EP. 33: REIMAGINING AGING AND LATER LIFE
WITH LOUISE ARONSON, MD
A geriatrician and award-winning author discusses how we can reconceptualize human longevity and shares her hopeful vision for the future of aging.
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Episode Summary
Advances in modern medicine mean a greater proportion of people today than ever before will live well into old age. Despite the seemingly encouraging trend, geriatrician Dr. Louise Aronson argues that we have made old age into a disease, a condition to be dreaded, denigrated, neglected, and denied. Dr. Aronson has made it her life's work to help us reimagine the rich possibilities of human longevity and of later life. Her bestselling book, Elderhood, was a finalist for the 2020 Pulitzer Prize for general nonfiction. In this episode, Dr. Aronson explains what makes geriatrics a meaningful career for her, discusses the faults in our society’s conception of elderhood, and shares her humane and hopeful vision for the future of aging.
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Louise Aronson, MD, MFA, is a leading geriatrician, writer, educator, professor of medicine at UCSF, and the author of the New York Times bestseller and Pulitzer Prize finalist Elderhood: Redefining Aging, Transforming Medicine, and Reimagining Life. A graduate of Harvard Medical School, Dr. Aronson has received the Gold Professorship in Humanism in Medicine, the California Homecare Physician of the Year award, and the American Geriatrics Society Clinician-Teacher of the Year award. Her current work is focused on expanding geriatric care and public perceptions of old age to more accurately attend to the decades and diversity of elderhood, and developing innovative programs and practices to empower older adults to retain agency and maximize wellness as they age.
At UCSF, Dr. Aronson has served as director of the Pathways to Discovery program, the Northern California Geriatrics Education Center, the Optimizing Aging Project, and as Chief of Geriatrics Education. Her writing credits include the New York Times, Atlantic, Washington Post, Discover, Vox, JAMA, Lancet, and the New England Journal of Medicine, and she has been featured on TODAY, CBS This Morning, NPR’s Fresh Air, Morning Edition, Politico, Kaiser Health News, Tech Nation, and the New Yorker. Currently, Dr. Aronson divides her time among patient care, community-based aging innovations, teaching, health advocacy in the media, and writing.
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In this episode, you will hear about:
• An overview of what geriatrics entails - 1:47
• The need to recognize elderhood as distinct a life stage - 4:42
• Dr. Aronson’s reflections on what drew her into caring for older patients - 6:15
• The ways goals of care change in elderhood - 8:24
• Dr. Aronson’s approach to caring for her patients holistically - 13:27
• How physicians can change the “losers and winners” paradigm in healthcare - 17:34
• A discussion of structural and cultural ageism and the insidious ways it harms our society - 23:03
• How American culture and medicine elevates patient autonomy and how this can sometimes be harmful to older patients - 30:59
• A discussion of Dr. Aronson’s writing and what motivated her to become an author - 38:49
• How Dr. Aronson experienced and overcame burnout - 42:57
• Advice to new clinicians on how to connect with patients and create a more meaningful career path - 46:08
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Henry Bair: [00:00:01] Hi, I'm Henry Bair.
Tyler Johnson: [00:00:03] And I'm Tyler Johnson.
Henry Bair: [00:00:04] And you're listening to the Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build health care institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across health care, from doctors and nurses to patients and health care executives. Those who have collected a career's worth of hard earned wisdom probing the moral heart that beats at the core of medicine. We will hear stories that are by turns heartbreaking, amusing, inspiring, challenging and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.
Henry Bair: [00:01:03] Advances in modern medicine and living conditions mean a greater proportion of people today will live well past their sixties than ever before. Despite the seemingly encouraging trend, geriatrician Dr. Louise Aronson argues that we've made old age into a disease, a condition to be dreaded, denigrated, neglected, and denied. Dr. Aronson has made it her life's work to help us reimagine the rich possibilities of human longevity and of later life. Her bestselling book, Elderhood, was a finalist for the 2020 Pulitzer Prize for general Nonfiction. In this episode, she shares her humane and hopeful vision for the future of aging. Louise, thank you so much for joining us and welcome to the show.
Louise Aronson: [00:01:45] It's my pleasure. Looking forward to it.
Henry Bair: [00:01:47] So you are just about the most well-known geriatrician in the United States for your writings and for your leadership role in various advocacy groups for geriatrics. But I think there's still a lot of people both in and out of medicine who don't really know what geriatrics is, or when you tell them geriatrics, nothing really comes to mind. Unlike, say, pediatrics. Right? Everyone has their own experiences with that. So for those of us who might not know what geriatrics is, can you tell us briefly what you do?
