A personal choice

understanding of a “natural order” and a language that separates “disease” from “health”. Instead, we are fast learning a new language: the language of risk. Our patients are patients not because they have disease, but because they are “at risk”. We are moving from practising medicine at the bedside, to practising it at the deskside. We are fast becoming economists. Who am I? When I interviewed for my current position, I made it clear from the first day that I was not alone, that if I were to move to another job, I would move with my partner. The section chief was candid and to the point. “I understand”, she said. “Faculty bring families and we have to accommodate this.” That remark sums up much of how our lives together have been. When a benefits counsellor noted that my partner was the beneficiary of my retirement income, she remarked that I should fill out benefits forms for him: library, gym, health insurance. I have never met resistance to who I am. My partner and I pass Christmas with relatives. Friends regard us as a couple. Real-estate agents want to sell us a house. We are a part of the natural order. Who are the elderly? They are people who experience ageing, which means they are at an ever-increasing risk of losing function and dying. In the industrialised nations, ageing is a big issue. The USA has a national institute devoted to ageing. The elderly are entitled to federal monies for retirement and health care. There are communities dedicated to them: apartment complexes, nursing homes, continuing-care communities. The names pile up. As a result of these various efforts, we are changing the thing called ageing. Compare textbooks of today with those of 30 years ago. There is dementia, systolic hypertension of the elderly, osteoporosis, and the latest disease—the loss of lean body mass called sarcopenia. The remark made by a senior cell biologist at a US National Institute on Aging meeting best expresses this change: “Once I thought I understood the distinction between ageing and disease. Now I plainly confess I no longer do”. In sum, the elderly are a major public-health concern because, despite all the talk of “natural ageing”, ageing has become a disease. What kind of disease is it? Symptoms do not count much any more. Many of our patients feel well. We no longer encounter them at the bedside, but at the deskside I am a physician, specifically a geriatrician. The Greek roots of the word physician mean that to be one is to be “a scientist of nature”. My goal is to restore my elderly patients to their natural state. But I am suspicious that “naturalness” is the condition that justifies what I do and who I am. I am suspicious because I cannot accept that ageing should happen because it is natural, any more than I can accept that tooth decay should happen because it is natural. Suspicious too because as a gay man I cannot accept the claim that the way I live is “unnatural” and therefore wrong. In short, I am in a bind: as I experience an everincreasing incorporation into the natural order, my patients experience less. As the naturalness of homosexuality waxes, the naturalness of ageing wanes. In this century, as gays were removed from textbooks of pathology, the elderly came into them. What does this tell us about how we practise health care? That even the most seemingly objective enterprises such as science and medicine actually derive their meaning and direction from an ever-changing culture? This simple fact of anthropology states the obvious. But how is this culture changing? The answer to this question begins to explain how it is that I am no longer “ill”, but that my chronologically old patients increasingly are, whether they feel that way or not. An anecdote helps explain what is happening. At a recent national geriatrics meeting, a youthful physician gave a talk entitled: “Successful clinical components in managed care for the frail elderly”. The speaker showed slides of pathways and networks, and spoke of relative risks and odds ratios. Disease management. At question time, an elderly physician stepped before the microphone, grimaced, waved his hands, and announced: “This isn’t medicine . . . This is economics. Where’s the medicine?” The speaker did not hesitate. “This is the medicine”, he insisted. “This is economics.” And then he said it. “I am a geriatric economist.” The point of this anecdote is that, as physicians, the meaning of what we do no longer comes from a common