Dr. Louise Aronson says the U.S. doesn't have nearly enough geriatricians — physicians devoted to the health and care of older people: "There may be maybe six or seven thousand geriatricians," she says. "Compare that to the membership of the pediatric society, which is about 70,000."
Aronson is a geriatrician and a professor of medicine at the University of California, San Francisco. She notes that older adults make up a much larger percentage of hospital stays than their pediatric counterparts. The result, she says, is that many geriatricians wind up focusing on "the oldest and the frailest" — rather than concentrating on healthy aging.
Aronson sees geriatrics as a specialty that should adapt and change with each patient. "My youngest patient has been 60 and my oldest 111, so we're really talking a half-century there," she says. "I need to be a different sort of doctor for people at different ages and phases of old age."
She writes about changing approaches to elder health care and end-of-life care in her new book, Elderhood: Redefining Aging, Transforming Medicine, Reimagining Life.
On how people's health needs become more complicated as they age
While old age itself is not a disease, it does increase vulnerability to disease. So it's the very rare person over age 60 ... and certainly over age 80, that doesn't tend to have several health conditions already. So when something new comes up, it's not only the new symptoms of potentially a new disease, but it's in the context of an older body of the other diseases, of the treatments for the other diseases.
If somebody comes in with symptoms and they're an older person, we do sometimes find that single unifying diagnosis, but that's actually the exception. If we're being careful, we more likely find something new and maybe a few other things. We add to a list [and], we end up with a larger list, not a smaller one, if we're really paying attention to everything going on in that person's life and with their health.
On how the immune system changes with age
Our immune system has multiple different layers of protection for us. And there are biological changes in all of those layers, and sometimes it's about the number of cells that are able to come to our defense, if we have an infection of some kind. Sometimes it's about literally the immune reaction. So we know, for example, that responses to vaccines tend to decline with age, and sometimes the immunity that people mount is less. It also tends to last less long. And that's just about the strength of the immune response, which changes in a variety of ways. But our immune system is part and parcel of every other organ system in our body, and so it increases our vulnerability as we get older across body systems.
On the importance of vaccines for older people
Older people ... are among the populations (also very young children) to be hospitalized or to die as a result of the flu. The flu vaccine, particularly in a good year, but even when the match isn't perfect in a given year, [protects] older people from getting that sick and from ending up in the hospital and from dying. ... That said, we have not optimized vaccines for older adults the way we have for other age groups. So if you look, for example, at the Centers for Disease Control's recommendations about vaccinations, you will see that there are, I believe, it's 17 categories for children, different substages of childhood for which they have different recommendations, and five stages for adulthood. But the people over age 65 are lumped in a single category. ... We're all different throughout our life spans, and we need to target our interventions to all of us, not just to certain segments of the population, namely children and adults, leaving elders out.
On how medications can change in how they affect the patient over time
Researchers have traditionally said, "Well, we're not going to include older people in our studies because their bodies are different and/or because they have other ailments that might interfere with their reaction to this medicine." But then they give the medicine to those same older people ... and so very frequently with a new medicine we will see all sorts of drug reactions that are not listed on the warnings. So message number one is just because it's not listed doesn't mean it's not the culprit. Another key point is really any medicine can do this. And it can do it even if the person has been on it a long time. ... We think of medicines as sort of fixed entities, but in fact what really matters is the interaction between the medication and the person. So even if the medication stays the same, the person may be changing.
On the importance of doing house calls in her work
What got me into medicine and what keeps me there is the people. And when you do a house call, you see the person in their environment, so they get to be a person first and a patient second, which I love. I also can see their living conditions, and more and more we're realizing and paying attention to how much these social factors really influence people's health and risk for good or bad outcomes.
Roberta Shorrock and Seth Kelley produced and edited the audio of this interview. Bridget Bentz, Molly Seavy-Nesper and Deborah Franklin adapted it for Shots.
TERRY GROSS, HOST:
This is FRESH AIR. I'm Terry Gross. My guest's new book opens with an observation that I think most people would agree with - we've created a society where we do everything possible to stay alive, yet we dread being old. She adds, the experiences of older people in our health care system are indicative of how current medical care is broken for all of us.
