Oh, I thought, maybe Elenoa can’t read. At the very least she couldn’t read well enough to do it in front of me. Trying to pretend I hadn’t just realized what I’d realized or noticed her shame, I said, “Terrific. It looks like you’re doing everything just right, and we don’t need to change any medications, so you’re all set. Can you show me her insulin too?”
Elenoa went to the refrigerator and showed me the vials lined up on a shelf in the door. Betty took two types, and Elenoa knew which was which and how much to give of each.
Then something occurred to me. If Elenoa couldn’t read, maybe she didn’t know numbers either. I hesitated for a minute, not wanting to make her feel worse. But then I did what I had to do for Betty’s sake. I made my tone warm and supportive, knowing full well Elenoa would not be fooled.
“Can you show me how you draw up the insulin?”
Moving even more slowly than usual, she picked up a syringe from the stack of them in a bowl on the counter and took a vial of insulin from the refrigerator. She placed them side-by-side on the countertop. Then she walked across the room and returned with a small square I recognized right away as an alcohol wipe. She tore it open, wiped the top of the vial, then paused. She seemed to be considering crossing the room again to discard the wipe and its wrapper. To my relief, she instead plunged the needle through the rubber lid. Turning toward the ceiling light, she pulled back on the plunger. For a moment, she didn’t move at all. She adjusted the plunger a last time and, without looking at me, handed me the syringe.
I looked at it and again worked to soften and neutralize my tone. “So this is what you’ll give her now, with breakfast?”
Elenoa nodded.
As gently as I could, I said, “Can you show me where the twenty is on the syringe?” I held it out. She took it and again turned toward the light. She squinted.
“Here.”
Elenoa was pointing at the right place on the syringe, but the clear insulin was way below that line, and there was a huge air bubble in the middle of the fluid. By my estimate, the syringe would give Betty ten to twelve units of insulin, not twenty.
I don’t remember how I responded in that instant. I do remember thinking, Aha, and Oh, my God.
Whether or not Elenoa was literate remained unclear, but one thing was certain: she couldn’t see well. And she couldn’t do much about the problem with no health insurance and a poverty-level wage—most of which, I would later learn from Tokoni, Elenoa sent back to her children and mother in Tonga.
“The insulin isn’t right,” I said. Then I took off my glasses. “Without these, I couldn’t get it right either.”
She looked at me and we both half smiled.
If Elenoa couldn’t read the amount of insulin, she could give Betty too little, raising her sugar and increasing her risk of infection, heart attack, confusion, incontinence, and a variety of other problems. If she gave too much, she could kill Betty. I wanted to be kind and a bit funny to lighten the situation, but it was serious, and Elenoa knew it as well as I did. I tried to think through work-arounds. After all, Betty’s family could not afford standard, agency-based in-home care, and Elenoa needed a home and a job. While she couldn’t see well, she could provide most of what Betty needed. Maybe, I thought, I could find a pharmacy that would pre-fill the syringes, and Elenoa could give the injections. But that would be expensive.
We had a big problem, and then, in the same instant, Elenoa and I had the same idea.
“Tokoni,” she said, and with relief I nodded my agreement.
DUALITY
“I seem to have entered a new phase,” my mother informs me two months before her eighty-fourth birthday. “There just aren’t men anymore.” The evening before, she had been with a large group of friends, all women. One was divorced; another still had a husband, but he was quite ill. Every one of the others, herself included, was a widow. She’s not looking for romance, she clarifies, just normalcy. “It’s unnatural,” she adds. “This huge part of life is missing.” She found it strange and sad to think that the rest of her life would have this significant absence.
Across locations and racial, economic, and ethnic groups, my mother’s experience is typical. Old age is profoundly gendered. Its skew hurts both men and women, though in different ways. Women are 51 percent of the population overall but 57 percent of people over sixty-five, 68 percent over eighty-five, and 83 percent of centenarians. The gender imbalance of advanced old age dates back to at least the twelfth century in western Europe. Women haven’t outlived men in all countries and decades since then, but they almost always have. Some people think this makes advanced old age a women’s health issue.
