If you look at the curricular overview maps for schools from the perpetually top-ranked Harvard Medical School to the much-lauded newcomer, Dell School of Medicine in Austin, Texas, you will see the same things: required rotations in surgery and medicine, pediatrics and women’s health, and psychiatry and neurology, but no mention of aging or geriatrics. Almost without exception, learning about the specialized care of old people is an elective endeavor left to each student’s interests and discretion.
It’s worth considering how and why a group with a growing social footprint and significant health care utilization and costs—one that an overwhelming majority of clinicians interact with regularly—might be relegated to a status other than required in medical curricula. And it’s worth considering how bright young people can enter medical school intent on learning as much as they can in order to take good care of all patients but, after an average of about twelve teaching sessions about older patients, think they’ve learned enough.
There are some great innovations in med schools all across the country. Many of these new models may improve training and care, but most haven’t questioned the fundamental structures and assumptions of medicine.
A randomized clinical trial found that medical students who completed a clerkship year containing a specialized rotation in geriatrics3 (as they already do in pediatrics and adult medicine) acquired more knowledge and skills in geriatric care than did students who did not—a conclusion that may seem self-evident. But something else about this study is disturbing: the specialized geriatric clerkship did little to improve students’ attitudes toward old patients.
Another study illustrated how our definitions of medicine and medical care, as well as the structure and priorities of our health care system, put health professionals off old patients.4 Among the seventeen identified themes were despair at the futility of care, being unsure how to handle ethical dilemmas, and feeling depressed by the decline and death of their patients. Medical students also reported frustration at low reimbursement rates and low prestige despite fellowship training. Although they found communicating with older adults enjoyable, it was also time-consuming and challenging.
Their comments illustrate failings of medical culture, medical education, society, and our health care system. Taking each item in turn: Care is never futile, though treatment can be. Too often those two words are used interchangeably, though they have very different meanings. Given how commonly ethical dilemmas occur across medical specialties and how important they are, students must be given sufficient training to feel as comfortable with them as they are made to feel sticking metal and plastic into living human beings. If not, we aren’t preparing them for medical practice.
Considerable evidence shows that a great many Americans do indeed receive futile or harmful treatment,5 particularly late in life or at the end of life. We should be relieved that young doctors want to avoid the moral and medical distress of futile care for their patients, and change the system that causes that kind of harm to patients and clinicians. Society and medicine both need to build better systems for dealing with aging and death. Those facts of life are not improved by attitudes and reimbursement policies that make them harder than they already are existentially. Almost everyone is happier doing work, no matter how difficult it is, if they feel able to do it well and appropriately recognized for their efforts.
We teach doctors in training that certain things are important and others are not. If medical education wants to produce clinicians able to provide safe, evidence-based, high-quality, high-satisfaction care to patients of all ages, we must do more than include the entire human life span somewhere in doctor training, as the 2016 mandate requires. We should instead retire the centuries-old adult-as-norm model. Children and old people are 40 percent of the population and over half of health care utilization—numbers likely to keep climbing. Treating them as exceptions is demographically and biologically inaccurate. A better approach would replace our current “normal + variants” approach to organs, diseases, and specialties with an equally weighted child-adult-elder lens.
Here’s what an age-inclusive curriculum might look like: When medical students are taught normal anatomy, physiology, and pharmacology, they would learn the norms at all three major life phases. When they learn about diseases and pathophysiology, their curriculum would include classic presentations in patients of all ages, as well as conditions unique to each life stage. And when they do core rotations, their training would expose them to the full diversity of specialties, clinical settings, and approaches to care with the simultaneous goals of ensuring broad general competence in graduates, providing students with the necessary experiences to make informed career decisions, and producing a workforce that meets society’s needs.
RESILIENCE
Approaching her eighty-sixth year, my mother says to me: “There are just so many things I have to do in the morning. I have to put the drops in my dry eyes. I have to take my thyroid medicine right away so it’s on an empty stomach but I can still have breakfast at a reasonable hour. I have to do the neti pot with my nose or it runs all day and I cough. I have to put the cream on my face for the rosacea. I have to do my stretches and exercises to loosen up my parts and get them going. I have to get my hearing aids in and then pin back my hair because I can’t put it behind my ears anymore with my glasses and hearing aids already there. It’s incredible to think I used to just get up, wash my face and start my day.”
This is true of all parts of her life, yet in her old age, my mother never ceases to amaze me with her resilience. Widowed and with friends dying at regular intervals, some expected, others suddenly, she sometimes seems sad but never depressed, and she sometimes complains, but minutes later she’s back to living her life and commenting on the world’s larger issues. “I’m trying to be low-maintenance,” she tells me. “Until I can’t be.”
