Elderhood

by Louise Aronson

  High-quality care for the decades of life beginning at age sixty-five often requires different approaches and metrics than those developed for younger adults. Paradigms based not on chronological age but on more dynamic variables that also include illness burden, functional status (a real-world marker for physiological fitness), health goals, and life expectancy have been proposed in areas of medical care from cancer screening29 to surgery.30

  Currently, we don’t know enough about how the substages of old age differ biologically, immunologically, or in health risks because we haven’t studied them the way we’ve studied subphases of childhood and adulthood. In part, that’s because in the past the relative rarity of old people made it hard to enroll enough of them in trials and would yield results of use to fewer people. But our population has been aging for over a century, so that’s not the whole story.

  Studying very old people poses unique practical challenges, from demands that are more onerous for older participants to the impossibility of getting informed consent from people with dementia. It also can be hard to distinguish age effects from those of the many diseases and medications most of us acquire in our later years. Last but not least, many people have argued that studying old people is a less-good use of resources than studying younger populations. But life is rarely a zero-sum game. Most Americans are or will become old, and all of us benefit from a healthier populace. Frequently, research on older adults helps younger people, too. In one recent study, young and middle-aged adults who received more aggressive treatments for colon cancer fared worse than the older adults who received what some clinicians would call “less care.” You can’t distinguish age from disease or better from worse if you don’t look at all the options. And you can’t safely prescribe medications for people if you haven’t studied those medications in those people’s bodies.

  I met Arturo seven months after he had been hospitalized for diverticulitis and then, two weeks later, for pneumonia. When he was finally home and healthy again, his dementia worsened, and he had trouble sleeping. Part of this was likely the dementia, but another part was situational. Except when the physical therapist came and helped him out of bed, he lay on the same mattress in the same room, day in and day out. There was a window and a TV and his daughter, Teresa, who brought food or sat with him chatting when she got home from work, but come bedtime, he was in the same place and position he’d been all day and sleep eluded him.

  In the weeks after he came home, Teresa did everything she could think of to help him sleep. She gave him warm milk. It didn’t help. He suggested a slug of bourbon might be more effective, but she thought that would be a mistake with his medications and the forgetfulness and confusion that had gotten so much worse during his weeks in the hospital.

  The less Arturo slept at night, the more he dozed during the day. By nighttime, he was wide-awake. Sometimes he hallucinated, calling out to people who weren’t there. The apartment was small, so if he was up talking or watching TV, Teresa slept poorly. She’d already missed days of work when he was sick, and now she was showing up exhausted and impaired. She reasoned that if he could sleep at night, they’d both be in better shape.

  On her way home one Wednesday, Teresa stopped at the pharmacy and found an entire aisle devoted to sleeping medications. Always dutiful, she read the warnings. The cautions were mostly about things her father no longer did: driving a car or operating heavy machinery. Many had cautions about use in children or pregnant women as well. At home, she gave him the pills, and they seemed to help a little.

  In the months that followed, Arturo complained that his vision was getting worse. His family assumed that it was old age. His grandson bought him a larger television. Then one day he couldn’t pee and ended up back in the hospital. They said he had an enlarged prostate blocking his urine and putting him into kidney failure. They put in a urinary catheter and told Teresa he would need to have a catheter for the rest of his life.

  I met him the next month. He’d actually been referred to us after the first two hospitalizations, but we always had a long wait list. Sometimes people died or worsened before we could get to them. There weren’t enough of us, and since people who are homebound and their 24/7 caregivers tend not to have the time or wherewithal to make a fuss, either no one noticed how many old San Franciscans had inadequate access to the health care they needed even when they had perfectly good insurance, or it wasn’t the sort of thing they cared about enough to take action.

  Four to six million older Americans are homebound, and homebound old people31 have 22 percent more emergency department visits and 57 percent more hospital admissions than nonhomebound old people. Housecalls reduces those numbers, sometimes considerably, saving the health system money, and patients and families much pain and hardship. This is partly because the cost of one emergency visit32 equals the cost of ten housecalls—numbers that demonstrate our system’s skewed and counterproductive reimbursement and priorities.

  During my history and physical exam of Arturo, Teresa said something about the blindness and urine problems being new and fairly sudden. That made me look up from my computer. I asked her a question I had asked earlier, but this time I had her show me any medication she had given him over the last few months.

  The culprit was on top of the refrigerator, not with the official medications, the ones with labels from the pharmacy as a result of a doctor’s prescription. Like most people’s, Arturo’s over-the-counter medications were neatly organized in a pillbox, with separate compartments for each day’s morning, noon, afternoon, and nighttime doses. Like most people, Teresa had assumed that medications she could get over the counter without a prescription were safe if taken as directed, weaker than those that required a prescription.

  “Why are so many medicines so easy to buy if they’re so dangerous?” she later asked me, as the pieces came together.

  It’s a good question. Her father’s sleeping medication was sold over the counter, and its side effects and toxicities weren’t mentioned on the packaging. Because of Arturo’s prostate disease, the pills shut down his urinary tract, leading to kidney failure. They worsened his glaucoma. While the medicine helped him sleep at first, eventually it worsened his confusion and that made him more likely to hallucinate, so neither Arturo nor Teresa were getting much sleep.

