Elderhood

by Louise Aronson

  COMBUSTION

  I had always imagined that when a straw broke a camel’s back, the animal would buckle, her legs folding beneath her, her defeated body landing on the ground with a resounding thud.

  But when it happened to me, it wasn’t like that at all. It was actually very quiet.

  I stood alone in a sixth-floor conference room after a meeting, checking e-mail on my cell phone. I was having a good day in a great month and terrific year as a doctor and medical school professor. That afternoon, none of my patients was seriously sick or actively dying, I had recently been awarded a major national grant and acquired two prestigious new job titles, and the meeting, the first with one of my grant teams, had gone very well.

  When my phone rang, I almost didn’t answer. But the person on the other end of the phone was the sort of person whose call you should answer if you possibly can, and so I did.

  After I gave progress reports on my pending tasks and received responses of pleasure and gratitude, the person said something that was something fairly normal in our world, something small, something light. Something very much like a straw.

  That was when I felt the snap. When my metaphorical back, or perhaps the doctor part of me, broke.

  I remember looking at my watch. I remember thinking: Oh, and Oh shit. I remember finishing the call in a friendly, businesslike manner.

  After hanging up, I noted the sounds from surrounding offices: clicking keyboards, voices from behind a closed door, a copier’s whir and swish. Nothing was out of the ordinary for a workday midafternoon, yet for me, everything had just changed. Reality as I had lived it for over twenty-five years had shattered. The breakage seemed to me less like a dropped ceramic flower pot, obviously fractured but in large shards that might be glued back together, and more like a car’s windshield after a collision: a still-intact surface in hundreds of tiny, irreparable pieces.

  I’m mixing metaphors. But when a person is broken, she becomes a jumble of seemingly incompatible thoughts and emotions. What I didn’t realize in the aftermath of that fateful phone call was that a broken person is also given the opportunity to see her life, and the world, differently. What I did realize was that I was experiencing what over 50 percent of American physicians are also currently experiencing: burnout. These levels of distress are unprecedented, and as bad for patients as for their doctors.

  The person at the other end of the telephone that fateful day had been well intentioned and supportive. The words leading up to my snap were about looking forward to the good work we both expected me to do. Suddenly, I knew I couldn’t, and that terrified me. I had known I was unhappy, unhealthy, and exhausted, that I was spending most of my clinic time on the computer, not with patients, and most of my academic time on projects that were good for my career and bad for me, but I hadn’t realized that I was in such rough shape that words like Keep up the great work could break me. The standard in medicine is to ignore discomfort and distress of all kinds—physical, mental, emotional, and spiritual—and to carry on. That’s what I’d been doing for months, or maybe years.

  Burnout has three criteria. The first is emotional exhaustion. In that state, a person is tapped out at the end of the day and unable to recover with time off. This was certainly the case for me. By early 2015, I had stopped reading at night and begun sitting in front of the TV, unable to do anything more constructive or restorative unless shepherded by someone else. I wasn’t depressed; I still enjoyed my patients, my family and friends, good food, and much more. But I jumped at the slightest unexpected sound and found myself suddenly, aggressively pulling our good-natured dog across the street at the tiniest hint of danger. During my ten- to twelve-hour workdays I ate little, letting my cells do the screaming I could not. Their demands became the background music to my days, giving them an extra edge and urgency, a metaphor writ imperceptibly on my body. At night and on weekends, after working and starving, I ate and ate, filling the void and sedating my distress. Because I came out even on body weight, I thought I’d invented a creative new version of work-life balance.

  This is not the story my spouse would tell. That story would go like this: I had become scary. The slightest thing would transform me from the calm, cheerful person I mostly was with patients and colleagues into a whirling dervish of wrath. I behaved as if everyone and everything was out to get me: the idiot in the car ahead of me who stopped at the newly yellow light when I had no time to spare; the godforsaken computer that wouldn’t let me format a document the way I needed to; the woman in our neighborhood with her rambunctious off-leash dog; all the people everywhere who didn’t seem to do their jobs as well as I thought they should. (Luckily, getting help made a big difference, and we’re still happily married.)

  My internist didn’t believe me about the depression. As she checked boxes in the electronic medical record, she had me complete a depression screening test. I sped through it.

  “Oh,” she said when she saw the confirming results. “Well, you said you weren’t depressed.” We smiled at each other and moved on to my vision and arthritis, fatigue and cough.

  Just before I left, she said, “Wait. Let’s do this one too.” It was the anxiety scale.

  I sped through that one too.

  We counted the boxes I’d checked. The scoring options went from no anxiety to mild, moderate, severe, and very severe. It seemed I belonged in the last category.

  In medicine, we use the word erosion to describe places where surface tissue—tooth enamel, say, or skin, those essential outer parts that protect the whole—has been gradually destroyed by chemical or physical action causing a wound. If you are too sick to turn yourself over, the constant pressure of your own weight can wear away skin and produce ulcers at your tailbone or hip, heel, or ankle. In teeth, cavities form when normal mouth bacteria convert food sugars to enamel-destroying acid plaque. Notably, erosion in medicine is evoked exclusively for physical processes and parts and not for a person’s more abstract components, such as their agency, hope, psyche, soul, and self.

