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By the time you read this, I shall be 60. The prospect is somewhat surreal. When I was young, my image of 60-year olds was of feeble arthritics with patchy memories. As I have grown older, that image has changed. Most of my contemporaries are at the peak of their careers. Some visit the gym two or three times a week. Others go mountaineering or on sailing holidays. Perhaps people of my age have always had to adjust their stereotypes as they reached 60—or perhaps I belong to a generation that has seen an exceptional transformation in the lives of older people. Probably both are true.
Either way, it was inspiring to see a remarkable movie recently called “Young at Heart”. It shows a group of about two dozen singers whose average age is 80, with some well into their 90s. Most are gifted amateurs, although some are retired professionals. The movie follows them through a 2-month period of rehearsals for their 2006 concert in Northampton, Massachusetts. Their longstanding director, Bob Climan, trains them with uncompromising choral discipline as they learn new songs including “Yes We Can Can”, the Allen Toussaint hit for the Pointer Sisters (where the word “can” is repeated 71 times in varying complicated rhythms) and Sonic Youth’s “Schizophrenia”. They also perform punk classics such as “Should I Stay or Should I Go” by the Clash, or “I Wanna Be Sedated” by the Ramones. Originally broadcast as a Channel Four documentary in 2006, the movie has now been shown worldwide and is available as a DVD.
No illusions
In interviews scattered between footage of the rehearsals, individual singers make it clear that they have no illusions about illness, death and dying. They all share the resolution that the show must go on, regardless. Some sing from wheelchairs, while their more agile peers bop and boogie at the microphone. One or two take time off for chemotherapy or other medical treatment. Almost inevitably, two of them die during the preparations for the concert, including one who has starred in the prior publicity. The surviving singers mourn them, and then go back to rehearsing. On the night, the concert hall is filled to capacity, with audience members of all ages on their feet whooping with delight and—without a doubt—an entirely new kind of vision and hope for their own old age. One of the most passionate performers at the concert, an Englishwoman in her 90s, survived for the concert but died afterwards. The movie is dedicated to her memory. It has won audience awards at film festivals in Atlanta, Los Angeles, Paris, Bergen, Ghent, Warsaw and elsewhere.
“Young at Heart” challenges us to think differently about old age. It should also challenge us to think differently about old age medicine. How many of the doctors who treated members of the chorus, I wonder, had the remotest idea that the “patients” in front of them were fitting in their clinic appointments and even their ward admissions during a hectic schedule of belting out rock lyrics in the rehearsal room? How often do we find out from our own patients in their 80s or 90s what they are doing to keep themselves young—and away from us for most of the time?
Council of elders
A wonderful piece of research from Harvard Medical School encourages us to do just that. Arlene Katz and a team of educators describe how they appointed a “Council of Elders” to help young doctors to understand more about old age.1 The council was part of the geriatrics rotation in a primary care residency programme and consisted of four elders—three women and a man—with a combined age and collective wisdom of 360 years. Two of the women were over 100. The junior doctors were asked to present cases to meetings of the council whenever they came across challenging dilemmas in caring for older patients. The aim of the meetings was to overcome ageism in attitudes towards old people, and to build dialogue across generations and cultures (including the different cultures of medicine and of lived experience.) As the authors point out, the project made doctors aware of their own stereotypes and adverse values, “with implications for decision-making with the patient, not for the patient”.
This awareness grew particularly when trainees presented cases to the council. In doing so, they realised they had to change their language from the cold, impersonal discourse of routine medical speech into something more direct and heartfelt. For example, a trainee who might have started a ward presentation by saying “This 76-year-old dementing woman with hypertension, depression, whose husband is abusive,” introduced her case to the elders with quite different words instead: “I’d like your advice about someone who is very special to me…The thing that is so wonderful about her, and that shines through so brightly, is her personality: she can light up the room. The thing that makes it difficult for her as well although her memory is failing her, her body is very much intact…[her husband] treats her like a baby, which makes her wonder how she could go on”. In this way, the patients were transformed in the doctors’ imaginations from mere routine “cases” into individuals who could be their own parents—or even themselves at some time in the future.
Different perspective
What the elders brought to the dialogue was an entirely different perspective on what it means to be old. For example, they emphasised the importance of old people continuing to give service to others (“if you start thinking of someone else…your own little difficulties don’t seem so important”). They questioned the idea that separating from your husband in old age was unthinkable, or that moving into residential care represented a failure. They counselled doctors to be more challenging with their patients: “You gotta give her something to do. You give her a job…” one elder advised. “And then when she misses, you bawl her out gently.”
The impact of the elders on the trainees was clearly profound. One of them commented: “[In] the hospital setting…we see elderly patients who are pretty debilitated, often times demented and diseased. [But here we saw] people in the community that are “old-old”…and are really “with it”. It’s really enlightening.” The existence of the council gave the trainees all kinds of new understanding. One remarked on how diverse old people are in their views, similar to any other age group. Another proposed that there should be a multicultural elder board to help doctors understand patients of different origins from their own.
Radical change
It is impossible to do justice here to the richness of the paper—just as one cannot possibly convey the effect of watching the old people singing and dancing in “Young at Heart”. But the conclusion of the authors is that what mattered most about the project was the radical change in attitude of the junior doctors towards dialogue with the elderly. They learned not just to listen, but to take seriously the sense and shape of the old people’s world. They learned to respect, inhabit and even speak their language, and to engage with them with a new vitality. One remarked that he now carried them around in his own imagination, consulting them inwardly in order to help him with his decision-making. Indeed, he became more curious about the decision-making process itself—how we each make medical decisions, how we judge their appropriateness, what assumptions we base them on, and what views or assumptions we may be unaware of.
“What is gained by participating in a project like this is…”, the authors write, “a more clear sense of knowing “where we are and what’s happening”, a sense of what can and cannot be done in caring for others, and of what they can still do in caring for themselves”.
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Footnotes
Competing interests None.
Provenance and Peer review Commissioned; not externally peer reviewed.