Elderhood

by Louise Aronson

  For too long geriatrics has been like a small religion. We believers are fervent, and everyone else thinks we’re fringe or unimportant. We believe that we know the truth, but others don’t see it that way. When I teach communication to medical students, I tell them that when most people are not getting their message, chances are the problem is not with the audience but with the explainer and explanation. If as America ages—the baby boomers are entering legal old age at a rate of ten thousand people per day—the field of medicine devoted to the health of older adults remains small, there can be no question that geriatrics is doing something wrong. The better question is: How do we change our approach to ensure old people of all ages and backgrounds stay healthy as long as possible and get good health care when they need it?

  In his introduction to Nascher’s 1914 classic Geriatrics, the renowned pediatrician Abraham Jacobi asked, “Now why is it that the growing interests in many of the branches of medical science and practice has not equally been extended26 to the diseases of old age?” The minority of clinicians who paid attention to the special needs of older patients had been asking similar questions for centuries. Jacobi also provided an answer: “The cause of this neglect27 must be sought in the general mental attitude toward the aged.”

  Nascher was more specific: “Until it receives the attention its importance deserves, and we know more about the metabolic changes in the period of decline, we must fall back upon empiricism in the treatment of diseases in senility.”28 In other words, because we didn’t study old people, we didn’t understand their unique physiology, and because we lacked that essential knowledge, we could not offer older patients the targeted treatments offered younger ones. As a result, treatment of older patients was based on coarse observations, not studies, and doctors didn’t know why some strategies worked and others did not.

  Nascher also addressed the presumed source of this “mental attitude,” using language that perfectly captures the feelings of many people today, including doctors:

  We realize that for all practical purposes the lives of the aged are useless, that they are often a burden to themselves, their family and to the community at large. Their appearance is generally unesthetic, their actions objectionable, their very existence often an incubus to those who in the spirit of humanity or duty take upon themselves the care of the aged … There is … a natural reluctance to exert oneself for those who are economically worthless29 and must remain so, or to strive against the inevitable, though there be the possibility of momentary success, or to devote time and effort in so unfruitful a field when both can be used to greater material advantage in other fields of medicine.

  As often happens today, Nascher conflates extreme old age with the entirety of that life phase and emphasizes the negative traits of a minority of old people while failing to mention any of the well-documented positives of the majority. His perspective also stems from a belief, equally prevalent now, that “the prolongation of life is after all the aim and goal of the physician’s endeavors.” One of the distinguishing features of modern geriatricians generally, and certainly this one, is that we believe the aim and goal of medicine is the optimization of health and well-being—whatever that means to a specific patient. Sometimes that includes prolonging life, and sometimes it does not.

  People complain that older people complain too much. But we all speak of the stuff of our lives. Parents of babies talk about babies, parents of teenagers speak of teenagers. Those who work discuss work. Those who do and see more speak of doing and seeing more, and those who do and see less talk of the details and rhythms of their smaller world. Is smaller less or just smaller? Is a still life art, even if it’s not a sprawling tableau of human life?

  If older people talk more about their bodies, it’s in part because of what the old body does or will not do, what it screams or insists on, has become more prominent in their lives. Comfort and abilities, facile to the point of unconsciousness in youth for most people, require attention, effort, or the recognition of impossibility. The relationship between person and body changes as we age.

  The fading of certain activities from foreground to middle, then back across a human life, doesn’t only occur because of biology. It’s also because we live in a world designed for the young and middle-aged, one where an old person often needs a device or helping hand because no one considered them when planning that world. We all recognize the bodily transformation of age, and even if we can’t fully explain it, we understand it as the product of genes and choices, luck and repeated use. But what of that shift of potentially competing interests from foreground to back? Do we examine, objectively and thoughtfully, its contributors? Do we consider, alongside debility and choice and character traits, that one reason bodily laments feature so frequently is that we have systematically and structurally stripped, for reasons both benevolent and nefarious in intention, old people from the larger world and the larger world from the lives of old people?

  In contemplating what medicine is and should be, whether for old patients or younger ones, I prefer the famous words from the original Hippocratic oath: to cure when possible, to heal sometimes, to care always. But Nascher and I are agreed on some of the reasons that make caring for older adults so interesting and fulfilling. When a phase of life is considered difficult, and when, on top of that, the group currently living through that phase is neglected, disparaged, and vilified, opportunities to relieve distress and make a real difference are countless. Just as a dehydrated older patient may go from appearing to be at death’s door to looking essentially back to normal after the infusion of a half bag of intravenous fluids, so can I make a meaningful difference in the life of most old people with a warm hello or a sincere interest in talking to them. It should take more than that.

  Because old patients are near the chronological end of their lives, most medical decisions, and many in other arenas as well, invoke the grand issues, mysteries, and questions of life and death. In geriatrics, it is far harder to reduce medical care to a disease or organ. Most illnesses also raise existential issues. This may well be what some people dislike most. In a world where if infection = antibiotics and dying tissue = surgical removal, the grand unanswerable questions of existence may inspire passion and curiosity in some and feelings of distress or helplessness in others.

