THE OPEN MIND
Host: Richard D. Heffner
Guest: Dr. Mark Williams
Title: “What it Means to be Old in America”
I’m Richard Heffner, your host on THE OPEN MIND.
Years ago – three decades ago, and more, in fact – I did a television program called “Problems of Everyday Living”. And many of my viewers used to say then that they could always tell just exactly what was going on in my life, how old my youngsters were, what generally they were up to, and so on. How? Just by taking note of the topics I chose to do on the air, of course, just which problems of everyday living I would have guests in to talk about. Well, nothing really ever changes. Except that I get older…and older still. And these days you in the audience don’t have to look too far, probe too deeply to see how often that fact of life (aging!) surfaces here on THE OPEN MIND – sometimes directly, sometimes obliquely.
At least it’s better than the alternative…and increasingly there are a good many skilled and caring professionals, like my guest today who are determined to help make it better still.
Dr. Mark Williams is the Director of the Program on Aging, and Associate Professor of Medicine at the University of North Carolina School of Medicine.
Dr. Williams’ carful researches and insightful writings on what he has called “The Timeless Journey” are not only critically acclaimed, but are also wonderfully blessed with a real understanding of what it means to grow and to be old in America. What it takes for us and from those around us to cope with the aging process here in our nation. So I welcome you, Sir, and want to ask you a question…you’ve written that “aging is not the accumulation of disease, should not be considered simply as a prelude to death, but rather as the culmination of life”. You’ve also written that “a civilization can be measured by the ways it supports of denies the full circle of life”. Taking those things together, where does it place this nation, how sympathetic are we generally to that point of view?
Williams: I think one of the most important social issues we face really is how we care for the older people in this country. All of us grow older and age, and what do we have to look forward to, particularly in American society today? Some of us may escape economic uncertainties, a political oppression, various diseases of one kind of another, but we all get older and the resonance between or appreciation for what we’ve done and how we can contribute in a meaningful way in society is one of the fundamental issues. In America we don’t have as many options or alternatives for older Americans as we could have, and so I think that we need a raising of our collective consciousness about the contributions of older people and meaningful ways for them to be occupied.
Heffner: What do you mean “we don’t have as many options”?
Williams: Well, when a person retires, it’s interesting that they are often perceived as a drain on the economy. We know that problems with health care and the cost of medical care create economic tensions, and there’s often a perceived generational struggle for finite resources. But I think that, for older people in particular, to have a sense of value and participation into meaningful activities of life is a very important thing. There’s an ambivalence in this country that’s very curious to me. Some of the most powerful people in this country and in the world, are people of such ages that they would be forced to retire from many US corporations. So on the one hand, people feel the need to retire, they look forward to their retirement, and then all of a sudden, what can they do? There’s no obvious socially appropriate role for someone once they get into their seventies, eighties or nineties. And yet, these are vital human beings that have a tremendous amount of experience, wisdom, and riches to pass on to other generations and there are just very few outlets for them to share what they do.
Heffner: In a strange way, I gather from what you’ve written, we have no, we have no experience, no substantial experience in dealing with the aged because it’s only been in recent times that we can expect to live as long as we do today.
Williams: That’s true. This is really a historic moment. Just 88 years ago at the turn of the century, the life expectancy in this country was 47. Today, a baby born in this country has a better than fifty-fifty chance of living beyond the age of 75, for a baby girl 78, for a baby boy around 72. To put those numbers in perspective, in prehistoric civilizations, the life expectancy was around 18. In the days of the Roman Empire, two thousand years ago, the life expectancy was around 30. So you can see that it took nineteen hundred years for that life expectancy to increase by fifty percent, to around 47, and just within the last 88 years it’s almost doubled again. So that people should expect to live into their seventies and eighties, and this has created a wonderful opportunity for us.
Heffner: Well, it’s interesting. You say, “it’s created a wonderful opportunity” because I was going to quote you again. You say, “America is on the threshold of redefining what it means to be old in our society”. How do we know that it means to be old in our society? How do I, as an aging person, come to have some sense, really, of what it means? You can tell me, but what are the means by which aging values are legitimated?
Williams: I think there are a couple of ways. The first point is that everyone ages a little differently. People become more unique and differentiated and so there’s a richness in that variety that older people bring to the society. I think the converse of that is that society needs older people for the inter-generational richness that they bring, the wisdom and experience. And one interesting thought is, that perhaps this increase in longevity isn’t an accident of technology, but maybe a counter-balancing influence that as we gain enormous powers to split atoms, to cure various diseases and to wield these powers, that it takes wise sensible people to help manage that technology in a socially effective way.