  At the hospital, when asked about medications, she had even mentioned the sleeping pills. Yet no one had said anything. Maybe they, like Teresa, assumed the medication was safe.

  “We used to give patients that all the time,” said a friend of mine who’s a retired nurse. “I only stopped taking it myself when my daughter read online that it was dangerous.”

  Current over-the-counter medications harm older adults and current warnings value certain lives over others. When an old person gets sick, we assume it’s par for the course. A quote often attributed to Hippocrates offered sound geriatric advice on this topic: “Leave your drugs in the chemist’s pot if you can cure the patient with food.”

  CHOICES

  In the third year of medical school, doctors-in-training moved out of the classroom and into hospitals, spending two to eight weeks in each of the core medical specialties. At its start, the only thing I knew for sure was that I wouldn’t be a surgeon. I was born nearly blind in my left eye, so I lack depth perception, and no one wants a surgeon who can’t tell for sure where her scalpel is in relation to their colon or artery.

  Of course, my first rotation was surgery. Within hours of arrival at the hospital, I watched with fascination as a resident and senior surgeon opened a patient’s abdomen, removed its faulty parts, made additional improvements, and—after hours of concentrated, painstaking work—closed it again. Later that evening, the patient woke up, sore, groggy, and considerably healthier. It was amazing.

  On the second day, I scrubbed in on several cases, one surgery with each of the three residents on my team, all male, all over six feet tall. By midday, I realized that we all look more or less the same inside, and the slow
process of cutting, cauterizing, and reattaching, while terribly important, wasn’t very interesting to me. “It’s way better when you’re doing it yourself,” explained the kindest member of my supervising quartet. In the final days of my rotation, Ahmad would guide me through an amputation, the rare sort of surgery where my lack of depth perception didn’t matter, and I would realize that he was right.

  In the interim, I learned many things about surgery, making it clear that even with perfect vision it wasn’t for me. Most mornings, my team of residents would discuss our patients in the cafeteria. The only times in fifteen or forty hours that we would eat, these sessions were also where I learned in person what some men sound like when women aren’t around. As a female medical student not going into surgery, I achieved a unique state of being simultaneously present and invisible. They “pimped” me about my cases, aggressively testing my knowledge while listening to my patient updates. The rest of the time, they spoke in ways I’ve otherwise only ever overheard. By the end of the first month, I could pretty accurately guess the rating on a scale of one to ten each resident would assign any unsuspecting women who passed through their sightlines. I assume that had my own looks warranted a higher rating, this might not have happened. I also assume that Ahmad’s kindness stemmed in part from his having suffered similar insults. Further, I realized that making repairs on a sleeping patient wasn’t too different from making them on a hard drive or a vacuum cleaner. While cognitive skills are essential, much of the actual work is physical and technical. I wanted a specialty where the challenges were more intellectual and relational.

  Pediatrics remained at the top of my list for the first five months of my third year. In the sixth month, I did my required rotation on the toddler ward at Children’s Hospital. Very quickly, I realized that sick kids saw doctors as mean and scary—and that included me. Like the nursing staff, some doctors had long-standing, affectionate relationships with families, but theirs were more formal and skewed by a power differential. They also spent less time with the children. These little patients had heartbreaking stories of genetic bad luck, parental abuse, or horrific misfortune. At every procedure, they cried and screamed, too young to understand what was being done to them. Meanwhile, my classmates on our outpatient rotation reported that in clinics most kids were healthy, therefore medically “uninteresting.” By winter break, I knew I would not become a pediatrician.

  Over that vacation, I began reading books on mental illness. Psychiatry was my next rotation, and I liked the idea of a specialty where talking to patients was paramount. I was eager to learn the medical take on such human basics as mood, behavior, identity, and sanity, and gain the skills to translate these concepts into better lives for patients. On my first day, after an orientation, I was told to join a therapy group already in progress. I entered a room of young to middle-aged adults arranged in a large circle.

  Trying not to be disruptive, I scanned the room to pick out one of my supervisors. When I couldn’t, I moved quickly toward one of the two empty chairs and tried to figure it out from the discussion. On an inpatient psych ward, I reasoned, that should be easy. Thirty minutes later, other than the doctor leading the session, I still wasn’t sure who was who. More disturbing still was that when I began tending the sickest patients, I would sometimes have thoughts like This person is completely crazy. That could have been funny, considering where I was, if it weren’t so clearly morally reprehensible. By the first week’s end, I had to admit that I didn’t have what it took to be a good psychiatrist. To my surprise, I found that although I considered myself less science-oriented than the average doctor, I wanted a specialty that would allow me to use more of my newfound biological knowledge and technical skills.

