Our losses become a part of us, they shape us. The tearing, searing grief might last days, or weeks, or months, or years, but it always ends. Nobody, however, ever “recovers.” Nobody “gets over it.” Having known, having loved, and having lost makes us who we are.
Just ahead of reading this, I received the news that my aunt had died. My life has entered the season when those who are precious to me are dying. It brings a sort of gloom that is hard to shake. But love what your patient said about her house, these moments are also a reminder of the best things we enjoyed in our lives. The people that shared their lives with us. An empty life has nothing to grieve. It also has nothing to celebrate.
Adam, once again a spectacular reflection. I am a few years behind you in my journey as a primary care internist, but I know the patients about whom you write...I see them, too. "Aging is not for the faint of heart" is my quip. If you have the heart of a primary care physician, you try to go through what your patients go through alongside them...as much as possible. You truly want to feel what they're feeling in order to let them know there is someone else in the world who is feeling it, too. But, there's only so far that'll take you. There's an unscalable wall separating us from the 90-yr-old widow with debilitating rheumatoid arthritis or the 82-yr-old veteran with metastatic prostate cancer. That wall gets more scalable as time goes by, little by little. But for now, we have to accept it's unscalable. So, we stick to validating them, hugging them, crying with them...
What a wonderful commentary. It strikes home because I will be 71 this year. I agree with the prior comment by the orthopedic surgeon. Good for you for saying what you wrote! I've been very athletic my entire life, and most of my joints hurt under certain condition (I have had three joint surgeries). But I think the issue is, how do we handle this problem? Do we allow a disability to become a handicap, or do we say say, as I do, screw it, I'll keep working out, doing what I can? I work through the discomfort unless I feel it's damaging, and I figure I will stop working out only when they start throwing dirt on my pine box.
I enjoy most of your posts and really enjoy the sensible medicine discourse.
However, I strongly disagree with your first point. And I think physicians need to change their perspective on this to do service to our patients.
Aging is NOT painful.
We have many studies that demonstrate radiographic findings of "degenerative" change or age related changes are NOT correlated with pain. Pain is a very complex phenomenon and we know fears, anxiety, words and saying can worsen pain.
I used to just nod and grunt some sound in agreement when patients made these comments. Now I make active efforts to dispel this myth. I reinforce that the body still has ability to recover, adapt, heal and strengthen. As an orthopedic surgeon, I see my more elderly patients recover easier and quicker than my young patients after joint replacement surgery. I tell them too and it always make them happy to hear they are recovering quicker than my 50 year olds, a little nugget to dispel are ageist beliefs. Although with age, we need to accept some loss of strength, balance and vigor, this does not mean it is replaced with pain and misery. These deteriorations in of themselves do not have to be painful - in the physical sense - although these loses can produce the fear and anxiety that can provoke or worsen chronic pain.
Pain is a complex entity. By the time someone reaches an elderly age they have years of experience in events causing pain. Pain pathways can be reinforced by our culture which perpetuates ageist beliefs. Fear of loss of independence and mobility can exacerbate pain. This seems to be increasing, I believe related to those entering their senior years having had the experience of seeing their parents age (whereas prior generations people died of other disease and not of "old age"). Fear of injury and falls can cause patients to avoid activities and moving. Immobility can worsen pain and cause further decline. We know physical activity, movement (motion is lotion) are important modulators of pain and help strengthen the body to prevent injury and falls. These fears can lead to patients limiting their activities, again important for social and mental well being, which also has strong ties to pain.
I see many patients in clinic who retain vigor and perhaps feel a bit stiff in the mornings or if they over did it - but aren't in "pain". These people have rejected the notion that aging is painful and keep active and moving, which seems to be the tried and true best medicine against every chronic disease. We should encourage our patients to reacquaint themselves with old hobbies, things that brought them joy, or endeavor something new, maybe parkour (google parkour for seniors).
It is a major disservice for medical practitioners to accept and reinforce again as painful. Grey hairs and wrinkles are not painful. Many elderly patients are pessimistic, fearful and anxious about aging. Rather we need to remind our patients all that's good about their bodies, encouraging a more positive mindset about aging that will thus allow are patients to keep doing what they need to do to maintain their best health - - staying active!
