If you're a fit 84-year-old and you have a heart attack, should you be sent to the cardiologist or a geriatrician?
Dick Sainsbury argues it should be the former, even though he's spent decades working in geriatric medicine.
A keen cricketer, Sainsbury had his own health scare 25 years ago, when he went into cardiac arrest on the cricket pitch and was revived by his teammates, who were all doctors.
His anecdotes, thoughts, papers, and teaching points from his career have formed the basis of a book about aging called All Experience is an Arch.
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Sainsbury tells Kathryn Ryan he got into the field after a hiccup in his training meant he missed an exam and he had to look at a six-month venture as a registrar in geriatric medicine instead.
Although initially reluctant, it didn’t take long for him to realise he had found a place with multiple disciplines to learn from, he says.
“You only have to see one older person who is in terrible difficulty, who is really unwell, get better and be restored to their own home to realise it’s actually a worthwhile field to be in.”
It is the work of Marjory Warren, who took over the aged beds at a UK hospital right before World War II, that’s given much credit for the development of geriatric medicine.
She was looking after people in 800 beds, but she believed most would do better in the community if they had their simple needs met.
“What she did was to systematically review each patient, one by one, and found that a considerable number of them had unmet needs which you could … address and make the person more independent,” Sainsbury says.
“It was particularly hard to do at the time because this was 1942, it’s right bang in the middle of the second world war, but nevertheless, she was a very determined woman and got it done and people began to take notice and then after the second world war in the UK, everybody got in to it.”
A few decades later, New Zealand doctors began to pick up on the field because it was common for most to have some overseas experience before starting their careers, Sainsbury says.
Now based in Christchurch, Sainsbury is a retired geriatrician and emeritus professor at Otago University, who spent six years on the New Zealand Medical Council and eight on the Artificial Limb Service.
Thinking about ageing and advanced care
He believes attitudes towards ageing in particular can affect not only physical health but also psychological health too.
And so, he shies away from defining age in terms of years.
“I think of it more in biological terms. The current buzz word is frailty and by this people mean the concept whereby people are beginning to lose abilities and function and are therefore vulnerable to things that might come along like flu in winter and so on.
“My favourite definition is Henry Ford, who said you are old when you stop learning and for that reason, there are old 20 year olds and young 80 year olds’.”
He also sees that family meetings are necessary to set goals for a patient’s care and sort out any differences in opinions.
“Advanced care planning consists of all sorts of things, particularly getting an enduring power of attorney so that people know your wishes about treatment, vigour of treatment and if you’re no longer able to do that yourself, advanced directives, and now of course the end of life choice bill is with us.”
Sainsbury’s worry with the End of Life Choice Bill is that vulnerable older people may be pressured into making decisions.
“Proponents will say there are safeguards and so on, but I have seen situations where in other decision making, like going in to a rest home or decisions about money, older people who have been pressured against what I think they really require.
“My observation is that in other countries that have enacted this sort of legislation, it’s gradually got looser and looser and people refer to this so-called slippery slope principle, and if that does happen, and it does concern me, then older people may be vulnerable to being pressured into making decisions which really aren’t what they genuinely want.”