  For every hour they spend face-to-face with patients, doctors now spend two to three hours on the electronic medical record, or EMR. They also spend “pajama time” at home at night finishing electronic notes they can’t finish during their long workdays. Many of us lament this. Much less discussed is how technology that has undermined efficiency and the doctor-patient relationship became the national standard. Or why medicine bought electronic record systems from businesses with vastly different priorities from those of clinicians and patients, or why, having seen the harm to clinicians in systems that already adopted that technology, more and more health care organizations followed suit. Instead, we discuss the alarming, increasing rates that doctors get sick, take drugs, get divorced, and leave medicine, and how they commit suicide at rates higher than the general population. We institute programs on wellness and resilience, but don’t change anything fundamental about the priorities and systems that make such programs necessary. We blame the victims.

  As a doctor, I use the particular electronic medical record that holds the health information of a majority of Americans. It’s a system designed to facilitate billing, not care. Its greatest asset is that the accounting department can quickly find the information needed to plug into formulas that link activities to charges. To make their jobs easier, we clinicians must provide required data in specific places in interconnected windows that resemble nothing so much as a fun house where doors lead to doors, and mirrors lead to confusion. We are also strongly encouraged to use standardized text, as if my visual disability or cancer surgery or inflammatory arthritis were identical to yours. Or as if one doctor’s take on a particular patient were always identical to another’s. This need to input copious information in particular language and places incentivizes cutting and pasting old notes to make new ones, and erring on the side of leaving things in rather than highlighting what may matter most. Medical notes are now so full of noise and jargon that it’s often impossible to figure out
what actually happened during a specific encounter. One night on call, the lab paged me about a dangerously abnormal test result in a cancer patient I don’t know. I read and reread her notes, unable to tell which of the three cancer diagnoses on her chart was active. This is typical. Meanwhile, patients’ illness stories and their doctors’ analyses of those particular experiences, neither of which aid billing, are often altogether absent.

  Electronic medical records are not the only contributors to physician burnout, but they are the technological embodiment of the nefarious values driving our health care system. The biggest EMR company apparently dismisses complaints from patients, doctors, and nurses. Our concerns don’t matter, I’ve been told by multiple sources, because we’re not their customers. Medical centers and health systems are, and they just keep on buying the product. In defending their actions, health leaders tout the EMR’s reliability, its accessibility from anywhere, and its usefulness for research and quality improvement. Those are significant benefits. Unmentioned is its often redundant, recycled, and outdated information or its frequent, significant, systematic information gaps with real potential to harm or kill patients. Such flaws would not be tolerated by most businesses or consumers. As anyone who works with data knows: garbage in equals garbage out.

  I do not feel sentimental about the days of handwritten patient notes and the illegible, sometimes unsafe, hard-to-find, and practically impossible-to-share records they produced. But I do feel nostalgic for something essential that was lost when they were replaced by electronic record platforms. Heedlessly and unnecessarily, this particular approach to cyberdata collection has desecrated the most precious, meaningful elements of the patient-doctor relationship: the human connection, direct and intimate, laden with subtleties, significance, and respect for each person’s unique feelings and needs. In our brave new world, very little worth is accorded to activities such as spending a clinic visit talking through the impact of a patient’s new diagnosis on her health and life or building the sort of relationship that enables discussion of the real reasons why another patient can’t lose the excess weight causing his diabetes and high blood pressure. The things I most want from my doctors and try hardest to give my patients—things like attentive listening, shared decision-making, and individualized treatment—don’t much matter. In such a system, I am penalized if my patient doesn’t get a colonoscopy, something the EMR and my health center track, but struggle to find a place to document the half hour I spent with her and her daughter discussing why her multiple advanced illnesses and short life expectancy mean that she would likely incur all the risks and inconveniences of that screening test but none of its benefits.

  The screen-focused physician is one reason patients complain doctors don’t listen or know them. It’s one reason 81 percent of physicians now say their workload is at capacity or overextended; half would not recommend medicine as a career. It’s not that electronic records are the sole cause of the historically unprecedented disillusionment of doctors today, but they are paradigmatic.

  Erosion results in a wound, the worn-away part present like the negative space in a sculpture. When I tried to learn how best to use our new electronic record system, my institution sent me to trainings with a young man who informed my large group of doctors that he hadn’t been trained on what he called “the clinician interface.”

  Months later, when I went to the lead doctor in our practice to ask for help because the system-generated notes seemed so worthless that I found myself creating both those required checkbox, robotext records and also narrative notes that captured the important elements of my patient visits, her unspoken words and actions made me feel that she thought my concerns were the time-sucking ramblings of a technologically inept person with an irreparable cognitive deficit and an annoyingly flawed character.

