'Aging in the Modern Age'

CAERS SUBSTACK ARTICLE #69

‘Aging in the Modern Age’

CAERS Substack Article #69

I turned 65 last year so that officially makes me a senior citizen, or as I refer to it, ‘an old fart’. I’m getting more aches and pains, I don’t have the energy I once did, and fewer things excite me. But I am not complaining; I have known too many people who have died much younger so I feel very blessed.

In fact, I am at the age where death is more on my mind than ever before. In some ways this is rather odd because for much of my career death was a part of my everyday life: I had an older practice, I cared for patients in nursing homes and I did palliative care as well. But it is different now; those closest to me are dying, not just patients under my care, and at some point, I will be among them. Both of my parents are deceased, so the stage when my generation are the ones expiring has suddenly crept up on me.

I have found over the years that for many people there is a point at which they come to peace with dying because they have been through enough and see little or no chance of the situation reversing. Sometimes their loved ones accept that, and sometimes they don’t. It is not this stage that worries me. What gnaws at me is the time before that, when I am fairly sickly but there is still some hope that I may survive with reasonable functioning but it requires enormous energy, work, and often extensive interaction with the medical system to make it happen. In other words, like most of us, I suspect, I want that period of time to be as short as possible; get better quickly or let go, but don’t linger in a frustrating and painful limbo for too long.

In many respects, we have been in a kind of limbo the last few years during the pandemic; so many of our usual activities, including exercise, were put on hold under the threat of impending disaster. I feel that I have aged a lot more than 3 years since March 2020 when COVID reared its ugly head, and that my death is far closer because of it. But there is something even more worrisome that is disturbing me.

Despite the fact that many tens of billions of additional dollars have been injected into the medical system the last three years, I think that there is some evidence that mainstream medicine has never been in worse shape. I don’t think the backlog has been cleared yet. I don’t believe the care of the elderly and most vulnerable has improved significantly. I sense that those still working in the system are more burned out and demoralized than ever.

All of these serve to amplify problems already in existence prior to the pandemic. I have always supported the wise use of technology in health care. Medicine is a data driven endeavour so it makes sense to utilize computers, for example, to manage and communicate important data well. But in the process, we have failed to realize that technology is a means to an end, not an end in itself. The goal is to deliver good patient care, not simply to complete electronic forms nor to develop policies that will guarantee accreditation for medical facilities.

I applaud the trend towards more ‘evidence-based medicine’, but beyond the incredible difficulty of gathering good evidence, it is primarily a left-brain exercise and will always have its limits. Intuition and clinical judgment have their place. So do experience and clinical acumen. These have largely been replaced by protocols, guidelines and algorithms that to a significant degree remove thinking and feeling from clinical care. Social skills are already underdeveloped in many who have grown up in the texting-not-talking twitter-verse. And that has spilled over into health care, the one place where interpersonal relationships are of paramount importance. Lack of bedside manner is a common complaint among those receiving care. Given my training, I have become cynical about whether those in the system have much understanding of, or use for, medical ethics.

So, it is not just my becoming older and frailer that concern me. It is the fact that I have less trust that the system in which I worked and served the public will be able to care for me and reduce my suffering. The system is a microcosm of the world itself: it has become more money- driven and materialistic. I have seen how much profit drives research and clinical care. And like the world in which it is embedded, it has become shallower: we don’t know how to have ‘difficult conversations’ anymore. Instead, we stare at our computer screens, order more tests and offer more new therapies so as to avoid authentic conversation about gut-wrenching issues.

Active surveillance, rigorous intelligent dialogue and progress-enhancing controversy, all hallmarks of medicine in the past, were all but absent during the pandemic and that is deeply troubling for me. I feel very fortunate to have had the career I had, so I take no pleasure in saying that I worry about the direction the profession is heading and I dread interacting with it. A continued expansion of MAID (Medical Assistance In Dying) that outstrips our understanding and use of medical ethics is not the sign of a well-functioning, compassionate system.

Trust is such an important part of interpersonal relationships. It can take a long time to build but can be lost quite quickly and I am afraid that my rapidly waning trust in the medical profession is not isolated to me alone. In addition, I feel more out of touch with the values that guide our world today. How much emphasis is there on nurturing the virtues of integrity and conscientiousness rather than the narcissistic pursuits of fame and fortune? How much do we encourage rational thought, fairness and respectful dialogue rather than obsession with our own feelings?

Maybe these are the kinds of questions people throughout history have often asked when they reach my age. If so, likely it is simply a reflection of having been around long enough to see patterns that are less obvious when we are earlier in our journey. Our values should change, and improve, as we mature if we want our species to survive and grow. Each generation needs to do better than the previous one for that to happen. Let’s hope that aging in the modern age meets that expectation.

J. Barry Engelhardt MD (retired) MHSc (bioethics)

CAERS Health Intake Facilitator