Age and Ageing 2015; 44: 353–355 doi: 10.1093/ageing/afv040 Published electronically 23 March 2015
© The Author 2015. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email: [email protected]
COMMENTARY
Geriatric medicine and cultural gerontology DESMOND O’NEILL Trinity College Dublin—Centre for Ageing, Neuroscience and the Humanities, Trinity Centre for Health Sciences, Tallaght Hospital, Dublin 24, Ireland Address correspondence to: Desmond O’Neill. Tel: (+353) 14143215; Fax: (+353) 14143244. Email: [email protected]
T.S. Eliot once proposed that there were two sorts of problems in life. One prompted the question, ‘What are we going to do about it?’ and the other provoked the questions, ‘What does it mean? How does one relate to it?’ Geriatric medicine, an eminently practical specialty, has concentrated with good effect on the former but with notable exceptions has yet to devote significant time to the latter. Into this breach has developed an innovative and exciting movement in gerontology to provide a deeper and more comprehensive insight into the meaning of ageing. Largely encompassed by the terms of cultural, humanistic and narrative gerontology, their intent and methodologies in many ways mirror the relationship between the medical humanities, narrative medicine and medicine. Keywords: ageing, geriatrics, humanities, culture, narrative, older people
T.S. Eliot once proposed that there were two sorts of problems in life. One prompted the question, ‘What are we going to do about it?’ and the other provoked the questions, ‘What does it mean? How does one relate to it?’ Geriatric medicine, an eminently practical specialty, has concentrated with good effect on the former but with notable exceptions has yet to devote significant time to the latter. The meaning of ageing is a central but unarticulated aspect of our daily practice. Our good fortune to engage with people at the most complex and enriched stage of life is reflected in the high levels of professional and personal satisfaction reported by geriatricians [1] but not in the discourse of geriatric medicine which remains largely one of decline and failure [2], rarely reflecting the marvels of population ageing or of the individual and societal gains of ageing into later life [3]. Equally, while the challenge of ageism is widely recognised, the factors underlying personal and societal ambivalence to ageing remain poorly understood. Without a broader context, we may lose sight of the core values of those we serve and the benefits of ageing, diminish our possibilities for academic and professional enrichment, and negatively impact on our ability to influence and attract others to the field. This was neatly illustrated by a recent paper bemoaning the lack of enthusiasm of trainees in the USA for geropsychiatry in which the authors described mental health problems of later life as ‘the underside of the
Silver Tsunami’ [4]. Given that there are no appreciable upsides to a tsunami, it is no wonder that the best and brightest are not attracted to work with a demographic trend characterised in such negative terms by its presumptive champions. A focus on technique and methodology at the expense of a wider perspective on ageing is not unique to geriatric medicine: other branches of gerontology, and in particular social gerontology, have also been frustrated at the reduction of the study of later life to paradigms of social welfare and public policy which are also dominated by frailty and burden [5]. Into this breach has developed an innovative and exciting movement in gerontology to provide a deeper and more comprehensive insight into the meaning of ageing. Largely encompassed by the terms of cultural [6], humanistic [7] and narrative gerontology [8], their intent and methodologies in many ways mirror the relationship between the medical humanities, narrative medicine and medicine. While ‘culture’ as a term is open to broad and conflicting usage, cultural gerontology (the most commonly used term for this movement in European gerontology) can be described as a tendency, or a field, with a central focus on meaning, a desire to transcend old paradigms, and to bring a fuller, richer account of later years than heretofore presented in gerontology and geriatric medicine. An increasing focus of the humanities in recent decades has been critical to the development of the field, including literature, film [9], music
353
Downloaded from http://ageing.oxfordjournals.org/ at University of California, San Diego on June 5, 2015
Abstract
D. O’Neill
354
America. Broader platforms are provided for cultural gerontology by the European Network of Ageing Studies (www. agingstudies.eu), whose conference takes place in Graz, Austria, in 2017, and the North American Network of Aging Studies (www.agingstudies.org), with a conference in Oxford, Ohio, later this year. Geriatric medicine has always been a creative and innovative specialty, with a strong humanistic attitude, an interest in the narratives of our older patients and their families, and a keen sense of the interplay between society, ageing and the healthcare professions. Cultural gerontology represents an opportunity for the discipline to develop an enhanced articulacy and deeper understanding about these aspects of our philosophy and practice, and to develop and share these insights with other researchers in the field, mindful of TS Eliot’s verse that: “Each venture is a new beginning, a raid on the inarticulate”.
