“I am wearing polka-dot boxers today,” said Kyle Thorndike with a smirk revealing teeth as straight and white as piano keys.
The other twenty students let out short, nervous chuckles, except for the poker-faced Jennifer Stein, who sat next to Kyle and was the next in line to speak. My instruction to the second-year medical students gathered in the drab basement room of the hospital had been this: Introduce yourself by saying something that nobody else in the room knows. After the first grueling year of medical school, the students already knew each other quite well, bonding in lecture halls and tutorial rooms, Facebook wall posts and weekend parties. Over the years, I have found this a good way to break the icy gloss of competitive anxiety that the students come with on the first day of class.
“TMI,” hollered Cathy, who had just revealed that she was allergic to peanuts. Everyone laughed some more.
There’s about a fifteen-year age spread between my students and me, but their lingo had somehow seeped into my vocabulary, from TMI (too much information) to PIA (pain in ass) and KISS (keep it simple, stupid). In the next nine months they will have to learn mine: AMI (acute myocardial infarction), DDX (differential diagnoses), QOD (every other day), WBAT (weight bearing as tolerated).
The laughter slowly died and the class’s attention descended on Jennifer.
“Let’s see,” she began in a deep, leathery voice. “I used to dive and I was part of the national team that competed in Sydney in 2000. I majored in molecular biology at Stanford, spent a year at NIH to do research in cell signaling pathways…”
Listening with half my mind to Jennifer’s treatise of accomplishments, I scanned the young faces before me and wondered what novel paths they would carve with those razor-sharp minds brimming with ambition and idealism, the mental sarcasm yet to creep in. Sure, they all seemed eager enough, but a part of me wondered how many of them truly wanted to learn pathophysiology and physical diagnosis, and how many considered my class only as a necessary nuisance, a way station along the path to the most lucrative specialties in medicine. I knew all too well that during the first year of medical school, as they traced the aorta’s course from the heart to its tributaries in the brain, they gleaned from their senior peers that the ROAD (radiology, ophthalmology, anesthesiology, dermatology) was the straightest path to paying off their medical school debt, a nice house in an upscale town, private school for the kids, and eventually a comfortable, early retirement.
Not too long ago, I was among them, an ambitious overachiever poised to go into a prestigious, high-return-on-investment specialty, perhaps oncology or cardiology. That is, until one summer when I turned my back on all that I had worked hard for and everything I felt I was due.
On a breezy, blustery August morning ten years ago, I flew home to Pasadena from Providence for the first time in a year. It was a strange homecoming of sorts; the previous night had been the last of my medical internship, that rite of passage that transforms medical student into physician. After a year marked by thirty-six-hour calls and marginally edible hospital food, I was glad to be back home—the first doctor in my family—and basking in my parents’ admiration. I feasted on homemade wontons and adobo, as I told embellished tales of my medical exploits. After lunch I lounged in the backyard on my favorite hammock, as turquoise hummingbirds buzzed by and the warm Santa Ana winds lulled me to sleep. I was in that idyllic, postprandial state far away from the stress of the hospital when my mother called my name. Grudgingly, I left the hammock and walked back toward the house.
Half an hour later, I was standing in front of my uncle Pablo’s expansive house in Arcadia. On the car ride over, my mother informed me that to make more money my uncle had turned his house into an old folks’ home, a board-and-care facility that provided care to half a dozen elderly people with disabilities that precluded them from living at home. A brown-skinned, dwarfish attendant opened the door for us and gave a shallow bow as we entered. My mother shuttled me through what had once been the living room but now served as a lobby, past artificial plants and a not-so-grand-looking baby grand piano, past a couple of cotton-haired women in wheelchairs, and through a long, sterile hallway redolent with disability and desperation.
At the end of the hallway, in what must have once been the master suite, lay my grandmother, Celedonia Marcelo. Above the bed hung a still life of a beach scene and a bunch of yellow lilies in a clear glass vase sat on the nightstand. Through the sprays of sunlight filtering through the curtains, I saw that my grandmother’s face was calm, her breathing unlabored. But underneath the closed lids, her eyeballs fidgeted as though they were tracking a hummingbird buzzing from flower to flower.
My mother sat on the edge of the bed and picked up her mother’s rope-veined hands.
“Your Ama was just at the hospital,” she said, gently caressing the papery skin riddled with the needlemarks of intravenous lines and purplish bruises of blood draws.
I stood there in my shorts and T-shirt, flip-flops firmly planted on the plush carpet. The last time I had seen my Ama—“Grandmother” in Chinese—was a year earlier; she was in her kitchen, cooking up a storm of her signature dishes afritada, mechado, arroz caldo, and empanada. She was a short woman with thick gray hair held in a tight bun, large, obsidian eyes, and naturally tanned skin. For as long as I had known her, she had been a ball of perpetual energy, her pear-shaped body bouncing around her house the entire day, cooking, cleaning, chatting on the phone, playing mahjong like there was no tomorrow. I found it difficult to reconcile this with the shriveled old woman underneath the sheets, the emaciated impostor claiming to be my Ama, the loose skin under her chin quivering like a deflated balloon with each breath.