Louise Aronson: [00:02:23] The way I like to explain it, it's very apropos that you said about pediatrics, because I basically say we do for older adults what pediatricians do for children and internists do for adults. Family docs often take care of everybody. But just as we can all tell, a kid from an adult, from an elder, peoples needs medical, social change. So what do I do? I provide medical care to to old people and actually increasingly a range of old people. Geriatrics has traditionally focused on the oldest or sickest old. The argument being that there are relatively few of us, and I would argue that is both historical, that we're fewer old people and ageism, which is alive and well pretty much everywhere, including in each of us. We don't mean to be that way, but we're all born young. We imprint on ourselves young. So what I think we do differently is we consider how the patient's functional status, life expectancy, different illnesses, medications and priorities influence their health care. So as an internist, I was trained to think about diseases and organs and to look at the literature and apply that to my patient's disease or organ. But you can take something relatively simple, like a broken arm If you are an older person who already has some trouble walking, you might not be able to use a walker. So for me, just to put a cast on and say by that's not going to help the person and what else do they need to do in their life? And if they're younger, old, a lot of people will put the cast on and say bye, because that works. But we need to think about why were you falling, because there is lots of data on how to keep that from happening and also lots of data that people fall for different reasons in different stages of old age. And then I need to think about your bones and your osteoporosis and have we diagnosed it or treated it. So it's really I don't know. It's fun because it stretches over decades and it includes not just organs and diseases, but human beings and their social systems and physical environments.
Tyler Johnson: [00:04:42] For those who are just getting into the medical field, you may sometimes hear pediatricians will sometimes chide internists and say, you know, children are not just small adults, meaning that they have a sort of a very different set of things that you have to think about because the world is different if you're approaching it as a child and as a cancer doctor. I've come over time. So we're starting to have some geriatric oncologists where that's really their field of specialty. And I have started to appreciate as I talk with them and look at the work they do, that it's also true that I think elders are not necessarily just old adults, right? You can't just think of them as adults who are a little bit older. You have to think, as you were explaining so nicely, that they really do have a distinct set of concerns and a distinct set of parameters that you have to consider when you're figuring out how to best take care of them.
Louise Aronson: [00:05:32] I think that's absolutely true. And it's so funny with the precedent of pediatrics being what it is that in our daily lives, it's so obvious that 80 is different than 40. A small child knows that they're different. We also have known about changes to the immune system for over 100 years. We know that outcomes are bad, but so often when older adults have bad outcomes, it's because we have applied data from research studies on middle aged people to them, and then we blame old age as opposed to the science that had a fatal flaw from its inception. So I think you're just right. And I am hopeful that we are beginning to acknowledge that and act accordingly.
Henry Bair: [00:06:15] Well, thank you very much for that explanation. Can you tell us what first drew you to this particular field of medicine?
Louise Aronson: [00:06:22] You know, it didn't even cross my mind for many years of my training. And it was actually a medical student who was working with me who first noticed that I was drawn to the older people. And I was kind of shocked and maybe a little taken aback. There's my ageism, right? It's probably, I don't know, 29 at the time. Who knows? And then I realized I was and I started to think about it. And part of it is that I am interested in individuals and stories and cultures and in caring for an older adult. I need to pay attention to all those things to make the right decision for them at that point in their life. When people are younger, it's often just full course press. The goal is longevity. Right. You're 23. We need to keep you alive when you're 93. It might be different even when you're 73, depending on what else is going on. So I realized a few things. One is I love talking to them, especially in the Bay Area. They come from all over the world. They have decades of stories. Their families are often involved. So I really enjoyed that. I like the medical complexity and the creativity required. If I had to do the same thing every day, I'm just not that person. I think some people like I'm really good at cataracts. I'm going to do cataracts for 50 years. I could not do that. So I love variety. I love to keep learning new things. And I realized that geriatrics would provide that for me. Lastly, there was sort of an ethical, moral imperative, because when we talk about underserved populations, one of the populations that gets left out is older people. Proportionately, there are just almost no geriatricians, no specialists in the care of the people who disproportionately require medical care. So it seemed like I could be doing a social good while doing things that kept me intellectually stimulated and personally fulfilled.
Tyler Johnson: [00:08:24] I'm wondering, one of the things that we have talked a lot about, we've had a number of doctors on this show who are ICU doctors or oncologists or doctors who, as you say, are taking care of people when in situations where by definition what we're talking about is very aggressive care, often very invasive, involves a sort of a high risk, high reward proposition. Some of that, of course, happens in elderly populations as well. But especially as you were sort of alluding to earlier, as people get older and then especially as they start to recognize that they may be nearing the end of their lives, that calculus changes. Right. And aggressive and invasive care may make less sense. And care that is focused on other important goals may make more sense. And so and I know that you've you've written about this as well, but I was hoping that you could talk to us a little bit about how do you reconceptualize what the goal of care is as you take care of patients who are older and how do you help them to articulate the things that are most important to them when they may be in the ironic position of not even knowing what it is that they really want?
