Part 2 continued to be epic - with first author Rafael Kramann joining in this time. Check out the storify from Hector below -
And the stats were equally impressive - overall picture captured by this tweet from Matt:
#NephJC does #pericytes - part 1
Not #parasites or ... #pedicure?
This was a fantastic chat last night, with great questions from Mal Parmar, Scott Brimble, Dylan Burger and others; clear and articulate answers from Ben Humphreys - and a link heavy tweeting from Matt Sparks. The transcript will read almost like a review article - or commentary.
Stay Tuned for the EU/African chat, occurring in just over 2 hours at 8 pm *BST* - with first author Rafael Kramann joinin in this time.
In the Literature...
We mentioned the #MICE project in the newsletter a few days ago (what newsletter?? Check out and sign up - low volume, once a week, will keep you updated) - authored by Tejas Desai, Edgar Lerma, Ryan Madanick et al. It's published on the Winnower platform and has already accumulated some interesting reviews, including Chi Chu & Francesco. Two in particular stand out for their insightful comments - out-rivalling any peer review you may have seen, by Len Starnes and David Goldfarb, the latter written in his incomparable signature style.
Another fun paper (CoI alert: includes Swapnil and Joel as co-authors) is a 'Ten Steps for Setting up an Online Journal Club' - available here ($walled). This was a fun experience - crowd-sourced, written from start to end in a matter of days, and shepherded quite ably by Teresa Chan to publication.
Being Mortal: Chapter Seven
I did not like the Immortal Life of Henrietta Lacks. I thought the story of the HeLa cells and the story of Ms Lacks and her family was interesting and introduced me to a history of medicine that had previously been invisible. The story was fascinating but the book fell flat because of the way that the author, Rebecca Skloot, inserted herself into the story. Every chapter that was told from Ms. Skloot's point of view came across as having low stakes and was generally uninteresting. I finished the book with the belief that this point-of-view writing was a poor technique for non-fiction.
I was wrong. While it didn't work for the Immortal Life, Dr. Gawande uses it to dramatic effect in Being Mortal. Gawande is a recuring character in the book and the previous chapters we are taken on his journey from a doctor with conventional western medicine understanding about dying o a much deeper and richer understanding. In chapter seven, however, Gawande changes from a researcher to an active participant as his dad suffers a devastating illness and he needs to put his new found knowledge of hospice, assisted living, palliative care and end-of-life decisions to use.
“The scan revealed a tumor growing inside his spinal cord.
That was the moment when we stepped through the looking glass. Nothing about my father’s life and expectations for it would remain the same. Our family was embarking on its own confrontation with the reality of mortality. The test for us as parents and children would be whether we could make the path go any differently for my dad than I, as a doctor, had made it go for my patients. The No. 2 pencils had been handed out. The timer had been started. But we had not even registered that the test had begun.”
In 2006, Gawande's father, Dr. Atmaram Gawande, went for an MRI to diagnose a slowly progressive pain in his neck associated with numbness in his left hand. The scan revealed a spinal cord tumor.
The Gawande's then consulted a pair of neurosurgeons, one in Boston and one at the Cleveland Clinic. Gawande explains the bedside manner of both doctors by describing a paper by the medical ethicists Linda and Ezekiel Emmanuel that described the three type of relationships doctors could have with patients:
- Paternalistic
- Informative
- Interpretive
Gawande describes all three types. The first is the doctor we read about from the 50's. The all knowing God-like figure that tells the patients what they should do and does not discuss options that the doctor does not think are optimal. We would like to think that we are past this but in reality it is more common than we care to admit.
The second type, informative, is the opposite of the paternalistic relationship. The doctor informs the patient of the facts and figures needed to figure out the best option and then lets the patient make the decision. Gawked explains that this works best for for simple issues with clear choices and straightforward trade-offs. The more complex and emotional the issue the more this method breaks down.
The Emmanuels third option, interpretive, is a hybrid of the two earlier models. “Here the doctor’s role is to help patients determine what they want. Interpretive doctors ask, “What is most important to you? What are your worries?” Then, when they know your answers, they tell you about the red pill and the blue pill and which one would most help you achieve your priorities.”
The chapter winds its way through his father's illness and we see Gawande struggle to use the lessons he has learned to help his father. They make some excellent decisions, they make some mistakes, they meet some excellent physicians and some clunkers. The face decisions on hospice, medical decision making and hospice. Despite some missteps, by the end of the chapter his father is in hospice and living a surprisingly full life.
