By Atul Gawande. Published by Profile Books in association with the Wellcome Collection, 2014, hardback, 288 pages. ISBN 978-1846685811, £15.99.

This book is a jeremiad against the way Western society views mortality in general and old age in particular. We have tried to deal with mortality by treating it as a medical problem. “The prevailing fantasy”, Atul Gawande writes, “is that we can be ageless”. We bundle elderly people into nursing homes because when it comes to our loved ones we think safety should trump autonomy at any cost (when it comes to ourselves it is the other way around). We pay remarkably little attention to the kind of social capital that is available in these places. Gawande observes that in the USA most nursing homes market their services according to what they think will please their residents’ families, not their residents. When his wife's grandmother, Alice Hobson, became unable to continue living on her own, her family moved her into a ‘senior-living complex’ that “involved the imposition of more structure and supervision than she'd ever had to deal with before”. After a fall, Alice was moved to a skilled nursing floor, where all privacy and control were gone. “She woke when they told her, bathed and dressed when they told her, ate when they told her. She lived with whomever they said she had to… She felt incarcerated, like she was in prison for being old.”

Nursing homes acquired this role willy-nilly. The expansion of hospital care in the postwar period created a need for step-down facilities into which patients could be discharged. Nursing homes were the preferred instrument. Gawande quotes the medical historian Bruce Vladek's comment that describing the history of nursing homes from the perspective of the elderly “is like describing the opening of the American West from the perspective of the mules”. They were sent there in their droves to give substance to the idea that …

https://mh.bmj.com/content/medhum/early/2015/05/19/medhum-2015-010715.full.pdf

Being Mortal: Illness, Medicine and What Matters in the End

Attitudes of Australian medical students towards older people are important, as they can influence clinical practice. Initially I aimed to measure student attitude change after curriculum innovation. Literature review of Australian medical student attitudes revealed a gap for a valid, contemporary measure, inspiring the AASD. Review of international measures of student attitude identified semantic differential as the preferred instrument-type. A qualitative study of 151 medical students at the Universities of Wollongong (UOW) and Sydney (USYD) produced opposite word pairs for the AASD. The AASD was piloted at the University of New South Wales (UNSW), (n=140, response rate 77%). Removal of a redundant item pair resulted in a 19-item instrument (Cronbach’s α = 0.84). An AASD survey of New South Wales (NSW) medical students (n=321, response rate 72.6%) at UNSW, USYD, and UOW revealed: 1) A four-factor solution on exploratory factor analysis (Instrumentality (I), Personal Appeal (PA), Experience (E) and Sociability (S)), 2) No sequencing bias, 3) Cronbach’s α = 0.86, and 4) A positive mean AASD score (73.2/114), positive mean scores for three factors (PA, E and S) and negative mean I score. Female students had a significantly higher mean E score. Confirmatory factor analysis (CFA) demonstrated adequacy of fit for AASD survey data from outside NSW to our four-factor model. Melbourne University, University of Western Australia and University of Adelaide students (n=188, response rate 79%) had a mean AASD score (72.8/114) comparable to NSW data.

Mark A G Wilson

Papers

Development of the Australian Ageing Semantic Differential AASD), a novel instrument for measurement of medical student attitudes towards older people