Key points • Geriatric medicine has focused on the pragmatics rather than on the meaning of ageing. • Cultural gerontology provides a framework for better understanding of the meaning and individual experience of ageing. • There are cogent professional and academic reasons for geriatricians to engage with cultural gerontology.
References 1. Leigh JP, Kravitz RL, Schembri M, Samuels SJ, Mobley S. Physician career satisfaction across specialties. Arch Intern Med 2002; 162: 1577–84. 2. Robinson S, Briggs R, O’Neill D. Cognitive aging, geriatrics textbooks, and unintentional ageism. J Am Geriatr Soc 2012; 60: 2183–5. 3. O’Neill D. The art of the demographic dividend. Lancet 2011; 377: 1828–9. 4. Bartels SJ, Naslund JA. The underside of the silver tsunami— older adults and mental health care. N Engl J Med 2013; 368: 493–6. 5. Twigg J, Martin W. The challenge of cultural gerontology. Gerontologist 2014; doi: 10.1093/geront/gnu061. 6. Andersson L. Cultural Gerontology. Westport, Conn: Auburn House, 2002. 7. Cole TR, Van Tassel DD, Kastenbaum R. Handbook of the Humanities and Aging. New York: Springer, 1992. 8. de Medeiros K. Narrative Gerontology in Research and Practice. New York: Springer, 2013. 9. Chivers S. The Silvering Screen: old age and Disability in Cinema. Toronto, Buffalo: University of Toronto Press, 2011. 10. Bennett A. Music, Style, and Aging: Growing old Disgracefully? Philadelphia: Temple University Press, 2013. 11. Baars J. Aging and the art of Living. Baltimore: Johns Hopkins University Press, 2012. 12. Lewis DC, Medvedev K, Seponski DM. Awakening to the desires of older women: deconstructing ageism within fashion magazines. J Aging Stud 2011; 25: 101–9.
Downloaded from http://ageing.oxfordjournals.org/ at University of California, San Diego on June 5, 2015
[10], philosophy [11], fashion [12] and history [13]: there have also been important contributions from social and psychological themes such as the body and embodiment [14], identity and subjectivity [15], visual imagery of ageing [16], consumption [17] and perceptions of time and space [18]. The prospect of accessing yet another field of gerontology may seem daunting to the busy geriatrician [19], but even a modest investment is hugely rewarding in terms of understanding and engagement of our everyday practice. For example, the literature on clothes worn by those with dementia will strike an immediate resonance with any geriatrician [20], and indeed may be an unconscious aspect of our overall assessment process. Equally, a stimulating reflection on arts and dementia, engagingly entitled Shall I Compare Thee to a Dose of Donepezil [21], highlights the peril of imposing a pharmacological model on an aspect of life that most of us take for granted, that of aesthetic engagement [22]. From a research perspective, there is also a clear imperative for clinicians to engage with cultural gerontology. Much of the existing body of work, while admirably directed to positive aspects of ageing, is almost exclusively situated in the domain of social and psychological gerontology [23]: notwithstanding, it is striking how much of the work relates to age-related disease, disability and care issues. Gerontologists of all hues, from cultural gerontology to geriatric medicine, would benefit from an interdisciplinary engagement, mindful of the challenges of ensuring scholarship in integrative research [24]. A number of factors should facilitate participation by geriatricians in research in cultural gerontology. Even allowing for the uncertainty over its definition [25], the almost universal presence of the medical humanities and narrative medicine in undergraduate and increasingly in postgraduate medical education provides a foundation for developing geriatric medical humanities. Applying cultural gerontology to the medical humanities provides wonderful material for