Over the year after my insightful medical student’s observation, I started paying more attention to when I was most intellectually engaged and emotionally fulfilled. She was right; I found old people, with their long personal histories and complex medical problems, a pleasure and a challenge in all the best ways. There was just one problem: we didn’t have geriatrics at my medical center, and although I could have trained elsewhere, I wanted to stay in San Francisco.
Sorting out this situation would require one of the defining skill sets of a geriatrician: I needed to use a blend of scientific data, interpersonal skills, and pragmatic creativity to achieve my goal in a health system that wasn’t set up with old people in mind.
LANGUAGE
Three of the most common expressions used to talk about old age are “silver tsunami,” “exceptional senior,” and “successful aging.” One is a metaphor, the second emblematic, and the third a trope. Each is familiar and memorable. But on a deeper level what they are really saying is, respectively: our society’s increasing numbers of old people will destroy life as we know it; old age is so instantly and universally incapacitating that ordinary activities become exceptional; and illness and death signify failure. This language is catchy, and seductive. Almost everyone uses it.
At a “reimagining aging” conference, a famous researcher lecturing on aging science and population trends used another popular expression, the aphorism “Seventy is the new fifty.” The audience loved it, especially coming from him. While it would be great to help people maintain their health, comfort, and function in old age, his quip implied that younger is always better and seventy has nothing to recommend it. Perhaps most concerning was that this accomplished white-haired scientist couldn’t see how some of the most popular sayings about old age do more harm than good.
There are sayings about aging that everyone likes, and others that people find reassuring when they are young or young-old, and preposterous as they grow older still. You’re only as old as you think you are is one of them. Ursula K. Le Guin rebutted this popular falsehood and several others with her usual wit and brilliance: “If I’m ninety and believe I’m forty-five,4 I’m headed for a very bad time trying to get out of the bathtub.” She goes on to note that when people say You’re only as old as you think you are “to somebody who actually is old, they don’t realize how stupid it is, and how cruel it may be.”
Another expression I hear often, one my father invoked several times, is Old age isn’t for sissies. Of that one, Le Guin had this to say: “Old age is for5 anybody who gets there. Warriors get old; sissies get old … Old age is for the healthy, the strong, the tough, the intrepid, the sick, the weak, the cowardly, the incompetent.” She acknowledged that most people say such things with good intentions but equated telling her in her eighties that she wasn’t old with telling the pope he’s not Catholic. She concluded her thoughts on the subject with a most important and poignant insight: “To tell me my old age doesn’t exist is to tell me I don’t exist.”6 In old age, as in so many other parts of life, when our self-delusions are indulged, our reality and true selves, along with all our needs and opportunities, are erased.
The language of death is telling too, although in different ways. Euphemisms abound, even among doctors. People rarely say someone died. Instead they say: she passed away; we lost him; she’s been gone five years now; he has joined his beloved wife/daughter/parents; she is no longer with us. Read most obituaries and you will find people die in just one of several ways: suddenly, after a long battle, surrounded by family, peacefully at home, or following a brave struggle. More rarely these days we learn someone shuffled off their mortal coil, succumbed, or finally gave up. The religious sometimes go home or to meet their maker, cross over, return to the Lord, or rest in peace. The sacrilegious occasionally joke that someone croaked, kicked the bucket, or bought the farm.
We use the word premature to describe death before old age. The word signifies an occurrence prior to the point of full development, as if the person missed out on key parts of life. But when people do not die prematurely, they moan, “There’s nothing good about this aging business.” Both can’t be true, so how does this happen and why does it persist?
Consider the panoply of popular insults for old people: biddy, blue-hair, BOF (boring old fart), BOOF (burned-out old fart), buffer (stupid but not unpleasant old man), codger, cougar, crone, fogey, FOP (fucking old person), gaffer (old man), geezer, goat (old man with sexual interest in women), has-been, LOL, old bag, old bat, old crow, old fart, old fogey, old-timer, OP, over-the-hill, pop, rhino (opposite of cougar), sea hag (ugly old woman), witch. These words denigrate, ridicule, and reduce old people, lifting up those who are not yet old and widening the gulf between age groups. They say old is “other,” less than, unappealing, abnormal. In Susan Sontag’s 1972 essay “The Double Standard of Aging,” she explained that as the United States turned into an industrial, secular society, youth had become a metaphor for happiness7 by virtue of its association with energy and appetites. The economic and power structures required consumption for their continued flourishing, and what better way than to revere the new. By making novelty necessary for happiness, people aspiring to the American dream were compelled to throw away the old for the new.
Youth remains a dominant metaphor in American culture, but what it implies has changed in the digital era. As technology and science have replaced industry and religion as the fundamental belief structures, even among many people who disavow science and believe in God, happiness has ceded the stage to success. Youth’s traits—speed and particular forms of beauty and productivity—have become the defining characteristics of achievement, fame, and prosperity. We don’t just want faster, slicker devices; we want humans that way too. We prize youth, though doing so means that all of us will spend most of our lives in a state of failure.