Louise Aronson: [00:09:40] Right. Many of us don't know what we really want. And also you can think, you know, and then you end up in the situation and you change your mind. I tend to think about it not necessarily out loud with the patient, but in my head and sometimes explicitly with the patient, depending on who it is as a mixture of a few things. One is the person's health. How many comorbidities and medicines do they have? Because as those numbers go up, the risk of whatever it is goes up and the benefits go down. The next thing is their functional status, because there are some people with all kinds of medical problems, but they're still working and they're walking a few miles a day and they're running and playing with their grandkids or great grandkids. Functional status is one of the best predictors of outcomes. The next one is their age, because, you know, if you're super functional in, you're 103. I think we can safely say your horizon is different than if you were even 73, right? And most people who are 103 are wise enough to recognize that we're not talking 15 years. Is it theoretically possible there was that woman in France? There have been some people in Japan and Nepal, but I think we could safely assume that that's not all on the board.
Louise Aronson: [00:10:59] And then perhaps most importantly is who is this person and what matters to them? Are they alive because they're working? So if they can't work, maybe they don't really need to stay alive so much longer. Are they looking for? Forward to a grandchild's wedding. Is it? Meeting their friends three times a week. And actually, two of the friends are dying and the third one has some dementia. So that's less important, you know. And so this can really go either way, but it's kind of talking to them about things like purpose. What makes you excited to get up in the morning and pleasure and all these things? And some people will say, even some geriatrician say, well, how is a doctor doing that? Well, I think a doctor is partly doing that because we don't have really health care teams. We don't have an efficient health care system. The doctor doing it also signals a degree of importance. There are articles and little journals people will have heard of, like JAMA, the Journal of the American Medical Association, showing the Association between Purpose and Health from ages. It's actually there's a great graph for maybe I want to say 2019 or 2020 where the the correlation between purpose and health is pretty much the same for people in their nineties and people in their teens.
Louise Aronson: [00:12:17] So so it's really putting together health function, life expectancy and age and values. So those five things and then making a decision on the one hand. So that's the person centered approach. Then you have to bring in the science too. So what does the science say? But I don't just look at the journal articles that are related to that. I also look at the age of the people who are studied because the average age of the person was studied was 40 and the range was like 13 years in my patients, 70 or 80 or 90 or whatever, then their outcomes may not be my outcomes, particularly if there's renal dysfunction, which people don't think about. I mean, now we're doing more with certain kidney tests. I won't get into the nitty gritty there. That may help us be more accurate, but if you're a slim person without much muscle and it looks like you have normal kidney function and you're 85, chances are you do not have normal kidney function. So we need to think about that, too, because the toxicities go up. So those are all the things I think about. There's the five person centered things and then there's the science and how well can I apply it to my particular patient?
Henry Bair: [00:13:27] I really appreciate the fact that, as is illustrated by your writings and by our conversation so far, you really bring this holistic approach to patient care. I mean, just now you mentioned exploring what your patient's purpose in life was. Right. And that's just not something that we often hear about in a clinical setting. Is there a story you can share that illustrates why this approach to patient care is the most meaningful work that you can do?
Louise Aronson: [00:13:58] It also depends if you're thinking sort of younger, healthier, old versus not. Let me tell first about a pretty healthy person. So 72 year old still working full time. This is a recent case. So had COVID and was still feeling tired, which was why she came to me. But she also had a couple of autoimmune things. So thyroid condition, a skin condition. She had some arthritis, she had some high blood pressure. She so a variety of medical things, but but super high functioning. And so when you take the holistic approach, you also want to say you want to look at systems. So her bones over time, her muscles, you start losing muscle mass. This is my most depressing geriatric statistic, in my opinion, in your thirties. And there was literally an audible gasp at the geriatrics meetings a couple of decades ago when data was shown because almost everybody is 30 or older. So you start losing muscle mass and you really have to focus on building muscle. Which one of the studies in the New England Journal of Medicine that made me a geriatrician showed that that could be done for people in their eighties and nineties successfully. So thinking about the bones, right. I'm going to treat osteoporosis, but I'm going to think more holistically What can we do with physical therapy? What can we do about balance, which has to do with specific balance training? Maybe something like Tai Chi, which we should probably all start doing around 50 or 60 building muscle, etc.
Louise Aronson: [00:15:33] then thinking holistically about who's your support network. If somebody is in their seventies, they're maybe going to retire. Although actually recently somebody contacted me about an article about people in their eighties and nineties working. So it might be we don't need to retire anymore if you like what you're doing and or if you can't afford to retire. But sort of thinking about those things because we know people, especially males who retire, have a tendency to die, particularly if they don't have something to do with themselves. And that's partly because a lot of the social network not not in huge numbers, but there is this one year risk, partly because a lot of the social network is happening there. And this may also be generation specific. So thinking about social support and how is that going to go forward, thinking about the physical environment the person's living in, and when do they start thinking about transitions so that the home feels like a home and it's not a place the kids are moving the person when something happens.
Louise Aronson: [00:16:29] So that can be one approach. And then if you take a frail elder, one of the stories I told in the book that I also told in Health Affairs was a woman who basically lived up all these stairs and was just falling apart, basically, and and including a pharmacist to change, whittled down the pharmacist and a physician to whittle down her medications, get them delivered to her at home. In addition to writing all her medical problems and adjusting the doses of medications that no longer made sense, given her sort of water to fat ratio in her body and and a variety of other things. So the social worker was key to getting the help at home. The physical therapist was key to getting her walking more safely. The occupational therapist helped her reset up her home because people often have trouble reaching things. Number one, they get shorter. Number two, if you don't talk to these 70 year olds about rotating your shoulders, you're going to lose the ability to reach up by your later eighties or nineties. So those are just a couple of examples.
