Mark Williams
Chief, Division of General Medicine and Geriatrics, University of Virginia
"Aging Well Into the 21st Century"

Old age puts our society to the test. What is the meaning of life for that society? What societal benefits are shared as we go through the lifespan? To what extent is our society willing to help us when we approach the end of life?

In thinking of this important obligation I want to focus on three themes. These themes will be themes of diversity. The fact that each of us age at different rates. The second theme is that we have a considerable amount of choice regarding the nature, quality and extent of our old age. And the third theme is wealth and poverty because our historical accounts, our literary sources and our cultural impressions tend to buy us this view towards a more affluent view of aging. It intends to obscure the chasm that can exist between rich and poor.

Now to do this what I would like to do is to speak about aging from seven different perspectives. And I’m going to propose the ambitious task in doing that in approximately twenty minutes. But I think that issues of aging are so interesting and diverse and complex that I would like this to be a discussion and a dialogue. Those of you that know me know that I can easily fill an hour of rambling, but I would prefer to focus my remarks and then use your questions as a way to focus more deeply into aspects of aging.

So the first area of inquiry I want to consider is the biology of aging. Here there is a central fact chronological age and biological age is not the same thing. As we age we become more unique and differentiated. We become less like one another. And this has profound implications in terms of our social policy because if we entertain one-size fits all approach to health care we are destined to mistreat many people that have very special needs.

In my medical practice I see people everyday who have different aging in different organ systems. Some people have young brains and old joints, young hearts and old blatters, or whatever it might be. So again, the central fact that we age uniquely and individually through life has very important policy implications. And the way that we think about those changes, the malaise that we feel with the changes that naturally occur when we age is a reflection of our societal values and how they influence our own views About how our bodies change over time. We could spend a lot of time talking about that.

The second area has to do with changes in our intellect. Are we destined to become senile, forgetful and fall into a state of mental disrepair? The answer to this question is no. For most of us the fear that we will become dependant on others because of mental impairment is ungrounded. To be sure there are a number of conditions that cluster in old age and I would like to remind you of three very important symptoms. The first symptom: forgetting where you placed your car keys -- you may know someone with this symptom. The second symptom: forgetting someone’s name at a social event. The third symptom: walking into a room and saying, “Now what did I come in here to get?” These are symptoms of being perfectly normal. These are not the early warning symptoms of Alzheimer’s disease. Why is this funny and a concern? Because in our society, an older person cannot afford to make a mistake; so that if we forget someone’s name -- I have a wonderful family, a beautiful wife, two children, two boys 17 and 13. As far as my 17-year-old son is concerned, I already have progressive dementia. He already knows as much as I do and then some so there are these differences in our expectations about mental status. And in a way I would like to say that in regarding mental capability that aging particularly mental changes may be a myth and that what happens is we grow old in other peoples eyes and then those other people convince us that we are old. Kind of gets back to the Satchel Page quote “How old would you be if you didn’t know how old you were.” But because our society is intolerant of mistakes in elderly people.

My advice to medical students at the University of Virginia is this if you a secret fantasy do it now don’t wait until your 75 or 80 if you want to Las Vegas to play the slot machines if you wait and do that the age of 75 for the first time your family is going to wonder if this person has all of a sudden developed a problem.

The third area I’ve spoken of the changes in our body and the uniqueness that occur over time. Changes in our intellect creativity have no upward age limit and we could talk about that for several hours. The third area has to do with the psychology of aging the view from within. How do we relate to these various stereotypes and views about aging? We can tell those stereotypes very quickly and simply by looking at television by looking in print media and getting a sense of how older people are portrayed in the media. If we watch the evening news, now the message becomes loud and clear if you want to be happy in contemporary America you need to be young, good looking and regular.

There are a number of destructive stereotypes and I’m going to over state them to make a point but these are very insidious in our society. One stereotype portrays the older person as a doddering old fool, a forgetful stumbling around kind of person. Everyone’s worst nightmare and stereotype about aging and there are a number in the media. And not to long ago there was this complete denial of aging stereotype some automobile company had a car going through a children’s playground and then it said aging ahead and the car made this detour and goes off in the desert somewhere to do who knows what. But that’s one type of stereotype the other type of stereotype is more subtle. That shows the older person in a state of continued youthful vigor. The older woman who jumps off the golf cart waltzes in and puts on a plastic undergarment to control urinary leakage and goes off into the sunset with her husband. The problem with that is not so much that it’s a positive image that’s wonderful, but when people don’t live up to these unrealistically high ideals they seem to think the problem is within them rather than having it as a societal stereotype.

