Science and technology can be transformative, but "neither is well suited to addressing critical aspects of human life, from individuality to suffering to wellness," writes Louise Aronson, a geriatrician at the University of California, San Francisco, in her new book. "This is especially true," she writes, "in the years after a person turns sixty." Despite this fact, the number of doctors who specifically address the problems of the elderly is small. Of the roughly 223,000 primary care physicians in the U.S. only about 4,000 are geriatricians, according to the American Medical Association--although older adults make up more than 40 percent of hospitalized adults.
American medicine in the 21st century "worships machines, genes, neurons, hearts and tumors, but cares little about sanity, walking, eating, frailty or suffering," writes Aronson. She argues against viewing old age as a curable disease rather than a stage of life, like childhood, that should be addressed with sympathy and studied with care and discernment.
We caught up with Aronson by phone during her book tour for Elderhood; Redefining Aging, Transforming Medicine, Reimagining Life. Below is a transcript of the conversation, lightly edited for clarity and brevity.
In the book, you complain of the information missing from electronic health records (EHRs) and the amount of incorrect or unreadable information that fills them. How is that affecting medical practice?
Everywhere I've been to talk about my book, everyone says, "What is it with the doctors never looking at me or touching me?" Everyone asks the same question. In Portland after I gave a talk, someone told me that [a local health] system had just reduced primary care appointments from 15 to 10 minutes. If you come in with a cold, that's fine. But let's say you're 80, or 60, or even 40, with a new cancer diagnosis — you can't heal, you can't have an important therapeutic relationship in 10 minutes. So they are setting up patients for bad care and clinicians to burn out. Most people enter medicine to take good care of patients. The level of moral distress is overwhelming if you can't do that.
I have done this crazy thing where I have a less than full time job that allows me to schedule extra time so I can pay attention to my patients in the office and later write a good note. Otherwise I would have had to stop seeing patients. For a long time I wrote two notes in one — one for billing, one with important clinical information. It was insanity. Now it's a bit better. I do only one note, but it still has a lot of irrelevant information and it takes a lot of time. I can see another provider's note, which is great … sometimes. Yesterday I saw a neurosurgical consult from a patient with a new brain lesion. In the free text, it listed a variety of signs and important findings the patient had reported. Then the review of systems and physical — which Epic calls "smart text" and I call "robo-text" — said the exact opposite.
The shortcuts lead to colossal misinformation. It's fascinating! Efficiency has gone down, the doctor-patient relationship eroded, records are full of bad information, and the doctors know it, the health systems know it, Epic knows it, yet people keep adopting these systems. With the actions they take and where they put the money, health system leaders absolutely are saying the doctor-patient relationship is of low value, that the mental health of providers is of low value.
What improvements have you seen in EHRs since they were brought in, and what could be done to make them better tools for treating older people?
Already some of the modifications make life better. In Epic there are horizontal four- to seven-layer menus and a few vertical menus, and within those menus were more drop-down menus and sometimes sub-menus in the drop-down menus. Now you can make your own screen so the things you don't use regularly can go away. But it takes time to do that and understand it, so it's biased in favor of people who love the tech stuff. I'm a geriatrician -- why do I need a child growth chart? We have had to fight and fight and fight to get the right information into the chart and instead of a national approach to these problems, each health system is dealing with them on their own.
How is geriatrics doing as a specialty? The pay is far lower than many other fields.
Geriatricians do primary care but we're also in homes, hospitals, nursing homes and do end-of-life care. It has a great range and that has worked in our favor. Reports are it's holding steady, or maybe in the last couple years showing an uptick. There is now so much more information about aging than there was. When I started, you'd see one or two articles a year in the newspapers. Now I have trouble keeping up on a daily basis. Some of the most interesting science in medicine is related to aging. And prevention — instead of just watching people get sick and then coming in with expensive measures to help them, there's all this good evidence for helping you delay disease or frailty. And that interests people … the potential for creativity in aging and a redefinition of geriatrics is huge.
You're a 5th generation San Franciscan. Are your patients facing additional pressures these days because of the tremendous expense of housing?
There's a woman named Eva in the book who had made 30 visits to our medical center in the past year, but an important underlying problem was isolation. She's living up a long set of stairs in the hills, but where is she going to go? She lives in a rent-controlled apartment. You see populations being edged out. The number of older homeless people is just going up and up and up. The homeless aren't all mentally ill or drug users as the media often portrays. A lot of them just can't afford a home anymore. Which is crazy.
You're pretty scathing on EHRs in this book, but surprisingly open to the idea of robot caregivers.
My first reaction to hearing about them, I was in a meeting, and I started mechanically tapping on a colleague's shoulder and saying, "It-ees-O-K--It-ees-O-K." If I am seeing a patient who is living alone and hasn't seen anyone in a month I often feel that touching them is the most important thing I can do, which is tragic. Robots shouldn't be an excuse to abdicate care. But if a robot can do things — like lifting people into beds — that risk hurting caregivers, and thereby give the humans more time for social interaction, that would be really good. When my father needed help to go to the toilet he told me, "Now I'm officially an old man." That was a good insight. If you could tell your robot to take you to the toilet and didn't have to feel shamed in front of an adult child, that would be awesome.
You've met your share of Bay Area techies?
Yes, there is a huge market to placate the worried adult children, who have a lot of power but different priorities from parents. The elderly, like their children, want independence, enjoyment out of life, control, but their adult kids often are driven by concerns of safety and it can get a bit Big Brother-ish.
We had a guy come in, maybe about 30, who was talking about developing sensors for incontinence. He starts out saying, "When people are over 50 they have these needs." I'm sitting between two guys about my age. I was like, "Are you guys wearing your pads?" The idea that 50 is the same as 70 or 90 or 110 was just so funny. Dude, you gotta work on your presentation here! You can't make assumptions about where someone's going to be when they are 50 or 70. The phrase "70 is the new 50" suggests that 70 is bad. In fact, the data shows people are happier, less stressed when they are 70. If people knew that truth, they wouldn't be so scared of elderhood!
This story was written with the support of a journalism fellowship from the Gerontological Society of America, Journalists Network on Generations, and the Silver Century Foundation
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