Dr. Louise Aronson is a geriatrician who has treated patients ranging in age from their 60s to over 100. As the body ages, its needs and vulnerabilities change. And older adults often react to medications in a different way than younger adults do. In her new book, "Elderhood," Aronson writes about changing approaches to elder health care and end-of-life care, and she writes about her own experiences helping care for elders in her family. In addition to her work as a geriatrician, she's a professor of medicine at the University of California, San Francisco, where she directs the health humanities.
Dr. Louise Aronson, welcome to FRESH AIR. Let's talk about some of the differences between medicine for adults and medicine for older adults. You write we're supposed to look for a single, unifying diagnosis that explains all a patient's symptoms, and that often works in young or mostly healthy people, but in older people, that's the exception to the rule. Why is that true, and what are some of the differences there when you're looking at different symptoms and trying to diagnose what's going wrong?
LOUISE ARONSON: So over time, people have more health issues that come up. I mean, throughout most of human history, you know, the average life span was maybe 30 or 40 years. And there are ways in which our bodies change and wear out. And while old age itself is not a disease, it does increase vulnerability to disease. So it's the very rare person over age 60, you know, even more likely 70 and certainly over age 80, that doesn't tend to have several health conditions already. So when something new comes up, it's not only the new symptoms of potentially a new disease, but it's in the context of an older body of the other diseases, of the treatments for the other diseases.
And it's rare to find - you know, if somebody comes in with symptoms and they're an older person, we do sometimes find that single, unifying diagnosis. But that's actually the exception. And if we're being careful, we more likely find something new and maybe a few other things. We add to a list. We end up with a larger list, not a smaller one, if we're really paying attention to everything going on in that person's life and with their health.
GROSS: So the immune system changes as we get older. What are some of the changes in the immune system, and what does it leave older people more vulnerable to?
ARONSON: Yeah. So the immune system, like the other obvious systems - I mean, we look at older people, and we can see the changes in the skin where it's thinner, and it's wrinkled, and it actually has fewer nerve endings and often fewer hair follicles. All the organ systems are having similar changes, just some aren't as obvious as others. So in the immune system, our immune system has multiple different layers of protection for us. And there are biological changes in all of those layers. And sometimes it's about the number of cells that are able to come to our defense if we have an infection of some kind. Sometimes it's about literally the immune reaction.
So we know, for example, that responses to vaccines tend to decline with age. And sometimes the immunity that people mount is less. It also tends to last less long. And that's just about the strength of the immune response, which changes in a variety of ways. But our immune system is part and parcel of every other organ system in our body. And so it increases our vulnerability as we get older across body systems.
GROSS: So with vaccines, does that mean older people need more or more frequent vaccines, or that - don't even bother?
ARONSON: (Laughter) That's such a good question. So definitely, I'm not arguing for don't even bother. Vaccines are tremendously helpful. And despite the waning immunity, vaccines have been a wonderful way to protect older adults. So older adults, let's take a really common illness, like flu, which happens every year. Now, vaccines aren't perfect. But we have data going back years and years that flu vaccines protect older people from the worst outcomes. And older people are the most likely to be - among the populations. Also very young children - to be hospitalized or to die as a result of the flu. And the flu vaccine, particularly in a good year, but even when the match isn't perfect in a given year, protect older people from getting that sick, and from ending up in the hospital and from dying. So vaccines absolutely do help.
That said, we have not optimized vaccines for older adults the way we have for other age groups. So if you look, for example, at the Centers for Disease Control's recommendations about vaccinations, you will see that there are, I believe, it's 17 categories for children, different substages of childhood for which they have different recommendations, and five stages for adulthood. But the people over age 65 are lumped in a single category. And we all know, walking down the street, you can almost invariably tell a 65-year-old from an 85-year-old from a 105-year-old. Our bodies change.
And yet, we have not studied - there are people working on this now. I should be fair to that. But we have not studied with the same rigor and interest how a vaccine works in an older body and how to optimize that. And ways of optimizing that might include giving vaccines more frequently if their impact is waning, and also looking at different mechanisms of delivery that get around some of the changes in the older body.