presenting a rich context of ageing to medical students [3], and early research outcomes are encouraging for such approaches [26]. Indeed, the influence of cultural gerontology, predominantly driven by the imperative of research over that of education, might benefit the medical humanities, where these priorities are reversed with resulting dissatisfaction among the end-users of curricula [27]. Geriatricians should also be encouraged by the major contributions to cultural gerontology by a handful of remarkable colleagues. The late Robert N. Butler not only coined the term ‘ageism’ in the context of a broad dialogue about the meaning of ageing in contemporary society [28], but also formulated the influential theory of the life course review [29]. Pioneering research by Gene Cohen into creativity and ageing gave us the insight that late life creativity occurred not in spite of advanced age but because of it [30]. The writing of Mark Agronin provides a deeply perceptive guide to the inner richness of late life with dementia and disability [31]. Developing momentum in geriatric medicine and cultural gerontology can be facilitated by special interest groups in professional societies, as presently exist in the American Geriatrics Society and the Gerontological Society of
Geriatric medicine and cultural gerontology 23. Twigg J, Martin W, (eds). Routledge Handbook of Cultural Gerontology. London: Routledge, 2015. 24. McGaghie WC. Varieties of integrative scholarship: why rules of evidence, criteria, and standards matter. Acad Med 2015; 90: 294–302. 25. Moss H, O’Neill D. Medical humanities—serious academic pursuit or doorway to dilettantism? Ir Med J 2012; 105: 261–2. 26. O’Donnell L, Carson L, Forciea MA, Kinosian B, Shea J, Yudin J et al. What students experienced: a narrative analysis of essays written by first-year medical students participating in a geriatrics home visit. J Am Geriatr Soc 2013; 61: 1592–7. 27. Shapiro J, Coulehan J, Wear D, Montello M. Medical humanities and their discontents: definitions, critiques, and implications. Acad Med 2009; 84: 192–8. 28. Butler RN. Age-ism: another form of bigotry. Gerontologist 1969; 9: 243–6. 29. Butler RN. The life review: an interpretation of reminiscence in the aged. Psychiatry 1963; 26: 65–76. 30. Cohen GD. Creativity and aging: ramifications for research, practice, and policy. Geriatrics 1998; 53(Suppl 1): S4–8. 31. O’Neill D. Reflections on ageing. BMJ 2011; 342: d3395. Received 20 February 2015; accepted in revised form 4 March 2015
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Downloaded from http://ageing.oxfordjournals.org/ at University of California, San Diego on June 5, 2015
13. Thane P. The Long History of old age. London: Thames & Hudson, 2005. 14. Gilleard C, Higgs P. Ageing, Corporeality and Embodiment. London: Anthem Press, 2013. 15. Biggs S. Choosing not to be old? Masks, bodies and identity management in later life. Aging & Society 1997; 17: 553070. 16. Martin W. Visualising risk: health, gender and the ageing body. Crit Soc Policy 2012; 32: 51–68. 17. Drolet AL, Schwarz N, Yoon C. The Aging Consumer: Perspectives From Psychology and Economics. New York, NY: Taylor & Francis, 2010. 18. Angus JE, Kontos P, Dyck I, McKeever P, Poland B. The physical significance of home: habitus and the experience of receiving long term home care. Sociol Health Med 2005; 27: 161–87. 19. O’Neill D. Am I a gerontologist or geriatrician? J Am Geriatr Soc 2012; 60: 1361–3. 20. Twigg J, Buse CE. Dress, dementia and the embodiment of identity. Dementia (London) 2013; 12: 326–36. 21. de Medeiros K, Basting A. ‘Shall I compare thee to a dose of donepezil?’: cultural arts interventions in dementia care research. Gerontologist 2014; 54: 344–53. 22. Moss H, Donnellan C, O’Neill D. Hospitalization and aesthetic health in older adults. J Am Med Dir Assoc 2015; 16: 173 e11–6.