Heffner: I like that. I like that point of view particularly much. But I must ask you then what role your own profession, what role have the doctors played in helping us be, or being themselves more sensitive to the plusses of living longer?
Williams: Well, I’m pleased to say that there are a number of advances in medical care in addition to advances in medical technology, and I would like to make that distinction because the technology is important. But the care of sick people and the maintenance of health of people, regardless of their age is a key medical responsibility. There are medical teaching programs that are becoming emphasized…are emphasizing geriatrics in their curriculum fellowship programs, developing to train more physicians. But I also have to say on the other side, that at times I’m disappointed in some of my colleagues. Not so much in the field of geriatrics, but with busy practices and not enough time and with the reimbursement structure for health care being what it is, often a quick answer is given to a very complex set of problems. Not only that, I think the medical psychology is to define illness as is, and use that technology, and often has very little to do with what’s important in the person’s life.
Heffner: You say “medical psychology”. You’ve written in a sense that…about the diagnosis syndrome and you raise the question: “How critical is it to determine precisely the nature of the underlying disease when one is helping an elderly person cope with illness”?
Heffner: I gather you’re saying it isn’t all that important in many instances.
Williams: I would say in most instances. Knowing the disease, of course, is important if the disease is quickly remediable, curable, or both. But just knowing the diagnosis doesn’t really tell you what a person can do or how they manage in their daily lives. If I give you a list of diagnoses, if I say, “here is an eighty year old man, who has difficulty going to the bathroom, has diabetes mellitus, has a large prostrate, hypertension and arthritis”, you can’t tell me from that list of precise diagnoses whether that man sits on the Supreme Court of the United States or is a resident of a local nursing home. And it’s exactly…
Heffner: Both things are true.
Williams: That’s right. And that difference of function, of getting through the day isn’t always apparent from the diagnosis. The person may have arthritis, but one person’s hands may hurt, another person’s hand may not hurt. One person may be able to put on their clothing in the morning, another person cannot. And it’s exactly at that level of function and helping a person in distress that is not diagnosis dependent.
Heffner: Well, is the diagnosis sometimes a substitute for the kind of care an aging person could respond to?
Williams: I think that pursuing a diagnosis is very comfortable from a physician’s standpoint. There’s a lot of seductive technology there that can provide a very precise definition of anatomy and quantify certain types of function in very precise ways and they’ve been major scientific advances, and I use them every day in my practice. But it’s much easier to order a particular nuclear medicine scan or a blood test than it is to help a person interact with their illness and actually put them on the road to recovery. And for many older people that’s exactly the issue. If I ask my older patients “which would you prefer, a detailed list of your problems and the medical data regarding them, or how I can help you function better in your daily lives and improve your creativity, productivity, well-being and happiness, which would you pick?” They all pick the latter.
Heffner: But the medical profession seems, generally, to pick the former.
Williams: That’s correct. I think that the attention to function and a person’s quality of life is becoming emphasized more in practice, but it’s something that takes a while to look at and, again, with the pressures of economic reimbursement, and in others it’s a thorny…
Heffner: You mean that the pressures of economic reimbursement, that’s shorthand for the economic question, for the dollars that come in and the time that must be spent, I presume.
Williams: Yes. Let me give you an example. A couple of years ago in a well known geriatric clinic a half hour of my time was billed for around $12, and as part of a study I can say that working with other health professionals, that half-hour multiplied by several different clinic visits saved some people from going into a nursing home at an enormous cost savings to society. If I had that same person go to a podiatrist to have their toenails trimmed, and that’s all, not for a foot evaluation, but just for their toenails trimmed, the reimbursement for that was around $40 to $50. If I had other specific tests ordered, an electrocardiogram or a chest x-ray, the physicians interpreting those tests would get $50 or $60. So the amount of time and energy compared to what you could make, going off on a diagnostic…
Heffner: Kick, let’s call it.
Williams: Kick. That’s right. Or economy, differences in economies of scale.
Heffner: But aren’t you taught as a would-be, about-to-be physician, in medical school, aren’t you taught the importance of diagnosis? And isn’t that a stumbling block in your search for something different…treating the illness rather than diagnosing the disease?
