How do we reward this kind of work? Chad Boult, the geriatrician who was the lead investigator of the University of Minnesota study, can tell you. A few months after he published the results, demonstrating how much better people’s lives were with specialized geriatric care, the university closed the division of geriatrics.
“The university said that it simply could not sustain the financial losses,” Boult said from Baltimore, where he had moved to join the Johns Hopkins Bloomberg School of Public Health. On average, in Boult’s study, the geriatric services cost the hospital $1,350 more per person than the savings they produced, and Medicare, the insurer for the elderly, does not cover that cost. It’s a strange double standard. No one insists that a $25,000 pacemaker or a coronary-artery stent save money for insurers. It just has to maybe do people some good. Meanwhile, the twenty-plus members of the proven geriatrics team at the University of Minnesota had to find new jobs. Scores of medical centers across the country have shrunk or closed their geriatrics units. Many of Boult’s colleagues no longer advertise their geriatric training for fear that they’ll get too many elderly patients. “Economically, it has become too difficult,” Boult said.
But the dismal finances of geriatrics are only a symptom of a deeper reality: people have not insisted on a change in priorities. We all like new medical gizmos and demand that policy makers ensure they are paid for. We want doctors who promise to fix things. But geriatricians? Who clamors for geriatricians? What geriatricians do—bolster our resilience in old age, our capacity to weather what comes—is both difficult and unappealingly limited. It requires attention to the body and its alterations. It requires vigilance over nutrition, medications, and living situations. And it requires each of us to contemplate the unfixables in our life, the decline we will unavoidably face, in order to make the small changes necessary to reshape it. When the prevailing fantasy is that we can be ageless, the geriatrician’s uncomfortable demand is that we accept we are not.
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FOR FELIX SILVERSTONE, managing aging and its distressing realities was the work of a lifetime. He was a national leader in geriatrics for five decades. But when I met him he was himself eighty-seven years old. He could feel his own mind and body wearing down, and much of what he spent his career studying was no longer at a remove from him.
Felix had been fortunate. He didn’t have to stop working, even after he suffered a heart attack in his sixties that cost him half his heart function; nor was he stopped by a near cardiac arrest at the age of seventy-nine.
“One evening, sitting at home, I suddenly became aware of palpitations,” he told me. “I was just reading, and a few minutes later I became short of breath. A little bit after that, I began to feel heavy in the chest. I took my pulse, and it was over two hundred.”
He is the sort of person who, in the midst of chest pain, would take the opportunity to examine his own pulse.
“My wife and I had a little discussion about whether or not to call an ambulance. We decided to call.”
When Felix got to the hospital, the doctors had to shock him to bring his heart back. He’d had ventricular tachycardia, and an automatic defibrillator was implanted in his chest. Within a few weeks, he felt well again, and his doctor cleared him to return to work full time. He stayed in medical practice after the attack, multiple hernia repairs, gallbladder surgery, arthritis that all but ended his avid piano playing, compression fractures of his aging spine that stole three full inches of his five-foot-seven-inch height, and hearing loss.
“I switched to an electronic stethoscope,” he said. “They’re a nuisance, but they’re very good.”
Finally, at eighty-two, he had to retire. The problem wasn’t his health; it was that of his wife, Bella. They’d been married for more than sixty years. Felix had met Bella when he was an intern and she was a dietitian at Kings County Hospital, in Brooklyn. They brought up two sons in Flatbush. When the boys left home, Bella got her teaching certificate and began working with children who had learning disabilities. In her seventies, however, retinal disease diminished her vision, and she had to stop working. A decade later, she’d become almost completely blind. Felix no longer felt safe leaving her at home alone, and in 2001 he gave up his practice. They moved to Orchard Cove, a retirement community in Canton, Massachusetts, outside Boston, where they could be closer to their sons.