© The Author 2015. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email: [email protected]
COMMENTARY
Geriatric medicine and cultural gerontology DESMOND O’NEILL Trinity College Dublin—Centre for Ageing, Neuroscience and the Humanities, Trinity Centre for Health Sciences, Tallaght Hospital, Dublin 24, Ireland Address correspondence to: Desmond O’Neill. Tel: (+353) 14143215; Fax: (+353) 14143244. Email: [email protected]
T.S. Eliot once proposed that there were two sorts of problems in life. One prompted the question, ‘What are we going to do about it?’ and the other provoked the questions, ‘What does it mean? How does one relate to it?’ Geriatric medicine, an eminently practical specialty, has concentrated with good effect on the former but with notable exceptions has yet to devote significant time to the latter. Into this breach has developed an innovative and exciting movement in gerontology to provide a deeper and more comprehensive insight into the meaning of ageing. Largely encompassed by the terms of cultural, humanistic and narrative gerontology, their intent and methodologies in many ways mirror the relationship between the medical humanities, narrative medicine and medicine. Keywords: ageing, geriatrics, humanities, culture, narrative, older people
T.S. Eliot once proposed that there were two sorts of problems in life. One prompted the question, ‘What are we going to do about it?’ and the other provoked the questions, ‘What does it mean? How does one relate to it?’ Geriatric medicine, an eminently practical specialty, has concentrated with good effect on the former but with notable exceptions has yet to devote significant time to the latter. The meaning of ageing is a central but unarticulated aspect of our daily practice. Our good fortune to engage with people at the most complex and enriched stage of life is reflected in the high levels of professional and personal satisfaction reported by geriatricians [1] but not in the discourse of geriatric medicine which remains largely one of decline and failure [2], rarely reflecting the marvels of population ageing or of the individual and societal gains of ageing into later life [3]. Equally, while the challenge of ageism is widely recognised, the factors underlying personal and societal ambivalence to ageing remain poorly understood. Without a broader context, we may lose sight of the core values of those we serve and the benefits of ageing, diminish our possibilities for academic and professional enrichment, and negatively impact on our ability to influence and attract others to the field. This was neatly illustrated by a recent paper bemoaning the lack of enthusiasm of trainees in the USA for geropsychiatry in which the authors described mental health problems of later life as ‘the underside of the
Silver Tsunami’ [4]. Given that there are no appreciable upsides to a tsunami, it is no wonder that the best and brightest are not attracted to work with a demographic trend characterised in such negative terms by its presumptive champions. A focus on technique and methodology at the expense of a wider perspective on ageing is not unique to geriatric medicine: other branches of gerontology, and in particular social gerontology, have also been frustrated at the reduction of the study of later life to paradigms of social welfare and public policy which are also dominated by frailty and burden [5]. Into this breach has developed an innovative and exciting movement in gerontology to provide a deeper and more comprehensive insight into the meaning of ageing. Largely encompassed by the terms of cultural [6], humanistic [7] and narrative gerontology [8], their intent and methodologies in many ways mirror the relationship between the medical humanities, narrative medicine and medicine. While ‘culture’ as a term is open to broad and conflicting usage, cultural gerontology (the most commonly used term for this movement in European gerontology) can be described as a tendency, or a field, with a central focus on meaning, a desire to transcend old paradigms, and to bring a fuller, richer account of later years than heretofore presented in gerontology and geriatric medicine. An increasing focus of the humanities in recent decades has been critical to the development of the field, including literature, film [9], music
353
Downloaded from http://ageing.oxfordjournals.org/ at University of California, San Diego on June 5, 2015
Abstract
D. O’Neill
354
America. Broader platforms are provided for cultural gerontology by the European Network of Ageing Studies (www. agingstudies.eu), whose conference takes place in Graz, Austria, in 2017, and the North American Network of Aging Studies (www.agingstudies.org), with a conference in Oxford, Ohio, later this year. Geriatric medicine has always been a creative and innovative specialty, with a strong humanistic attitude, an interest in the narratives of our older patients and their families, and a keen sense of the interplay between society, ageing and the healthcare professions. Cultural gerontology represents an opportunity for the discipline to develop an enhanced articulacy and deeper understanding about these aspects of our philosophy and practice, and to develop and share these insights with other researchers in the field, mindful of TS Eliot’s verse that: “Each venture is a new beginning, a raid on the inarticulate”.
