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Evidence-Based Care for the Elderly:
Uses of “the Grandmother Principle”

This Letter to the Editor regards “gestalt” as a clinical decision-making tool for improving medical outcomes in the treatment of elderly patients. Oxford Learner’s Dictionary Online defines gestalt as “a set of things, such as a person’s thoughts or experiences, that is considered as a single system which is different from the individual thoughts, experiences, etc. within it.”1 Using a gestalt in treating older patients involves viewing the patient as a whole and applying the biopsychosocial model to patient care. Applying the biopsychosocial model in this way is an adaptation of the sociological imagination by C. Wright Mills:

“In 1959, sociologist C. Wright Mills defined sociological imagination as the ability to see the impact of social forces on individuals’ private and public lives. Sociological imagination, then, plays a central role in the sociological perspective … [a]nother version of this holistic model is the biopsychosocial perspective, which attributes complex sociological phenomena to interacting biological (internal), psychological (internal), and social (external) forces … “2,3

Although some may disagree with his definition, Chad Cook, MD argues that clinical gestalt is an ontological, “top down,” approach to clinical decision-making. He defines clinical gestalt this way: [End Page 1]

“ … the theory that healthcare practitioners actively organize clinical perceptions into coherent construct wholes. This implies that clinicians have the ability to indirectly make clinical decisions in absence of complete information and can generate solutions that are characterized by generalizations that allow transfer from one problem to the next.”4

Cook points out that gestalt based decision-making is subject to five errors: “1) the representative heuristic (if it’s similar to something else, it must be like that; 2) the availability heuristic (we are more inclined to find something if it’s something we are used to finding); 3) the confirmatory bias (looking for things in the exam to substantiate what we want to find; 4) the illusory correlation (linking events when there is actually no relationship); and 5) overconfidence.”4,5 Dr. Cook writes that gestalt-based decision-making is not good enough, however, and that decision-making errors can be improved through predictive modeling. Predictive modeling is defined as a “specialization within research that deals with creation of decision rules that marginalize errors in decision-making during diagnosis and intervention.”4 What Cook is arguing for is a model of patient-centered care that reduces the risk of unconscious bias leading to negative medical outcomes.

Since gestalt-based thinking relies heavily on the sociological imagination, even in the absence of decision-making rules, it is capable of reducing bias such as confirmation bias and errors in medical decision-making. Using the gestalt encourages us to connect the macro to the micro: we are led to consider how structural level problems that affect the elderly in general, such as poverty, affect an individual’s overall health (without relying on stereotypes and generalizations). Seeing how the macro is connected to the micro increases empathy and emotional intelligence. It also may help physicians to make better medical decisions when the effects of cumulative disadvantage on an elderly one’s health may not be apparent.

It is important to consider how we bring together evidence-based medicine with more complementary modes to facilitate effective, compassionate care. In particular, it is critical to confront the challenging aspects of geriatric medicine in a rapidly aging society. This background will give the reader a strong appreciation for the conclusion in this letter that the “Grandmother Principle,” a form of gestalt-based clinical decision-making, is a valuable tool in modern medicine.

It has been said that the value that a society places on its elderly speaks volumes about its morals. Practical considerations come to bear here as well: the elderly population in the U.S. is growing exponentially but there are not enough physicians trained specifically to treat the ailments common to old age.6 Older adults have a higher burden of chronic disease than younger adults and may have atypical presentations to common diseases. Additionally, neuropsychiatric conditions such as dementia, delirium, and atypical depression commonly affect the elderly.7 Intersecting social disadvantages such as having limited material resources, poverty, and structural ageism often affects their access to care (M. M. Gosdin, personal communication, May 19, 2016). It takes a physician with experience taking care of elderly patients to meet their health care needs. Seasoned Professor of Geriatric Medicine and Gerontology at Johns Hopkins University School of Medicine, John Burton, MD, has said that “if you’ve seen one [End Page 2] older adult then you’ve seen just one.” Here, Dr. Burton is emphasizing the fact that older adults are highly heterogeneous in the biological, psychological, and sociological determinants of their illnesses.

For reasons described below, geriatricians are the Van Goghs of the medical world, with creative thinking as the paintbrush. They are also the sociologists of the medical profession, and like the great 20th century sociologist C. Wright Mills, geriatricians must apply the sociological imagination in a meaningful way, emphasizing the societal-patient interactions that impact a patient’s health care and healthcare outcomes.8 Employing a sociological imagination to clinical practice requires re-examining commonly accepted truths while connecting personal health problems to social issues. Connecting the many social determinants of health to the individual is an essential component of patient-centered geriatric care. To understand individual patient needs fully geriatricians must gain an understanding of the patient’s social location while remaining socially aware and reflexive. The sociological imagination teaches us to look beyond our own personal experiences and biases, which often serve as barriers to effective health care and creative problem-solving.

