Don’t Spoil the Ending

Abigail Zuger in The New York Times:

BookPerhaps we should reform the medical profession by keeping the young and immortal out of it. Let’s bar medical school entry till age 50: Presumably that would fix our present bizarre disconnect between the army of doctors bent on preserving life and the tiny band able to accept death. Doctors would come equipped with the age-bred wisdom to understand the continuum, and they would demand a health care system that did likewise. That’s not happening any time soon. As things stand, though, at least we have the bittersweet pleasure of watching the occasional thoughtful defection from the mighty army to the little band. Dr. Atul Gawande, possibly the most articulate defector yet, has made his considerable reputation primarily as a fix-it man. As a Harvard surgeon he patches up organs; as a longtime writer for The New Yorker he has both described and prescribed for many of our profession’s troubles. The recent widespread enthusiasm for checklists to minimize medical errors can be traced more or less directly to his pen. Now Dr. Gawande (heading for 50) has turned his attention to mortality, otherwise known as the one big thing in medicine that cannot be fixed. In fact, the better doctors perform, the older, more enfeebled and more convincingly mortal our patients become. And someone should figure out how to take better care of all of them soon, because their friends, neighbors and children are at their wits’ end. It is one thing to understand this helplessness, as most young doctors do, by watching the trials of patients and their families; as an observer Dr. Gawande has visited this territory before. It is quite another thing to be socked in the gut by age and infirmity unfolding in one’s own family — an experience that has to be the world’s finest postgraduate medical education.

Dr. Gawande completed that curriculum in three courses: his grandfather’s extraordinarily long and atypically happy old age, his wife’s grandmother’s extremely long and typically unhappy old age, and his own father’s struggle with age and illness. The grandfather lived to almost 110 years old in a small Indian village, surrounded by family members who cared for him and catered to his every whim. All was not idyllic — a patriarch’s prolonged survival can certainly play havoc with everyone’s financial expectations — but his was the kind of empowered aging to which most aspire. Instead, what they usually get is the slow entrapment experienced by Dr. Gawande’s grandmother-in-law, a self-sufficient New Englander whose horizons were increasingly hemmed in by the terrible dictates of “safety.” She was not safe to live alone, not safe to drive, not safe to manage her own finances — she was not safe to live at all, really, yet condemned to live on. A balance between a reasonably risk-free old age and one worth living is surpassingly difficult to devise; it is the rare institution or family that manages it, as Dr. Gawande’s extensive reporting makes clear.

More here.