Elderhood

by Louise Aronson

  Numerous exposures to violence shouldn’t necessarily affect how we respond to the distress of others, but they seem to. In this regard, it seems that violence functions a bit like smell and opiates, stimulating a phenomenon called tachyphylaxis, in which a person’s response rapidly diminishes with repeated exposure. We stop noticing the perfume, or need more narcotic, or we no longer register another person’s suffering. Some people argue that the last of those insensitivities is an essential adaptation to an environment replete with danger and misery. That may be true in part, but studies also show a near universal decline in empathy during medical training. Some of what we classify as healthy adaptation may be toxic acculturation. We stop perceiving patients as people and see them instead as tasks, impediments, or problems—as other or less than. When a plurality or even a visible minority of people in one setting or profession become insensitive to the essential humanity of others, the culture itself is unwell.

  In almost all situations, context matters and stress erodes empathy. Both influence not only what happens but what we see and how we understand it. When I was a resident, the hospital was my home. There are 168 hours in a week; most months, I worked 100 hours a week. That sort of immersion is known to ease and speed acculturation. When combined with restricted access to basic life functions, including drinking, eating, urinating, sitting, and sleeping, it begins to resemble indoctrination. We saw our colleagues far more and more often than our families or friends. The norms around us became our norms, especially when we felt most stressed or frustrated, scared, angry, overwhelmed, or exhausted. By my second and third years of residency, I was very competent at my job. In all contexts, I felt like a doctor. It’s only now that it occurs to me that when I felt like a doctor, I felt important, powerful, and (mostly) benevolent, and I noted the violence less or accepted it more easily; it was just part of the work. Only as I emerged from training and began resuming more of what might be called normal7 life activities was I able to see, in unquestioned ubiquity, medicine’s violence and the threat of it.

  But that isn’t quite right either. I keep thinking of the concept of conscience and remembering situations in which I submitted to cultural norms even when I suspected or knew they were wrong. Throughout my residency and occasionally since, my patients have sometimes needed procedures only a different sort of specialist could do. In many of those instances, the other doctor forged ahead without allowing me enough time to draw up local anesthetic or order and administer premedication. They didn’t seem to care when a patient was moaning or holding the side rail in a grip so tight their knuckles blanched.

  Violence is easy for people without empathy or a conscience, but even among nonsociopaths, some are more inclined to it than others. In medicine, we tend to see surgeons as more violent and their subculture harsher. While there is evidence for the accuracy of such generalizations, they blur the more important truth that most of us have done little to question or reform the violence we so often encounter.

  “Empathy,” writes Rebecca Solnit in The Faraway Nearby, “is first of all an act of imagination, a storyteller’s art, and then a way of traveling from here to there.” In all interpersonal relationships, and so in all medical care, the here is me and the there is you. Physicians have produced an extensive literature about empathy. There are scales to measure it and interventions to increase it, and still it plunges downward as people become doctors, and the innovative new curricula we come up with every decade or so make no difference. I see this year after year when teaching reflective writing to doctors and doctors in training. With medical students, shock and horror at witnessed medical violence bubbles up in their stories, sometimes inadvertently, often insistently. They identify with the patient. When I teach the same material to practicing physicians, it is evident that by residency, and certainly thereafter, the horror largely vanishes, replaced by other topics, such as mortality, suffering, affection, impotence, or disillusionment, in which the violence is at most the main event’s unacknowledged backdrop.

  There are also countless articles by doctors about doing things they instantly or later regret, and about standing by or laughing or helping while other doctors say or do reprehensible things. These stories often lead to shame so profound that people don’t talk about the events for decades. One article of this sort that caused controversy a few years ago involved a male doctor’s admission that during medical school he had played along with a male physician’s indefensible behavior while the latter’s hand was inside an unconscious postpartum patient’s vagina. Very notably, the article’s content was not the primary reason it got so much attention both in the medical blogosphere and in publications from Cosmopolitan to the New York Times. The fuss erupted because the medical journal had insisted that the author remain anonymous. Its editor in chief stated that this unprecedented action was taken to “prevent the identification of others in the story, most importantly the patients involved,” but because years had elapsed and names had been changed, and because unconscious women having life-threatening bleeds following delivery of a baby tend to remember things other than the name of the medical student standing by during the day’s traumatic events, many found it hard to believe that the patient was the journal’s primary concern.

  There are so many ways in which a culture of violence is built and reinforced, and so many ways, direct and indirect, that all of us become part of the aggression and its consequences.

  MISTAKES

  Now and then, like all doctors, I make mistakes.

  In medical school, we had been taught to ask about sexual orientation by saying, “Do you have sex with men, women, or both?” Asking about a stranger’s sexual practices does not come naturally to most people. If you are in your twenties, asking a fifty- or eighty-year-old “grown-up” what they do in bed or in bathroom stalls or in dark alleys or on business trips feels wrong. The afternoon my class spent practicing that question included a fair amount of sweating, terror, flushing, humor, awkwardness, and anxiety. You had to remember that you were asking solely to ascertain whether the person’s practices posed health risks. You weren’t prying or being rude or engaging in voyeurism. You were going to be a doctor, and a doctor needs to know such things to keep her patients healthy and safe. You had to prepare your mind and face and voice for answers that surprised, disgusted, or intrigued you. You had to listen without preconceptions or judgment, searching only for something that might raise concern about your patient’s safety, health, or well-being. Then you could gently offer advice from your expertise. As in normal life, unless it involved a child or abuse, the rest was none of your business.

