Like a number of geriatricians, I have come to believe that modern medicine does not work well for old people. Old patients serve as a mirror, reflecting the limitations and sometimes the absurdities of modern medicine. There are three areas that are particularly problematic for old people: the medicalization of everyday life, the primacy of diagnosis, and reimbursement for medical care.
In Medical Nemesis, Ivan Illich argued that medicine has expanded into almost all aspects of human existence.1 All cultural and personal aspects of the struggles of life — growing up, raising children, and dealing with adversity, crime, sadness, ambition, disease, and death — have been brought under the rubric of physical and mental health. This removes a huge range of human experience from the realm of personal wisdom and individual understanding and places it in the realm of medicine, with its accompanying aura of biologic determinism and technological susceptibility.2
Medicalization is not limited to behavior; new physical illnesses have been created, too. The most important of these are the proto-illnesses — diseases that do not cause symptoms and produce no suffering but are thought to be dangerous because there is a higher likelihood of real disease later on.High blood pressure is a proto-illness, as are osteoporosis, high cholesterol levels, aortic aneurysm, colonic polyps, and carotid-artery stenosis.
Critics of medicalization face a serious difficulty. We do not want to sound like reactionaries or machine-smashing Luddites longing for a bygone era. There is clear truth embedded in medicalization. It is true that some children have difficulty sitting still in a classroom and respond well to the early recognition of this problem. It is true that treatment of high blood pressure and osteoporosis has averted much morbidity. Thus, the benefits of medicalization are clear. Unfortunately, so is the harm.
Cassell has argued that, with medicalization, the role of physicians has become so expanded and technologized that we fail at our most important task — providing relief from suffering.3 Medical care of the elderly is particularly distorted by this new focus. Medicalization externalizes experience, whereas the major tasks of aging are internal. Every clinician has witnessed the medicalized 80-year-old obsessed with arthritis, Alzheimer’s disease, and serum cholesterol levels. Contrast this patient with someone else in the same physical condition, who admits that her knees are bad and that she has trouble remembering things. Which patient is better off? Attention to some proto-illnesses arguably could benefit 80- and 90-year-olds: certainly osteoporosis, probably also high blood pressure. But 80-year-olds can ill afford the ceding of responsibility and loss of control inherent in medicalization. The challenges of very old age are spiritual, not medical. The appropriate role of the physician is as counselor or helper, not as scientific expert.4
One of the tenets of modern medicine is that we must diagnose accurately before we can treat. With the technology currently available, such diagnosis frequently translates into a direct visualization of the pathologic process. We see the gastric ulcer or colonic polyp through fiberoptic tubes; we visualize the gallstones, the hiatal hernia, and the carotid and coronary blockages so that we can decide on appropriate treatment.
What if we find pathology wherever we look? Such is the case with the very old. Is hiatal hernia still a disease if three fourths of women in their 80s have one? To think so can result in considerable harm. The most recent example of the harm caused by overtesting involves measurement of prostate-specific antigen (PSA) to screen for prostate cancer. The introduction of that test has resulted in an epidemic of prostate cancer in older men who otherwise would have lived happily without knowing they had cancer. The quadrupling of the use of radical surgery in these patients is of no proven benefit.5-7 The primacy of diagnosis reflects a confusion of means with ends.8 The goal of medicine is to relieve suffering, to help, and to heal. Correct diagnosis, based on our understanding of pathophysiology, is one means to achieve that goal. However, in modern medicine understanding is often afforded higher status than successful treatment. So little of what is done for old people seems aimed in any direct way at making the patient feel better. One of my friends who heads a geriatrics program tells the story of his father-in-law, an older gentleman in good health except that he had an inguinal hernia. He had an abnormal finding on nuclear cardiac scanning, a procedure routinely conducted before herniorrhaphy. This finding led to cardiac catheterization, which identified a critical stenosis. Before the bypass surgery to correct the stenosis could be performed, he underwent carotid endarterectomy to repair an asymptomatic stenosis found on routine Doppler examination.
He had an intraoperative stroke, which delayed his heart surgery for six months. A year later, he was almost back to normal, with some residual clumsiness on one side. His hernia (still unrepaired) was not bothering him as much, because of his decreased activity.
Here is the scariest part of the story: he was grateful — thankful that his doctors had found the heart and carotid problems in time. Grateful also are the legions of older men who have undergone radical prostatectomy for prostate cancer discovered by PSA screening, grateful that their doctors found it in time.
