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.

Research shows that doctors who have been in practice for 20 years are usually less skilled than they were fresh out of medical school. These older doctors are stuck in habitual ways of thinking and acting, and haven’t updated their models or approaches for years. Rather than having 20 years of experience, they often have 1 year of experience repeated 20 times.

There is great reason for hope on the not-so-distant horizon, but those battling against the ravages of aging right now must do so in a world in which most doctors have never even thought about why we age, let alone how to treat aging.

I deeply respect doctors, but I want to be very clear on something: at every hospital in the United States, many doctors are doing the wrong things, pushing pills and interventions when an ultra-aggressive stance on diet and behavior would do far more for the patient in front of them. Suicide and burnout rates are astronomical in health care, with approximately four hundred doctors per year killing themselves. (That’s equivalent to about four medical school graduating classes just dropping dead every year by their own hand.) Doctors have twice the rate of suicide as the general population. Based on my own experience with depression as a young surgeon, I think a contributor to this phenomenon is an insidious spiritual crisis about the efficacy of our work and a sense of being trapped in a system

I tend to choose a doctor in the forties age range, male or female, in general preference to an older one. … They understand the full implications of modern medical technology a great deal better than their elders, are more open to new ideas, and usually are keenly aware of today's medical controversies, including law and ethics.

we’ve always predicated our quotations on the assumption that life expectancy in the United States would continue to rise. But during the past three years it has in fact started to go down.

There are 2.9 hospital beds for every 1,000 people in the United States. That’s fewer than Turkmenistan (7.4 beds per 1,000), Mongolia (7.0), Argentina (5.0) and Libya (3.7). In fact, the US ranks 69th out of 182 countries analyzed by the World Health Organization. This lack of hospital beds is forcing doctors across the country to ration care under Covid-19, pushing up the number of preventable deaths. America’s numbers are similarly unimpressive when it comes to medical doctors. The United States has 2.6 doctors per 1,000 people, placing it behind Trinidad & Tobago (2.7), and Russia (4.0 doctors per 1,000, for a country that is described as being “in transition”). Life expectancies at birth are lower in the US than they are in Chile or China. The US has a higher maternal mortality rate than Iran or Saudi Arabia.

Before the eighteenth century the demographic impact of the profession of medicine remained negligible. Relatively few persons could afford to pay a doctor for his often very expensive services; and for every case in which the doctor's attendance really made a difference between life and death, there were other instances in which even the best available professional services made little difference to the course of the disease, or actually hindered recovery. ...Only with the eighteenth century did the situation begin to change; and it was not until after 1850 or so that the practice of medicine and the organization of medical services begin to make large-scale differences in human survival rates and population growth.

There is, however, a skill to it, a developed body of professional expertise. One may not be able to fix such problems, but one can manage them. And until I visited my hospital’s geriatrics clinic and saw the work that the clinicians there do, I did not fully grasp the nature of the expertise involved, or how important it could be for all of us.

Several years ago, researchers at the University of Minnesota identified 568 men and women over the age of seventy who were living independently but were at high risk of becoming disabled because of chronic health problems, recent illness, or cognitive changes. With their permission, the researchers randomly assigned half of them to see a team of geriatric nurses and doctors — a team dedicated to the art and science of managing old age. The others were asked to see their usual physician, who was notified of their high-risk status. Within eighteen months, 10 percent of the patients in both groups had died. But the patients who had seen a geriatrics team were a quarter less likely to become disabled and half as likely to develop depression. They were 40 percent less likely to require home health services. These were stunning results. If scientists came up with a device — call it an automatic defrailer — that wouldn’t extend your life but would slash the likelihood you’d end up in a nursing home or miserable with depression, we’d be clamoring for it. We wouldn’t care if doctors had to open up your chest and plug the thing into your heart. We’d have pink-ribbon campaigns to get one for every person over seventy-five. Congress would be holding hearings demanding to know why forty-year-olds couldn’t get them installed. Medical students would be jockeying to become defrailulation specialists, and Wall Street would be bidding up company stock prices. Instead, it was just geriatrics. The geriatric teams weren’t doing lung biopsies or back surgery or insertion of automatic defrailers. What they did was to simplify medications. They saw that arthritis was controlled. They made sure toenails were trimmed and meals were square. They looked for worrisome signs of isolation and had a social worker check that the patient’s home was safe. 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.

Of hundreds of known diseases and their predisposing characteristics, some 85% of our aging population will succumb to the complications of one of only seven major entities: atherosclerosis, hypertension, adult-onset diabetes, obesity, mental depressing states such as Alzheimer's and other dementias, cancer, and decreased resistance to infection. Many of those elderly who die will have several of them. And not only that; the personnel of any large hospital's intensive care unit can confirm the everyday observation that terminally ill people are not infrequently victims of all seven.

The United States spends more on health care than any other advanced economy, but we don't see better outcomes in exchange. Incredibly, in many parts of the country, life expectancy is actually shrinking, and when it comes to maternal mortality, the United States is one of only thirteen countries where rates have gotten worse over the past twenty-five years. Meanwhile, working families are overwhelmed by medical bills, which are one of America's leading causes of personal bankruptcy.

Returning Medicare to solid footing represents our greatest entitlement challenge. . . . Like Social Security, Medicare is currently being rocked by the swelling numbers of baby-boomer retirees. . . . [However] the rising cost of health care adds just as much to the weight of the Medicare burden as does the age wave. . . . So it is healthcare itself that must be brought under control if we are to keep our Medicare bills from overwhelming the next generation.

I’m 65 and I guess that puts me in with the geriatrics. But if there were fifteen months in every year, I’d only be 48. That’s the trouble with us. We number everything. Take women, for example. I think they deserve to have more than twelve years between the ages of 28 and 40.