I hope I’m like her in thirty years, and I feel certain that hers is a standard I will not attain. Some people are more resilient than others. I’m making progress, but that particular form of toughness isn’t one of my strengths.
In medicine these days, resilience is a popular concept. Some considered it the profession’s number one weapon against burnout. Like many medical centers, mine now sends out e-mails touting opportunities for resilience training. I delete those e-mails. I’d rather learn my resilience outside the institutions that claim they want to help me cultivate it while continuing the structural injustices that jeopardize it. Nationwide, health care’s medicine-as-business mentality, “death by a thousand clicks”6 electronic record systems, and antisocial priorities harm patients, waste money, and erode clinician morale.
Some of the techniques I’ve used to make myself healthier are addressed in resilience training: regular exercise and meals, enough sleep, days off, and replenishing activities. Of course, another way to describe these things is “a healthy lifestyle.” But modern medicine doesn’t support healthy lifestyles among its practitioners any more than it emphasizes health and wellness in patient care.
After I quit the ACE unit, I had trouble finding clinical work as a geriatrician in our health system. I could no longer drive reliably enough to do housecalls. I didn’t seem to have the mettle for what passed as eldercare in the hospital, and my institution’s sole outpatient geriatrics clinic was small, without room for another clinician. I could have changed systems, but there were wonderful colleagues, inspiring students, and many other parts of my job that made me eager to stay. In the end, I did what geriatricians do best: I took all my knowledge and experience, looked around at both what existed and what was needed, and came up with a creative, pragmatic, evidence-based, and socially useful solution. I decided to try and start a new clinic that would approach elderhood the way pediatricians approach childhood. It would combine the best of modern medicine’s disease-fighting ability and the best of traditional geriatrics’ function and personal priority-based care with the wellness and health promotion emphasis of the new specialty cal
led integrative medicine. The new clinic’s goal would be to help old people in all stages of old age optimize their health, lives, and well-being.
New clinics, even when they are just clinical sessions added into an existing practice in a thriving health system, don’t take shape overnight. Before I could get started, I had to get support from institution leaders, develop a self-sustaining business model, learn more about prevention, health maintenance, and wellness, and decide how the new clinic could be most useful to older San Franciscans. That turned out to be a lot of fun. Clearly, I was coming out of my burnout.
It’s impossible to avoid medicine’s resilience evangelists. They are everywhere. At a continuing education training in another state, I was seated in the middle of a large auditorium of doctors when our next speakers announced they would be talking about burnout. One was a medical school dean, the other a program leader. Their presentation offered resilience-building exercises and tools.
After maybe half an hour, I went to the microphone and asked if they would be discussing any of the structural contributors to burnout. One of them assured me that they would be. As I walked back to my seat, doctors I didn’t know nodded or gave me a thumbs-up. And then one of the speakers commented that there is lots of blame casting in the world and they wanted to take a different focus.
In my chair, I kept my face blank. It is typical in medicine to reduce complex problems to singular perspectives and solutions. As an educator, I know the most worrisome students are those who always blame others for their challenges, and as a professional I know that systems that similarly don’t carefully examine their own assumptions and actions in contributing to problems will never solve those problems. What I was suggesting was not the abdication of personal responsibility but that burnout could not be addressed without looking both at individuals and at the structures and culture of medicine: the powerful doing what the powerful do; the culture following money, not values; the politics that shape so much of our lives.
Not everyone is burned out, so clearly individual factors matter. But if over half of doctors are, and if that was not always the case, and if in study after study people list the same systemic and cultural contributors, it seems fair to me to discuss those issues, as well as ones of personal resilience.
Next the two doctor-leaders showed a slide about leadership in the age of burnout. I look up their bios online. They were people who make institutional policies: well-meaning shepherds who think they can address cultural and structural problems by sheer force of will and good intentions. Despite being doctors, their slides suggested that they didn’t realize their approach mostly palliated symptoms rather than addressing underlying causes. As the writer-photographer-critic Teju Cole has written about a human rights and social injustice journalist, “All he sees is need, and he sees no need to reason out the need for the need.”7 In medicine, the need is burnout, and the need for the need is American health care’s morally distressing norms, structures, and policies.
I have become more resilient since my burnout. I take better care of myself using many of the tools in their presentation, and others. But because it so often feels like doctor-leaders are themselves casting blame on those of us in moral distress, one of the most effective tools I use is the one that tells me when to be honest with other people about what happened to me and when to lie. That one is easy to apply: if a doctor asks, I usually lie; if anyone else inquires, I tell the truth. Among doctors, normal human emotions are still seen as evidence of weakness.