The “Grandmother Principle” emerges from the sociological imagination in the sense that applying it requires stepping outside of one’s comfort zone and traditional medical training to connect the many ways in which elderly patients experience illness and disease. Specifically, it takes into account how a patient’s biography is shaped by the larger social context in which it exists. Life experiences have a cumulative effect on one’s health therefore social location is especially important to compassionate and effective geriatric care.

Health care providers who take care of elderly patients must rely on a high level of medical knowledge, intuition, and creativity to provide the care that older adults require; in the words of Rita Charon, MD, of Columbia University Medical School, they must bring their “exquisite attention.” Although there are many quality clinical trials there are fewer “gold standard” research studies providing an evidence base to diagnose and treat even common conditions that affect older adults. For instance, the research that guides the medical treatment for acute myocardial infarction is not as applicable in older adults compared with younger ones:

“The supposed direct clear modern incisive application of evidence-based medicine as developed through Guidelines, with delivery of proven new management strategies, often seems to evaporate into a vague patchy, ad hoc approach when elderly patients present with acute cardiovascular disease.”9

Following the acute event, lowering a post-myocardial infarction Centenarian’s resting heart rate to the goal may cause unwanted side-effects (perhaps because of the inapplicability of the research findings, undiagnosed illness, or other reasons). Observation and “close reading” of the patient are key.10

Here is a simple example of whole-person approach to health care emphasizing quality of life. Suppose that your grandmother’s favorite snack was potato chips, but because of their salt content she was told by her nephrologist to avoid eating them. However, let’s say that your grandmother had a five-year life expectancy with maximal [End Page 3] medical therapy. To add to the picture, grandmother was previously an avid gardener but because of diminished mobility, she rarely leaves her house. She seemed miserable most of the time. If you observed that while eating a bag of potato chips, a huge smile on her face and improvement in her mood then you might keep giving them to her despite her physicians’ recommendations. In this example, gestalt-based decision-making was valuable. In fact, the philosophy of hospice and palliative care emphasizes quality of life and routinely relies on whole-person, gestalt based thinking. In The Lancet editorial, “Prolonging Life at All Cost: Quantity versus Quality,” the author writes:

“Maintaining hope at the end of life is very important, but managing expectations and changing outlooks so that this hope is focused towards quality of life, not just quantity of life, might mean that more people get the good death that they deserve.”11

If, when on bedside rounds, you encounter an elderly patient and find that there is no research (or perhaps equivocal research) to support a clinical decision, try asking yourself, “If this were my grandmother what would I do for her?” When a health care provider bases a geriatric related medical decision on gestalt, we call this applying the “Grandmother Principle.”

The “Grandmother Principle” borrows from a posteriori knowledge which is depen-dent on experience and empirical evidence. When discussing this style of clinical decision-making with a colleague, Thomas Finucane, MD, questions did arise, including:

“Are you saying that gestalts by experienced people are valuable and that the question they should be answering is the ‘grandmother question?’ Are you sure that is the right way to decide … what about the gestalts of people without much experience or training?”

Such gestalt is a valuable clinical decision-making tool and indeed experienced clinicians are more successful using gestalt based thinking.12 Not only that, but physicians work in an intense, results-driven environment that both demands use of and refines an individual’s gestalt. A physician can and should provide information about a patient’s condition and prognosis to facilitate patients that process through their clinician’s gestalt-based reasoning. At times that clinical discussion might change or at least shift the gestalt-based management decision based on the individual needs and expectations of the patient. Thus, physicians using this approach can empower their patients in the health care decision-making process.

This gestalt-based style of clinical reasoning may apply in certain clinical situations, such as when a physician is faced with the dilemma of more or less work up, the question of whether to discharge or not, to transfer or not, or more profoundly, the question of whether to treat or not. Examples such as the following may help illustrate the complexity of such decisions: the decision to take a septuagenarian with multi-morbidity to the cardiac catheterization laboratory, treating a depressed, wheelchair bound octogenarian with restorative hip fracture surgery, continuing memory enhancer therapy in nonagenarian with advanced dementia and complete dependence in activities of daily living, and transferring a frail, chronically delirious long-term chronic ventilator dependent centenarian from her familiar environment to an unfamiliar community [End Page 4] based weaning unit. Gestalt-based clinical decision-making might lead the clinician to initiate medical management for the septuagenarian; physical and occupational therapy for the octogenarian; increased socialization for the nonagenarian; and to encourage the centenarian to remain in her familiar environment.

