Desmond O’Neill: Gerontolysis

Desmond O'NeillIn an era when didactic teaching in medical education is frowned upon and where workshops and problem based learning rule supreme, it is refreshing to be reminded of the powerful impact of a high quality lecture.

A superb overview of how good lectures tap into expectation, ritual and theatre posits that lectures are particularly effective because they exploit the spontaneous human aptitude for learning from spoken (rather than written) information. [1]

And so it was at two remarkable keynote presentations at the British Geriatrics Society in Belfast the week before last. The setting—the glamorous Waterfront Hall—provided a suitably theatrical framing and heightened the experience, while the social renewal of meeting like minded colleagues during the breaks nurtured the sense of common purpose.

The first presentation was by Robert Francis QC, giving an overview of the Mid Staffordshire Inquiry. Up to now I, and I suspect many others, had absorbed the findings of this report largely in digested and second hand format of newspapers and journals, daunted by the prospect of reading almost 1700 pages. The impact of this talk, given without any visual aids, was humane, searing, and thought provoking.

Threaded through with details of individual experiences, reactions, and the most unhappy of professional stances, the narrative drew us into a shared desire to do better and reflect on how to counter the relentless drive to meet targets and cut expenditure in a management culture often deaf to reasoned clinical opinion. Worse still was the eventual dispiriting professional dissociation from pain and suffering, and the denial of personal and professional responsibility.

More encouraging was the focus on specialist nursing skills, a fresh approach to what older patients, the key client group of adult services, should reasonably expect, and an emphasis on supporting and training care assistants. That the author was a lawyer, rather than a healthcare professional, added weight to the perspectives and solutions proposed.

Encouraged to read the full report, as many probably were by this illuminating experience, I found it a compelling experience and as relevant for Ireland and the rest of the world as for the UK.

The second lecture moved and inspired us in different ways, and reinforced the sense of the lecture as a formal, spoken, social event. Professor Peter Langhorne has developed a remarkable ability to combine science, humanity, and a broad view of healthcare in the promotion of one of the most effective healthcare interventions of the last century—the stroke unit.

In a style marked by his trademark modesty and gentle humour, he started at the beginning for both himself (originally a fish physiologist) and stroke medicine, teasing out its roots in geriatric medicine, fittingly paying tribute to the pioneering work of George Adams in both geriatric and stroke medicine in Belfast.

His chosen title, “Geriatric Medicine and Stroke Medicine: mortal enemies or comrades in arms?” teasingly dissected some of the tensions between geriatricians and other subdisciplines engaged in stroke care.

This is perhaps best seen at the European Stroke Conference where myopia neurovascularia (also known as the thrombolytic orgasm—intense interest in thrombolysis followed by precipitate loss of interest) stalks much (but to be fair not all) of the presentations and discourse. In some ways one senses that for these physicians that disability after stroke almost represents some sort of shameful clinical failure rather than an important focus for our clinical attention and research.

The vision outlined in his talk was of a much fuller perspective, including after care and support in the community and in nursing homes after the acute event, one which resonated with the philosophy of geriatric medicine and indeed the interesting comparison between gerontological, stroke and general nursing in stroke care. His ongoing input to stroke research (and the European Stroke Association) is a shining beacon of how science and humanity can, and ought to be, boon companions.

For me personally, his talk was encouraging, as I had the good fortune to lead on an Irish National Audit of Stroke Care (2008) that paralleled this broad view, traversing the spectrum from prevention through hospital to the community and nursing home. Sadly, while development in hospital stroke services has occurred since the report was published, regression to the hospital care matrix has occurred, with a sorry neglect of the after care aspects.

Indeed, to date the programme has resisted the inclusion of outcome measures of disability in the Irish National Stroke Registry, despite the fact that the WHO has recommended the modified Rankin Scale for stroke services, and it is in use in a number of low to middle income countries.

A measurement of disability on outcome is not only important as a marker of care needs for an individual patient, but can also be used for planning the delivery of services. Stirred by Peter Langhorne’s view of stroke, I feel emboldened to continue fighting for the reinstatement of this broader vision for stroke in Ireland.

The final part of his talk reverted to geriatric medicine, and to the recent Cochrane review (on which we had both collaborated) which affirmed its remarkable effectiveness. Peter mused on the continuing resistance in some quarters to the wider roll-out of geriatric medicine in acute care: could it be that the term “comprehensive geriatric assessment” does not convey the impact and success? Perhaps, he said with a twinkle in his eye, drawing on the impact that thrombolysis has had on the attention of professionals and public alike, might we not take a leaf out of their book and rename it “gerontolysis!”

Desmond O’Neill is a consultant physician in geriatric and stroke medicine, and was chair of the council on stroke of the Irish Heart Foundation from 1997 to 2009.


1.   Charlton BG. Lectures are such an effective teaching method because they exploit evolved human psychology to improve learning. Med Hypotheses. 2006;67(6):1261-5.