“But walking slowly, his feet shuffling, he went the length of a basketball floor and then up a flight of twenty concrete steps to join the families in the stands. I was almost overcome just witnessing it. Here is what a different kind of care—a different kind of medicine—makes possible, I thought to myself. Here is what having a hard conversation can do.”
Being Mortal: Chapter Six
Hector Madariaga, NSMC intern and transplant fellow wrote the summary for this chapter.
Chapter Six: Letting Go
Most of this chapter describes the sad case of Sara Thomas Monopoli and her journey from being diagnosed with metastatic lung cancer while 39 weeks pregnant with her first child to her demise a few months later. She was only 34 years old. Sarah failed multiple rounds of chemotherapy and despite continually deteriorating, she, nor her family, came to terms with her impending death and she passed in the ICU without saying goodbye.
Dr Gawande discusses the fact that 25% of all Medicare spending is for the 5% of patients in their final year of life, and most of that money is spent in the final few months. He describes the finances of breast cancer where $28,000 is spent in the first year, primarily on surgery, radiation and chemotherapy. After that the costs fall to $2,000 per year until the final year of fatal cases of where the costs swell to $94,000. (ref)
“Our medical system is excellent at trying to stave off death with $12,000-a-month chemotherapy, $4,000-a-day intensive care, $7,000-an-hour surgery. But, ultimately, death comes, and few are good at knowing when to stop.”
This intense medicalization of death arguably does more harm than good. A study in 2008 showed that cancer patients who were put on a ventilator, given defibrillation, chest compressions, or admitted to an ICU had a substatnitally worse quality of life in their last week of life. Worse, is that this trauma is passed on to loved ones. Caregivers of these patients had three times the rate of major depression. (JAMA 2008)
He describes how advancements in medicine make death a long process rather than an event that lasts a few hours to days. He describes ars moriendi, literally the art of dying. These were prescribed customs people followed when they died. These procedures were published in popular pamphlets and described seeking forgiveness from God, letting go of worldly possessions, and provided friends and families prayers and guidance for the final hours. Gawande argues that we need a new ars moriendi appropriate for the contemporary reality of the end of life.
“So I sat with her sisters in the ICU’s family room to talk about whether we should proceed with the amputation and the tracheostomy.
“Is she dying?” one of the sisters asked me.
I didn’t know how to answer the question. I wasn’t even sure what the word “dying” meant anymore. In the past few decades, medical science has rendered obsolete centuries of experience, tradition, and language about our mortality and created a new difficulty for mankind: how to die.”
e also describes his rounding with Sarah Creed, a nurse practitioner on the hospice service. He interviews the patients and explores their decision to go into hospice care. One
thing that I learned is that hospice care is not about “letting nature take its course” or to prolong life (that’s the goal of medicine), but to focus on patients' priorities. Their first patient had end-stage heart failure with pulmonary fibrosis. Sarah helped her get medication refills which had been sitting at the pharmacy.
He also explores the rational of terminal patients when they are given a poor prognosis and why they continue to pursue therapy with the hope of extending their lives, when in fact, they only have months to live. Sarah explains that 99% of her patients understand they are dying but they all still hope that they are not. Only about quarter of them have accepted their fate.
The next patient is Dave Galloway, a former firefighter with pancreatic cancer. He is in terrible pain and Sarah has to convince him to use the PCA pump more often. Gawande goes in to detail about a "comfort pack" which is a bundle of useful medications for everything from dyspnea to delirium. Dave's wife knows how to use the medications and is provided with a 24-hour phone line she can call for advice of what medications to use in which situations. The comfort pack provides her an ability to provide care to her husband through his final days and keep him at home comfortably.
Gawande talks a bit about how difficult a problem this is to solve, since solutions often sound like rationing. He then goes on to discuss the story of Nelene Fox, the women who sued Health Net when they refused to pay for her bone marrow transplant for breast cancer. The insurance company did not pay for the experimental procedure. A jury awarded $89 million to her family. Legislators in 10 states then enacted laws requiring insurance companies to pay for bone marrow transplants. The procedure has since been shown to be ineffective for breast cancer. [Note: Intererested readers should check out The Emperor of All Maladies, a great book that digs into the science behind bone marrow transplant for breast cancer and the scientific fraud that perpetuated this practice.]
