Some Thoughts on Aging and Other Medical Problems, Part II

THE OPEN MIND
Host: Richard D. Heffner
Guest: Dr. Christine K. Cassel
Title: Some Thoughts on Aging … and Other Medical Matters, Part II
VTR: 4/11/02

I’m Richard Heffner, your host on The Open Mind. And this is our second program with Dr. Christine Cassel, the new Dean of the School of Medicine at the Oregon Health and Science University; formerly Professor and Chair of the Department of Geriatrics and Adult Development at the Mt. Sinai School of Medicine in New York.

And Dr. Cassel also was the first woman President of the American College of Physicians and is past Chair of the American Board of Internal Medicine. Last time I noted, too, that Dr. Cassel is recognized by her peers as a social activist and a “policy wonk.” And I want to pursue those points a bit further today, though I want further to ask her … first, Dr. Cassel about the question that has concerned me every since I knew you were going to join me here. And that is, when does an aging person like myself look to geriatric medicine and not primarily to an endocrinologist, to a cardiologist, or to any of the other medical specialists.

CASSEL: Good question, Dick. We get that question often. And there are many different answers to it. In general, if you look at the geriatric practices in academic health centers around the country, they tend to start around age 75 or even 80. At Mt. Sinai the average age of our patients was 85 in our geriatric practice. So, it tends to be at the sort of upper end of the age spectrum.

On the other hand, there are increasingly places that are appealing to people who, you might call “the young old”. People who want to stay healthy as they age. And who would like to have a physician and a health care team that can help guide them in continuing to be healthy as they age.

But your point about the specialists is a very important one. Because as we get older, we’re at risk for more and more different medical problems. We may have a little hypertension, we may have a little thyroid problem or diabetes. We may have arthritis. We may have some surgical problems, prostate cancer, breast cancer that needs treatment by a specialist. So we end up going to a number of specialists. And, as you get to be older, there may not be anybody who looks at the whole picture. Who is, as I like to say, “my doctor” and who can understand the interactions of medications that you’re taking, who can help to coordinate the care and most, importantly help answer your questions about important health care decisions that you need to make for yourself.

HEFFNER: Isn’t that true, in a sense, at all stages of life?

CASSEL: Absolutely. And many people when they hear about the principles of geriatric medicine will point out, “well, isn’t that just good medical care for everyone?”

HEFFNER: MmmHmmm.

CASSEL: And many of my colleagues in primary care specialties are absolutely doing the same thing, but for people of all ages. The fact is that it is … it becomes more critically important as you get older because the risks of both missing important treatable illness and of iatrogenic problems, or complications from too much medicine or the wrong kind of medical care are much, much greater as you get older. So you can sort of get through the middle years for most people, without that kind of coordinating care. But it’s much better and health care is delivered more efficiently, actually, if you do have a primary care physician.

HEFFNER: This is a little like having a pediatrician at the beginning of life …

CASSEL: Yes.

HEFFNER: … and a gerontologist at the end.

CASSEL: Yes. Exactly like that. And actually the specialty of geriatrics was modeled on the specialty of pediatrics. Ignacius Nascher in the first part of this century who is the physician from Vienna who was credited with inventing the term “geriatric medicine” made exactly that analogy. It was because pediatrics was just beginning to be talked about as a specialty for children. And they would say, “Well, children aren’t just small adults.” And the same thing is true as people get older. They’re not, they’re not just the average 70 kilogram man that we’re always taught about in medical school. You have to adjust the doses of medication, you have different risks for different kinds of problems. And you have the whole world of chronic care, which is something that most acute care medicine, deals with people in their middle years, is unaware of.

HEFFNER: How willing do you find that specialists, the cardiologists, the person who specializes in kidney disease, the person who looks at other organs of the body … how willing are they to say to a patient and how often do they say to a patient, an aging patient … “get thee to a gerontologist to help put all of these things together.”

CASSEL: Well, first they have to be in a community where there is a geriatric medicine expert to refer to. And we have such a dire shortage of specialists in this area, right now, that many communities don’t have a geriatrician. There are a lot of good specialists and good medical environments who wouldn’t know who to refer you to, in that instance. But if there is a practicing geriatric practice or group in the environment, many specialists will immediately tumble to how helpful that can be. And they realize that their practice is not set up to deal with all these complex problems. They may be set up to deal with heart disease or with arthritis, or with some other problem, but not with the … all of the patients problems. And they know that that patient is taking more and more of their time and that they’re out of their element in helping to coordinate all of the things that patient and their family might need. At that point, my experience has been that they’re more than happy to refer to a geriatrician.