Tyler Johnson: [00:17:34] Can I ask you maybe a more cultural or philosophical question, But that I think is something that's interesting to think about, which is we often see as a doctor who takes care of patients with cancer, it often feels as though many people have not all certainly, but many people have sort of one mode for engaging the medical system, which is the medical system is here to prolong my life as much as possible. And then when you reach a point where it's clear that that mode is not working anymore, I think a lot of doctors in fairness and a lot of patients, it's like there's a there's just not even a almost a recognition, let alone an understanding of what medicine might do after that. Right. Which I think reflects the fact that culturally we just don't talk about these things very well. Right. We have a very sort of winners versus losers paradigm for thinking about medicine, right? So if you get the surgery and it fixes your heart, then you won. And if you get the surgery and it doesn't fix your heart, then you're lost. Right? So I guess culturally, can you think of things that either are being done or that could be done that would help us to shift that paradigm so that that. Life. Extending care is seen as one valid function of medicine among many, rather than being, in effect, the only one.
Louise Aronson: [00:18:58] Yeah. I mean, I think we do it metaphorically, linguistically and practically. So some of it is not saying like and you see this in notes, like there's nothing more we can do, which is a complete lie. Like, we can, we can help you be comfortable. We can support your physical and social environments. We can think about your values and try and pull our all our team together to help you do what you want to do before you die. So we shouldn't use things like there's nothing more we can do, which even very famous doctors will do. There was something in The Guardian with Henry Marsh talking to Sid Mukerji, and they were like, When do you say stop or whatever? And it's like, No, it's not about stopping, it's about shifting focus. You can, as many people are doing, like you're talking about the Jarrow oncologists and the field of palliative care starting at the same time that palliation isn't necessarily death, but then they have a relationship with the team that's good at taking care of symptoms, including the symptoms associated with dying. I actually don't think we should outsource death as much as we do. I think if you're a cardiologist or an oncologist in a country and on a planet or a pulmonologist where the majority of people die of those diseases, there should be a level of competence among everyone. It should be required rotations every year of the training so that people are comfortable with it and have basic skills like do I send every patient with a heart to a cardiologist? No.
Louise Aronson: [00:20:36] Do I send every patient with hypertension to a cardiologist? No. But like when people are dying, often they're just tossed to palliative care or geriatrics. And I don't think that should happen. I think it's a basic skill set. And as clinicians, we should all be able to do it Linguistically, I think we need to use the word death. I see so many people in medicine using passed on, passed away, and there has been data for 20 years showing that if you don't use the word death, people don't always know they're dying or their families don't know they're dying. And if we're not comfortable with the word death, how are we going to be comfortable with helping people die? And 100% of our patients will die because all human beings die. So we have to be able to use the D-word as a society. I think we have to start addressing these things. And lots of people are from the death cafes to adult children or elders trying to talk about it. I get a lot of older people say to me, We try to raise this with our kids and they're like, don't be a downer. And what I tell them to do is to say, Well, in the first place they should be thinking about it too. And to say to them, Hey, look, your kids talk about school, you talk about work. This is one of the realities of our life stage.
Louise Aronson: [00:21:49] And the more we get to talk about and plan about with you, the more we stay in control of it and the less burden is placed on you. That is a win win. This is a conversation we need to have. If you're not comfortable with having it today, let's make a time and have it. And I think if we start in families doing that more and we as physicians feel comfortable with it, you know, when you're saying like there's there's a 30% chance this chemotherapy is going to help, you need to be able to say, and there's a 70% chance you're going to die of this. I hope not. And I'm going to do everything in my power to get you into that 30%. But if it were under my control, I'd cure 100% of people. So what I want to do is include the palliative care people so that if and when that happens, and let's remember that it's more likely than not and still we're doing everything to try and help you. You already are comfortable with the people who, together with you and I, are going to help make your your death the best it can be. And let's try and not have that happen to you right now. There just all these ways you can have those conversations that will help people. And as a society, talking about, I mean, imagine if everyone in health care started using the D-word in their lives. There's a lot of us.
Henry Bair: [00:23:03] That's a really great way of exploring a little bit our society's conception of death and dying and what we as a medical community can do to change the course of that conversation. But of course, as a geriatrician, you're not only dealing with death and dying, you're dealing with the ten, 20, 30 years before that happens. And I think just as much as we are beginning to see a change in the conceptualization of death and dying in America, I think there's also been a change, perhaps a very long time coming in our conception of aging and elder hood. Can you tell us more about how we have come to terms with aging? If we've come to terms with aging and what the future looks like?