GROSS: As a geriatrician, one of the things you have to deal with is that your patients are probably mostly on multiple medications, dealing with multiple problems. And you have to make sure that the medications are balanced and they're not having bad interactions with each other. And sometimes the symptoms they come and see you with are probably side effects of the medication. And also, older people respond differently to certain medications. What are some examples of that? 'Cause I think it's really useful to know what those medications are.
ARONSON: Absolutely. Well, older people respond somewhat differently to, actually, most medications because the way the body handles a medication depends on its being metabolized, generally in the liver or kidney. And those functions tend to decline or change with age. It's also the medication is affecting the rest of the body. That's what we hope for. But the rest of the body is also different. So any medication - this is one of the hard and fast rules of geriatric medicine - any medication can do anything, (laughter), in an older person. And I've had experiences. So a new blood thinner came out a few years ago, and a grandson called me about his grandmother to say, well, she's - it was a Saturday, and he said, she's so confused. She's just not herself. What should we do?
And I asked a variety of questions about any indication of infection or new problems, and there really weren't any. So the other critical question is, any new or changed medicines? And she was on this new blood thinner. Now, he said he'd looked on the Internet, as did I, to see if this reaction was listed, and it was not. But critically, the vast majority of medicines, although given to older adults since older adults have more diseases, are not tested in older adults. So researchers have traditionally said, well, we're not going to include older people in our studies because their bodies are different, and or because they have other ailments that might interfere with their reaction to this medicine. But then they give the medicine to those same older people, which is most older people.
And so very frequently with a new medicine, we will see all sorts of drug reactions that are not listed on the warnings. So message No. 1 is just because it's not listed, doesn't mean it's not the culprit. Another key point is really any medicine can do this, and it can do it even if the person has been on it a long time. You know, we think of medicines as sort of fixed entities, but in fact, what really matters is the interaction between the medication and the person. So even if the medication stays the same, the person may be changing. And the third critical point here is that don't assume that over-the-counter medicines are safe.
So you will see, if you look at labels, that there will be warnings for children and for pregnant women. And then they'll usually have warnings about diseases. But they don't tend to reference the population most likely to have an adverse drug reaction - to end up in the hospital because of it or to end up dead because of it. So older people buying over-the-counter medicines - and I'm talking particularly about sleeping medicines - those can cause older men, in particular, to have trouble urinating. They can make glaucoma worse, which threatens vision. They can lead to confusion and falls. Cold medicines can also do many of these things.
And in terms of, you know, speaking about adverse drug reactions, studies show that the most common reasons for hospitalization - and we're talking 100,000 people and way more annually - because of drug reactions or because of really simple medications - medications for blood pressure, medications that thin the blood for people with abnormal heart rhythms, medications for diabetes. So not fancy new treatments, necessarily, but things we might consider tried-and-true everyday remedies are more dangerous in older people. And that's, again, because we really haven't studied them and given them the same attention we've given to people in childhood or adulthood.
GROSS: So speaking of over-the-counter medications, a lot of older people take over-the-counter baby aspirin, small doses of aspirin, to thin the blood a bit to help prevent heart attack or stroke. A lot of older people also have internal bleeding. So what guidelines do geriatricians like you give about when over-the-counter baby aspirin is helpful and when it might be dangerous to an older person?
ARONSON: Again, it's because we assume it's over-the-counter, it's safe, and we've heard a lot about prevention. So it's important to distinguish primary prevention, which is taking a medicine before you have a disease to hopefully keep you from getting that disease, from secondary prevention, which optimizes the treatment of that disease once you already have it. And we often think of prevention as if it's one uniform thing, and there's actually many different forms of prevention.
Recently, a study came out showing that the harms of aspirin for primary prevention outweigh the benefits. This has been known for a while to be particularly true in women, but it's generally true in older adults. So as we get older, the risks go up and the benefits go down. Among the risks was one you mentioned, internal bleeding.
When I was a resident, there was rarely a call night - and I was on-call every third or fourth night for three years - where an older adult did not come in with bleeding from their stomach or upper intestine and vomiting blood. And that's because we were probably treating them in the same way we were treating younger adults. And they assumed if you can get things like aspirin and, its cousin, the nonsteroidals - things like ibuprofen and Nurofen, et cetera - over the counter, that it couldn't be too harmful. But it increases the risk of bleeding and death from bleeding in older people to a much greater degree than in younger people. It really can do it in all of us, but the risks begin to go way up, up.