Key points • Geriatric medicine has focused on the pragmatics rather than on the meaning of ageing. • Cultural gerontology provides a framework for better understanding of the meaning and individual experience of ageing. • There are cogent professional and academic reasons for geriatricians to engage with cultural gerontology.
References 1. Leigh JP, Kravitz RL, Schembri M, Samuels SJ, Mobley S. Physician career satisfaction across specialties. Arch Intern Med 2002; 162: 1577–84. 2. Robinson S, Briggs R, O’Neill D. Cognitive aging, geriatrics textbooks, and unintentional ageism. J Am Geriatr Soc 2012; 60: 2183–5. 3. O’Neill D. The art of the demographic dividend. Lancet 2011; 377: 1828–9. 4. Bartels SJ, Naslund JA. The underside of the silver tsunami— older adults and mental health care. N Engl J Med 2013; 368: 493–6. 5. Twigg J, Martin W. The challenge of cultural gerontology. Gerontologist 2014; doi: 10.1093/geront/gnu061. 6. Andersson L. Cultural Gerontology. Westport, Conn: Auburn House, 2002. 7. Cole TR, Van Tassel DD, Kastenbaum R. Handbook of the Humanities and Aging. New York: Springer, 1992. 8. de Medeiros K. Narrative Gerontology in Research and Practice. New York: Springer, 2013. 9. Chivers S. The Silvering Screen: old age and Disability in Cinema. Toronto, Buffalo: University of Toronto Press, 2011. 10. Bennett A. Music, Style, and Aging: Growing old Disgracefully? Philadelphia: Temple University Press, 2013. 11. Baars J. Aging and the art of Living. Baltimore: Johns Hopkins University Press, 2012. 12. Lewis DC, Medvedev K, Seponski DM. Awakening to the desires of older women: deconstructing ageism within fashion magazines. J Aging Stud 2011; 25: 101–9.
Downloaded from http://ageing.oxfordjournals.org/ at University of California, San Diego on June 5, 2015
[10], philosophy [11], fashion [12] and history [13]: there have also been important contributions from social and psychological themes such as the body and embodiment [14], identity and subjectivity [15], visual imagery of ageing [16], consumption [17] and perceptions of time and space [18]. The prospect of accessing yet another field of gerontology may seem daunting to the busy geriatrician [19], but even a modest investment is hugely rewarding in terms of understanding and engagement of our everyday practice. For example, the literature on clothes worn by those with dementia will strike an immediate resonance with any geriatrician [20], and indeed may be an unconscious aspect of our overall assessment process. Equally, a stimulating reflection on arts and dementia, engagingly entitled Shall I Compare Thee to a Dose of Donepezil [21], highlights the peril of imposing a pharmacological model on an aspect of life that most of us take for granted, that of aesthetic engagement [22]. From a research perspective, there is also a clear imperative for clinicians to engage with cultural gerontology. Much of the existing body of work, while admirably directed to positive aspects of ageing, is almost exclusively situated in the domain of social and psychological gerontology [23]: notwithstanding, it is striking how much of the work relates to age-related disease, disability and care issues. Gerontologists of all hues, from cultural gerontology to geriatric medicine, would benefit from an interdisciplinary engagement, mindful of the challenges of ensuring scholarship in integrative research [24]. A number of factors should facilitate participation by geriatricians in research in cultural gerontology. Even allowing for the uncertainty over its definition [25], the almost universal presence of the medical humanities and narrative medicine in undergraduate and increasingly in postgraduate medical education provides a foundation for developing geriatric medical humanities. Applying cultural gerontology to the medical humanities provides