You definitely got me thinking with this comment. When I first read, I thought, that's crazy. But the more I thought the more interested I am.
I think we have to accept that, as we age, we do accumulate physical ailments that are painful and our recovery is slower. There are things I did in my 20's that left me sore me the next day that in my 50's would leave be bedridden.
BUT, you are obviously right that our sensation of pain is ridiculously complex and far more than a physical sensation. As we age we accumulate all sorts of nonsense which I am sure makes many of us worse. I am no Deepak Chopra and don't think we can achieve a condition "that is free from disease, that never feels pain", and "that cannot age or die" but I bet we could all be physically better with a better mindset.
Thanks so much for the thoughtful, and stimulating comment.
Remember, then, your Grand Creator in the days of your youth, before the days of distress come and the years arrive when you will say: “I have no pleasure in them”; Ecclesiastes 12:1
Adam, Perhaps your best piece ever. Both as a physician and as a person, dealing with these issues is foundationally central to life, yet gets almost no attention, really. You have captured more important points and more nuance in this short piece than most pieces 10 times longer can do. Bravo.
Thank you for those thoughts on aging. Having spent most of my adult life in medicine, I am grateful for my good health at 78. I always advised elderly patients to take up hobbies or other activities to occupy their time in order to avoid some of the depression that may come with age. Someone told me a long time ago that the key to happiness is to be grateful for everything you have and never let envy enter your heart or mind. I always find comfort in music and there is a great song by Nat "King" Cole titled "This Is All I Ask" that reminds me to keep the proper perspective as I approach the finish line.
Thank you Dr. Cifu for another wonderful reflection. I am mid 70’s and am starting to say good bye to friends, bringing me to the realization that our time on this earth is coming to an end. It is a sad time of life and depression knocks at our door on a daily basis. I face it by telling myself that, just for today, I will stay in the present and not let the sadness or worry about tomorrow take over.
Thank you Dr. Cifu. This piece is beautiful. I just returned from my 50th reunion (high school) and some of us look great and others clearly have been dealing with terrible health issues and look 20 years older than most of us.
Most days I walk about 6 miles with my dog. When I hit 60 about eight years ago, I upped my physical fitness plan and added strength training, so I guess I am fairly obsessed with all of that and I love it.
But of course, the deaths around me keep coming, and I have recently been ruminating too much.
Strange predicament of being human and figuring out how to face this with humor and dignity and avoid as much as possible too much despair.
I keep telling my friends that it is important for them to have some younger friends so that somebody will be left as they get older.
As that guy said in the funny video years ago: reality hits you hard, bro.
In the meantime, I enjoy every cup of coffee, being in nature with my dog and my boyfriend ( when he’s not in pain) and reading an essay like this.
My husband's most recent way of coping with this fun and inevitable process is to constantly sing the late great Toby Keith's song, "Don't Let the Old Man In," a quote from the still inspirational Clint Eastwood, who continues to not "let the old man in."
I just read this sitting at my Friday place of work, a SNF (mixed rehab and long term care). This is my favorite of the eight buildings I visit each week. It’s my favorite not only because it’s the only large SNF I visit that still runs like a tight ship with a long time dedicated employee team, as it did prior to 2020.
But it’s mostly my favorite because when I’m here, not a day goes past where I can’t sit with my favorite 90-somethings. I plan Friday this way so this can happen. Yes they might have a SSRI or PRN anxiolytic that I follow (the scheduled ‘reason’ for the visit’ but it’s a chance to hear their stories, ask them how they’ve faced challenges, and provide a listening ear after a peer passes away. Yesterday in fact, I got to see some original photos of one resident’s father and siblings in their WWI uniforms. So very cool!
I feel most of my residents give me more than I give them. I feel blessed to have the privilege of being their psych NP as they complete their journey.
Something I wish I had thought of when I was working in a SNF was connecting any local college / university Communication Department with facility to see is they would have students interested in documenting 80/90-somethings experience. Just thought I’d pass that along.
Win for the resident and student and the community
Whenever I see a person in their 90’s I try to get in a little conversation about their life experience. They have seen so much change in the world. One of my fondest memories is listening to a woman telling me about the history of her church dating back to the 1800’s. It was a church not far from where I lived at the time and I would drive by it frequently.