It also can adversely affect the kidneys, and this is particularly true in people who already have some kidney dysfunction, which is very, very common as we age and in people who are on certain blood pressure medicines that are also commonly used that affect the kidney. So the risks, again, go up, and the potential benefits go down. And in the case of primary prevention, if you haven't had those conditions, it's likely that you're doing more harm than good.
GROSS: OK. Let me reintroduce you. If you're just joining us, my guest is Dr. Louise Aronson. She's a geriatrician who's the author of the new book "Elderhood: Redefining Aging, Transforming Medicine, Reimagining Life." We'll be back after we take a short break. This is FRESH AIR.
(SOUNDBITE OF CYRUS CHESTNUT'S "LOVE ME TENDER")
GROSS: This is FRESH AIR. And if you're just joining us, my guest is Dr. Louise Aronson, a geriatrician and professor of medicine at the University of California, San Francisco, and author of the new book "Elderhood: Redefining Aging, Transforming Medicine, Reimagining Life."
For a bunch of years, you did house calls to your elder patients. Why did you do that, and how is that helpful to you as a doctor? I could see how it would be helpful to them as patients; so many people who are, you know, in their 80s or 90s can't really get out of the house.
ARONSON: What got me into medicine and what keeps me there is the people. And when you do a house call, you see the person in their environment. So they get to be a person first and a patient second, which I love. I also can see their living conditions. And more and more, we're realizing and paying attention to how much these social factors really influence people's health and risk for good or bad outcomes. So you can see what the options are for food, what the social situation - you know, are people really being helpful in the home environment, or is it sort of chaos in that home?
There are lots (laughter) of sort of amazing anecdotes, including a couple who just kept having, for their outpatient internist, really strange problems with simple things like their blood pressure. Sometimes it would be really high, and sometimes it would be really low and a variety of other problems where it was just sort of bouncing all over the place. And they were also having more and more trouble getting to the doctor.
So off I went to do the house call. And at some point, I asked, you know, could I see their medicines and how they take them? And they led me into their dining room, and at the center of their dining room table was a big glass bowl in which there was an assortment of pills of varying colors. So because they had had childproof containers for their medicines, and the childproof containers tend not to be so childproof but are often adult- and elder-proof, they had dumped them all into the dish at the center, which seemed to them like a really good solution, except for there were multiple pills of the same shapes or colors, and their vision wasn't what it used to be.
So it seemed that maybe sometimes he was taking hers, and she was taking his, or somebody was taking two of one and none of the other. It just was not a good system. And that's the sort of thing you might struggle and adjust the medications in clinic, but it would never occur to you really to ask that.
GROSS: Your late father experienced something that happens to a lot of older people when they're hospitalized. During the end of his life, each time he was hospitalized - and he had multiple hospitalizations toward the end - he experienced delirium. So I'm sure a lot of our listeners have witnessed this with family members. First of all, I want you to explain the difference between delirium and dementia.
ARONSON: So both delirium and dementia are confusional states - changes in a person's thinking and cognitive ability to function. But delirium is acute. So it comes on suddenly. It's usually associated with an illness - can be a medication reaction, can be an acute illness, can be a major change in environment, like ending up in the hospital. Delirium tends to be short-lived, so can be hours, can be days or weeks. Although, we're increasingly learning that it - the longer it lasts, the longer the long-term effects of it are. But by definition, if a person becomes confused pretty quickly over hours to days, that is delirium.
This in contrast to dementia, which is a chronic condition of confusion and decreased cognitive ability that generally comes on very slowly and gradually, unless it occurs, for example, as a result of a stroke. But then also you have some delirium maybe before you get to the dementia. But dementia is insidious, very slowly progressive in most cases and is very different from delirium, except that, in both cases, people might be confused. They might have trouble paying attention. They might hallucinate. They might become sort of more active or less active.
GROSS: So I know one person who - an older person who is in the hospital, experiencing, like, hallucinations and disorientation, delirium. And when the doctor was told about it, the doctor said, all older people go through this in the hospital; don't worry about it. It turned out it was a bleed in the brain.