Louise Aronson: [00:23:50] I think we can say pretty confidently that most of us have not come to terms with age. People make comments all the time about like, Oh, it's just sucks to grow old. I don't know. It's so funny. I follow a junior colleague, sort of a mentee on Instagram who recently turned 35 and she was saying like, Oh, aging is kind of wonderful. And I was like 35. And then I remembered like I remember being horrified when I turned 30. So I was like, okay, I got to put myself back in my old mate like 35. And there's so much anti aging, which is so weird because usually your anti the ism right anti-racism anti violence anti, but instead we're like anti aging which is what we're all doing from the moment of birth, which makes no sense and there are more people celebrating it. So as you can see, but the listeners cannot. I now have migraine ahead. I did diet for many years, but but most people still diet. I was I was on our campus a bunch last week and I kept being in rooms where there'd be like one other person with a gray head. I mean, men men exception but among women. And do they end up looking younger than I do? They do, which is uncomfortable. But out in the world there is this trend among women 50 and older to just sort of be natural. And the advantage to that is that we could then associate gray hair with the decades of middle age and older adulthood and understand that it isn't a marker of obsolescence.
Louise Aronson: [00:25:20] And equally important is function the only reason to care about someone. We sort of have this industrial revolution notion of human beings that you have to be the fastest and you have to be working. What about the 50 years of Mercury? Did does that count for exactly nothing? So we make different judgments on on old people. And we also talk and I think this is a critical point. We talk about the bad things about aging, because I'm not going to pretend like the changes in your body. What I like to run as fast as I used to run, I sure would, but I can't, you know? So there are disappointments as you age. At the same time, most people are happier across nations, right? So that there is this U-shaped curve of happiness. We are happiest in childhood and elder hood and it's adulthood. That's kind of a bummer. So then you wonder, since adults are so powerful, are they just spewing these lies to keep themselves in control? I don't know. Like, well, why would you be happier? I'm like, Your time is your own people are more likely to live according to their values and priorities, to do things they put aside in adulthood while they were raising families and worrying about moving up the career ladder or just surviving. There are just so many ways in which people get to spend more time doing the things they want to be doing and less time doing the things they don't want to be doing.
Louise Aronson: [00:26:38] And that's whether you're a poor person somewhere or a person with lots of resources. The general height of the curve differs among more resourced and less resourced countries, neighborhoods, etc. But the curve holds. So I think we need to talk about the good. And then actually I said that was going to be the key point. But I think the final key point is in a world that is so structurally ageist, we don't let people live to their potential in elder hood. And if we did, what might Elder Hood be like if we stop telling people to retire and then yelling at them for not contributing to society, that just doesn't make any sense. You can't have both. You can't say you're not a working member and please retire. If we made things as accessible to older people as to children and adults, you'll see things everywhere, from parks to health care to whatever else. And you see kids and adults. Kids and adults. Well, what about elders? So we just have this structurally a just society and it would enable more people to contribute and to interact in productive ways because there are differences not just between older people and younger people based on age. There's that, but they're also different generations. They have different life experiences. So Harvard Business School has done some research to show that if you have a multigenerational team, you have a much more productive team because they have different strengths and different areas of knowledge.
Henry Bair: [00:28:02] I don't think I've ever heard of the term structural ageism before, but I see your point. Yeah.
Louise Aronson: [00:28:08] Once you look, it'll be everywhere.
Henry Bair: [00:28:11] I've never heard of that before, but as soon as you said it, I knew what you were talking about. Right. What are some other ways we can break down some of those barriers and start reversing the structural ageism in our society?
Louise Aronson: [00:28:24] Yeah. So important. We often think about, like, the potential in childhood and the potential in adulthood and like, oh, those poor old people. So if you're doing potential, potential, do potential for the third set as well. Wherever you think kids and adults add elders, I think that would make a huge difference. Also, we tend to think like, Oh. So we're going to help them instead of empowering them. We empower people in all sorts of ways and we sort of undercut older people like, Oh, you do this differently, so we're just going to do it for you, which we don't do to kids. We're like, okay, try again, or here, I'm going to set it up this way. And that is not to infantilize elders. It's just to show that we have double standards. Is there a greater burden of disability or do things tend to happen a bit more slowly as we age? Yes, but they still happen really well and they happen differently in ways that can be productive. And we sort of cut out all that opportunity both for individuals and for society. So I think we can do that. And then as aging people, I think we each need to talk about being old. You know, like even if you think about the recent presidents and presidential candidates and stuff, I mean, they're old men, right? They're all old men.
Louise Aronson: [00:29:49] And the two sides are like taking down the other one for their old man, which is kind of counterproductive. Right. So they're going to have different issues than a young person. But the young person, you can say, oh, my God, he did that because he's so young, he doesn't even know it. But we don't really talk that way. So so trying to keep in mind, like, are you blaming old age for something that is actually like, maybe it's the guys policies you don't like? Could you talk about that instead of his age? You know, so really not participating in that. And I think you still need to have a sense of humor. You know, there are jokes about every age group so that you don't just like, shut everything down. But there's a way in which for all of us in California, certain isms are just verboten. But it's totally fine for everybody to bond together, dissing on old people. That is prejudice and discrimination. You know, there's just no two ways about it. People think, Oh, it's so funny. It's a statement of fact. It's also like repeatedly shooting yourself in the foot because either you're going to die young or you're going to become one of those people. So create the world you want to live in.