A landmark study from MGH is also mentioned, in which they randomized 151 patients with stage IV lung cancer. Half received usual oncology care and the other half oncology care plus visits with a palliative care specialist. The results were fascinating. Those in the second group, stopped chemotherapy sooner, opted for Hospice care earlier and lived 25% longer. A similar study is also mentioned in where they too found that palliative care extends survival. As stated in the text:
“You live longer only when you stop trying to live longer.”
“If end-of-life discussions were an experimental drug, the FDA would approve it.”
The author also explained the end-of-life discussion in the community of La Crosse, Wisconsin in which their is a systematic and widespread effort to get people to discuss end-of-life wishes prior to the, you know, end-of-life. When ever someone in La Crosse is admitted to a hospital, nursing home or assisted living facility they complete a four question form:
Do you want to be resuscitated if your heart stops?
Do you want aggressive treatments such as intubation and mechanical ventilation?
Do you want antibiotics?
Do you want tube or intravenous feeding if you can’t eat on your own?
They increased advance directives from 15% to 85% in 5 years. The ICU doctor Gawande talked with explained that the benefit is not the answer per se but that people have discussed the issues long before they are admitted to the ICU. End-of-life costs in La Crosse are half the national average.
How to approach the end-of-life discussions? Every case has to be individualized; some general rules are: sit down, take your time to talk to family and patients, learn what’s most important for the patient under any circumstance and finally, listening. As Mrs Block, a Palliative care specialist says: “if you are talking more than half of the time, you’re talking too much.”
Being Mortal: Chapter Five
Francesco Iannuzzella wrote the summary for chapter 5.
Chapter Five: A Better Life
In order to maintain the integrity of their social network, and enjoy a higher quality of life, most elderly people would prefer to remain in their homes as long as possible. Nevertheless, at some time during their life, many of them will be admitted to a nursing home.
Traditionally, nursing homes have been organized to provide an efficient medical care to frail and impaired individuals with little or no attention given to quality of life. Fortunately, the deepest changes usually start on a very small scale and one single successful experience can radically change the way of doing something.
In the beginning of chapter five, Gawande describes the biography of one of these heroes, Bill Thomas, a man who rewrote the manual on how nursing homes operate.
Bill Thomas’s experience began in the early 1990s when he got a new job as medical director of Chase Memorial Nursing home in the town of New Berlin, NY. He was only thirty-one with little or no experience in eldercare. With his newcomer’s eyes, Bill began to question the basic assumptions all had taken for granted since then.
He identified “The Three Plagues” of nursing home existence:
- boredom
- loneliness, and
- helplessness.
Then, he tried to fix them experimenting a new approach to eldercare. His aims were clear: he wanted to replace boredom with spontaneity, loneliness with companionship, and helplessness with a chance to become involved in caring for another being. At the beginning, he didn’t make a great change in everyday Chase Memorial healthcare practice, but he adopted an easy and effective approach to bring life to its inhabitants: he introduced a lot of pets, gardens and children to the nursing home.
“He said, “Now, what about cats?”
I said, “What about cats?” I said, “We’ve got two dogs down on the paper.”
He said, “Some people aren’t dog lovers. They like cats.”
I said, “You want dogs AND cats?”
He said, “Let’s put it down for discussion purposes.”
I said, “Okay. I’ll put a cat down.”
“No, no, no. We’re two floors. How about two cats on both floors?”
I said, “We want to propose to the health department two dogs and four cats?”
He said, “Yes, just put it down.”
I said, “All right, I’ll put it down. I think we’re getting off base here. This is not going to fly with them.”
He said, “One more thing. What about birds?”
I said that the code says clearly, “No birds allowed in nursing homes.”
He said, “But what about birds?”
I said, “What about birds?”
He said, “Just picture—look out your window right here. Picture that we’re in January or February. We have three feet of snow outside. What sounds do you hear in the nursing home?”
I said, “Well, you hear some residents moaning. You possibly hear some laughter. You hear televisions on in different areas, maybe a little more than we’d like them to be.” I said, “You’ll hear an announcement over the PA system.”
“What other sounds are you hearing?”
I said, “Well, you’re hearing staff interacting with each other and with residents.”
He said, “Yeah, but what are those sounds that are sounds of life—of positive life?”
“You’re talking birdsong.”
“Yes!”
I said, “How many birds are you talking to create this birdsong?”
He said, “Let’s put one hundred.”
“ONE HUNDRED BIRDS? IN THIS PLACE?” I said, “You’ve got to be out of your mind!”