“Well, son,” my mother said, eyeing me. “Aren’t you going to examine her?”
I didn’t want to be there, and I knew it showed in the way I crossed my hands over my chest and stood closer to the door than the bed.
“But Ma, I don’t have my stethoscope…my equipment.”
My mother pursed her lips tightly and turned her attention back to Celedonia.
Realizing that my mother wasn’t about to let me leave, I inched closer and sat on the other side of the bed. I reached out a tentative hand and touched my grandmother’s shoulder.
“Ama,” I said softly. “It’s me…I’m back.”
She did not react so I shook her gently, leaned closer, and whispered in her ear to make sure that she heard me. The flickering movement of her eyeballs slowed, but her lids remained shut.
“Your Ama has been unresponsive since she returned from the hospital,” my mother said. “The doctor told us she just has a urinary tract infection and gave her some antibiotics. But something’s not right…”
I took Celedonia’s hand from my mother and felt the pulse on her wrist: weak, thready, too fast. My other hand absently felt for the penlight in the pocket of the white coat that was hanging in the closet of my apartment three thousand miles away.
“What do you need?” my mother asked.
I told her that I wanted to prop my grandmother’s eyelid open to look at her pupils. My mother immediately got up from her perch and left the room, shutting the door gently behind her.
While I waited for her to return, I dug deep in my mind and tried to recall what Dr. Elise Coletta had told me a few months earlier. Elise, as she liked to be called by her students, was the amiable physician I shadowed for a couple of afternoons during the required geriatric medicine rotation. As the geriatric specialist of the faculty, she was tasked to teach residents and medical students how to evaluate and treat elderly patients. Before I met with Elise, interns who had already gone through the experience spoke of dark, depressing nursing homes with carpets riddled with mysterious stains, stale air thick with the smell of urine, and decrepit old people tugging at their white coats as though they held their salvation. But when I got there, I found that it wasn’t as bad as I had expected. For sure the place wasn’t cheery, but while I trailed Elise as she went from room to room discussing a litany of medical problems in the elderly, little old ladies wearing lipstick and rouge looked up and smiled at me from their wheelchairs and walkers. We walked past rooms decked with pictures of grandchildren and great-grandchildren, and in the activity room a group of seniors clapped and sang along while a man in suspenders played “You Are My Sunshine” on the banjo. As a young resident, I found it all rather strange, and the medical conditions Elise seemed most passionate about—dementia, delirium, pressure ulcers, and end-of-life care—vaguely interesting though decidedly unchallenging, unappealing, and, well, unsexy. So I trudged behind her, listening with half my mind as the other half kept track of when I’d be able to leave, go home, and prepare for my cardiology rotation.
Back in Arcadia, alone with my Ama, not knowing how to help her, I wished I had paid better attention to Elise, asked more questions, taken more notes. But instead of Elise’s pearls of wisdom, what came to mind was the way smug residents like me treated patients like my grandmother. In the university hospital where I trained (and most other teaching hospitals for that matter), Celedonia was what we called a GOMER (get out of my ER), medical slang for an elderly patient perceived to be a waste of space in the emergency room. More often than not, we would roll our eyes at the sight of a GOMER being pulled out of an ambulance, strapped to a gurney, confused as a cow on Astroturf. They were the patients nobody wanted, the ones internists tried to turf to surgeons, surgeons tried to turf to neurologists, and neurologists tried to turf back to the internists. I would have tried that trick if I had anyone more competent to turf my grandmother to, but it was only us in that room.
It has been said that there is no point in a physician’s career when he or she is surer of himself or herself than the period between the end of internship and the first humbling incident—an unexpected death or a punctured lung from a misplaced needle—that forces the cocky young physician to come face-to-face with his or her ignorance. I hadn’t expected the humiliation to happen to me so soon, and certainly not with my own grandmother.
My mother returned with a large flashlight that looked more suited to flood a dark campground than for peering into an old woman’s eyes. Still, I took it from her and tested the reaction of Celedonia’s pupils, which turned out to be just fine. But as I was about to shut off the light, I noticed a strange tinge on her eye’s sclera, the white area around the iris. I asked my mother to draw the curtain open to let more daylight in. Like turning on a lamp, my grandmother’s sclera glowed bright yellow.
I reached out my hand and rested it on Celedonia’s abdomen while I kept my eyes trained to her face. I gently applied pressure over her belly button: no reaction. As I had been taught in medical school, I mentally dissected her abdomen into four quadrants and systematically palpated each section, picturing the organs that resided underneath the thin layers of skin and muscles. When I moved my hand over the right upper quadrant, the flickering movements of her eyeballs returned, followed by the slightest of winces. I pressed harder and to my surprise, her hand suddenly rose and spanked the back of my hand as though I had done something naughty.
