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:

“ … 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...