Williams: There’s no question that understanding the underlying reason for a person’s distress can be important, and in an educational framework it’s very important. It was actually one of the factors that pushed medicine forward as a scientific discipline in the sixteenth and seventeenth century, moving from the evil humors and the Greek philosophers into observation and the pathological correlations of disease. So I’m not saying that if a person has pneumonia you talk to them about their respiration, you give the antibiotic that’s specific for the bacteria in their lungs. But that is purely an acute disease kind of model, and that’s the setting in which many physicians are trained. When you get one step away from that acute disease, which more or less has been remedied by modern society in technology, you have all the chronic conditions: hypertension, diabetes, arthritis, demitting illnesses of various kinds. There’s where the problem comes in. So if I give a medical student or a resident the diagnosis, “Here’s a person with diabetes and rheumatoid arthritis. There are your diagnoses, now what”?
Heffner: You’ve still got to handle…
Heffner: The illness.
Heffner: Handle the symptoms.
Heffner: I dealt with that somewhat a few years ago when doctors were poking and poking and poking and sending me for one test after another, and finally I said, “Listen, you want to know what it is, come to the autopsy”.
Heffner: …and you’ll know then. But not too many of us are given to that kind of statement.
Heffner: What…what are the medical consequences, however, generally of aging?
Williams: It’s really remarkable that the closer we look at what has to happen, what are the inevitable things that happen as people age, as Jack Rowe who was the Chief of Geriatrics at Harvard and is now the President of Mt. Sinai once said, “It’s like peeling the skin of an onion. Medical science keeps stripping away these things that we thought were aging and finding out they’re diseases”. So we’re still peeling away and it’s remarkable how little seems to be left. It’s clear that things happen as people age. Limitations of reserve capability in various organ systems, but the astonishing fact is that it’s remarkably benign, and we lose ten to twenty percent of our organ system capability over time. For different people aging systems age at different rates, different individuals age at different rates. So, that is something that we have a lot of say-so about, too. How we eat, how we exercise, how we live our lives, has a tremendous amount to modulate what our old age will be like.
Heffner: That’s a charming way of putting it, “we have a good deal to say about what happens to us” in terms of the way we choose to live.
Williams: Absolutely. Well not only that, I think that in a sense, we’re the dwelling places of our own old age. So how or what is that body, spirit, emotional person going to be down the line? And it’s key for us to accept that fact that we continue to grow and evolve as we get older. It is not accurate, just not accurate, to assume that we all decline and fall apart.
Heffner: You see, that’s hard to grasp because culturally speaking that notion is one that commands a great deal of our attention.
Williams: Absolutely. And it’s clear that some organ systems fail over time. The amazing thing is how individual that is. And work form the Baltimore Longitudinal Study and other well-done longitudinal studies have shown some startling facts. It is clear, as was once thought, that three out of four people will show a decline in organ function over the years, heart function, kidney function and so forth. But amazingly, about fifteen percent of people show an improvement.
So for older men, about one in eight will show an improvement in how their heart works or their kidneys work, or their lungs work. So it’s just not appropriate now to say that it’s inevitable that kidney function declines with age. For many people it will, but for a few people it won’t and understanding why that happens is a great medical mystery and a source of research attention at this point.
Heffner: How sanguine are you that the points of view that you express are the points of view that will increasingly dominate, well, let’s say American medicine?
Williams: I guess it would be presumptuous for me to think that except that it’s the reality. I mean, as people get older they can see this in their own selves and what they have to offer.
Heffner: No, no. I didn’t mean that. I didn’t mean…I wasn’t taking what you have just said as a matter of fact. You said it as a matter of fact. I meant to what degree are those who were trained to be doctors now, the men and the women who are trained to be doctors, to what degree are they sympathetic to this approach, or are they continuing to follow the model that you’ve described?
Williams: As in everything there are different points of view. I think medical education lags sorely behind some of these changes. And some schools and institutions are flexible enough to get these principles into their curriculum at a very early point and continue to reinforce them throughout medical training. But it’s so much easier, from a point of view, to teach technology and curves on the board, numbers and things of that nature than it is the actual human interaction that takes place, to explore potential, to find out what medical problems or concerns influence the person’s full expression, and be able to deal with them effectively. It takes time, it takes a commitment and it takes the willingness on the part of the medical profession to reward people in those circumstances. I’m rewarded much more in institutions for the amount of grant money that I bring in or…than the quality of thinking. In academia a number of publications and so forth is the promotional standard.