  How doctors choose to spend their careers may depend in part on their tolerance for ambiguity and complexity, and their interest in questions that lend themselves as much to philosophy, psychology, and sociology as to science and statistics. In certain specialties, the most defining and time-consuming work takes place actually or essentially without the patient. Those doctors look at tissues and images of people who aren’t present or provide most of their care when their patients are unconscious. That’s great if they enjoy it, but it’s not how I like to spend my time. I’d rather be talking to patients and working with them, their families, and caregivers. Many older patients have multiple medical problems with functional and social implications, which adds to the variety and richness of conversations that inevitably touch on questions of meaning, purpose, and identity. I see such discussions as interesting, unique to each patient, and a meaningful way to spend my time. Not everyone agrees. A recent study of medical student perspectives on older patients quoted a fourth-year student saying that doctors “assume that when an old person comes in there’s going to be a ton of problems30 and it’s going to be a pain to address all of those issues.” The student did not mention that it’s a pain to address those issues because the health care system is not set up to do so.

  The most difficult part of patient care of any kind is dealing with the hardest parts of what it means to be human. But ask most people about their most significant, challenging, and worthwhile experiences in life, and most will name these same hard parts, from raising children to the death of a loved one. Hard isn’t, of itself, a bad thing. What is bad is when, through avoidance, judgment, tradition, or neglect, we fail to do our best addressing problems that wi
ll affect almost all of us eventually, directly and indirectly. How much better and richer would life be for all of us in a society that cared for a ninety-two-year-old for the simple reason that the ninety-two-year-old is a human being, and we care about human beings.

  Contrast the quoted medical student’s view of old patients as “a pain” with those of the British surgeon Marjory Warren at the end of her training. Faced with an entire ward of bedbound old people, she neither despaired nor ran away. She saw a need and an injustice, and her response was to disrupt, to innovate, and to transform. The impact of her work remains visible everywhere in medicine today, yet the prejudices that inspired it remain.

  For each of my patients, if knowing them and caring for them includes sadness and frustration, there is also, to the end, evidence of powerful humanity. Sometimes that takes the form of courage or humor, and other times it manifests as anger, even fury. Their rage can be long-standing, unrelated to current circumstances, or it can be just the opposite, a response to what their lives have become. It is there, in how we construct the circumstances of old age—from the sixty-eight-year-old who wants to work less but still work and maybe try something he didn’t dare risk earlier in life to the centenarian who can’t see, hear, or move as well as she’d like—that the world offers us so many opportunities to create an old age we need not dread.

  For a long time, when people asked why I became a geriatrician, I answered in one of several ways:

  “I didn’t mean to” was the opening line of one story.

  “I screwed up” began another.

  “I just loved older patients” started the third.

  Each reply was equally true, but even taken together they didn’t tell the whole story. There are so many good reasons, it’s hard to know where to begin. Since many people believe dealing with old patients is harder or less pleasant and fulfilling than dealing with younger ones, I often told the story about a Saturday night—or, rather, an early Sunday morning—when I was on call for the General Medicine practice. This was call from home—meaning I carried a pager overnight and on weekends, fielding calls that ranged from medication refills to grave illnesses requiring ambulances and handoffs to doctors in the emergency room.

  I was sound asleep around two A.M. when my pager alarmed. I turned on my bedside light, rubbed my face to wake myself up, and called the page operator. She gave me the patient’s details, the most salient of which was that he was an otherwise healthy twenty-two-year-old who had been out dancing and was complaining of shoulder pain. I dialed the number she gave me and identified myself as the on-call doctor.

  “Oh, hey, Doc,” he said. “How’re you doing?”

  “Fine, thanks,” I replied, wondering whether the middle-of-the-night pleasantries meant his pain wasn’t so bad after all or simply indicated stoicism and good manners. “I hear you’ve hurt your arm. Can you tell me what happened?”

  “I don’t know if I hurt it, but it definitely hurts.”

  I waited.

  “I was out dancing—Saturday night, you know?”

  I murmured affirmatively to suggest I might still be the sort of person who went out dancing, rather than a woman just ten years older than he was and thrilled to be in bed at ten P.M.

  “The music was pretty wild, and whenever I did certain moves with my left arm, the shoulder seriously hurt.”

  I began asking questions to establish when the pain started in order to figure out how he’d injured himself, what the injury was, and what next steps were needed for diagnosis or treatment and to manage his pain. On call in the middle of the night, my main concern was whether he needed to go to the emergency department for a dislocated shoulder or fracture and, if neither of those seemed likely, to come up with a plan for damage control until Monday, when he could be seen in clinic.

  “I didn’t fall or anything like that,” he said. “I’m not sure when it started. Maybe a month ago?”

  I blinked. “Did something make it worse tonight?”

  “Hmm. I don’t think so. It’s just that when you’re dancing, you really notice it, you know?”