  Next came neurology, then obstetrics and gynecology. Those weren’t for me either. I began to worry that the years and substantial expense of my medical education had been wasted. I was running out of both time and specialties, and concerned that I’d made a terrible mistake. Maybe I didn’t want to be a doctor. I considered my remaining options. I was drawn to fields that recognized people as more than the sum of their parts and ailments, valued considerations of context and culture, and acknowledged life’s inherent ambiguities. Those preferences ruled out dermatology, pathology, radiology, and anesthesia, with their focus on a single organ, cells, images, and machines, respectively.

  That left two options: family or internal medicine. Over spring break, I read John McPhee’s Heirs of General Practice and John Berger’s A Fortunate Man. I loved the idea of family medicine, but neurotic as I was about ever knowing enough medicine to do right by my patients, a specialty that required expertise in kids and adults, medical, surgical, and obstetric care might leave me in a state of perpetual anxiety and insecurity. I wanted breadth, but maybe not quite that much of it.

  Internal medicine was my last rotation. Right away, I knew I’d found my niche. It included everything about the care of adults except major surgery. Patients could have physical or mental illness, or both. They could be eighteen, one hundred, or anywhere in between. You could talk to them, and most could choose the treatment course that would work best for them. I loved its range and possibilities. Also, the internists I worked with that month were smart, thoughtful, and kind to each other and to their patients—traits not present on many of the teams I’d worked with in other fields.

  Internal medicine allowed a honing of specialized skills while offering an array of career opportunities: primary or intensive care, hospital or clinic, global, preventative, or occupational health. I would know how to take care of most internal organs and diseases and many different populations. For me, this was the perfect option.

  ADULTHOOD

  We don’t imagine that we, who strive to be and view ourselves as well-meaning and competent,1 might be neither.

  —Balford Mount, MD

  7. YOUNG ADULT

  TRAUMA

  It is summer, 1992. I am a new doctor in the emergency department at San Francisco General Hospital, standing in a chaos of crash carts and swarming, shouting men and women in green scrubs. The trauma room is rectangular, windowless, and whitewashed in bright, artificial light. Life-support equipment occupies one long wall and chrome cabinets line another.

  I am female, white, and young. The patient is male, brown, and younger still. I have just moved across the country to start my residency training in primary care internal medicine. He has suffered multiple critical wounds from a gun or knife. Both of us are new to this hotbed of urban urgencies and emergencies—a relentless montage of bleeding, breaking, nodding, gasping, screaming, and dying humans.

  At one end of the room is the bed; at the other, two opposing doors aligned so a person could race with a gurney in a straight shot across the room’s width. He is in the bed, of course, and I am standing in that race path.

  In those early days of being a doctor, I am surprised again and again to find myself the healthy, clothed person in the doctor-patient relationship. I ask people questions that would be considered rude in other circumstances and touch them in places their closest friends never will. To this patient, I look like everyone else in the blur of professional faces. But there I am, just standing and watching, fully cognizant that the patient and I are the only people in that busy, crowded space not moving in purposeful ways.

  Around us, doctors, nurses, residents, and medical students assess the patient’s airway, breathing, and circulation, do the head-to-toe survey, and locate and quantify his visible injuries and other, less obvious sites of damage, the vital organs and easily nicked arteries along the trajectory traveled by the blade or bullets. They put in IVs, order fluids, X-rays, and CAT scans, set up for a central line, page the senior trauma surgeon, and call up to the operating room and intensive care unit, setting other crews of competent people into action.

  I have been taught each of these steps and have some idea of what needs to be done, but “some idea” seems dangerously inadequate and abstract. I have no experience with
serious traumatic injuries and little idea how to actually do what needs doing. I don’t know how to decide what happens when, who should do what, how to figure out what has already been done or begun, or how to jump usefully into the fray. I also don’t know how to get answers to any of those questions in this moment when the patient needs everyone’s full attention. I am far more afraid of doing something harmful than doing nothing at all. After all, the bottom line about what is going on in this trauma room is that the patient is, to use a vernacular in which I’ll become fluent later that summer, trying to die.

  “You!” someone yells. “Prep the chest wall!”

  Relieved, I position myself on the patient’s left at torso level. There are tables of supplies on either side of me and countless people clustered along each of the bed’s four sides. I recognize the tall form and short ponytail of a woman I like who had been a year ahead of me in medical school. She’s training in general surgery.

  A bottle of antiseptic appears in my hands. I find gauze, rip open the packets, and soak them. I have read about chest tubes and once saw one inserted, so I know where to clean. Equally reassuring, I know from other procedures that the antiseptic effect will be maximized if I apply three layers, allowing each to dry before adding the next. I don’t consider that the method of application might vary contextually.

  I spread the tawny liquid at the patient’s armpit, below the thick, dark hair he probably didn’t have just a few years earlier, moving the gauze in long, circular sweeps and overlapping the wet lines so no skin is left vulnerable to infection. An injury has torn his lung, and the air it can no longer hold is filling the thin pleural space between the lung and inner chest wall, compressing the damaged lung and making it harder and harder for him to get the oxygen he needs. Once the outer chest wall has been cleaned, the surgeon will insert a thick tube into that space, draining the misplaced air and allowing his lung to properly inflate. I appreciate the urgency of the situation and am moving quickly, but I’m also focused on doing it well and getting it right.