HEFFNER: You make this sound as though its an area of great emergency concern.

CASSEL: It is. It’s an urgent need that our nation has. To be able to be to deal effectively with the aging population and to make sure that the health care that is provided is both effective and appropriate for that population.

HEFFNER: On the other hand I know that in an article that appeared in September 2001, some one … the interviewer, Claudia Dreyfuss, could have asked the question as to why we don’t have more people in this field. And your point is that our common culture sort of makes that not the sexiest or most dramatic …

CASSEL: Exactly … it’s either …

HEFFNER: … part of medicine.

CASSEL: … It’s neither considered sexy or dramatic, and for some reason, we think that’s what doctors should be interested in … are things that are glamorous, high-tech and very dramatic. Rather than things that meet the needs of people. And I think geriatrics is something that every baby-boomer who has been through the challenges of caring for their parents through a chronic illness, or maybe at the end of life … realizes “if I just had a doctor like that.” Or if they have a doctor like that, they realize how lucky they are. So, so the consumer is going to demand this kind of care in the future, I think. But until now, the system has not supported it. First of all, it doesn’t pay very well. You don’t get rich being a geriatrician. And a lot of economic incentives are important as people make their decisions about what specialty they want to practice in. Secondly, in part because of the economic factors, health care systems haven’t invested very much in geriatrics except for the more integrated systems that are really interested in, in creating a whole system of care where they realize that they have to subsidize this because it benefits the overall population. But most health care is very fragmented in this country. So there’s no incentive to subsidize that.

HEFFNER: Can you assume that at your institution, four years from now, five years from now, ten years from now you will be graduating many, many, many more geriatricians?

CASSEL: I have great confidence that that is going to happen. But more importantly, I also have great confidence that all the physicians who graduate, no matter what specialty they’re going to be in, will have better training in the care of the elderly. You mentioned earlier … cardiology as a prominent specialty. Because more and more can be done now for heart disease. But heat disease is a disease of aging. And many cardiologists are realizing that they need to know something about geriatric medicine. So there is actually a beginning of a movement among specialists to realize they’d better learn a little geriatrics for whatever their specialty area is because they’re seeing people in their 80s and 90s and they need to understand more about the aging process.

HEFFNER: You mentioned that what we are talking about here is, in a strange way, an interesting way … not a woman’s problem, not a women’s issue, but that women become involved in this question to a much great extent than men. Not as patients, but as care givers.

CASSEL: Well, as both. The first is that women have a survival advantage over men …

HEFFNER: Ahhh …

CASSEL: … it continues to be a biological mystery, why that’s the case. It’s actually a fascinating question. But women will live longer than most men, which means that married women will probably outlive their husbands. They tend to get a raw deal when it comes to pensions, many of them have not worked themselves as much as the husband has, and often … and the benefits are not accrued then to the woman as she ages. So statistically women are much more likely to live longer, and to endure severe poverty as they age. So to that extent it really is a women’s issue. There are many, many more women, for example in nursing homes because the families are not there to care for them. But, where people do age at home … far and away the most common scenario is that the woman is also the care giver. This is the daughter, the daughter-in-law, the niece, the god-daughter. Those just tend to be the people who provide the parent care or the care for older people.

HEFFNER: You think that’s essentially because they are kinder, gentler folk?

CASSEL: Well, I … could be. It could be.

HEFFNER: Well, what do you think?

CASSEL: But I think it’s a social … I think it’s a social role acceptance that women in our society tend to be the care givers for children; they tend to be the care givers for older people. Even as we’ve made advances with women in the work force and most families are two earner families and many couples share some of the work around the home. The fact is that when you get right down to it, all the studies show that the woman is the one who does the most of the … even if she’s working … also does the most of child care as well as of parent care. And, there are sometimes real economic consequences for the family because of that. She has to cut back on her work, may have to quit her job, may have to forego that promotion because of the needs of the family.

HEFFNER: Is there any indication that because of this phenomenon we find that women are more involved in the political efforts to bring about better solutions to aging problems.

CASSEL: There are a number of important leadership groups and women leaders in understanding … in advocating for better health care and better social policies for aging. And I think that’s no accident. And, as the baby-boomers age, I suspect we’re going to see more of that.

HEFFNER: You know there is a wonderful question at the very end of the New York Times piece from September, 2001. The last question: “Do you have a fear of aging yourself, personally?”

