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Desmond O’Neill: A tale of three cities—geriatric medicine in Australia

4 Jul, 13 | by BMJ

Desmond O'NeillSome minds improve by travel, wrote the nineteenth century poet and humorist, Thomas Hood: others, rather, resemble copper wire, or brass, which get the narrower by going farther. And so it was with the spirit of keen metallurgical inquiry that I stress tested this theorem on a recent ten day visiting professorship with the Australian and New Zealand Geriatric Medicine Society.

Wonderfully hosted by my colleagues, my first visit to the Antipodes involved three cities—Melbourne, Adelaide, and Brisbane—each with a very distinct character, although sharing the bonus of almost free bike hire (akin to the “Boris bikes” in London) in each.

The stand-out aesthetic experience in each city was the indigenous art, vibrant and rich, uniting a sense of the very new and the very ancient, with its modern iterations expressing a host of multi-layered messages. As late-life creativity was the focus of some of the lectures I was due to give, I was delighted to discover, and include, the work of artists Sally Gabori and Emily Kame Kngwarreye, both active into their ninth decade.

While I noted subtle differences between the practice of geriatric medicine in each state, the striking impression of the discipline in Australia and New Zealand was of vibrancy, energy, and confidence, coloured by the sense of humour and drollery universal to geriatricians in conclave.

The ANZSGM annual conference was hosted in Adelaide by the South Australian geriatricians, ably fronted by Robert Prowse and Peter Bastian. As well as a wide range of presentations of substantial depth and innovation, there were interesting keynotes whose themes included ageing and migration (23% of Australians, or their parents, are born outside of Australia), palliative care, and health economics.

A panel discussion on management of behavioural disturbance in dementia and the role of neuroleptics was particularly lively, with probably the most interactive audience participation I have ever experienced, aided by a helpful grounding of the debate by a number of GPs working in nursing homes. Add in real-time electronic voting using smart phones, and the panel members—a geriatrician-pharmacologist, a dementia nurse specialist, a palliative care physician and yours truly—were kept on their toes in discussing what is a subtle and challenging aspect of care no matter where one travels.

As I visited a number of very impressive clinical facilities, it became clear that a signal achievement of Australian geriatric medicine has been to persuade the federal government to adequately fund geriatric medicine in private services reimbursed by Medicare.

In most countries in the developed world operative procedures which may take a matter of a few minutes are reimbursed at an astronomically higher level than the hour of sophisticated clinical work that a comprehensive geriatric assessment often requires. The result is that geriatric medicine, an intervention of high efficacy, is virtually non-existent in private medicine in much of the world. That Australia has reversed this trend is truly the sign of a sophisticated society.

But where my horizons were narrowed—in the sense of sharpening my focus on what really matters—was my encounter with the winning combination of smart gerontological thinking and new technologies.

In the Prince Charles Hospital in Brisbane, the acute medical service is run largely by geriatricians. The highly capable lead clinician, Liz Whiting, and her team has developed an enormously impressive “journey board,” which embodies diagnosis, functional status and the workings and actions of the multi-disciplinary team on an electronic whiteboard which is intuitive, goal-oriented, and effective. I definitely want one for Christmas!

Over at the Centre for Online Health of the University of Queensland, I was then hugely impressed by how Len Gray has combined the iterations of cutting-edge gerontological practice inherent in the interRAI (the gold standard for assessing needs in older people, which although now adopted by over 30 countries—including most recently Ireland—was not adopted as a national Single Assessment Process instrument by the UK) with telehealth.

While sitting in on a tele-consult in a nursing home 210 kilometres away in Dalby (the nearest I got to the outback) I was struck by how use of the interRAI tool by the nurse in the home provided her with much of the information and some of the solutions needed in this case: it also clearly empowered her and facilitated the consultation. The technology, while of the highest quality with the robot quite acceptable to the patient, was the servant rather than the master of the process: the experience has urged me to rethink how we undertake telemedicine in our own service for stroke thrombolysis.

As I return to Ireland energized, I am deeply grateful not only to my Australasian hosts, but also to my loyal colleagues in my unit in Tallaght Hospital in Dublin, and in particular to my long-suffering wife and family, for the support they gave me for such a lengthy absence.

Those of us pursuing academic aspects of medicine do not often enough express our recognition and gratitude for the extent to which this enterprise relies hugely on the kindness, tolerance and support of others. It is a far, far greater thing that they do.

Desmond O’Neill is a consultant physician in geriatric and stroke medicine and immediate past president of the European Union Geriatric Medicine Society.

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