Tyler Johnson: [00:30:59] One thing that I wonder if you have any thoughts about when you go through medical training in the United States, it becomes clear very quickly that in at least many philosophical and especially practical ways, I think that we elevate autonomy, especially individual autonomy, over almost all other ethical considerations. Right. And so, you know, a classic case that you might discuss in medical school would be someone who is a person who's coming in and they've been getting cancer care. And they say, well, I want to I want to keep being really aggressive. And they have family members who are saying, no, we really think that you should start focusing on other things. But the point is just that the the patient's autonomy trumps everything else. Right. And it took me a while taking care of patients who sometimes come from other cultures to recognize that that's not actually self evident truth, like having someone who is embedded in a community or embedded in a family where the voices of the other people and that family or that community are also honored and valued and maybe do have some sway in terms of making the ultimate decision is actually also a very workable model that can, I would argue, in some ways be even better. And in some cases I worry that that focus on autonomy also sort of forms the basis for some of the a just ways that we look at our elders because they they often in order to thrive, they need to be embedded in familial communities or whatever it is, right? Like they usually just don't do as well as one soul person kind of living all by themselves. And so I guess I sometimes I just wonder that that's a sort of an unrecognized or even unarticulated philosophical underpinning of Western medicine that creates problems in in both of those frameworks. And I wonder what your thoughts are about that.
Louise Aronson: [00:33:06] Yeah, well, not surprisingly, I completely agree. I think it's part and parcel of sort of the Industrial Revolution efficiency thing. And then we have the American autonomy thing and they sort of collude to be not good, you know, and they take down people at all different stages. Right. So you can argue that that some of that is the basis for sexism, because if you're talking strength or power, then the average guy will be the average female. So for the elder specific ones, we also act like and this is more of a disability question, but we also don't do right by people with disabilities. We devalue them to, which is why people who have been able bodied when they develop some old age disability number one, they have dissonance with their self identification and identity. And number two, they are rightly recognizing they're moving into a lower status group in society because we tend to dismiss people with disabilities and not give them the opportunities other people get. But it's also true that we're almost all of us are interdependent. Yes, you could be the lone wolf off the grid in your cabin getting your own food, but other than that, we're all interdependent. So it is a myth, this autonomy thing. Like if you have a family, you know, do you do all the cleaning and all the cooking and all the everything, you probably don't. So you're already interdependent. It's a myth. It's an American myth. If you're working in health care, you know, you're on a team of people. Even if you're alone with the patient in the clinic, there's still somebody who checked that person in and the person who does, you know, there's all these people.
Louise Aronson: [00:34:52] If you're in the hospital, it's obviously your own teams. We're all always interdependent. But somehow the way it looks when we get older, we devalue. We see that as a sign of weakness. The other thing is we now know that even younger people at home in their apartments are sad and depressed and suicidal and having adverse health outcomes. So it's just not good for anybody at any age. And we need to recognize that more and celebrate the interdependence, not the one we actually want. Our admissions committee. And we were having a conversation last Friday about also how in medicine, as in many fields, sports, everything else, you hold up the top few percent. But who gets most of the work done? You know, yes, they're going to be a bottom few percent that maybe are causing problems, but the vast majority of us are in the middle most or all of our lives, and that's what's keeping the world running. So why don't we celebrate all of that? I think there are so many ways we might create that. Society by recognizing different sorts of strengths and abilities, which kind of ties in to what we talked about earlier of talking exclusively about the downsides of older age and not the upsides of the increased emotional intelligence, the better ability to prioritize, the more likely to get the right answer when posed with a challenge. All those things that do get better and you can do all of that sitting in a chair.
Henry Bair: [00:36:24] Well, I grew up in Taiwan, and I can confirm that this is an American myth in East Asia. It is extremely common when the patient is at the end of life or seriously ill or of advanced age. For the patient's family to be given the reins over medical decision making, even when the patient is not cognitively impaired in any way. The idea is that your family already takes care of nearly every other aspect of your life, so why wouldn't you trust them with these very important decisions? For me now being trained in the United States, I definitely see the stark cultural differences there.
Tyler Johnson: [00:37:08] Yeah, I really think it's a sort of a societal tell, right? I think it's like we we talk about it as autonomy, but anymore it really is becoming atomization. And as Dr. Aronson said correctly, I think it's it's a symptom of a wider of the same philosophical undercurrents that lead to this sense of sort of alienation and loneliness. Right? There's this epidemic of loneliness. And it's also true in the way that we often kind of disappear our elders, right? It's considered atypical and kind of strange to have multigenerational households in the United States, whereas in many other countries that's just the way things work, right? And so the idea that these people who have raised you and nurtured you and who have generations of accumulated wisdom, that you then just kind of put them somewhere else, it's kind of a kind of a strange thing. And by the same token, to your point, Henry, it's kind of a strange thing that they would be the ones to that when it comes to making these sort of life defining medical decisions that are often also very complicated. The idea that you wall the patient off from everybody else and say, well, just you make the decision and everybody else has to leave you alone. That actually speaks to some really strange and I would argue kind of backwards cultural currents.