Surely, it also makes it a men’s health issue—or, more accurately, a men’s health crisis. Why do men so consistently die sooner than females? If men can live into very old age but most don’t, and if the system is designed with them in mind, then is the problem that more care does more harm or that living into old age depends on more than biology? When I mention this glaring imbalance in public, people always call out certain facts: men are less likely to go to doctors; we raise them to be stoic, to endure, to not show weakness, so they wait longer before seeking help; men don’t like to follow someone else’s direction and are less likely than women to adhere to medical recommendations; men still carry the societal expectation of excellence and providing, and those stresses erode their health; men take more risks. The list goes on, but these are the possibilities that always come up. The answer is likely a mix of these and other social and biological factors. Given how consistently men die before women, you’d think addressing this disparity would be a major goal of medicine. It isn’t.
The relative longevity of females has long confounded doctors, particularly in the years when menopause meant old age. They noted that common diseases afflicted women earlier than men, a phenomenon that seemed linked to menopause. For centuries, now debunked humoralism offered an explanation: the acquisition of diseases and debilities with age was unsurprising after bad humors ceased being expelled from the body through menstruation. Still, doctors didn’t pay much attention to uniquely female aspects of aging. The prototypical patient in textbooks was male (good old “Norm,” still in many medical schools today), and aging female organs received far less study or commentary than the aging penis and prostate.
Because men are more valued for their achievements, power, and money and less for their appearance, age can offer them benefits in a way it rarely does for women. This is less the case now than in past years, but the primary target demographic of the trillion-dollar cosmetics industry confirms the ongoing import of a certain sort of appearance for women,1 even those who have achieved the most prized sorts of professional success.
When we care about something, when we really need it, we usually pay for it. In medicine urologists make more than gynecologists, although both do medicine and surgery. In fact, urology patients are much older than gynecology ones on average, so it may be that gender trumps age in terms of value, or it did in the middle of the last century when specialty prices and prestige were established. When it comes to old age, we worry there aren’t enough caregivers, yet as other jobs disappear with technological advances, we continue to pay caregivers—mostly women doing traditionally “female” tasks—nothing or low wages. These are among the ways we compound existing social inequities. Just as women make less money if they have kids but men do not, the mostly female people who are caregivers for older adults make less money immediately and over a lifetime, accruing less retirement and benefits because they must reduce the number of hours they work, take a leave, retire, or change jobs. Not surprisingly, women are more likely to be poor in old age.
Twenty-first-century elderhood consists of dying men and impoverished women. We must be doing something wrong.
CARE
“She’s just screaming and saying her leg hurts,” said the hospitalist when I responded to his page. “I can’t get anything out of her, and the husband is nowhere t
o be found. Does she have a leg problem?”
Every month or two, I visited Inez’s one-bedroom apartment in a run-down subsidized housing building just blocks from the heart of the Castro. Getting to her required surmounting a gauntlet of minor hurdles. First, I had to be buzzed in, at least in theory. It was never clear who, if anyone, was responsible for the main door buzzer, and as often as not, no one answered. Fortunately, people often milled in the entryway and common area just inside the glass front door. Many ignored me, but eventually someone would let me in. Sometimes that person appeared to be a rent-a-cop, an ever-changing cast of characters of diverse ages and races wearing an uncomfortable-looking uniform. The official would size me up and ask for identification. They didn’t want my medical center badge but would painstakingly copy my name from my driver’s license onto a sheet of paper used to log the visit date and time of entry and exit. Finally, they would nod, and I’d turn toward the nearby elevators.
But by then I would have attracted the attention of the residents in the common room. I never visited without being approached by one of those not necessarily old people sitting in wheelchairs in the lobby, watching the passersby on their colorful block midway between a huge Catholic church and a commercial intersection where businesses had names like Rock Hard and Does Your Mother Know. They seemed starved for conversation. Sometimes one would accompany me up to Inez’s floor, chatting as the elevator lurched slowly upward. I then walked to the far end of a long, dimly lit hallway, passing the open door to at least one apartment where loud music, pulled shades, and glassy eyes suggested active drug use. It was for these reasons that Inez’s husband, Esteban, needed to hear my voice before he’d open the door with a huge smile and a warm “¡Doctora!”