Wilma and Libby
The results were extraordinary:
- The number of prescriptions halved
- With a particular reduction in the use of psychotropic drugs
- Mortality fell about 15%.
This was the starting point for a larger program, named Eden Alternative, which over the last 20-years de-institutionalized nursing homes and ultimately lead to the so-called Green House project. Since the first Green House was built in Tupelo, Mississipi, in the year 2000, more than 150 Green Houses have been built in twenty-five states. With no more than twelve residents each, all Green Houses are small and communal with a physical environment made to preserve quality of life, self-sufficiency, privacy, and dignity.
How to explain the Eden Alternative success?
To answer this question, Gawande cites an American philosopher, Josiah Royce (1855-1916), who believed that in order to live a worth living we need loyalty, i.e. a dedication to a cause beyond ourselves. It doesn’t matter if this cause is small (as small as the care for a pet) or large, what matters is that is such a cause provide meaning to one's life. We all need loyalty, and elderly people need it even more.
“The elderly need loyalty to give meaning to both their life and their death.”
They need loyalty to give meaning to both their life and their death. With aging, simple pleasures, we all take for granted during our adulthood, may become a source of loyalty, a comfort to our pain. To testify to this truth, Gawande reports the interviews tof nursing home residents he met, whose quality of life strictly depends upon simple pleasures: living in a private room, going to the cinema, reading Fifty Shades of Grey, using a computer, preserving social interactions.
Gawande describes his experience visiting two different projects in the Boston area. The first one, it is a new human size retiring community called NewBridges on the Charles with great financial resources due to substantial philanthropic support. The second project is a subsidized apartment building (Peter Sanbord Place) for low-income elderly people, whose director Jacquie Carson deeply changed to allow her residents to continue to live their own lives.
The chapter ends by returning to the story of Lou Sanders who has deteriorated to the point where he no longer can live in assisted living and is admitted to a nursing home. However, he enters a Green House with private rooms and a thoroughly de-institutionalized philosophy. He rapidly adapts and explains that he knew it was the place for him when he saw that all the rooms were single. Little things can make all the difference.
The President of the ASN (@POTASN) is doing a Twitter chat, #AskASN
Tonight at 9pm Eastern Dr. Himmelfarb will be doing an hour chat.
Hashtag: #askASN.
Topics
Topic Zero- What is your favorite ASN memory?
Topic One: What does ASN mean to you?
Topic One: Why did you want to serve as ASN President?
Topic Two: What is ASN doing for the #NephWorkForce?
Topic Two: Why did the Match Task Force and the Council vote for the "all-in approach" to the Match? What does that mean?
Topic Three: Why are you on Twitter? What are you hoping to accomplish?
Topic Four: How has nephrology changed since you were a fellow?
Topic Four: How old are you? What color was your Burton Rose?
Topic Five: What does the ASN of 2025 look like?
Being Mortal: Chapter Four
Swapnil Hiremath summarized chapter four, bringing us to the the halfway point. Remember the chat is next Tuesday and Wednesday, July 14 and 15.
Chapter 4: Assistance
“Life is pleasant. Death is peaceful. It’s the transition that’s troublesome.”
Atul Gawande continues in Chapter 4 with vignettes of frail elderly individuals facing loss of independence, and the difficult choices they face. This time it is the story of Lou Sanders, a gregarious ex-veteran living in a working class Boston neighbourhood. Lou's comfortable life starts unravelling soon after his wife’s passing. As an aside, it is notable how a ‘tipping point’ often is the death of a partner (and though there have been no stories so far of single/unattached individuals, I suspect they would be doing much worse at this stage). [note to self: buy flowers on the way home tonight]. Being a very social person, Lou is adamant in refusing to move to a nursing home ‘full of old people.’ He even forces his daughter to swear to never ship him off to a nursing home. After a heart attack, followed by Parkinson’s and additional falls, he agrees to move in with his daughter Shelley, an extraordinarily supportive and willing caregiver. The realities of the modern nuclear family however intrude, and this transition is not as smooth – unlike the story of the author’s grandfather Sitaram living in a large joint family. The toll of being a full time working professional, homemaker, and also caregiver for her father’s increasing needs proves to be too much for Shelley. Medical problems include hearing difficulty, prostatism, incontinence and continuing falls. The last is exacerbated with postural hypotension (likely due to the autonomic dysfunction common with Parkinson’s – and/or the drugs used to treat it). Lou continues to refuse moving to a nursing home, and is ultimately and unhappily transitioned into an assisted living facility.