Her wit and mental clarity at 90 was fantastic. I was treating her knees for PT which unfortunately were severely arthritic. She was already out of bed, dressed and had breakfast in the cafeteria with the assistance of the nursing home staff. When I arrived at her room she looked at me with the great smile she always had and said, “Patrick. I just don’t have in me today.” I could hear in her voice this was not the day for me to use the powers of persuasion we therapist are famous for. I could tell the pain was just too much. I had a student with me that day so I ask her if she would just tell the student her “history” meaning medical. Which she did but the conversation continued onto her life which her church was the central part.
To this day I feel that that “PT” treatment was the best I’ve ever given to a person. I hope the student learned something that they could keep with them through their career. I know I have kept it with me (15 years now).
Such a great article. I was reminded when my physical health enforced retirement that nobody teaches us type A’s how to slow down! We spend half our lives acquiring things and building a sense of self; the other half getting rid of things and (sometimes quickly, sometimes slowly)a deteriorating sense of self. It’s in the acceptance where I find peace and serenity despite upcoming surgery #60 to repair a colon perf. Can’t wait to wave goodbye to the IR drain, but it’s saved my life! I still had a successful turkey season despite it. I’m doing the best with the limits my body has placed on me. What I’ve learned is as I age, I hope to continue to die living, not live dying.
Thank you.
This article made the yearly subscription well worth it.
Just ahead of reading this, I received the news that my aunt had died. My life has entered the season when those who are precious to me are dying. It brings a sort of gloom that is hard to shake. But love what your patient said about her house, these moments are also a reminder of the best things we enjoyed in our lives. The people that shared their lives with us. An empty life has nothing to grieve. It also has nothing to celebrate.
Adam, once again a spectacular reflection. I am a few years behind you in my journey as a primary care internist, but I know the patients about whom you write...I see them, too. "Aging is not for the faint of heart" is my quip. If you have the heart of a primary care physician, you try to go through what your patients go through alongside them...as much as possible. You truly want to feel what they're feeling in order to let them know there is someone else in the world who is feeling it, too. But, there's only so far that'll take you. There's an unscalable wall separating us from the 90-yr-old widow with debilitating rheumatoid arthritis or the 82-yr-old veteran with metastatic prostate cancer. That wall gets more scalable as time goes by, little by little. But for now, we have to accept it's unscalable. So, we stick to validating them, hugging them, crying with them...
Thank you Andrew.
Adam
What a wonderful commentary. It strikes home because I will be 71 this year. I agree with the prior comment by the orthopedic surgeon. Good for you for saying what you wrote! I've been very athletic my entire life, and most of my joints hurt under certain condition (I have had three joint surgeries). But I think the issue is, how do we handle this problem? Do we allow a disability to become a handicap, or do we say say, as I do, screw it, I'll keep working out, doing what I can? I work through the discomfort unless I feel it's damaging, and I figure I will stop working out only when they start throwing dirt on my pine box.
I enjoy most of your posts and really enjoy the sensible medicine discourse.
However, I strongly disagree with your first point. And I think physicians need to change their perspective on this to do service to our patients.
Aging is NOT painful.
We have many studies that demonstrate radiographic findings of "degenerative" change or age related changes are NOT correlated with pain. Pain is a very complex phenomenon and we know fears, anxiety, words and saying can worsen pain.
I used to just nod and grunt some sound in agreement when patients made these comments. Now I make active efforts to dispel this myth. I reinforce that the body still has ability to recover, adapt, heal and strengthen. As an orthopedic surgeon, I see my more elderly patients recover easier and quicker than my young patients after joint replacement surgery. I tell them too and it always make them happy to hear they are recovering quicker than my 50 year olds, a little nugget to dispel are ageist beliefs. Although with age, we need to accept some loss of strength, balance and vigor, this does not mean it is replaced with pain and misery. These deteriorations in of themselves do not have to be painful - in the physical sense - although these loses can produce the fear and anxiety that can provoke or worsen chronic pain.