Louise Aronson: [00:38:34] Yeah, we take a different approach. We tend to say like we need to discuss what's going on here and what the options are, who should be in the room for that conversation, and you just let them tell you. It works for works across cultures generally.
Henry Bair: [00:38:49] Well, Louise, I'd like to focus next on your writing. You are an award winning writer and you write a lot. You write a lot of short stories. And of course, you have your book, Elder Hood, which I have right here. And it's a massive book, and I struggle to describe what it's about. It's it's about a lot of different things. And and you draw from psychology and biology and sociology and history and anthropology, all those different kinds of things. I'm wondering if you can tell us how and why you started writing and what you hope to convey through your writing.
Louise Aronson: [00:39:21] Well, when I was a kid, I loved to read, and so I wanted to be a writer, but didn't have a lot to say. I didn't have the confidence to say what I did. And then I was intimidated by people who were good at it, like right out of the gate. I think I had some abilities, but it's kind of like the top 5% we were talking about. There are those people who are just instantly gifted. And then there's the vast majority of writers who, if you work at it, you can get somewhere. And then I thought, Oh, I should do something socially useful with my life. Which isn't to say that writing can't be. I just didn't have faith that I would be a person to do something socially useful with my writing until I became a doctor and knew something socially useful. And it also gave me the confidence to be not very good at it at first because I felt like, Well, I have this day job that I feel pretty good about and so I can go to this evening class or this Saturday class and basically be really bad at it. And then at first it was kind of just I wanted to do something. Creative medical training goes on forever, and I felt it was sort of sapping and training and accelerating the creativity out of me.
Louise Aronson: [00:40:32] And it was one of the things I liked about myself and that I like about life, whether it's gardening or cooking or writing or whatever. So I started doing it and I thought it would be separate. But then, like medicine is so intense and you see so many things that other people don't get to see that although I wasn't going to write about medicine, I started to. And then it was after the first book, which was fiction. Then I thought, I wonder if I could use this tool sort of the way some people do public health or epidemiology. I would do this to make a bigger impact than I can make in the clinic or in the hospital as one doctor. And that really changed everything. And that took me into nonfiction. And I found the tools of fiction were really useful in basically seducing the reader, which is your first step, because if you don't do that, then they're not going to keep reading. There's sort of a famous writing thing of like the goal of the first sentence is to make them read the second sentence. And the goal of the second sentence is to get them to read the third, etc.. So something that I thought was outside my medical life became inside. And it also meant that I was writing things where I felt I could have more impact.
Louise Aronson: [00:41:40] So I'll hear like, Oh, we sent this to the entire medical system, or this was presented to the Senate Committee on Aging or whatever else. And and I don't know that I necessarily have other mechanisms to have that impact. And then it's also just it's fun. I mean, I don't want to say like I sit down and it's a joy to write every day because people would be like, that's crazy. It's so painful, it's fun, it's painful, It's I don't know. But but it's also nice if you do that introvert, extrovert scale and both. So it's kind of the perfect thing in as a clinician I could be my extroverted self and giving talks and whatever and I love that. And then having the quiet time to sort of process and be creative. When I'm writing, I feel like that nurtures important parts of me that make me better able to be whole and present and thoughtful with patients and what somebody else needs for that. Like running also did that for me and now, now doing other things. So, so there are many different routes that way, but it is a pretty powerful way of making a difference and getting to do something a little different than your clinical work, which I think in the era of burnout is really important.
Henry Bair: [00:42:57] Well, speaking of burnout, you open up very candidly in your book at one point talking about when you experienced burnout. And I think it was from your description, you were able to hold it off for a while and then suddenly you weren't. You know, you also describe your path back from that. So can you can you share with us what that moment was like, what that episode was like and how you were able to rediscover what makes this a meaningful career?
Louise Aronson: [00:43:28] Well, I think we're sort of trained in medicine to soldier on. So I was soldiering on. And, you know, you hear this all the time with people in burnout, like, I don't know what it's like where you are, but people will suddenly be gone or they'll disappear or whatever, or or you'll hear them doing things that aren't so good and you'll be like, That's not who that guy is, you know? And you realize, Oh, that's probably burnout because the person's soldiering on. So so I think I held out and then I think the moment where I snapped was really where, as I say in the book, like the person on the other end of the phone said something which basically sapped any hope I had for getting the things that I knew were important. And we're going to help me deal with all the stuff that was crushing me. So I think that's what made me snap. Yes, I can put up with this. If I if I could just get a little give here for these things that I know will help me keep going. And it was just like that, was it? But I also think I waited too long and it was a little earlier in the burnout, not the burnout. Probably. They started setting in medicine decades ago, so it's always been there. But I just thought like, No, I can't do this. I don't know. It's just something inside was like, No, I just want just like having it was like having a two year old having a tantrum inside your head, like, we're not doing this.