The story of assisted living facilities, and how they came into being is one of the amazing stories that make Being Mortal such a compelling story. It is the story of Keren Brown Wilson, and her stroke-struck mother’s plaintive request to her, ‘Why don’t you do something to help people like me?’ Keren mother's request was a plea for autonomy and respect.
“She wanted a small place with a little kitchen and a bathroom. It would have her favorite things in it, including her cat, her unfinished projects, her Vicks VapoRub, a coffeepot, and cigarettes. There would be people to help her with the things she couldn’t do without help. In the imaginary place, she would be able to lock her door, control her heat, and have her own furniture. No one would make her get up, turn off her favorite soaps, or ruin her clothes. Nor could anyone throw out her “collection” of back issues and magazines and Goodwill treasures because they were a safety hazard. She could have privacy whenever she wanted, and no one could make her get dressed, take her medicine, or go to activities she did not like. She would be Jessie again, a person living in an apartment instead of a patient in a bed.”
So Keren and her husband, both academics, sketched out a plan for a new kind of place, and cleared endless bureaucratic and and financial hurdles to open ‘Park Place’ in Portland, Oregon. It had many innovative, almost radical, components – one of the most important being that the residents were called ‘tenants’, not patients, and had many more rights – such as a locked front door to their apartments. Despite this increased freedom, there was no trade-off with worsening safety as feared. The state of Oregon made Wilson track data – and it revealed improved outcomes (including satisfaction) with lower costs. In hindsight, much of this is now unsurprising, if we consider Maslow’s hierarchy of needs.
ource: https://en.wikipedia.org/wiki/Maslow's_hierarchy_of_needs#/media/File:MaslowsHierarchyOfNeeds.svg ; used under Creative Commons license.
Much of the research in this area is done by Laura Carstensen, now a Stanford Professor in Longevity, but once a high school educated almost single mother (read chapter 4 for the truly amazing story of how everything changed for her). Perspectives change as the end of life appears closer on the horizon, and comfort and companionship become valued over other ambitions. Unfortunately, the kind of assisted living started by Keren Brown Wilson has now morphed into something else entirely, with very few facilities including the core concepts from her original vision. The fate of Lou Sanders was in one such place. After initially coping and adjusting, the falls and more critical events force Shelley to ‘place’ him in a nursing home...
“a medically designed answer to unfixable problems, a life designed to be safe but empty of anything they care about.”
The power of Twitter
Last week, NPR ran a story on their Shots Blog based on a paper from JAMA Surgery, Quality Improvement Targets for Regional Variation in Surgical End-Stage Renal Disease Care. The story was one sided, and without balance. The truth is that irresponsible nephrologists are not the primary reason patients don't start dialysis with a fistula. Swapnil saw the post and went on a bit of a Twitter rant discussing the limitations of both the post and the article on which it was based. As is typical for our Twitter renal community, a number of other nephrologists chipped in with poignent observations and tweets. It quickly became a great academic discussion on the difficulties with fistulas.
I collected the relevant tweets and published a Storify of the entire event.
A few hours after I published the Storify I received an e-mail from Nadia Whitehead, the author of the NPR post. We did a 15 minute phone interview where I was able to provide some balance to the original article and I urged her to call Swapnil for some more feedback. She did that and posted a follow-up article a few days later.
I think this is a pretty good example of why doctors need to participate in social media in open networks like Twitter rather than behind the locked doors of private physician networks like Doximity and Sermo. We need to be engaged in the same media and networks that the public is immersed in so we can be heard and reman relevant. I think it also shows the value of curating these discussions with a tool like Storify. I played a minimal role in the discussion but she reached out to me, primarily, I imagine, because I was the author of the Storify. The Storify is what triggered the action on her part.
Being Mortal: Chapter Three
Graham Abra wrote this summary.
Chapter 3: Dependence
The chapter begins with the stories of Bella Silversone and Alice Hobson who struggle and are unhappy with their experiences in assisted living and skilled nursing facilities.
Gawande uses these narratives to set the stage for how society has handled the care of people as they age. In the United States, in the early 1900s, if individuals did not have family or financial independence the only option once they were unable to care for themselves was a poorhouse or almshouse. These institutions housed not just the elderly but also the mentally ill, young drunks, and out-of-luck immigrants. Housing was provided in exchange for labor and conditions were generally poor.
