream of the medical crop in patient care, humanity and clinical competence. However geriatrics has not avoided the major defects of the State health care delivery system itself: the emphasis on hospital care over community care; on individual care over improving aged care systems; on acute care over prevention; and on proximal biological risk factors over longer term social determinants of health and ageing. Geriatric medicine is seeing the demise of the internationally famous ACAT system and it has largely opted out of community care. Geriatrics needs to embrace and drive Community Health if we are not to be overtaken by the ageing of the baby boomers over the next 30 years.
Do you think geriatric medicine is a good career now? Would you encourage young doctors (or your own children) to go into our specialty? What can I say? Geriatric medicine is a great career path if you are set on becoming a doctor. However I encouraged my own children to opt for the arts and social sciences, keeping them poor but creative. Creativity is the basis of the good life.
Any quick tips for young geriatricians in the clinical and/or administrative arena? Work hard to change the health system towards job creation in community care – where the old people are and where they want to stay. Work hard to change the legal system towards active support for people who need assistance to die with dignity rather than live in distress.
What are you doing now? Running a program in Aboriginal Health and Ageing at Neuroscience Research Australia, enjoying life and preparing not to retire.