CASSEL: I do. And that may be part of why I’m doing this work. As I sometimes point out … this is not just altruism, this is enlightened self-interest. As I look ahead to the future I would like it to be a future where I can be, where I can expect to be active, to be treated with respect in whatever community I am, no matter how old I am. And to be … to get the caring that I need at the end and to have some dignity at the end of my life. I don’t say … I don’t think I’m very confident right now that that’s likely to happen. That actually leads to another important aspect of this aging society, which is that we still marginalize older people in our society. And in the work place where we could take advantage of all these healthy older people and people could stay very active and contribute to our economy as well as to our society, there tends still to be a preference for the younger person, “let’s hire that younger person” and I think we still have a lot … a long way to go in terms of accepting that fact that older people are as vital and as productive as they.

HEFFNER: Of course, your feeling is that as we do age as a nation, we’re going to change that attitude … out of necessity.

CASSEL: I hope so. And I think I’m … I expect to be one of the voices arguing for that. And I think there will be many others.

HEFFNER: Now, your … your move to Oregon …

CASSEL: Yes.

HEFFNER: We can’t, in the few minutes we have left, not touch upon the question of whether end of life matters are handled, in your estimation, better in your state now.

CASSEL: I believe from what I know that … that care at the end of life is far better in the State of Oregon, than it is in most other places in the United States. And it maybe related to the fact that the citizens of Oregon have twice, by large majorities, approved the legalization of physician assisted suicide. This, of course, is very controversial. People have very different points of view on this, very different religious as well as, as moral values about it. And I think that that’s completely acceptable. But what the citizens of the state of Oregon said is that “we want to do this in our own way, on our own terms.” Very few people actually make use of that law, and actually get an overdose that they can take themselves, as they die. But, because of the environment of openness and discussing it, because all of the health care world has to be aware of the reality of terminal or potentially fatal illness, and has to be willing to talk to their patients about, they have put in place a very good system of care for people at the end of life. Very few people die in the hospital in the state of Oregon. Many, many more people are able to die at home or in community settings. And, and to receive care on their own terms, even if they don’t decide to, to take an active suicide at the end of life.

HEFFNER: What do you think’s going to happen?

CASSEL: There?

HEFFNER: Yeah.

CASSEL: Ahhh, I hope that that will continue. It will undoubtedly continue to be challenged by people who, who disagree with the law. But, again, I think that this is one of the brilliant aspects of our nation, is that people should have a right to decide for themselves what they want to have happen with their own bodies. It’s a fundamental principle.

HEFFNER: Is that accompanied by an awareness of the need for concern, for palliative care?

CASSEL: It is, and as a matter of fact, every hospital in Oregon now has a palliative care team that sees patients who are facing the end of life or who might be beginning that trajectory. They don’t have to be imminently dying for that to be effective. And that’s another place where modern medicine really has failed us. We’ve forgotten that relieving suffering and helping to provide dignity for people as they die is one, one of the longest-standing most important and most effective roles for a physician.

HEFFNER: Why have we forgotten that?

CASSEL: We’ve become entranced with the high technology and life saving technology of medical care. It’s not surprising, it is pretty entrancing and there’s a lot of very exciting stuff there. But the fact is people still do die. The most common complaint that I’ve heard from families after the death of a patient is that no one would answer their questions. No one would give them a straight story. And physicians have not been trained how to do that. They’ve forgotten that that’s such an important part of their role is helping the family know what to expect. Helping to make arrangements so that the patient can get pain treatment or other kinds of care that they need at the end of life. And if they don’t want it, to not be tortured by high tech medical care up until the bitter end.

HEFFNER: You say families can’t find answers.

CASSEL: Right.

HEFFNER: What about the patients themselves?

CASSEL: Well, the patients themselves also need those answers and need some one who will talk straight to them and, and help work through the plans at the end of life. And this is something that physicians haven’t been as good at as they should be. And I think we need to get better at. The reason I emphasize the families is because very often by the time anyone is even talking about the fact that this is a terminal illness, the patient may already be unable to speak, or may be comatose. That’s way too late. We should be, as we identify a potentially life-threatening illness in a patient, we should be willing and able to bring up at that time the, the possibility that this could be a fatal illness. And are there questions that you have or things that are troubling you that you would like to talk to me about?

HEFFNER: It’s not been in the medical model, has it?

CASSEL: No.

HEFFNER: To, to do that.

CASSEL: No. It’s … if a patient brings up an issue like that, you pat them on the head and you say, “Now, now, dear, everything will be okay,” and you’re out the door. And, the patient knows better than that. Patients are not dumb. You know they can tell if there’s something going on. And often what they’re worried about is far worse that what the reality may be. And you could really relieve their anxieties by saying, simply, “if there is pain, I will help you. I will treat it. You won’t have to suffer.” That simple statement can mean an enormous amount to someone facing an illness. Now it doesn’t mean you’re going to die next month, or even next year. But if you have a relationship with a patient who can make a promise to you that, that they can keep, that you won’t suffer. That’s a huge value.