Although poorhouses have now disappeared as places of care for the elderly in the United States they have been replaced by institutions that often require us to give up most of the control of our lives. How this happened is the story of the medicalization of natural aging.
In 1946, the Hill-Burton Act provided large amounts of federal funding for communities to build hospitals. Medicine was becoming more powerful and for the first time was actually curing previously fatal diseases. Social security might have provided financial support but it didn’t “cure” infirmity and so the hospital became an attractive option for the elderly infirm.
Unfortunately medicine had no answer for the ravages of time and chronic illness so the hospitals began to fill with the elderly who were unable to care for themselves as the poorhouses emptied and closed through the 1950s. As their beds overflowed hospitals lobbied for help and in 1954 funds were made available for custodial units that provided a place for patients in need of extended “recovery.” Thus was born the “nursing” home.
In 1965 the Medicare bill passed and payment for medical services for elderly Americans in facilities that met basic health and safety standards was available. Unfortunately many parts of the country lacked access to such places and so, fearing a political backlash, the concept of “substantial compliance” was created – allowing facilities that were “close” to the standards and trying to improve to qualify for payment. This opened the door to profit through underfunded service. With a belief in the power of medicine to cure and payment on hand, 13,000 nursing homes were built by 1970, many with substantial quality problems.
The quality problems have improved over time and have been replaced by a focus on control and safety in order to meet payment requirements. The institutions where 50% of us will spend a year a more of lives were not designed to make life worth living at the end – they were designed to meet other goals.
After losing her love for life and signing a DNR, the chapter ends with Alice’s death.
Being Mortal: Chapter Two
Edgar Lerma, [EL] Chicago nephrologist and father of #NephPearls worked with Joel on this summary of the second exciting chapter of Being Mortal.
Chapter Two: THINGS FALL APART
Chapter Two looks at how life and death have changed with modernity. Gawande describes how the lifespan has increased from around 60 in the 1930’s to somewhere in the 80’s today. But he goes on to emphasize that the life span does not quite capture how much the shape of mortality has changed. He points out that modern medicine has dramatically reduced childhood mortality. Please look at the story of John Leal and his role in reducing infant mortality by 74% by inventing the concept of chlorinating city water.
Gawande describes the change in the ‘trajectories of life.’ In the past, life appeared to be a continuum, curtailed by disease or injury. This could happen at anytime from infancy, to childhood, to adulthood to older age. The risk was relatively flat, one day you were alive and the next you were kicked by a horse, or infected with influenza, or had a heart attack, and the next day you were dead. Modern medicine has changed that trajectory in a couple of different patterns. The most successful medical practices delay or prevent acute deaths. Treatment of serious infections or trauma care are good examples. Even some cancer therapy is successful at delaying the onset of decline without changing the basic pattern of health until a final acute loss:
“People with incurable cancers, for instance, can do remarkably well for a long time after diagnosis. They undergo treatment. Symptoms come under control. They resume regular life. They don’t feel sick. But the disease, while slowed, continues progressing, like a night brigade taking out perimeter defenses. Eventually, it makes itself known, turning up in the lungs, or in the brain, or in the spine, as it did with Joseph Lazaroff. From there, the decline is often relatively rapid, much as in the past. Death occurs later, but the trajectory remains the same.”
But for others, including those with chronic and progressive diseases, the trajectory has ups and downs, and following every deterioration, any recovery is incomplete and the overall trend is accumulating burden of illness. A classic example is chronic kidney disease. It is a chronic and progressive disease marked with episodes of AKI that further reinforce and accelerate the decline. People become weaker and weaker with incomplete recovery.
The effect of medicine has also introduced (or made more prevalent) a new type of death, a third pattern, a pattern not influenced by acute or chronic disease but just a slow withering decline, death by old age. Gawande spends a few great paragraphs describing the normal deterioration of aging and medicines frustration in dealing with it. Some facts:
- By age 60, people in industrialized countries have lost on average a third of their teeth.
- “As we age, it’s as if the calcium seeps out of our skeletons and into our tissues.”
- More than half of people develop hypertension by age 65
- Peak cardiac output occurs at age 30 and deteriorates after that
- By age 85, 40% of people have textbook dementia
This resonates with my [EL] CKD practice. I am repeatedly explaining that from age 40 onwards kidney function deteriorates as pat of normal aging. Furthermore, uncontrolled diabetes, hypertension, along with acute illness, accelerates this decline. My job, all of our jobs, as kidney specialists, is to slow this inevitable decline.