  The second criterion of burnout is depersonalization, which shows up as cynicism or a negative response to job duties. Here’s where, when the snap occurred, I lit up the burnout scale. My situation felt hopeless. Our health system had ads and billboards all over town and radio spots I heard countless times a day, yet adult patients of all ages waited over an hour on the phone only to be told there were no new primary care appointments. When I contacted the call center manager, I was told the administration was aware of the situation but providing more people to answer phones, and showing respect for potential patients’ time and health needs, was low on the list of priorities. With no marketing at all, the wait list for our geriatric housecalls practice was at nine months, and people routinely died before we could get to them.

  The human brain constructs stories from available information even when that information is partial. When a medical center CEO’s multimillion-dollar salary is reported in the local paper the same month that center’s janitors’ barely livable salaries are cut in half, a story emerges. When a medical school teaches that black lives matter while providing copious training in medical science but token teaching about the structural and social determinants of health, a story is being told. When health care organizations proclaim value-based patient care is their top priority but institute productivity metrics that prioritize numbers of patients seen over whether those patients’ needs are met, when they adopt electronic record systems that undermine the doctor-patient relationship, when their clinicians experience record levels of burnout and work dissatisfaction and they do nothing to alter the fundamental mechanics of daily life in their hospitals and clinics, an Orwellian story unfolds in the imaginations of patients and doctors alike.

  One contributor to my burnout unspecified in the criteria but now getting some press was the feeling that the institutions I worked for did not share my values and goals. Our leaders used words like health, primary care, and patient-centered at the same time as they systematically undermined those pillars of good medicine by focusing their deeds, attention, and money elsewhere. With the people framing medicine this way holding most of the power and resources locally and nationally, setting the policies and agendas that shape our health and health care, and controlling the facts of your job, you cannot help but conclude that you may never again get to do the work that drew you to medicine in the first place. Doctors across the country are suffering this sort of moral distress. It affects their work, lives, and health, and it’s the reason they stop practicing.

  The third burnout criterion is reduced accomplishment, as the doctor wonders whether what she does really matters at all. After the final straw, it became clear to me that there was no point in seeing patients, helping with our new medical school curriculum, or leading the innovative programs for which I’d won grant support. Each of those activities suddenly seemed to me about as useful as moving chairs to an upper deck of the Titanic.

  SEXY

  Television serves as a rose-tinted mirror held up to our societal obsessions, conceits, and fantasies. Increasingly, it is weighing in on the topic of old age.

  In the show Grace and Frankie, Jane Fonda (age seventy-nine in the third season) and Lily Tomlin (age seventy-seven) played scenes that often included jokes about one’s hearing and the other’s memory loss. Meanwhile, their now romantically partnered gay ex-husbands, Martin Sheen (age seventy-six) and Sam Waterston (also age seventy-six), after years of secrecy, at last let themselves come out to family and friends. Age liberated them from the conventions to which they submitted for decades, and the men finally claimed their true sexuality and identities.

  In contrast to most casting, the male leads are younger than the females. Not by much, but Hollywood usually pairs men with women ten to thirty years their junior. Apparently, the rules of the game change in old age. This is Hollywood’s traditional approach to heterosexuality across the life span: For the most part, teens fall for teens and young adults for young adults. In middle age, things change. Men fall for younger women, and women become mommies and bosses—roles commonly presented as mutually exclusive with sexuality and romance. In old age, the playing field evens up again, or maybe women gain a sli
ght advantage. But it’s not just women who are misrepresented. The association of manhood with virility is so strong that older men are put in a lose-lose situation, either portrayed as impotent in all senses of that word or described in language that suggests their sexuality is surprising, inappropriate, unbecoming, or repulsive. Jokes along the lines of “Grampa got game!” (said of Robert De Niro in the movie The Intern) commend thoughts and behaviors considered normal from age twelve through adulthood.

  Despite its charms, Grace and Frankie sends mixed messages. The leads are all attractive, even if Fonda and Tomlin would not have been considered aesthetic peers in decades past. (Old is old is old …) None of the characters have completely gray or white hair, and given the commonness of hair loss in male old age, it’s hard to believe that the selection of two still follicularly endowed male actors isn’t meant to signal ongoing vitality. We are not the first generations to link sexuality with youth25 or to downgrade women years or decades before men.

  A widowed friend in her seventies is often assumed to be much younger than she is. She has a great brain, a good sense of humor, flawless grooming, and a full life, but men don’t look at her much anymore, and she hates that. When I last saw her, she regaled me with stories about her recent adventures in online dating. Her conclusion: “I don’t want to be a nurse or mommy and only men looking for one of those look at me.” The ones who might have interested her were looking downward chronologically, not across.

  Other straight women find relief in the sexual invisibility of their old age. This has less to do with a loss of interest in sex than with the pleasure of shedding the need they once felt to groom, preen, perform, and perpetually prove their worth by asserting their attractiveness to the male gaze. Those women still make an effort to look good but are happy to worry less about attractiveness, to have more time for other pursuits, to feel safer out in the world, and to celebrate a more honest and accurate alignment of their inner and outer selves.