ARONSON: Oh. Right.
GROSS: So you know, as a geriatrician, how can you tell the difference? I mean, you're not going to give everybody with delirium an MRI, or are you?
ARONSON: No. Oh, that is a heartbreaking story. Where to even begin? I think the first most certain point is that it is bad medicine to write something off as a condition, if you haven't done a proper history and physical. So we have very good tools for assessing delirium in the hospital - rigorous, study-based proven tools to figure out if what this is is delirium. We also know that delirium happens as a result of disease, and that can be a bleed in the brain; it could be a bladder infection. But I think it's bad medicine to assume, to not evaluate a patient who is newly delirious.
And actually, this goes back quite nicely to our earlier discussion of a single unifying diagnosis. Just because a person may be in the hospital for a bladder infection or lung infection does not mean that they have not developed a bleed into their brain or something else. So a new situation, even if it's a common one like delirium in an older patient, warrants a good history, a physical, an examination and evaluation using all the very good tools we have to do that. This is happening more and more, and people are establishing special programs for older adults. But I guess I would say that just was not the best care that the person received there.
But I guess this also brings up the general point for older people and the people who are with them, which is if somebody is telling you, this is just what happens or this is just because you're old, question that. Yes, something's common; that doesn't mean it happens to everyone, and that doesn't mean that we know why it happens. Delirium, like most things in old age, has many causes, and its only responsible approach is to evaluate the individual in that particular situation.
GROSS: My guest is Dr. Louise Aronson, a geriatrician and author of the new book Elderhood. After we take a short break, we'll talk about tough decisions her family had to make involving her father's end-of-life care, and she'll tell us about experiencing something many doctors now contend with - burnout. And jazz critic Kevin Whitehead will review a live 1961 Stan Getz recording that's never been released before. I'm Terry Gross, and this is FRESH AIR.
(SOUNDBITE OF DOC CHEATHAM AND SAMMY PRICE'S "SQUEEZE ME")
GROSS: This is FRESH AIR. I'm Terry Gross. Let's get back to my interview with Dr. Louise Aronson, a geriatrician who has treated patients ranging in age from 60 to over 100. She's also a professor of medicine at the University of California, San Francisco. In her new book "Elderhood," she writes about changing approaches to elder health care, as doctors learn more about the needs and vulnerabilities of aging bodies. And she writes about her experiences helping care for elder adults in her family. When we left off, we were talking about her father's medical care in the last years of his life, when he was in and out of the hospital.
So when your father was in the hospital - again, toward the end of his life - you wanted to be seen as the good family member who wasn't going to be a pest and wasn't going to annoy the doctors and the nurses. And so your father's blood pressure was plummeting, you knew something was wrong, none of the doctors could figure out what it was. You had the suspicion it was internal bleeding. So he's in the hospital. No one's really coming up with a - with an answer. And you decided to literally take matters in your own hands.
GROSS: I want you to describe what you did and what happened.
ARONSON: Quite literally.
GROSS: And I should mention, before you tell that story, that this is a medically explicit story that might be upsetting for children. So parents, this is a heads-up to you. This story will just last a couple of minutes.
GROSS: OK. Dr. Aronson, you can explain now.
ARONSON: OK. So this was maybe seven or eight years before his death. He was in his 70s and had been quite fit and then had had a major heart surgery - four vessels fixed. And after that, he'd needed blood thinners. And he'd been home doing OK when suddenly he started to faint. So there we are in the hospital, and they say, sure enough his blood pressure's low. And they give him fluids, and it pumps it up. And they do blood tests and check his heart. His heart looked great, and the blood tests were all normal, except for the blood thinner; the blood was a bit too thin. So he's doing better, and they say, we're just going to monitor.
But then the blood pressure falls again. So I go get them, and they come in, and they give him more fluids, and they sort of check him, and he feels fine. So they go away again. And then it falls a third time. And you know, that just doesn't happen unless there's something wrong. And I went, in my head, through the list of what might be wrong, and I came up with the fact that he was bleeding. But I really could not get their attention. So I ended up saying to my father - and luckily, he was a physician and a very good sport with a good sense of humor - and I said, Dad, you know, I really think I need to do a rectal. Do you mind if I do that? And he said, well, kid, do what you have to do.