Witness this New York Times review of Jay-Z’s album 4:44: “ ‘Old school’ still has some currency in hip-hop. It nods to forebears, styles and history. ‘Old’ is a different story. ‘Old’ means you’re past your prime.8 It means you have nothing new to say—and even if you did, who would want to listen? ‘Old’ means maybe you know what’s new, but you want to do it the way you’ve always done it. So ‘old’ also means fixed, settled, stuck.”
This passage also reveals a prevalent double standard. If a Times reviewer wrote comparable words about what female or black means, I doubt his review would have been published. He might not even have had a job the next day.
In 1978 Susan Sontag defined illness metaphors9 as “punitive or sentimental fantasies concocted about that [illness] situation: not real geography but stereotypes of national culture.” While it may be too early to know for sure, I suspect that old age is the “illness” metaphor of this century. It invokes visions of the aged human body as broken-down machine or outdated software. And those are only the beginning. Other metaphors for old age and aging include a journey, a cycle, a season, our natural fate; a problem, burden, disease, or curse; a losing battle, or a clock winding down; the process of climbing a ladder or the state of being over-the-hill; a time that is golden or silver or gray. Punitive and sentimental indeed.
Words and metaphors can bring or strip distinction and status. We need to reclaim the unpopular words of old age to associate them with their original meanings. Old is the term for life’s third act, just as youth is the word for its first. It refers to much more than the late-stage phase of loss and disenfranchisement. Better still, if we didn’t deny people’s humanity as they reached that late stage, there would be no need to lament the language and metaphors of old age.
VOCATION
By my final year of residency, my outpatient clinic was full of old patients. When I didn’t know something about their care, I asked for help. But even among our remarkable faculty, no one knew much about the particular needs of my oldest patients. I decided to give my third-year talk on dementia, a topic that had received little attention, even though we saw it all the t
ime, especially in the hospital. The talk went well, and before I knew it, what had begun as fulfillment of a residency requirement turned into a presentation I gave for years.
The first and most daunting of these large group talks took place at the annual meeting of the American College of Physicians. I’d been invited because of my topic. Having read all the major and countless minor studies on dementia, I had formulated a coherent way to think about and manage this common and disturbing condition, thus qualifying me as an expert, at least within internal medicine circles. This would not have been the case with most common conditions treated by internists and other primary care clinicians for which there were already true experts with years of patient care and research on their résumés. I felt like a fraud until people started asking questions. This audience had recognized that they didn’t know what they needed to know in order to take good care of dementia patients. Less was known about dementia then—many people still believed senility was a normal part of old age—but there was a widespread feeling that our training hadn’t effectively prepared us to manage this common condition.
I hadn’t even passed my medicine board exams at the time, but suddenly I was an expert. Clearly, there was a huge need for aging information and expertise.
After residency, I did an extra year of training at UCSF in the new general medicine fellowship aimed at preparing young doctors for faculty positions. My program director told me to pick a specialty in which to gain more knowledge, and suggested dermatology, gynecology, rheumatology, or orthopedics. I proposed focusing on geriatrics instead, and, to my surprise, he said yes. Better still, my chief sent me to the annual UCLA geriatrics conference, all expenses paid—a wonderful thing for a person earning thirty-three thousand dollars a year despite twelve years of higher education and training. But that wasn’t why the conference changed my life. Until those five days I hadn’t fully understood how geriatrics differed from all other medical specialties and why that difference mattered in people’s lives as they aged. I say five days, but actually I had an “Aha!” moment.
Let me set the scene: a generic business hotel, a large room packed with tables and chairs, no windows, a conference with few breaks, little or no easily accessible water or food. By midmorning and midafternoon, my stomach growled and my brain felt as though it were floating. Many people skipped sessions to exercise, shop, or meet friends who lived nearby. Not me, not on my kindly boss’s dime. Never mind that this particular hotel was on the ocean, or that the average daily temperature in Los Angeles that week was in the low seventies. I attended every talk. My only opportunities for fresh air came early in the morning, during the ten-minute breaks, and after dark. I had never learned so much in so few days that was interesting and relevant to patient care.
Midweek, during the middle of another long day, a bearded UCLA faculty member wearing white pants moved to the podium. Dr. Ken Brummel-Smith’s10 topic was listed on the program as Rehabilitation. I’d learned close to nothing in medical school and residency about rehab medicine, and UCSF didn’t even have a training program in that specialty. Dr. Brummel-Smith began by discussing the most common reasons older patients needed rehab: strokes, heart attacks, fractures, surgery, and so forth. I had a fairly good sense of that already, just as I also knew the pathological changes in the brain and in the nervous and musculoskeletal systems caused by those conditions. Those are the focus of most medical talks, but he blew through them. Then he blew my mind.