Of the several ways to view medical care today, perhaps the most disturbing is the economic perspective. For several years I ran a large geriatrics program at a university-affiliated community hospital. In my more cynical moments I saw the hospitalization of my patients as a complicated feeding process; the various specialists would come around and perform their procedures, feeding from Medicare. It is with the elderly that the horror of such a practice becomes most clear. Overtreatment of 50-year-olds is mostly a matter of inconvenience and waste, whereas overtreatment of 80-year-olds borders on assault.
Now reimbursement is being turned on its head, moving from fee for service to capitation and from overtreatment to undertreatment. Surely the most profound result of this transformation is the demonstration of the degree to which medical decision making is dependent on reimbursement. It is difficult to preserve the cognitive fiction of the primacy of the patient in medical decision making when medical-procedure rates can be halved from one year to the next simply by changing the method of reimbursement from fee for service to capitation.
Capitation and managed care have embraced evidence-based medicine, which provides a scientific justification for economically driven efforts to reduce the use of resources. Evidence-based medicine is not kind to the elderly. This movement trusts only the products of randomized, controlled trials or, preferably, meta-analyses of those trials. But subjects over the age of 75 years are rarely found in such trials, thus rendering this population invisible to scientific medicine. If we teach only what we know, and if we know only what we can measure in clinical trials, then we can say little of importance about the care of the elderly. The most important resources required in caring for the very old — sufficient time and empathy — are not included in the critical pathways of managed care.
In my 25 years as a part-time clinician, I have thought a great deal about why I was drawn to geriatrics. My initial reasons had to do with the intrinsic appeal of the cohort that is now very old — the combination of wisdom and toughness that stemmed at least in part from the shared experience of coming of age during the Great Depression. However, more recently I have realized that part of why I love being a doctor for old people is that it is easy; the rules are simpler and success is clearer than when one is providing primary care for younger adults. With the elderly, there are real problems to confront, real suffering to relieve, and real courage to admire every day.
For today’s physicians, what percentage of their time is spent relieving suffering? Proto-illnesses cause no symptoms, so the satisfaction derived from treating them must be based on the statistics of risk reduction. Our level of discomfort with this reality is reflected in our overestimation of the benefits of such interventions.
It is almost as if the relief of individual suffering is too small a job. This sentiment was evident after the death of Mother Theresa. The recurring observation was that she did nothing to change the root causes of poverty; she only relieved the suffering of some of its individual victims. The belief in progress inherent in this opinion is almost touching in its naiveté. It allows people to distance themselves from each other, to treat “root causes.” People treating root causes seldom get dirty.
What is needed is a new model, a new mindset for physicians providing care for the very old. There are certainly models that seem to work better than the white-coat-scientist model currently in use. One alternative is the hospice model. Although this model evolved for the compassionate care of the terminally ill, many values of hospices are appropriate for the care of older patients who are not dying, including an understanding that each person is unique, a realization that everyone dies, a recognition that comfort and happiness are very important, an appreciation of the many unmeasurable adverse consequences of medical evaluations and treatments, a willingness to make compromises in carrying out plans, depending on changing circumstances, and an ability to treat without diagnosing.
One common misunderstanding about the hospice approach involves a false dichotomy between quality and quantity of life. It is often assumed that a focus on such pragmatic issues as preserving independence and relieving suffering comes at the cost of potential years of life lost. Withholding useless treatments does not enhance the quality of life at the cost of quantity. Indeed, it is surprising, given the high visibility of such discussions, how few examples one can find in medicine in which such a choice is actually at issue.9,10
More important than a new model, however, is the need to bridge the gaping chasm between what we do and what we know to be true. It is disturbing how many of my middle-aged colleagues in academic medicine have horror stories regarding the medical care of their parents or in-laws. These anecdotes should be listened to. Their collective weight may be as close as we get to a documentation of the failure of modern medicine with respect to the elderly. These rueful stories reveal the profound disjunction between our scientific rhetoric and our deepest desires for compassionate care.
Anecdotes and individual opinions are maligned in modern medicine; we demand data, the products of scientific inquiry. But data do not convey values, and the practice of medicine is also about values.11 Many important issues of old age cannot be measured by machines or expressed by numbers. We need to tell more stories and to think and talk to each other about what the goals of medicine are and what they should be.