So I did a rectal, which means I put a glove over my hand and I stuck a finger into his rectum. And sure enough, I came back with a glove full of blood. And I went out into the hallway, and he was in the intensive care unit shortly thereafter and in surgery that night. It's one of those situations - but what happens if your child isn't a doctor? Or if you just want to know because you care about your parent? We shouldn't have to apologize for being concerned about our relatives who are ill and not doing well.
GROSS: So what reaction did you get from the doctors and nurses after you did the rectal exam yourself?
ARONSON: Well, when I came out with the bloody glove, they just mobilized right away. I mean, several people followed me into the room. They called the intensive care unit right away. We had a couple of doctors. We had nurses. He got an IV in the other - so we didn't really discuss what I had done. They recognized the gravity of the situation, and then they took over, and I sort of faded into the background, becoming his daughter and not his doctor at that time. So they responded well.
GROSS: Is it hard for you to know when to and when not to intervene medically as a doctor when you're talking about members of your own family?
ARONSON: Yeah. So what I try and do is pick doctors I really trust and respect to care for my family members and then really just behave like a daughter. You know, occasionally, you see things or notice things that they might not know. So my mother had sort of a belly pain at one point, a little while after a fall. And she's had a history of colon cancer, so she was being evaluated for that. I had been out of town when that happened. And when I got back into town, I went right over to see her. And when she opened the door, I noticed that she was shorter. I could see over her head. And so that gave me a clue that it might actually be a compression fracture in her spine, from the fall, and the pain was radiating to her front.
So then I did contact her doctor and say, hey, I have an idea. But, you know, do I expect her doctor to know an inch or two, you know, in one direction or the other on my mother's height? I absolutely don't. And I do actually give a lot of informal advice to people in my family and friends and - about their relatives, too, and then that's a pleasure to be able to do so.
GROSS: You had a tough choice to make when you and your mother were helping your father when he was dying. And he was put on morphine for the pain, but the morphine made his swallowing problems worse. So he was - it was, like, a long period of dying; it's not, like, he was, like, necessarily days away from death, I think, at this point. So can you talk about the decision you had to make and what you did?
ARONSON: Right. So he had a fall and was in bed and was having so much pain that he was literally, you know, lashing out and screaming and barring his teeth - really, really miserable pain. And there was nothing - you couldn't move the hospital bed. You couldn't move him over. You know, you couldn't sit him up to eat or help him use the bathroom. I mean, really basic things impaired by this awful pain. And this was a guy who had his teeth drilled without anesthesia, who after his prostate surgery walked the next day then went home. This was not a guy who was wimpy about pain. He was sort of unusual, actually, in what he could withstand. So clearly, the pain was awful.
On the other hand, when he'd had the heart surgery we talked about earlier, which was seven or eight years earlier, he had had a complication which had led to him needing a feeding tube for three months. He'd come off that. But when we gave him enough pain medicine in this before-death situation where he had had a fall and clearly had some sort of fracture, he just couldn't swallow safely, and he would cough and choke. So we had to choose between treating his pain and allowing him to eat. And you could argue, OK, we don't treat the pain and he keeps eating and living.
And I think that help - the thing that helped mitigate this was that his quality of life had become really bad over the last year. Even after the heart surgery, he'd been quite good for many years, even though he was frail, and he had dementia; he was a jovial guy with a good sense of humor. But the year before, he'd had another fall and then surgery. And he had just never bounced back physically and mentally. And for the six months before this last fall, he had really stopped smiling or joking or doing much of anything other than going to meals. So he had been clear - we were lucky in that I make everyone in my family address these issues - he'd been very clear about the states in which he would not want to be artificially kept alive. And so we treated the pain, and that meant that he died.
GROSS: How soon after your decision did he die?
ARONSON: I think it was maybe 10 days or so. You know, we danced around with it a little bit. If we give just a little bit at this time of day - you know, we did everything to make it possible. And it was so clear that he was more comfortable and happier with the pain medicine onboard, so...
GROSS: Was he in a mental state where you could actually talk with him about the choice you were making?