  He woke me up to ask about a problem he’d had for a month that didn’t interfere with his daily activities—didn’t even stop him from going out dancing—and hadn’t gotten worse. Did he think doctors sat up all night hoping someone would call?

  I asked a few more questions to make sure I hadn’t misunderstood.

  “Well,” he said at some point, “I told my buddy it was bugging me and he said I should get it checked out, so I called.”

  I told him that I couldn’t make a diagnosis over the phone but that his friend was right, he should have it evaluated and treated so he didn’t develop chronic problems. I added that the after-hours line was for emergencies and he needed to call back Monday morning for a clinic appointment but that I’d let his primary doctor know what was going on.

  It took me a while to fall back asleep.

  I’m an early riser, so I was up reading the Sunday paper when my pager went off again about two minutes past seven that morning. The caller was an octogenarian who had woken up in the early hours unable to use her left side. I called back immediately.

  “Good morning, Doctor,” she said with slightly slurred speech. “I hope I didn’t wake you. I waited until seven but I know this is serious so I thought once it was morning I needed to call.”

  I confirmed her symptoms and safety, asked the 911 operator to send an ambulance to her house, telling the emergency department to expect a patient several hours into a major stroke. Then I sat with my cold cup of coffee mulling the obliviousness of the young caller and the thoughtfulness of the life-threatened older one. I considered that although I’d cared for wonderful adults of all ages, these two patients were in many ways representative of their age groups and generations. I knew without question which I preferred.

  My older caller that night should have phoned sooner; her situation was precisely why doctors take calls. Yet I still remember her because even though she didn’t know me and despite her crisis, she was thinking of me with concern and generosity. It’s always a pleasure to deal with another person who sees you not simply as a means to an end but as a human being worthy of kindness and consideration. When people of varying ages are tested, older adults score higher on traits like emotional intelligence and wisdom.

  Still, the doctor-patient relationship isn’t a friendship; it’s the doctor’s job to care for the patient, not vice versa. At least, that’s the ideal. In practice, doctors are human, even if we sometimes pretend otherwise. Since from the beginning one of the primary appeals of medicine for me was patient relationships, it seemed sensible to choose to work with a group of people who, on the whole, treated me well and cared about the quality of our professional relationship. On the patient side, there may be more to it than that, having to do with the gulf between what we all hope for from a doctor and what we must be prepared to accept. That gulf may be wider and deeper if you are in a category of person often unseen, discounted, or subject to disregard.

  TRUTH

  In December 2011 just before Christmas, I locked my car and ran-walked the block and a half toward my destination, a dilapidated clinic down the hill from a recently renovated hospital. Every time my right foot hit the pavement, I was reminded why I needed the podiatry appointment for which I was about to be late. Nearing the entryway, I admired its worn grandeur: tapered semicircular walls extended welcoming arms from either side of the sliding glass doors, and a half-moon of sidewalk stretched to the quiet side street.

  That’s when I noticed a woman standing at the curb. She had propped her cane on her walker and was squinting toward the nearby boulevard. It was about four thirty; I’d asked for the last appointment of the day for my pre-op so I could leave work as late as possible. The woman was well into her eighties, with a confident demeanor, and clothes and hair that revealed an attention to appearance and suggested a middle-class existence. She had a cell phone in one hand and seemed to be wa
iting for a ride.

  When I came back out after five o’clock, night had fallen. But for her tan winter coat and bright scarf, I might have missed her standing in the shadows, leaning against the curved wall. She still held the mobile phone, but now her shoulders were slumped and her hair disheveled by an increasingly cold evening breeze.

  I hesitated. On one side of San Francisco, my elderly mother needed computer help. On the other, our dog needed a walk, dinner had to be cooked, and several hours of patient notes and work e-mails required my attention.

  I asked if she was okay. When she answered, “Yes,” I waited. She looked at the sidewalk, lips pursed, and shook her head. “No,” she said. “My ride didn’t come, and I have this thing on my phone that calls a cab but it sends them to my apartment. I don’t know how to get them here, and I can’t reach my friend.”

  She showed me her phone. The battery was dead. I called for a taxi with my phone and helped her forward from the entryway wall to the curb. Tired and cold, she suddenly seemed frail.

  We chatted while waiting. Eva owned a small business downtown—or she had. She was in the process of retiring, having been unable to do much work in recent months because of illnesses. She’d been hospitalized twice in the past year. Nothing catastrophic, yet somehow the second stay had dismantled her life. Since then, things had never quite gotten back to normal.

  The doctor in me noted that Eva had some trouble hearing, even more difficulty seeing, arthritic fingers, and an antalgic gait that favored her right side. But her brain was sharp, and she had a terrific sense of humor.

  Finally, the cab arrived. The driver watched as I helped Eva off the curb, an awkward, slow process because of her cold-stiffened joints, the walker, and our bags. As I turned to open the backseat door, he sped away without his passenger. I stared, dumbfounded, and pulled out my phone to call the company and complain. Eva was more sanguine.