But two days before the hospitalist’s call, there had been no smile. Instead, he had said, “Passa,” and led me quickly back to their bedroom. There, Inez, obese and bedbound with moderately severe vascular dementia, lay propped up in her hospital bed, her mouth open and chest visibly rising and falling. A quick assessment revealed low oxygen levels, high pulse and blood pressure, and what might have been hard-to-hear breath sounds in one lung. Because of her size and inability to move in bed or take deep breaths on command, Inez’s lung exam was always difficult.
I had Esteban give her one of her nebulized breathing treatments while I called an ambulance and the emergency department.
At her most healthy, Inez had a significant array of active and debilitating medical diagnoses and, despite my best efforts, an obscenely long list of medications. Now it seemed she had pneumonia, an asthma exacerbation, and—because of underlying conditions and acute illness—some heart failure and dehydration as well. However, neither that day nor previously in the two years I’d been her doctor had she had a “leg problem.”
“If her leg hurts, that’s new,” I told the hospitalist over the phone.
“Did she fall at home?”
“She’s been bedbound for years,” I said. “Doesn’t even try to get up at this point. Can she describe the pain?”
“She’s just screaming. Won’t answer questions. The resident gave her something, so I’ll go by and try again in a bit.”
“That’s not her baseline,” I said, meaning Inez’s usual behavior and ability to communicate.
When she was well, Inez answered my questions to the best of her ability, speaking to that moment in time with accuracy even if she couldn’t say much about the hours or days preceding it. She could list perhaps two of her medical conditions and one of her medications, and only in Spanish. She never screamed or hallucinated or behaved in the way the hospitalist was describing. Even on days when Inez didn’t feel well, she greeted me with a smile and asked after my family. Sometimes, too, I got a glimpse of who she had been before her strokes and the dementia, the person she sometimes still was. If I happened to be wearing a colorful shirt or sweater, she commented on how nice I looked and had me turn or come close so she could inspect the fabric and tailoring. Best of all, a few weeks before her hospitalization, she had offered the Spanish equivalent of “va-va-voom” to me behind the backs of her husband and our clinic’s new, tall, and broad-shouldered social worker as soon as the men’s attention was elsewhere. Then she raised her bushy eyebrows and winked her good eye at me as if to say did I really think I could fool her into believing it was mere coincidence that I was wearing a skirt on the exact same day I arrived to see her accompanied by such a handsome man?
I quickly relayed some of this to the hospitalist, listening to the background noises of a busy hospital on his end of the line. He was probably standing at the nurses’ station.
“Could be a DVT,” he said, meaning a blood clot in the leg.
I had another concern. “She’s big and deadweight. Something could have happened when the paramedics were moving her or since she got to the hospital.”
I felt certain no injury had occurred at home. Esteban was a meticulous caretaker. He checked and double-checked Inez’s pills, carefully arranging them in a large pillbox. When they were short on money, he gave her meat and ate only beans himself. Although also eighty years old, with his wiry body and easy grin, he sometimes seemed more like Inez’s son than her husband. Still, if he had dropped her in a transfer from bed to wheelchair, he would have needed help to get her up, and I would have heard about it. By my estimation, he weighed about 140 pounds and she was well over 200.
“Right,” said the hospitalist, his tone making clear Inez’s home situation and cognitive and functional baselines were of no interest to him. “I’m thinking clot, fracture, dislocation, maybe even a large bruise or wound we missed when she came in.”
I had entered the same list into my note as we spoke, with one addition: the need for repositioning.
“I can’t explain this,” I said, “but she always lies on her right side. If I move her during my exam, she’s uncomfortable. Her husband says it’s been like that for years.”
The hospitalist made a sound that might have been an unsuccessfully suppressed sigh.