ARONSON: No. So at this point, he had probably moderate dementia, and he'd been delirious in the hospital after the fall. Different ones of us tried. We tried at different times of day. We tried, you know, all the tricks of the trade, but he really couldn't engage in that complex or potentially abstract discussion. He just couldn't follow it, and he couldn't have the conversation, so we had to go based on his advanced directive. And he'd been very clear about his wishes.
GROSS: Let me reintroduce you. If you're just joining us, my guest is Dr. Louise Aronson. She's a geriatrician and a professor of medicine at the University of California, San Francisco. Her new book is called "Elderhood: Redefining Aging, Transforming Medicine, Reimagining Life." We'll be right back. This is FRESH AIR.
(SOUNDBITE OF THE WEE TRIO'S "LOLA")
GROSS: This is FRESH AIR, and if you're just joining us, my guest is Dr. Louise Aronson. She's a geriatrician and author of the new book "Elderhood: Redefining Aging, Transforming Medicine, Reimagining Life."
I want to talk with you about a problem you faced a few years ago when you realized you were just burning out in a way that was threatening your physical and your mental health. What were the symptoms of your burnout? How did you know something was wrong and you actually needed to take action and change your life?
ARONSON: Right. There were so many symptoms. It was just sort of all day long, every day. I could not sleep properly. And I'm actually a pretty good sleeper, but I was waking up in the middle of the night, anxious and worrying about patients and all the tasks I hadn't done. I was incredibly irritable, so if a loud noise would happen, I would literally startle and have goosebumps all over my body and have sort of a fight-or-flight response.
I started having these rants in my head about things big and small. Perhaps the biggest thing was our new electronic medical record, which required that I spend two to three hours clicking boxes and putting useless information into the medical record. Far more time for each patient's note was spent on the computer than with the patient, and it was taking me hours and hours and hours. So for what might have been a four- or five-hour clinic, I was putting in 10 hours or more, and so much of it was information that nobody needed or wanted except for the people in billing. It wasn't actually communicating anything important about either my patient or my thinking about their condition that, you know - something that would be of use to me later or to any colleague seeing that same person.
So that was really infuriating, but I would also - if I was driving to work and somebody did something little, I would just have that flood of emotion and fury. I felt like I was losing my temper constantly and that I wasn't taking care of myself. It was all I could do to get to work and to function as a decent human being at work, and that almost felt like putting on a pretend suit - you know, someone else - and that effort left me exhausted. So I would come home. I didn't read. I didn't eat healthy food. I watched hours of pathetic, bad TV.
ARONSON: And then the cycle - you know, I mean, the sort of thing maybe if you've just had surgery and you're drugged, you would watch, but really bad, bad, bad. And then the cycle would start again, and it was just horrible.
GROSS: So is there an actual medical diagnosis of burnout?
ARONSON: Yeah. There is a diagnosis of burnout, and it's sort of emotional exhaustion. And, you know, the irritability is typical. Decreased engagement with your activities, work, social, etc. - there are some pretty strict criteria. And the shocking thing is just how many people in society generally but particularly in medicine - most figures cite almost half of us having burnout at any one moment. We know that burned-out doctors provide less good care, so this isn't just a sort of woe is me doctor issue. It really is - yes, doctors are people, and they're suffering, and so that matters. But their suffering matters all the more because it's going to make their care of patients less safe and not SO good, and we're all patients or potential patients.
GROSS: So you were given a test measuring your, like, anxiety and stress levels. So what was that test like?
ARONSON: It was a series of questions about, you know, how you feel and how anxious you feel and how frustrated you feel and how angry and - you know, do you startle? How's your sleep? You know, all these things that I was just describing to you - and I was just off the charts. I was in the highest category. It was crazy.
GROSS: So once you realized, like, you really had, like, a medical condition that was threatening your health, how did you decide how to treat it? It's not like you could take a pill and just continue on as you were going. I mean, I guess you could've considered that. You could have just taken anti-anxiety medications, right?
ARONSON: Exactly. I also had several other health conditions at that time that I had essentially been neglecting because it was all I could do to get through the day. And it became clear that it had gone from bad to worse, and it was going to go from worse to something else. And I literally just kind of snapped, and I thought, I can't do this, and I shouldn't do it. It's not fair to anyone. And so then, you know, my doctor fit me in, and we dealt with this. And the anxiety was one part of it, but it was also addressing all the other issues.