Instead of linking treatment to that pathology—the only approach I’d ever been taught by any teacher in any specialty in seven years—he focused on finding out what the person needed to be able to do to be happy and safe in their individual daily life. What a patient needed from rehab, he explained, and from medical care generally, depended in large part on their answers to that question. Equally counter to usual medical teaching, he told us that even when you couldn’t fully restore the body, you could often fix a problem so the patient could do what they needed to do in spite of compromised abilities. Sometimes that required changing how they did things, moving furniture, using equipment, or using a different body part. When it came to function, which was what patients cared about, there were many ways of getting around the mismatch between what a body could do and what needed doing. Strengthening the body was essential, but it was just the beginning. To empower people in their lives and restore their independence to the greatest extent possible, you also had to work on their environment, social network, community, imagination, and adaptability. It sounds absurd to me now, but I remember sitting in that windowless, over-cool hotel ballroom and thinking: This is the most radical, sensible, paradigm-shifting lecture I’ve ever heard. I was giddy.
It was also the moment when I realized that medical training doesn’t just erode doctors’ empathy11: it brainwashes the common sense right out of us.
The term geriatrics was coined in 1909 by the Austrian-born chief physician of New York City hospitals, Ignatz Nascher. In the most widely available photograph of him, the father of American geriatrics appears stocky, with a full face and broad shoulders. Close-cut graying hair hugs his mostly bald pate in an ear-to-ear semicircle above intense eyes, full lips, and a strong chin. He wears a dark suit coat, a striped tie, and a pressed white shirt. He looks like a businessman.
Choosing as his model that other age-specific realm of medicine, pediatrics, Nascher combined the Greek words for old age12 (geras) and relating to the physician (-iatrikos). By emulating another recently developed and already rapidly growing specialty, he hoped that the fields would develop together. As he later argued in Longevity and Rejuvenescence, he believed a word and field were needed “to emphasize the necessity of considering senility and its diseases apart from maturity13—apart, that is, from adulthood. He used the word senility not as an indication of dementia but in its traditional Latin usage meaning the state of being old.14 Nascher also considered disease pathologies distinct from the “normally degenerating body” of the older patient, and he distinguished between diseases that might have complications in old age, those that didn’t change with age, and diseases specific to old age.
The belief that older patients require specialized study and care has existed since classical times, although as Pat Thane, a historian of European old age, noted, its advocates “have never been numerous or powerful.”15 In 1627 the French physician-professor François Ranchin wrote in Opuscula medica words that might emerge from geriatricians even today:
The conservation of old people16 and the healing of their diseases … has been neglected by our forefathers and even by modern authors too. What has been written about the conservation of old people and the healing of the diseases of old age, is so bad and so unproductive that we get the impression not only that this noblest part of Medicine was not cultivated but even that, yes, it has been flatly suppressed and buried.
Like geriatricians today, Ranchin described the manifestations of general diseases in old people, the effects of aging itself, and disorders specific to older adults. And like old patients of today, those of his era had little or no knowledge of or contact with the small numbers of doctors focused on old age. “For most of recorded time,” Thane reports, “neither philosophical nor medical comment on old age (a small proportion of the full range of medical discourse) touched the actual lives of most older people.”
In mid-eighteenth century Europe, this began to change. With advances in pathology and microbiology, particularly in France and Italy, gérocomie17 became a well-defined area of medical specialization. By the mid-1800s, all medical teaching in Paris included dedicated sections on old patients. The impetus for this specialized geriatrics research and care came from hospices, residential facilities for the poor and mentally ill where older adults too frail to keep working often lived out the last years of their lives. Initially, visible age-related pathologies of specific organs garnered the most attention, while the pathological advances of the time contributed little to new therapeutics. Medicine could do l
ittle for conditions that regularly impaired and killed old people, such as pneumonia, cancer, and neurologic diseases, although the new attention to frail patients revealed the harms of long-standing practices, including bloodletting and induced vomiting. Treatment advances later in the nineteenth century introduced surgery for broken bones, cataract removal, and digitalis for heart conditions.
By the turn of the nineteenth century in France, its once exclusively custodial “hospices” were transformed into medical institutions for care, teaching, and research, much like public hospitals of today. Old people were not the only residents, but they were numerous, and physicians seeing large numbers of both adult and old patients began calling for the recognition of old age as a distinct life phase and for specialization in médecine des vieillards. Yet, despite the establishment of many other new specialties at that time, geriatrics did not become an official medical field in France for another century.
In most countries, even official status did not lead to recognition of geriatrics alongside pediatrics and adult medicine. In the United States of the early 1900s, Nascher lamented the lack of lectures about old patients18 in medical schools; in 2019, all schools have lectures, but only a small minority have required geriatrics rotations. At Harvard, long the nation’s top medical school, the first geriatrics lecture19 was given in 1942, but when the school launched its latest curriculum in 2015, it included required clinical rotations in pediatrics, obstetrics, and surgery, even though most doctors will not take care of kids, manage pregnancy, or perform surgery once they finish their education. It did not include geriatrics, although most doctors will take care of old patients and many will do it often. The next year, UCSF’s new curriculum increased geriatrics teaching more than sixfold. That sounds transformative, except we went from four to twenty-seven hours over four years while continuing to define normal and pathological by adult standards and keeping geriatrics an optional clinical experience. There are so many ways to communicate the relative unimportance of an entire category of human being.
Elderhood Page 17