I glanced at my mother, who was staring at me; this was the first reaction she had seen Celedonia make since she fell ill.
“What did you do?” she said incredulously. “I mean, how did you make her do that?”
“I’m not sure,” I said, shaking my head thoughtfully like my medical school professors used to do during rounds. “But I think there’s something wrong with her liver…or gallbladder. Did she get an ultrasound at the hospital?”
When I returned to Providence, I sifted through the binder that Elise had given me and read an article about the demography of the aging U.S. population. In 2011, the first baby boomers will turn 65. Unlike my grandmother, who was a child of the Depression and had nine children, the boomers are better educated and wealthier but have fewer children to depend on. As I read on, what struck me the most was their sheer number: in the next twenty-five years as all boomers reach retirement age, the number of Americans sixty-five years and older will surge from 37 million to over 70 million.
According to the Institute of Medicine, while older adults currently constitute only 12 percent of the U.S. population, they account for a whopping 26 percent of all physician visits, 35 percent of all hospital stays, 34 percent of all prescriptions, and 38 percent of all emergency medical service responses. In 2030, the elderly will constitute 20 percent of the U.S. population and this onslaught could bring our health care system to its knees. Geriatricians are physicians who specialize in the care of the complex problems of elderly patients like my grandmother. In 2007, there were just over 7,100 physicians certified in geriatric medicine to care for the 37 million older Americans. By 2030, it is estimated that there will be a need for 36,000 geriatricians. If the laws of supply and demand were at work, one would assume that medical students should be training in droves to become geriatric medicine practitioners, but not so.
I can still clearly recall the baffled look on my residency program director’s face when I told him I was considering geriatric medicine as a career. I had already told my co-residents and friends about my interest, and their nearly universal reaction was, “Why?” Before I verbalized my intention to anyone, I had asked myself the same question. When internists choose to enter a fellowship in, say, cardiology or oncology, they invest an additional two or three years of their post-residency life to become specialists, and in return, they reap the rewards of this investment in the form of higher status, better incomes, and other perks. Geriatrics is the only specialty that actually causes a decrease in physician income with additional training. This paradoxical relationship between geriatric training and income is explained by the fact that older patients are time-consuming to care for and tend to have more complex medical problems. Coupled with this, reimbursements from Medicare and Medicaid, the largest payers of health care for elderly Americans, remain low and are in danger of further cuts, thus perpetuating the marginalization of geriatric medicine as a specialty. This is in sharp contrast to the system in Britain, where physician compensation scales up with the age of the patient. Not surprisingly, geriatrics is the most popular specialty among British medical students.
If not me, then who will care for the deluge of older American patients like Celedonia? If none of the bright, idealistic students in my class choose the road less traveled over the ROAD paved in gold, what will happen to our parents, grandparents, and the rest of the baby boomers? Some policymakers say that until the incomes of geriatricians are adjusted to approach those of cardiologists, gastroenterologists, and other specialists, fewer and fewer young physicians will enter the field and the shortage will worsen. Others say that more than the income discrepancy, our society’s denial of aging and aversion to the old keeps the best and brightest young minds from becoming geriatricians. Still others say that the problem is more basic: the practice of geriatrics is like trying to put out fires that have been smoldering for years and will not die—chronic diseases like dementia, arthritis, and osteoporosis cannot be cured—making it inherently less satisfying to the physician who signed up for the healing, not the firefighting, profession. Young doctors want to heal and to cure, not to be mere stewards of the incurable—doctors of none.
To cure sometimes, to relieve often, and to comfort always was the aphorism of Edward Trudeau, an American physician who fought the then-incurable white plague: tuberculosis. Like others, I too originally wanted to become a healer. But Elise and Celedonia taught me that when a cure is not possible, to relieve pain and to provide comfort in times of suffering are equally worthy goals. Now that we have all but conquered tuberculosis through public health interventions and potent antibiotics, I wonder whether we will ever vanquish the seemingly incurable medical and social ills that come with aging, and resolve the even more daunting issue of who will care for our nation’s elderly.
I saw Elise at a geriatrics conference near the end of my fellowship training. I recalled the surprised smile on her face when I thanked her for inspiring me to go into geriatrics. That was the last time I saw her. About a year later, Dr. Coletta died after a brief illness at the age of forty-seven, too young for anyone but especially for someone who had devoted her career to the care of the elderly and her life to inspiring young physicians like me to share her passion.
Celedonia was found to have terminal hepatic cancer. Her nine children looked back at the full life she had led and decided to ensure her comfort as she made the transition from that life to a dignified death. According to a German proverb, death is the poor man’s doctor. But when death came for Celedonia and found her surrounded by the people who loved her, she was a very rich woman indeed.