“I know it sounds crazy,” I said, “but someone should check her position in the bed and put her on her right side if she isn’t already.” Imagining his eye roll, I added, “If it works, it’ll save your intern time and the health care system the cost of X-rays she doesn’t need.”
“Let’s walk through the plan,” he said, and began outlining his thoughtful treatments for Inez’s atrial fibrillation, pneumonia, and volume overload. Before hanging up, I repeated my suggestion about repositioning her as a first step for the leg pain, since, if successful, in addition to the benefits I’d already listed for him, it would relieve her pain and eliminate the need for the pain medications that were worsening her confusion and chronic constipation. Again, he didn’t respond.
Here were the cultural divides between inpatient and outpatient care and between internal medicine and geriatrics. My colleague focused exclusively on diseases and X-rays and medications, not seeing that, for a frail older adult like Inez, information about her baseline function and home situation was equally important—particularly since, with sickness layered over her dementia, she was unable to communicate her norms and needs for herself.
After hanging up, I called Esteban. Having first cared for his increasingly ill wife over two days and nights at home and then waiting the better part of a third night with her in the emergency department, he had gone home to sleep but was heading back to the hospital shortly. No one had phoned to tell him how Inez was doing, so I explained that her breathing was better, but she was in pain. I asked him to move her into a more comfortable position if he could when he arrived, and he said he would.
That evening, Esteban left me a voice mail. He reported with obvious pleasure and relief that Inez was much better. Then he added that she’d had awful leg pain when he’d first arrived, but once he’d moved her onto her right side, the pain went away. He said the nurses told him that she could probably return home the next day.
I logged into our
electronic record and read through the normal X-rays of Inez’s pelvis, hip, leg, and knee. There was no mention of her bed position in any of the doctors’ notes. I was reminded of a comment by a medical student after a visit to an impressive and all-inclusive site for the care for the elderly. The student, just months shy of his MD, had commented, “That’s not medicine, that’s just taking care of patients.”
EDUCATION
Less than two decades into the twenty-first century, medical education has changed in unprecedented ways. Pedagogically, we have shifted from what we want to teach to what learners need to know. In the digital age, “textbooks” are interactive, nonlinear, and multimedia. Students gather for active learning in small groups while lectures are podcasted or streamed; use of stories, gaming, videos, and other forms of so-called edutainment are often required. With the rise of the quality and safety movement, we have incorporated into every level of education attention to systems, interprofessional teamwork, and quality improvement. In response to society’s need for more primary care physicians and in recognition that most doctors spend a majority of their work time in clinics, not hospitals, we have developed outpatient rotations for core clinical training. We increasingly ask learners to look beyond organ systems at common genetic, metabolic, and immune system pathways. For the first time in 2016, the licensing body for medical education in the United States required programs to ensure clinical competence across the entire human life span.
Still, much of what was taught and emphasized in my medical school days remains prominent. Most doctors in training still get intensive exposure to the populations that dominated health care a century ago,2 when most Americans died before becoming old. Students do the same core rotations I did twenty-five years ago—largely the same core ones my father did in the 1950s when the average age at death was sixty-eight. Today, a sixty-five-year-old can expect to live another twenty-five years (half will live longer than that), octogenarians are forty-eight times more prevalent, and “old” includes people two and three generations apart. That’s why almost all doctors see old patients. People over sixty-five account for over 30 percent of patients seen in surgery, psychiatry, and neurology; over 40 percent in internal medicine, orthopedics, and emergency medicine; and more than half of patients in cardiology and ophthalmology. All those doctors learned about each other’s specialties, and they spent months learning about the care of children and pregnant women, though most don’t treat either of those groups. Only a small minority received specific training in the care of old people, and some of that training, even today, isn’t really geriatrics at all. Instead, it’s traditional education about diseases that occur more commonly with age. Geriatrics isn’t just about who is being treated or what diseases they have; it’s also about how and where they are cared for and what and who else besides usual medicine and doctors might help their health and well-being.
Elderhood Page 40