wonderful material for presenting a rich context of ageing to medical students [3], and early research outcomes are encouraging for such approaches [26]. Indeed, the influence of cultural gerontology, predominantly driven by the imperative of research over that of education, might benefit the medical humanities, where these priorities are reversed with resulting dissatisfaction among the end-users of curricula [27]. Geriatricians should also be encouraged by the major contributions to cultural gerontology by a handful of remarkable colleagues. The late Robert N. Butler not only coined the term ‘ageism’ in the context of a broad dialogue about the meaning of ageing in contemporary society [28], but also formulated the influential theory of the life course review [29]. Pioneering research by Gene Cohen into creativity and ageing gave us the insight that late life creativity occurred not in spite of advanced age but because of it [30]. The writing of Mark Agronin provides a deeply perceptive guide to the inner richness of late life with dementia and disability [31]. Developing momentum in geriatric medicine and cultural gerontology can be facilitated by special interest groups in professional societies, as presently exist in the American Geriatrics Society and the Gerontological Society of
Geriatric medicine and cultural gerontology 23. Twigg J, Martin W, (eds). Routledge Handbook of Cultural Gerontology. London: Routledge, 2015. 24. McGaghie WC. Varieties of integrative scholarship: why rules of evidence, criteria, and standards matter. Acad Med 2015; 90: 294–302. 25. Moss H, O’Neill D. Medical humanities—serious academic pursuit or doorway to dilettantism? Ir Med J 2012; 105: 261–2. 26. O’Donnell L, Carson L, Forciea MA, Kinosian B, Shea J, Yudin J et al. What students experienced: a narrative analysis of essays written by first-year medical students participating in a geriatrics home visit. J Am Geriatr Soc 2013; 61: 1592–7. 27. Shapiro J, Coulehan J, Wear D, Montello M. Medical humanities and their discontents: definitions, critiques, and implications. Acad Med 2009; 84: 192–8. 28. Butler RN. Age-ism: another form of bigotry. Gerontologist 1969; 9: 243–6. 29. Butler RN. The life review: an interpretation of reminiscence in the aged. Psychiatry 1963; 26: 65–76. 30. Cohen GD. Creativity and aging: ramifications for research, practice, and policy. Geriatrics 1998; 53(Suppl 1): S4–8. 31. O’Neill D. Reflections on ageing. BMJ 2011; 342: d3395. Received 20 February 2015; accepted in revised form 4 March 2015
355
Downloaded from http://ageing.oxfordjournals.org/ at University of California, San Diego on June 5, 2015
13. Thane P. The Long History of old age. London: Thames & Hudson, 2005. 14. Gilleard C, Higgs P. Ageing, Corporeality and Embodiment. London: Anthem Press, 2013. 15. Biggs S. Choosing not to be old? Masks, bodies and identity management in later life. Aging & Society 1997; 17: 553070. 16. Martin W. Visualising risk: health, gender and the ageing body. Crit Soc Policy 2012; 32: 51–68. 17. Drolet AL, Schwarz N, Yoon C. The Aging Consumer: Perspectives From Psychology and Economics. New York, NY: Taylor & Francis, 2010. 18. Angus JE, Kontos P, Dyck I, McKeever P, Poland B. The physical significance of home: habitus and the experience of receiving long term home care. Sociol Health Med 2005; 27: 161–87. 19. O’Neill D. Am I a gerontologist or geriatrician? J Am Geriatr Soc 2012; 60: 1361–3. 20. Twigg J, Buse CE. Dress, dementia and the embodiment of identity. Dementia (London) 2013; 12: 326–36. 21. de Medeiros K, Basting A. ‘Shall I compare thee to a dose of donepezil?’: cultural arts interventions in dementia care research. Gerontologist 2014; 54: 344–53. 22. Moss H, Donnellan C, O’Neill D. Hospitalization and aesthetic health in older adults. J Am Med Dir Assoc 2015; 16: 173 e11–6.