The fourth area is family as the microcosm of culture. People who give care to others when they need it tend to receive care when they need it. Societies that treat children well tend to also treat older people in that society well. This is a lesson that seams to resonate throughout history and through various cultures. Now a days our family network is different. In the past the family caring for elderly people was a societal expectation and it still is a major and dominant expectation. But things have changed. We tend to rely more on others and government and state programs for that care rather than our family resources. How do we deal with these changes in our family? The fact that families lived close together it was a more agriculturally based program. Now family members are all over the globe. Regretfully the divorce rate is about 50 % so that increase within longevity it’s possible to see five-generation family reunions, but it’s also possible for a young child to have six living grandmothers. So these are difficult challenges that our society faces. Generally speaking older people do well in societies that are stable and supportive. Societies that are on the move, in nomadic societies older people tend to do not as well. We can make up our own views about the kind of societies we have now in America and ways that that societies are evolving.

The fifth area is work and retirement. Retirement does not mean enjoying pleasures denied by work. It often means the beginning of an empty future. To afford that emptiness we have to prepare projects that go through our lifespan. There are a number of activities around the Charlottesville area. This is a very rich and robust community. A lot of diversity. A number of social programs. The Charlottesville Senior Center the program at JABA a number of community agencies work hard to provide those options. But we need projects that give meaning to the time we have. I would say to you that in some ways retirement has almost lost its meaning. It may mean a change in the pay scale but not a change in health or productivity.

The sixth area, next to the last, the sixth area has to do with the sociology of aging the fact that old age and members of a society resonate through a sense of group identity and we see this today in the news. We see an individual soldier on the battlefield feeling a sense of responsibility pride and participation as being part of a larger group. So as we age in our society, how do we feel? How does the group treat us? What kind of support is there? There are debates about generational equity. Will there be the funding for older people who need help and services in the future? What about our complexity of our social programs? Our social, medical and healthcare programs which I`m a member are becoming more and more complicated. I’m not convinced with that complexity we’re gaining increase in security or in quality. Now to be sure, there are medical errors and they need to be changed. We have this complex system and all we have to do is inject some quality in that system. It isn’t necessary going to solve it. I think we are very close to the point now that if we simply simplified the process of care, simplified the paperwork, simplified the access give people the choice who they want to see. That will simplification would improve the quality by allowing people to send time on what’s important. Because I have to say to you, that in our contemporary system, when I admit someone to the hospital I have to fill out equitant of an income tax form. It’s getting more complicated and having lived for a while in Rochester, New York I will say the equivalent of a New York State income tax form. Some people know what I mean by that. So again the fact that healthcare professionals in the interest of safety doing the right thing, accountably, responsibility the fact that we spend more time with paper then with people to me indicates a fundamental flaw in our system.

The last area, this has to do with the power of mortality and the fact that old age is counterpoised against the certainty that we die. The meaning of life in old age really is reflected because it is counterpoised against this certainty. To me understanding and appreciating our mortality invigorates and gives our lives a sense of vitality. What it means is that our moments cannot be relived no matter how affluent you are no matter what our health status is. At the moment we have to confront a finite future. The death rate in this country is one per person it has remained remarkably constant, but rather than again being pre-morbid preoccupation with death, to me it adds a sense of expectancy and excitement, awareness and appreciation. It means when I kissed my wife goodbye this morning it was with the expectancy that we were going to be apart. I don’t have any guarantees I know the law of probability is in my favor and that I will very likely get home and enjoy a joyous reunion with her again. Every time I drive 29 I’m reminded we don’t have guarantees. And if my time comes today and I look death in the face the least I can say is I have said my goodbye. I will not have that I wish I had done this that or the other.

