Reflections on a Half Century of Medical Practice: The art of listening to the elderly patient

In the United States geriatrics is a neglected field. The reasons are not hard to find. Doctoring the elderly is intellectually taxing and extraordinarily time consuming. The elderly never present with a single problem. Their complaints are numerous due to co-morbidities involving different organ systems. In addition to addressing multiple symptoms, the doctor needs to sort out whether the patient’s ailments relate to a polypharmacy of drugs. If this were not taxing enough , obtaining a careful history is waylaid by the infirmities of old age. Patients are forgetful, are easily distracted from the key issues, and meander to the unrelated. Further, a doctor has to decipher whether the complaints are a consequence of the psychological stresses of daily living or augur some serious malady, while a depressed mood can magnify a commonplace disorder till it becomes a life-threatening condition.

Our population is skewing to the oldest. Those 85 and over are increasing by around 165 percent annually, far more than any other age group. The elderly account for much of the ever-mounting health care expenditures. One would surmise therefore that geriatricians would be intensely recruited and highly recompensed. The very opposite is true. They are an endangered species and the lowest paid among medical specialists. The reason for such perversity is straightforward: Market medicine, the system undergirding American health care, is oriented toward maximizing profits for investors. A far larger return can be extracted from intervening with tests and technology than from human interactions. The topsy-turvy economics of health care thus tilts toward procedures. The highest remuneration goes to specialists who are essentially technologists focused on particular organ systems. Over the past several decades, the far more profitable technological procedures have been replacing time-consuming history taking and listening to patients.

The essential thesis of this essay is that listening to patients is the bedrock of a sound health care system. It is especially important in caring for the older patient. My great teacher and cardiology mentor at the Peter Bent Brigham Hospital (now Brigham and Women’s Hospital) in Boston, Dr. S.A. Levine, taught me that listening is the quintessential art of clinical medicine.(1) It is the most difficult of all the skills in the physician’s repertoire. Even after five decades as a clinician I have not quite mastered that elusive art.

Obama, the Promise of Nuclear Abolition, and the Nobel

I continue to be asked about Barack Obama and the Nobel Peace Prize. A previous essay dealt with some aspects of the issue. My brief answer is that he did not merit the big prize, yet I am pleased that he is the recipient. This contradictory response deserves elaboration.

The new president inspires hope. An end to the malignant Bush era is a relief not only for Americans but for the entire world. Sharp changes from catastrophic foreign and domestic policies have been promised. Among a generation of anti-nuclear activists, expectations are high that President Obama will begin dismantling nuclear arsenals.

Indeed, on April 5, 2009, a mere 10 weeks after occupying the White House, in an open-air rally in Prague’s Hradcany Square, Obama stated:

“The existence of thousands of nuclear weapons is the most dangerous legacy of the Cold War… . Today, the Cold War has disappeared, but thousands of those weapons have not. In a strange turn of history, the threat of global nuclear war has gone down, but the risk of a nuclear attack has gone up.”

He added:

“As a nuclear power, as the only nuclear power to have used a nuclear weapon, the United States has a moral responsibility to act. … So today, I state clearly and with conviction America’s commitment to seek the peace and security of a world without nuclear weapons.”