  By the time Kate came to see me in the early spring of my intern year, I felt completely comfortable with the question and thought I pulled it off quite well. Kate was just out of college, new to the West Coast, and very healthy. She had long brown hair and wore a miniskirt over green tights and retro pumps. When we got to the sexual history part of the interview, I asked the question, certain I knew its answer.

  “Women,” Kate said. “Only women.” She had her head tilted down slightly, but her eyes were looking straight at me. The surprise showed on my face. I had made faulty assumptions based on stereotypes, and we both knew it. I scrambled to recover, asking subsequent questions in an even, reassuring tone. Though we continued as if nothing had happened, the truth hung like a stench between us.

  Mistakes come in many shapes and sizes. When patients aren’t sure whether they can trust their doctor, they are less likely to be honest when questioned, and less likely to bring up personal concerns. I had hurt Kate’s feelings that afternoon and damaged our relationship. If I were Kate, I would have changed doctors. She didn’t. She was young, so maybe she didn’t know she could. Or maybe she thought all doctors were prejudiced, a bias she might have acquired through the same channels that I had acquired the biases that made me wrong about her. Every time Kate came to see me over the next couple of years, I felt guilty, and every time she left my office, I knew I’d
missed another opportunity to bring up what had happened.

  My failure to apologize to Kate was the first instance of a pattern. I would do or not do something that was less outright error than a misstep falling short of obvious ideals—seeing normal test results, then getting busy with clinic and forgetting to let the patient know; a follow-up call a month or two after the immediate aftermath of a spouse’s death. Later, I would feel horrible, think obsessively about my lack of consideration, tell myself to phone, to say something. And, too often, I would do nothing. Recurring mistakes tell a doctor so much about who she is, especially when intuitively she knows better.

  Even well-trained doctors with the best intentions make mistakes. What matters are the kinds of mistakes they make and how often they occur. Some come as a result of sincere efforts to address complex situations, and others signal professional incompetence. The former are more common than the latter. Almost without exception, recognizing my errors, apologizing for and learning from them, has not only made me a better doctor but also brought me closer to my patients and their families. Apologies join patient and clinician in shared humanity.

  Studies also show doctors who apologize6 are less likely to be sued. There are few things more insulting and infuriating than knowing something went wrong and having a doctor or hospital pretend it didn’t, essentially ignoring your distress while filling their circled wagons with lawyers and jargon. That’s the sort of response that transforms disappointment and sadness into anger and litigation. I suspect doctors who apologize usually feel better too. Apologizing doesn’t eliminate my regret, but it renders it more tolerable and that makes it possible for me to learn from my mistake.

  In our second year as residents, we got more responsibility and independence. I led teams of doctors and medical students in the hospital and in my clinic. I could decide whether to walk down the hall to consult with a supervisor. I needed the senior doctors less often, but I consulted them that winter about Maria Calderon. I knew I was missing something; I just couldn’t figure out what. As it turned out, neither could my supervisors, though in fairness to them their impressions would have been tainted by what I told them. It was only when she was correctly diagnosed that I realized I’d been looking for the symptoms that “Norm” would have had, not what I should have been looking for given her eighty-six years.

  In the biological science of aging, normal is defined as “due to the natural course of events rather than a pathologic process.” That can be hard to determine without also knowing all the causes of diseases and aging, and perhaps even quixotic, given that how humans define aging and disease has varied by culture and over time. But it’s even more complicated than that. Many diseases are age-related, and with scientific progress, changes initially attributed to aging can turn out to be the consequence of disease. Conversely, aging can mimic disease, which further muddles the picture. There is also the question of whether what’s normal changes with age. Normal is often considered inevitable and universal, while pathological implies a deviation—but is it fair to compare patients who are twenty years old to octogenarians? If disease is common in old age, does that mean it’s normal? It gets confusing, and the best answers to many of these questions come from philosophy, not science.

  Such debates notwithstanding, doctors have noted the unique norms of old age for millennia. Hippocrates commented that “the fevers of old men are less acute.”8 Aristotle discussed an increased vulnerability to disease9 among old people and how even minor diseases might result in death. In Britain in 1863, Dr. Daniel Maclachlan considered what is now known as “multimorbidity,” noting that older adults often had several diseases simultaneously,10 complicating diagnosis and treatment. Around the same time, the most famous nineteenth-century French physician, Jean-Martin Charcot, also noted the “special characteristics”11 of older bodies when sick. In 1866 he wrote that even the “gravest disorders manifest themselves by slightly marked symptoms.” In the early 1990s doctors were often aware of these special characteristics, but they contributed little to the lens used to assess and manage older patients.