So In summary when we think about aging we’re not thinking about a disenfranchised minority, we are thinking about our own selves in the future and therefore the issue is not what does aging mean or what can I do? The question is who are we becoming? What are we sowing now? And what is it we wish to read? From a stand point of health policy and because I know there are some very important and influential people in this room that we will be the architects of the geriatric health care system of the future because of that fact we will get what we planned for and deserve. And who among us does not deserve the very best. I will stop there and be delighted to entertain your questions.

Do you think at someone the right to die will be a subject of geriatrics?

Williams :

We do a pretty lousy job of care at the end of life in this country and there are a number of aspects and reasons for it. I think for one thing we have successfully insulated ourselves from death. In the old days and not that long ago when people celebrated thanksgiving and there was a turkey or ham or a chicken on the table it was not a great mystery where that food came from. People said grace around the table in this basic celebration that life lives on life. Weather you are a vegetarian or not our bodies are sustained on living beings that we have to consume in order to maintain our health. Nowadays it’s too easy for us to zip through the take-out line of a fast food restaurants or a cafeteria and fail to appreciate that sacrifice that has been made for our behalf and in addition it is the natural human cycle of birth and living and death becoming very mysterious at the end. So I think it gives death more power over is than it needs to. This is played out in hospital after hospital all over the country. And I am not going to pick on our own hospital here at U.Va. which has a very fine palliative care program, we have hospice of the piedmont we have a number of organizations that are attuned to that but even though there is this psychology to medicine in a global nature to do more to squeeze out every last bit of living you can. Again because the death rate is one per person from my value structure there is a time where the quality of remaining life becomes much more important than the quality. So we have a long way to go.

I ask myself sometimes from the standpoint of ethics of medical education. What are we teaching our students what do our students see in this regard. They see a cacophony of mixed messages. And again from a policy standpoint they see that sometimes families could be bankrupted because of insensitive state and federal regulations that really don’t provide the kind of care. I believe there is an awareness and the need to deal with end of life issues but I don’t think that is going to be solved by handing off that care to someone from a palliative care background. It is something that needs to be put back in the covenant between a doctor and a patient.

My own observation is that the reason that we require the superstructure that we have now living wills, powers of attorneys documents that everyone has to keep with them or put on their refrigerator to make sure that wishes are honored while that is a part of our society to me it reflects a deeper picture and that is a symptom of an underlying social diseases. A loss of confidence in the doctor patient relationship. IF we have that confidence if we develop that relationship then we have the documentation. Now to be sure I am required by law to go over that with my patients. And I do that but I have to tell you that deep in my heart even if that person has signed an advanced directive that does not make me sleep any easier at night Now let me tell you what I mean. I will never ever go against a person’s expressed wishes but I also know that sometimes people will change their mind.

When you contemplate the projections for Medicare and the people who don’t have access to a doctor they like or trust, what is to become of people whose doctors are not like you and to whom they have no access?
I think that we need to move away from what I would call a kind of fast food approach to healthcare. That basically says one size fits all, come in to our particular practice plan whatever it happens to be. All of our physicians are pleasant and board certified and so forth. That model devalues the nature if a doctor patient relationship. So let me say, I’ll throw my values right on the table, I don’t believe healthcare is a business. A part of my soul dies everyday when hear in the walls of academe across this nation the medical conversations have changed from what is the latest approach or I’m dealing with a particularly thorny situation can you help me out. The conversations have to do more with market share, with developing a new product line, with increasing the through put in the clinic. Those are the metrics that are used in some places to judge a phyicians productivity. My doctor is a great doctor he has good through put in his clinic. So to me what is missing in the equation is an appreciation of quality. Right now there is such a gap that people go to various physicians and it’s assumed that they are all basically the same. There is no way that a stellar physician can charge more or somehow be acknowledged in the system for people wanting to see that particular person as supposed to next available. I think for freedom of choice in our society somehow we have to link paying for healthcare back to the individual so that people can choose who they want. Many of us will choose convenience depending on the nature of the problem. That is perfectly o.k. I do it myself. Sometimes convenience is what I want. Sometimes quality is what I want and I am willing to wait to see the best or whatever it happens to be. Our system does not really allow that. So I am open for a new experiment in healthcare that somehow maintains freedom of choice that puts the payment control in the hands of the individuals. By doing that I think we will we be able to reward quality because people will go to those individuals who they feel offer more value for their time and energy.