Gawande emphasizes that this deterioration is normal and unavoidable. We hold up the exceptional 97-year old marathoner as something to strive for rather than a story of remarkable genetic luck.
He then describes various theories about aging and different models to explain why we age. He looks at models of aging from complex systems to genetics. He describes the cellular mechanics of aging in skin, hair, and the eyes. It is a fascinating trip through the biology of aging.
As part of this tour we are introduced to Dr. Felix Silverstone a senior geriatrician at Parker Jewish Institute in New York. He is introduced as an expert geriatrician with over a 100 publications. He is is however old and now experiencing what he spent a career studying.
These societal changes bring about two revolutions: a “biological transformation” of the course of one’s life and also a “cultural transformation” of how one thinks about that course.
One of the societal changes of modernity has been the ‘rectangularization’ of the pyramid of life.
n the past, the elderly tended to be outnumbered by the younger generation; however, as people tend to live longer, there are almost equal numbers represented by the young and the elderly. This has wide ranging implications. For one, the number of people supporting retirees is shrinking compared to the number of retirees. The time when a large working population is supporting a small number of retirees is gone.
The second issue that he brings up is that medicine has done a poor job preparing for the changing demographics. The number of geriatricians with the skill and experience in handling such patients is not keeping up with the need. Structural changes in medicine perversely are causing geriatric centers to close in the face of increasing need.
“Although the elderly population is growing rapidly, the number of certified geriatricians the medical profession has put in practice has actually fallen in the United States by 25 percent between 1996 and 2010.”
As a subspecialist, I [EL] tend to view my patients in a reno-centric point of view. I feel that I am very good at diagnosing and treating kidney related problems. However, I do realize that as I fix my patients’ kidney related issues, e.g., blood pressure control, diabetes control, etc., there are some on the problem list that won’t ever get resolved, e.g., the lower extremity edema of my CHF patient with LVEF ~ 10% or the salt intake of my patient who depends on Meals on wheels, etc.
Oftentimes, my untrained mind, wonders why is it that whenever I see elderly patients, it’s as if the primary care provider hasn’t adjusted their BP meds or checked their proteinuria, etc. Gawande addresses this by explaining that geriatricians have a unique point of view. An example is a story about Dr. Juergen Bludau, a geriatrician, who paid more attention to an elderly patient’s feet, and if she is able to bend over to clean them. It all boils down to the idea that this intensely practical approach translates into decreased falls. Dr Bludau said that “the job of any doctor is to support quality of life: as much freedom from the ravages of disease as possible, and retention of enough function for active engagement in the world.” Gawande describes how effective the work of geritricians is by explaining a landmark randomized controlled trial of geriatric versus usual care.
“Within eighteen months, 10 percent of the patients in both groups had died. But the patients who had seen a geriatrics team were a quarter less likely to become disabled and half as likely to develop depression. They were 40 percent less likely to require home health services.
These were stunning results. If scientists came up with a device—call it an automatic defrailer—that wouldn’t extend your life but would slash the likelihood you’d end up in a nursing home or miserable with depression, we’d be clamoring for it. We wouldn’t care if doctors had to open up your chest and plug the thing into your heart. We’d have pink-ribbon campaigns to get one for every person over seventy-five. Congress would be holding hearings demanding to know why forty-year-olds couldn’t get them installed. Medical students would be jockeying to become defrailulation specialists, and Wall Street would be bidding up company stock prices.
Instead, it was just geriatrics. The geriatric teams weren’t doing lung biopsies or back surgery or insertion of automatic defrailers. What they did was to simplify medications. They saw that arthritis was controlled. They made sure toenails were trimmed and meals were square. They looked for worrisome signs of isolation and had a social worker check that the patient’s home was safe.
How do we reward this kind of work? Chad Boult, the geriatrician who was the lead investigator of the University of Minnesota study, can tell you. A few months after he published the results, demonstrating how much better people’s lives were with specialized geriatric care, the university closed the division of geriatrics.”
The chapter closes by rejoining Felix Siverstone as he ages and enters a nursing home with his wife. He thrives in this environment and even starts a journal club for retired physicians (NephJC geriatric edition!)
The chapter is a great set up for the rest of the book, it informs the readers, sets the stage, raises the stakes. The tension is set.