  * * *

  Maria Calderon had a long list of diseases, the worst of which was trigeminal neuralgia, a facial nerve pain so severe that sufferers sometimes kill themselves. I had been her doctor for a year and a half when she complained of feeling unstable. When a patient uses the word dizzy, most clinicians will tell you that something inside them clutches, if only for a second.

  People mean so many different things when they use that word. It can express vertigo, a general feeling of unwellness, feeling faint, or feeling out of sync with the world, physically, mentally, or spiritually. It could be caused by specific conditions of the ear, heart, nerves, brain, eyes, or psyche, or be a sign of a stroke or an abnormal heart rhythm, anxiety, or a drug side effect. It could simply signal the need for new glasses. Given all Maria’s diagnoses and medications, I came up with a handful of plausible causes. I cleaned her impacted left ear, adjusted her drug regimen: Was her blood pressure low? Were her sugars high? Was the dizziness from the pain medicines for her trigeminal neuralgia? I repeatedly checked her heart and nervous system. Nothing helped.

  Then I went on vacation, and after Maria fell at home, she was seen in clinic by one of my co-residents. Sunny made the diagnosis of Parkinson’s disease as Maria walked down the hallway toward the exam room. I hadn’t seen it before in the early stages or in someone as old and frail as Maria, but Sunny recognized it right away. Maybe, not knowing Maria, she hadn’t been distracted by Maria’s existing diagnoses and medications, any one of which could cause dizziness. I confessed my missed diagnosis to my supervisor, and he told me he’d made the same mistake a decade earlier; it was far easier to spot Parkinson’s in an otherwise healthy sixty-year-old than in a frail, arthritic eighty-six-year-old.

  When I saw Maria a few weeks later, two of her daughters were with her. Given the new diagnosis and all her other problems, they were going to move her to Sacramento with them. I apologized for not seeing the Parkinson’s, and the three of them looked at me with surprise. The daughters had brought me presents to thank me for my very good care of their mother. Maria said she would miss me, took my face in her hands, and blessed me. We hugged good-bye in the exam room doorway, and then she was gone. Some days being a doctor can fill you in equal measures with joy, satisfaction, sadness, and chagrin. Sometimes you know you have the best job in the world.

  COMPETENCE

  One morning on a routine housecall, I climbed steep brick steps and rang a doorbell. After a brief wait, I rang again. The doorbell, visibly in need of repair, drooped from the stucco wall. You had to hit it just right for it to chime. I made sure I heard it ring and restarted my waiting clock. Millie moved very slowly. Often, before she opened her door, I could read and sometimes answer an e-mail. After I’d responded to several messages, I called our office coordinator to make sure she’d spoken to Millie the previous afternoon and confirmed the appointment. She had. I thought: This isn’t good. Millie had dementia, alcoholism, and a marginal home situation supervised by a nephew who lived an hour away. I was fairly sure she wouldn’t have gone out; she hadn’t for years, and there was also the practical challenge of her front steps. I punched in her number and heard the phone ringing inside the house. I was debating whether to call her nephew or 911 when I heard a noise. It stopped, then started again. It sounded like it was coming closer, so I waited.

  Finally, the door moved inward from the frame, though without fully opening. When Millie still didn’t appear, I carefully pushed it. She was leaning against the wall, looking awful: disheveled, sweaty, pale, weak, and breathless. I grabbed a pillow off the sofa and lowered her to the floor. After a quick assessment and a few key questions, I knew she had spent the many hours with chest pain and several other symptoms of a heart attack. I found an aspirin in the bathroom and put it in her mouth while phoning her nephew. I started with him, not 911, since her advance directive said to avoid hospitalization.


  He and I agreed Millie should go to the emergency room to confirm the diagnosis and get her comfortable at the very least. That would give us a better sense of severity and care options, and time to arrange visiting nurses and home help. Millie couldn’t weigh the pros or cons but she was amenable, which she wouldn’t have been if she had felt well. The last time she’d gone to the hospital, years earlier and before I’d met her, she’d suffered through alcohol withdrawal, then a rehabilitation unit stay where of course they wouldn’t let her drink. She didn’t see the point in any of that. I called 911 and finished my assessment while we waited.

  Ten minutes later, the paramedics had taken over, and I phoned the emergency department to tell them what to expect. I was way behind schedule and had an urgent add-on appointment. When I was told there’d be a wait before I could speak to the doctor in charge, I said I couldn’t wait. I gave the clerk the essential information and continued to my next housecall.

  A few hours later, I called the hospital to see how Millie was doing and learned she was still waiting to be seen. That made no sense. I told the doctor in charge what had happened that morning, and immediately she set in motion the wheels of appropriate care. Later, we pieced together what had gone wrong. My message had been abbreviated beyond recognition through a series of hand-offs that began with a nonclinician taking notes and ended like a child’s game of telephone. The paramedics had been summoned to another emergency just as they arrived to drop her off, accidentally taking their paperwork with them, and the emergency department was overwhelmed with critically ill patients. When the triage nurse had asked how she was doing, Millie had said, “Much better, thank you. How are you?” The paramedics had treated her en route, and without chest pain or shortness of breath to report and unable to remember recent events, she’d invented a stomach flu to explain why she was there. She had been parked in the hallway ever since.