Cultivating resilience doesn’t mean never feeling sad or angry. It’s about contentment and the happiness born of connection, meaning, and purpose. With aging and in old age, resilience requires accepting you are still yourself despite changes, losses, and limitations and recognizing your ongoing personal and spiritual development. It means finding a purpose that may differ from prior goals and inspires learning or helping someone else or going somewhere new. It requires knowing what matters most to you, being clear with others about your priorities, and living in an environment that meets your needs, optimizing your independence and comfort. Resilience emerges when a solid dose of optimism is tempered with just enough pessimism to match goals with realities.
Anne Fadiman’s father lost his sight at age eighty-eight. In the hospital after being told his one seeing eye could not be saved, he told her his life was no longer worth living. People feel this way for many different reasons. For Clifton Fadiman, a huge reader and critic, two reasons stood out: he didn’t want to burden his wife, and he would no longer be able to read. Anne asked him to wait six months before doing anything about wanting to die. He agreed. A short while later he attended a program for visually impaired persons and described his first day there as perhaps the most interesting day of his life. The program gave him strategies for independence that helped him be less of a burden and do much of what he enjoyed most. He lived many more years, and after his death his daughter wrote:
I believe the period between my father’s first class at [the low-vision program] and his final illness was in many ways one of the happiest of his life. This was in spite of his age; in spite of his losses;8 in spite of the moment every morning when he awoke from a dream in which he was invariably sighted, and then remembered he wasn’t. It is said that old people can keep their minds agile by learning how to speak Italian or play the oboe. My father learned how to be blind … He had considered himself a coward. Now he knew he wasn’t.
A blind old man sitting in a chair listening to a book or the radio may not meet many people’s criterion of courage. In these early years of the age of elderhood, a time when most people still fear and dread the label and reality of old, the failing seems less one in the concept of courage and more in the imaginations of those who can’t see it in all its forms.
ATTITUDE
In “Letter from Greenwich Village,”9 Vivian Gornick describes encountering a short stretch of newly poured concrete on an icy winter’s morning in Manhattan. Workmen had left a wood plank and flimsy rail for pedestrians. She was about to cross when she saw a “tall, painfully thin, and fearfully old” man at the other end. Wordlessly, she held out a hand for him. Wordlessly, he took it and came across. Face-to-face on the icy New York street, the man was the first to speak. This is how Gornick describes the entirety of their conversation:
“Thank you,” he says. “Thank you very much.” A thrill runs through me. “You’re welcome,” I say, in a tone that I hope is as plain as his. We each then go our separate ways, but I feel that “thank you” running through my veins all the rest of the day.
At first, given the mundanity of this exchange, we can only guess at the source of Gornick’s thrill. Maybe there was something about him—his looks, gaze, or manner—that she found unusual or surprising, sexy or familiar. She doesn’t keep us in suspense:
It was his voice that had done it. That voice! Strong, vibrant, self-possessed: it did not know it belonged to an old man. There was in it not a hint of that beseeching tone one hears so often in the voice of an old person when small courtesies are shown … as though the person is apologizing for the room he or she is taking up in the world.
This anecdote is equally remarkable for Gornick’s insights into our cultural norms of old age as for the man’s defiance of them. The traits she ascribes to his voice are ordinary in the larger realm of adult voices. What made them noteworthy was her expectation (and likely ours) that strength and self-possession are invariably lost by the time a person becomes frail and “fearfully old.” The man’s tone implies that the meekness so common in older voices is not intrinsic to their owner’s chronological station. That means our usual social stance in advanced old age is unnecessary and, worse, that we who are not yet old are colluding with those who are to perpetuate this demeaning cultural behavior.
One centenarian, Diana Athill, whose most recent books were written in a care home, says that in old age “one’s chief concern must be how to get oneself through time with the minimum of discomf
ort to self and inconvenience to others.”10
The man’s voice, Gornick tells us, “did not know” it was supposed to beseech. It didn’t believe the sort of person who occasionally needs assistance of others is faulty and culpable. It didn’t subscribe to the human worth metrics of ability and self-sufficiency that have been revered since the Industrial Revolution. Immune to current social norms—rules based on assumptions that older individuals are burdens, that older adults as a group are a problem to be solved and a catastrophe of tsunami proportions, and that helping them is inconvenient—the man’s tone divorced his frailty from its customary accompaniments of apology and neediness.
The exceptionality the old man displayed after crossing the icy plank differs fundamentally from the “exceptional senior” championed in the media—the octogenarian gymnast or custodian; the nonagenarian grocery bagger, assembly line worker, product designer, or CEO; or the centenarian marathon runner. Those supposed exemplars are indeed exceptions, often as much because of their abilities or courage to redefine work and who does it as because of their age. By contrast, the man in Gornick’s anecdote did something ordinary, something any one of us could do: he retained his agency, self-respect, and perspective, assessing the scale of the help Gornick offered and replying with commensurate, rather than elaborate, thanks.
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