When ‌‌Doctors Talk About Patients, We Often Begin With Age

From a New York Times guest essay by Daniela J. Lamas headlined “As a Doctor, I See Aging Differently”:

When ‌‌doctors talk about patients in the hospital, we so often begin with age. A 75-year-old man with shortness of breath. A 30-year-old woman with joint swelling. Knowing our patients’ ages allows us to focus on the most likely diagnoses and to develop a mental image of the patient before we enter the room.

But it also serves another purpose. ‌Doctors find ourselves using age to frame the patient’s story and in effect to grade its degree of tragedy. A college student dying from respiratory failure after the flu is unacceptable, an end we must fight against with all that we have. But if this patient were in her 80s, we might think differently of the narrative and the appropriate clinical interventions. Someone in her 30s should receive aggressive chemotherapy or a risky surgery or an organ transplant, but for someone in her 70s, those same interventions might do more harm than good.

This used to make sense to me. A human life span has a clear arc that ends naturally somewhere around the ‌‌eighth or ‌‌even ninth decade. But lately, as my parents age and I enter into motherhood in my 40s with a “geriatric pregnancy,” I have found myself thinking differently about age and its meaning in medicine.

We are at a unique time in this country when it comes to aging. Our president recently turned 80, and the Senate is, on average, the oldest in history. People regularly survive medical diagnoses that would have meant an early death in years past.

At the same time, the field of anti-aging is gaining credibility, with tantalizing data that suggest that science might be able to extend not only life span but also “health span” — the amount of time that people spend healthy and active, with a good quality of life. Though I am a critical-care doctor who tells patients and their families to look death in the eye and acknowledge reality, I am captivated by the promise of longevity medicine.

Throughout my 20s and much of my 30s, the years melted one into another, and I barely noted their passing. But now, at 41, I am pregnant for the first time, an act that assumes a reasonably long future. Perhaps it is also an act of denial. I will be in my 60s when my child goes to college, my partner not much younger. As I plan for new life, I am more aware than ever that time is finite.

Yet aging looks and feels so different to me from what I once thought it would. On a recent trip to my family’s home in Miami, I stood in the backyard and watched as my formerly sedentary 70-year-old father leaped up to grab a set of pull-up bars. He lifted his body against gravity, one pull-up after another, a feat that I have never achieved — even before pregnancy. He keeps a half dozen supplement bottles in his refrigerator, on the same shelves where I once found half-eaten chocolate bars. As his 60s drew to a close and the reality of old age began to creep in, my father — a cardiologist and researcher who has no plans to retire in the foreseeable future — started to delve into the growing body of academic papers on how he might slow the ticking clock.

He e‌mails me the research from time to time, and I sift through it. One message was titled, “Will prob be around for high school graduation.” I took a beat before realizing that he was referring to the high school graduation of his first grandchild, to the fear that his own life will intersect with this little person’s only briefly, to all that we wish we could ignore.

They say that thinking about death is like staring at the sun — you can tolerate it only for a moment before it becomes too painful. It is easier to come at it from my father’s angle, reading not about death but about the science of how to extend life. I find myself drawn in by images of aging mice racing longer, the promise within the science. What if the arc of aging that I have come to expect while working in the hospital is not inevitable?

Longevity researchers would tell you that aging itself is a disease that we can understand and treat, cancer and heart disease and dementia only its symptoms. They would tell you that the first person to live until 150 has already been born. In a way this sounds preposterous, the dream of biotech billionaires, fueled by denial and fear of death and the illusion of control. But on the other hand, there is real science here. So I let myself imagine. Maybe he will make it to that high school graduation after all.

Simply being able to entertain this reality, and even more so thinking that it is in any way within our control, is a privilege ‌ — as was the choice to start a family after my ‌‌40th birthday. The wealthiest among us live on average nearly 10 disability-free years longer than the poorest. As the data behind anti-aging science become more robust and actionable, this difference is likely to grow even more profound.

In the hospital, we see this firsthand. I recently cared for a 50-year-old long‌time smoker and drinker on dialysis who collapsed in his bathtub at home and waited there for a day or more before someone heard him calling for help. As we stood outside his room in the hospital, his nurse and I took note of his age — just a few years younger than the nurse, not even 10 years older than me. “An old 50,” his nurse commented, shorthand to describe a body punished by illness, by decades of chronic stress, by factors that are within and outside our control.

If you could measure my patient’s physiological rather than chronological age, what would you find? We talk about measuring frailty ‌ — weakness and fatigue and decreased physiological resiliency. This is most likely more meaningful than chronological age when it comes to making medical decisions about what interventions a patient can withstand, but the metric is murky‌‌ and without a gold standard.

On the forefront of longevity science, there are companies that offer a simpler answer. Prick your finger and send off a few drops of blood, and in return you will receive a report that offers its own estimate of your genetic age, based on impurities in your DNA and the length of your telomeres ‌— the protective DNA sequences at the end of our chromosomes that shorten and fray over time. Perhaps this value is meaningful, but it is not entirely clear that having a younger genetic than chronological age confers a longer or better life.

But it might. And so there’s a part of me that’s tempted to send off my own blood, but I am not sure I want the information that I would receive in return. Perhaps it would worry me; perhaps it would offer me false reassurance. Either way, as I make the rounds of my patients in the intensive care unit and feel the occasional stirrings of the growing baby within me, I am aware that even if we can slow the clock, there is never enough time.

A few months ago, I found myself in a panic about a mole on my back, convinced that I had developed melanoma. This is not an implausible fear — we see stories begin this way all the time in the intensive care unit. I could imagine the patient presentation: a 41-year-old woman with no significant past medical history, six months pregnant when she was diagnosed with metastatic melanoma. I scheduled myself an urgent appointment with a dermatologist, who took one look at my back and announced that I had no reason to worry. These were simple “age spots.” For a moment I was taken aback. ‌ “Age spots? But I’m ‌‌——” ‌

“In your 40s,” she interjected, kindly but firmly. “It’s only natural.”

Daniela J. Lamas, a Times contributing Opinion writer, is a pulmonary and critical-care physician at Brigham and Women’s Hospital in Boston.

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