Heffner: But isn’t that a reflection of the totality of American life, the kinds of rewards that we offer to the kinds of people who do different work? Yet, as you say, I know you feel that, I know that from what you’ve said and from what I’ve read of what you’ve written, that this is an extraordinarily important theme for us to follow…
Heffner: …even if only because it’s the most practical approach because there are so many, many more older people now.
Williams: Not only that, but I think we all have to realize that older people are not a disenfranchised minority. As I said before, some people may escape political oppression or various diseases, but everybody ages. So what we’re talking about in many ways are ourselves in the future. So what kind of medical care do we want for ourselves? And I think ultimately we’ll get the kind of care that we’ve planned for and deserve.
Heffner: Dr. Williams, one of the areas that I wanted to question you about, and we just have about five minutes left, had to do with medication.
Heffner: I gather that over-medication, well, that under-medication is a problem with some people, but that over-medication is increasingly problematic. I wonder if you’d comment on that.
Williams: I think it’s a very serious problem. I think that in my own experience in our geriatric clinic, I’m disappointed to have to say to you that probably the single most important thing that I do is undo medical care: stop medications, re-arrange diagnostic tests, offer second opinions for various kinds of procedures. And I think that the decisions are very delicate ones. Of course we want to reduce the risk of heart disease, high blood pressure and some of its sequel, but for example, the medications to treat hypertension can cause tremendous difficulties, sexual dysfunction as one, fatigue and so forth, and all of a sudden the balance becomes more problematic. Which would you prefer, reduction of cardiovascular risk to maybe one chance in whatever at the expense of loss of sexual activity and energy and feeling good in the morning? Or what? And these are very difficult decisions and I think that careful weighing of what the medicine is supposed to do and what would happen if the medicine wasn’t there is important.
Heffner: Look, no matter what else one can say though, the end does come.
Heffner: You see it as a process.
Heffner: You see it as a culmination…
Heffner: …of living which is, if one stops to think about I, an intriguing and very positive and very real…
Heffner: …approach. What are the concerns you have about our involvement now in distributing our resources in terms of aging, in keeping us alive as we get older and older still? I wonder whether you have a philosophy, a point of view. If you were the God Committee and had to make choices, what would the criteria be in terms of the question of aging?
Williams: I don’t really think aging is that much of an issue. I think it’s a personal and individual issue and set of decisions. I think that, in general, our society does a very poor job in handling the last moments of life. I honestly can’t say in good conscience that a person who dies after an unsuccessful cardiac resuscitation attempt is treated any more humanely than the Eskimo elder that’s put on the ice floe. So that they’re very difficult sets of decisions that we have to make and I think that often physicians, unwilling to confront these decisions – their own mortality and those of others – often err of the side of heroics, trying to keep terminally ill people alive. I see families disintegrate under the pressures that are put on them by this tension.
Heffner: But when you say “terminally ill persons”, you’re not referring to an age category. You’re talking about an illness category.
Williams: Sure. It might be a twenty-five year old person with AIDS, it might be a fifty year old person with cancer, might be a ninety-five year old person with a combination of various diseases.
Heffner: Dr. Williams, it’s so interesting that you talk about the possibility that doctors’ ability or inability to deal with these problems, that’s a reflection of their own difficulties in dealing with their own mortality…
Heffner: Doctors working at this harder, I trust. And I think I’m getting the signal that our time is just about up…am I, indeed…yes, see…all good things must come to an end, which is not inappropriate to what we were talking about.
Williams: That’s right.
Heffner: Dr. Williams, thank you so much for joining me here on THE OPEN MIND.
Williams: My pleasure.
Heffner: And thanks, too, to you in the audience. I hope you’ll join us again next time. And if you care to share your thoughts about today’s program, please write to THE OPEN MIND, P.O. Box 7977, FDR Station, New York, NY 10150. For transcripts send $2.00 in check or money order. Meanwhile, as an old friend used to say, “Good night and good luck”.
Continuing production of this series has generously been made possible by grants from: The Rosalind P. Walter Foundation; The M. Weiner Foundation of New Jersey; The Mediators and Richard and Gloria Manney; The Richard Lounsbery Foundation; Mr. Lawrence A. Wien; and The New York Times Company Foundation.