Louise Aronson: [00:44:49] So I think coming back was about really getting clear on what I needed and what my priorities were and getting better and articulating that and saying no. I mean, I think I had that that medicine achievers thing and I had that female. Although some guys do it too, like inability to say no and wanting to please everyone. And then eventually it just all gets to be too much. And as it's beating you down, you take less good care of yourself, which makes you even less resilient. So you end up on this downward spiral. And so it was really establishing boundaries and holding to them better and thinking about what matters most to me and how can I structure my life to get more of that. And it's not about having the perfect job or whatever else, because we all have to do some stuff we don't want to do. That's just, you know, welcome to grown up life, but it's sort of about the balance and finding the right one for you. And then we have to admit that it's very privileged people like me who can then come back and make some tweaks. If you're working in a factory or you're a caregiver, you don't have any of those options. So we make a lot of noise about all of us, but we're still luckier than many of the people who are suffering burnout right now.
Tyler Johnson: [00:46:08] We're nearing the end of our time. We know that a lot of our listeners are relatively young. Either they may be pre-medical students or medical students who are just starting out and then they fall all on the spectrum. But I guess for someone who has done so much thinking and writing about medicine in general, as well as someone who has specifically focused on sort of how we can help doctors to pay better attention and deliver better care to a population of people who have sort of been hiding in plain sight, if you will. What advice would you give to medical trainees especially, but all to all health care professionals in terms of how to be able to provide more meaningful humane care?
Louise Aronson: [00:46:53] Love that question. One is to really remember it's about taking care of people and the interaction with the person is a huge part of that care. It's not just putting orders in a computer. Notes are a means of communicating. Enjoy yourself, because that's what's always given people. That's that's why people have persevered and done the long hours. Yes, the pay will now you might be better off doing I don't know what, but anyway, the pay is still very, very good by most metrics. Not not the billionaire metric, but I don't know. I have trouble relating to that. Generally, who knows what that would be like, But you're going to get a good salary. It's also a chance to do something meaningful. So think about what what really matters to you and what you enjoy, and then enjoy it. Like enjoy the people around you. Enjoy the patients you're taking care of. Take time to notice that to to use it as a way of developing relationships that bring your life, pleasure and meaning. While doing the job. And so that's going to determine which specialty you go into and how long you get to spend with a patient. Patients need more time. Doctors need more time to think about our health care system is is in trouble right now. So I feel like the young people who are coming in now may well have a chance to redesign it. So so think about what you'd like it to look like. But speaking of older people, don't just design it for you guys who are digital natives. In some ways that makes sense going forward because in I don't know how many more years everybody will be a digital native, but you don't want to write off a huge percentage of the population.
Louise Aronson: [00:48:38] And by that I don't just mean old people. I mean all the people who are the most underserved, most needy among us, who live across the digital divide for reasons of race and poverty. And then I would say also that another way to get meaning is to not pick your specialty based on salary and prestige, but based on sort of joy and making a difference. Because when you look at the specialties where people quit the most, have the most divorce, have the most drug addiction, it's the same sexy ones everybody wants to go into. It's much less the other ones where you really get meaning and purpose. That's what's going to carry you through. And you're going to make enough money either way, a little dependent on your debt, which also needs to be solved. And then think about opportunities to combine things you're interested in. So we talked about me and writing, but like if you're into tech, you know, tech and medicine is huge and even tech and aging know. And just remember, it's about people. It's about people. And that's, that's what's so amazing about medicine, making a difference in people's lives. You know, like, like not every day is perfect, but you go to bed and you're like, I got up and I tried to make the world better and some human lives better. Boy, can you sleep well if that's what you did all day.
Henry Bair: [00:49:57] Well on that lovely thought, We'd like to thank you again, Louise, for taking the time to join us and for sharing your stories and insights with all of us.
Louise Aronson: [00:50:07] Absolutely. You guys had great questions. It was a pleasure.
Henry Bair: [00:50:12] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program, notes and transcripts of all episodes at the Doctors Art. If you enjoyed the episode, please subscribe, rate and review our show available for free on Spotify, Apple Podcasts, or wherever you get your podcasts.
Tyler Johnson: [00:50:31] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor, patient or anyone working in health care who would love to explore meaning in medicine with us on the show. Feel free to leave a suggestion in the comments.
Henry Bair: [00:50:45] I'm Henry Bair.
Tyler Johnson: [00:50:46] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.
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LINKS
Dr. Aronson is the author of the nonfiction book Elderhood and the short story collection A History of the Present Illness, as well as several essays and articles on ageism and aging and a blog.
Follow Dr. Louise Arondson on Twitter @LouiseAronson, Instagram @LouiseAronsonSF, and LinkedIn.
