I’m Dr Phillip Periman from Amarillo TX.
In Atul Gawande’s book, Being Mortal: Medicine and What Matters in the End, I found the second chapter the most sobering. In “Things Fall Apart,” previously published as an essay in The New Yorker, Gawande discusses the inevitability of the biological decline of old age.
In fact, this chapter influenced my own decision to retire from the active practice of medicine at age 78. I know of no one who can do at 88 what they did at 78.
Gawande describes how modern medicine extended the average lifespan and changed the way we decline. Prior to the 20th century, most people who survived infancy, childhood, and childbirth could expect to live healthy, active lives well into their forties or beyond. Then, something untoward would happen and the individual would die suddenly, like falling off a cliff.
Medicine has altered the pattern of decline in victims of chronic diseases such as heart, lung, and liver failure. Gawande writes, “Our treatments can stretch the descent out until it ends up looking less like a cliff and more like a hilly road down the mountain.” Many of us do even better and now live a “full lifespan” and die of old age.
He reminds us old age is not a diagnosis. The complex system of a human being with all its back-ups of extra kidney, lung, and teeth breaks down. Gawande argues this is less genetic and more the end result of wear and tear, so at a certain time, all living processes come to an end. Our hair pigment stem cells die off so we become gray; our lung capacity decreases, our immune systems do not work as well, our joints deteriorate and are replaced with titanium ones.
Medicine has been so effective at keeping us going that today we have as many 50-year-olds as we have five-year-olds. Gawande notes, “In thirty years there will be as many people over eighty as there are under five…throughout the industrialized world.” One might expect a growth in doctors caring for the elderly; however, Gawande reports that “the number of certified geriatricians that the medical profession has put in practice has actually fallen in the United States by 25 percent between 1996 and 2010.”
Gawande thinks this is largely due to physicians’ dislike for taking care of the elderly. One geriatrician interviewed by him outlines how many of the problems of the elderly are chronic and difficult to treat: high blood pressure, diabetes, arthritis, memory loss, poor vision, and deafness. He says, “There’s nothing glamorous about taking care of any of those things.” Gawande does note that the lack of geriatricians “ has to do with money - incomes in geriatrics and adult primary care are among the lowest in medicine.”
I think this is a much greater issue. The average medical student graduates with $193,000 in debt. They have to choose a specialty that will pay more. Hospitals resist becoming geriatric centers because Medicare, the insurer of the elderly, does not cover that cost. Gawande notes that caring for the elderly “requires each of us to contemplate the unfixable in our life…in order to make the small changes necessary ” for better care of the elderly.
To paraphrase Gawande, continuing the prevailing fantasy that we can be ageless not only flies against the realities of our biology but also results in huge wasted expenses for medical interventions during the last months of our lives. This money would be better spent on improving our well-being as the frailty of age descends upon us. Given that 40% of us who live to 85 will have dementia and half of us will spend at least a year in a nursing home, altering our approach from the treatment of symptoms to a process that allows us to age with meaning and purpose seems imperative to Gawande and to me.
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