I ended up taking a leave of absence in which I could have all these medical appointments. I could work on sleep and health and priorities and try and figure out how I had gotten myself into that situation. So I think, as with many things, there were lots of situational pressures that put me into burnout. But we also know that some people burn out and others don't, although, you know, if you really have rates of 30, 40, 50%, I don't think we can just blame the individuals. But people have different sorts of coping skills, and I realize that mine probably needed some attention and refinement.
GROSS: What is the new life you created for yourself professionally?
ARONSON: Around that time, I was working on this book, as it happens. So that gave me the idea. As I thought about elderhood as the later life analog for childhood and adulthood, I recognized increasingly something I'd always known but hadn't probably thought about enough, which was that in geriatrics, we have always said there aren't enough of us. So there may be 6,000 or 7,000 geriatricians. Compare that to the membership of the Pediatric Society, which is about 70,000. And yet, you know, for hospital stays, for example, 6% of hospital stays are kids. And 39 or more percent are older adults, so there's just a woefully inadequate workforce.
So we have always said, because there are so few of us, we will focus on the people who need us most, meaning the oldest and the frailest. And in thinking about my own health and thinking about elderhood more broadly writ - reading about its whole history and the literature of it and the science of it for this book - I got really excited by the notion of elderhood as a long phase in which we should intervene earlier.
I mean, geriatrics was actually developed very explicitly in 1909 to be the analog of pediatrics. So just as a pediatrician is taught how to care for newborns and toddlers all through teens and young adults, we need to be focusing on people as they age into their 60s or 70s and helping them also do more of the preventive healthy aging that will delay the things they dread most about aging.
So I developed this new vision of geriatrician as doctor through the many decades of old age. And I will say my youngest patient has been 60 and my oldest 111 - so we're really talking a half century there - and thinking about how I need to be a different sort of doctor for people at different ages and phases of old age. And then I was very fortunate in that our Osher Center For Integrative Medicine was thinking similarly about a greater emphasis on prevention. Prevention is cheaper and more effective than doing what our health system generally does - which is let people get sick and then, you know, jump in with fancy technology and hospital care and drugs - putting much more emphasis on helping people optimize their health before they develop those diseases and disabilities.
Although I should also say, I love taking care of older, frailer people. And there are ways of implementing this sort of life optimization for a person. I guess two weeks ago, I saw someone in her early hundreds who has a fair amount of dementia, and we could think about things that improved her life physically and her health and her well-being, as well. So this really applies across the decades of elderhood.
GROSS: You've treated a lot of elderly people. You've had a lot of patients who've died. How has that affected how you think about your own future death?
ARONSON: Well, many people take the approach that if you don't tackle it or look at it or think about it or plan for it, it's better. But actually, it's really not. I mean, I've seen - so now I've been a geriatrician for about 25 years, so I've seen so many deaths and so many ways of dying and ways of aging. And I think it really demystifies it. It makes it less scary.
I'm not saying that everything is happy. You know, get yourself a geriatrician, and you're going to age perfectly and die, you know, happily with your family surrounding you every time. I'm not saying that at all. I'm just saying that I understand its realities, and it's not - it doesn't scare me. I feel like there's so many ways this can happen, and I understand what they are.
I'm also really clear on my values, on who I want to make decisions for me, on what I would want to do and not do in various conditions. And the best way of getting the old age and deaths that you want are to plan for them and to make sure the people around you know what it is you really value and what it is you don't much care about.
GROSS: Dr. Louise Aronson, thank you so much for talking with us.
ARONSON: It's been my pleasure and honor. I have been listening to you forever - I believe since you started. So thank you for having me on.
GROSS: Oh, thank you for saying that. It's been my pleasure to have you.
Dr. Louise Aronson is the author of the new book "Elderhood." She is a geriatrician and a professor of medicine at the University of California, San Francisco. After we take a short break, jazz critic Kevin Whitehead will review a 1961 recording of Stan Getz's "Live At The Village Vanguard." It's never been released before. This is FRESH AIR.
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