HEFFNER: Strange question. Is there a different … I talked about the medical model a moment ago …

CASSEL: Right.

HEFFNER: … mentioned it. Is it different in the West than in the East? Is it different in medical training at the frontier of our nation than it is here in the East where we’re sitting now, where the training has been going on for many more decades and scores of years than in the West?

CASSEL: There are some differences that I’ve noticed. I did my training in San Francisco and then came East to Chicago and New York and now I’ve gone back to Oregon. And I think there is some difference, although it’s not as much as some people might think. But it’s not so much a difference in medical training as it is a difference in what the community of care involved. There are actual, very astounding studies of the variation in how technology is used across the country. And, for example, more than 80% of people who die in the East, and especially in New York, die in the hospital. In Oregon 40% of people who die, die in the hospital. Now that doesn’t … it’s not completely about medical training, it’s about what kind of resources are available in the community. How many elderly people in New York live alone, in apartments where, even if they wanted to stay home, it wouldn’t be practical for them to be at home. There may not be the same sort of community receptiveness to home care and options for people. And as a part of that … I don’t think the medical world is as comfortable with the idea that you should go home and that should be where you are.

HEFFNER: Well, you know, I have a little house in Palm Springs, California, known as “‘God’s waiting room” …

CASSEL: Yes. {Laughter]

HEFFNER: And a doctor there said something so interesting to me, he actually said it to my wife. He said, “We don’t treat diseases here, we treat individuals. We treat people.”

CASSEL: Wow, keep that doctor … you got a good doctor.

HEFFNER: Ahhh, absolutely. But I wonder how often I would hear that here in the East where we’re sitting now? That’s why I asked the question, whether there’s something different?’

CASSEL: There are different cultures and I think if you … I have found, in New York, for example if you go to a party in someone’s home, a lot of the discussion is about what specialists you’ve seen. This specialist, that specialist, the other specialist and, and it’s a very specialty oriented medical culture. Whereas I think what many people realize at a certain point that they really would like is a doctor who takes care of people, not diseases. Now, that doctor has to be knowledgeable about diseases and has to either have the expertise or be able to get the expertise when its needed. But the most important thing, I think, especially as we age, is somebody who will be your doctor.

HEFFNER: Other physicians at this table have talked about the enormous importance of computerization, that doctors cannot … a) we’ve decided they’re not gods, and b) we’ve decided they can’t know everything …

CASSEL: Absolutely.

HEFFNER: Therefore, the computer may enable them to be human beings and practice the way you suggest, but at the same time, have access to expert knowledge.

CASSEL: Electronic information systems are dramatically changing how we practice medicine. Both from the perspective of the patient and the physician. For the physician you can get on-line, instant medical information about any condition, and, most importantly, what is the up-to-date evidence related to that condition and the computer can do this for us. Increasingly, I hope, going forward, we’re going to have personalized medical information that the physician and the patient together can look at for … related specifically to that patient and the results of their lab tests and the trends and, what they need to know about their own illness. But, right now, even where that doesn’t exist, patients themselves can get on line and find out all kinds of information on the Internet about various medical conditions. The problem is there’s no filter to it. So a lot of it is junk, and that’s a big problem right now. We really need to figure out how we can have some validation of the information that’s out there.

HEFFNER: And the answer to that question?

CASSEL: Well, some organizations are putting important things on line. Like the American Federation for Aging Research has a website that has good scientific information. That’s one among many and I think … NIH has its own website where you can be very confident that the information you’re getting is good information. But I think doctors are going to learn how to respond to patients. Patients come in with these print outs and they say, “tell me, doctor, which of these is true?” And instead of being impatient and annoyed when that happens, I think we’re going to have to learn how to make that to our advantage.

HEFFNER: God willing. Dr. Cassel, thank you so much for joining me today. I’ve only one question and we have no time left, so you’ve got to say “yes” and that is that you’ll come back and join me again some time here at this table.
CASSEL: It would be a pleasure, Dick. Thank you.

HEFFNER: Thank you. And thanks, too, to you in the audience. I hope you join us again next time. If you would like a transcript of today’s program, please send four dollars in check or money order to: The Open Mind, P. O. Box 7977, F.D.R. Station, New York, New York 10150

Meanwhile, as an old friend used to say, “Good night and good luck”.

N.B. Every effort has been made to ensure the accuracy of this transcript. It may not, however, be a verbatim copy of the program.