If health care providers utilized this form of reasoning in their everyday practice then the practice of medicine would be patient-driven, yet still practical. The “Grandmother Principle,” is a specific application using one’s gestalt to guide health care decisions when caring for medically complicated elderly patients, and should be considered an appropriate supplement to traditional evidence-based medicine.

As we practice medicine on a daily basis we will also find that there are some clinical questions that can be answered with available research and others that cannot. Those answers with a strong statistical foundation allow a health care provider to practice evidence-based medicine with a high level of precision and accuracy. In geriatric medicine, there is a lack of research in many important areas and many studies do not have statistically significant research results applicable to elderly populations. Geriatric patients who are also a part of underserved populations may be among those to benefit the most, especially when there are differences in race, culture, and ethnicity between the patients and the providers, as the application of this principle may have the secondary effect of mitigating unconscious bias, both for the practitioner and for those the practitioner must interact with in providing care.

Thus, the geriatric practitioner, trained in the art and science of medicine finds that the science is sometimes inadequate because the evidence is sometimes missing—and—that relying on the art must deviate from or go beyond the standard algorithms (which after all are only guidelines). Using the gestalt proposed here relies upon an awareness of complex psychosocial variables and emotional intelligence, cultural competency, clinical judgment, and assessment of highly complex, interrelated psychological and societal factors.

Each individual medical practitioner has a personal experience with the various sociological variables that impact his or her perspective and practice of medicine. Thus, each person’s gestalt is different, but having passed the rigorous training requirements to become a medical provider, and taken an oath to provide patient care to the best of one’s ability; it may be assumed that an individual’s application of his/her gestalt will be in the best interest of the patient. Even operating under such an assumption, it may be well to recall these lines from the Hippocratic Oath, and to recall them frequently:

“I will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of overtreatment and therapeutic nihilism. I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug … I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick … “13

In fact and practice, the art of medicine encourages deviation from evidence-based algorithms when they do not apply to the patient. However, a “non-evidence-based approach” to clinical problem-solving, when appropriate, is undervalued in modern [End Page 5] medical education. Similar to the sociologist who answers questions using the sociological imagination, geriatricians have a formal scientific tool, the “geriatric gestalt,” that enables them to provide the type of health care that is required for elderly patients.

Geriatrics is one of the most challenging fields in medicine today. The gestalt of geriatricians is different from that of non-geriatricians, by virtue of their training, and the deductive reasoning that is implicitly taught in the hidden curriculum of geriatric medical education. Geriatricians must use clinical imagination where the evidence for standard decision-making is thin. Interdisciplinary studies exploring the specific wants and needs of elderly patients is needed and would provide an evidence-based framework for effectively implementing the “Grandmother Principle.” Research also must be conducted so that predictive modeling can further reduce error that may result from application of gestalt based decision-making. This theoretical approach to patient care is already being used by physicians, but now has a formal name and we have identified areas for improving its application.

Samuel K. Williams, Joanne M. Braxton, Melissa Gosdin, Nathan Nobis, and Denise A. Williams

SAMUEL K. WILLIAMS III is a graduate of Morehouse College, Meharry Medical College School of Medicine, Boston University Medical Center’s internal medicine residency, and Johns Hopkins University School of Medicine’s Geriatric Medicine and Gerontology fellowship. JOANNE M. BRAXTON is David B. Larson Fellow in Spirituality and Health, Library of Congress John W. Kluge Center, Frances L. and Edwin L. Cummings Professor of the Humanities at the College of William and Mary, and Community Faculty in Family Medicine at Eastern Virginia Medical School. MELISSA GOSDIN is faculty in the Department of Criminal Justice, Psychology and Sociology at Albany State University in Albany, Georgia. NATHAN NOBIS is Professor of Philosophy in the Department of Philosophy and Religion at Morehouse College in Atlanta, Georgia. DENISE A. WILLIAMS is a Registered Medical Assistant at Phoebe Putney Memorial Hospital in Albany, GA where she focuses on providing medical assistance to the Urgent Care patient population.

Please send correspondence to Samuel K. Williams III, 1658 Georgia Ave., Albany, GA 31705; Phone: (229) 291-7680.

References

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