Pain is a complex entity. By the time someone reaches an elderly age they have years of experience in events causing pain. Pain pathways can be reinforced by our culture which perpetuates ageist beliefs. Fear of loss of independence and mobility can exacerbate pain. This seems to be increasing, I believe related to those entering their senior years having had the experience of seeing their parents age (whereas prior generations people died of other disease and not of "old age"). Fear of injury and falls can cause patients to avoid activities and moving. Immobility can worsen pain and cause further decline. We know physical activity, movement (motion is lotion) are important modulators of pain and help strengthen the body to prevent injury and falls. These fears can lead to patients limiting their activities, again important for social and mental well being, which also has strong ties to pain.
I see many patients in clinic who retain vigor and perhaps feel a bit stiff in the mornings or if they over did it - but aren't in "pain". These people have rejected the notion that aging is painful and keep active and moving, which seems to be the tried and true best medicine against every chronic disease. We should encourage our patients to reacquaint themselves with old hobbies, things that brought them joy, or endeavor something new, maybe parkour (google parkour for seniors).
It is a major disservice for medical practitioners to accept and reinforce again as painful. Grey hairs and wrinkles are not painful. Many elderly patients are pessimistic, fearful and anxious about aging. Rather we need to remind our patients all that's good about their bodies, encouraging a more positive mindset about aging that will thus allow are patients to keep doing what they need to do to maintain their best health - - staying active!
You definitely got me thinking with this comment. When I first read, I thought, that's crazy. But the more I thought the more interested I am.
I think we have to accept that, as we age, we do accumulate physical ailments that are painful and our recovery is slower. There are things I did in my 20's that left me sore me the next day that in my 50's would leave be bedridden.
BUT, you are obviously right that our sensation of pain is ridiculously complex and far more than a physical sensation. As we age we accumulate all sorts of nonsense which I am sure makes many of us worse. I am no Deepak Chopra and don't think we can achieve a condition "that is free from disease, that never feels pain", and "that cannot age or die" but I bet we could all be physically better with a better mindset.
Thanks so much for the thoughtful, and stimulating comment.
As Solomon well said it:
Remember, then, your Grand Creator in the days of your youth, before the days of distress come and the years arrive when you will say: “I have no pleasure in them”; Ecclesiastes 12:1
Adam, Perhaps your best piece ever. Both as a physician and as a person, dealing with these issues is foundationally central to life, yet gets almost no attention, really. You have captured more important points and more nuance in this short piece than most pieces 10 times longer can do. Bravo.
Wow. Thank you.
Thank you for those thoughts on aging. Having spent most of my adult life in medicine, I am grateful for my good health at 78. I always advised elderly patients to take up hobbies or other activities to occupy their time in order to avoid some of the depression that may come with age. Someone told me a long time ago that the key to happiness is to be grateful for everything you have and never let envy enter your heart or mind. I always find comfort in music and there is a great song by Nat "King" Cole titled "This Is All I Ask" that reminds me to keep the proper perspective as I approach the finish line.
I will listen to it tonight!
Adam
Thank you Dr. Cifu for another wonderful reflection. I am mid 70’s and am starting to say good bye to friends, bringing me to the realization that our time on this earth is coming to an end. It is a sad time of life and depression knocks at our door on a daily basis. I face it by telling myself that, just for today, I will stay in the present and not let the sadness or worry about tomorrow take over.
So so well said. Thank you.
Adam
Thank you Dr. Cifu. This piece is beautiful. I just returned from my 50th reunion (high school) and some of us look great and others clearly have been dealing with terrible health issues and look 20 years older than most of us.
Most days I walk about 6 miles with my dog. When I hit 60 about eight years ago, I upped my physical fitness plan and added strength training, so I guess I am fairly obsessed with all of that and I love it.
But of course, the deaths around me keep coming, and I have recently been ruminating too much.
Strange predicament of being human and figuring out how to face this with humor and dignity and avoid as much as possible too much despair.
I keep telling my friends that it is important for them to have some younger friends so that somebody will be left as they get older.
As that guy said in the funny video years ago: reality hits you hard, bro.
In the meantime, I enjoy every cup of coffee, being in nature with my dog and my boyfriend ( when he’s not in pain) and reading an essay like this.
Thank you Dr. C.
What a wonderful way to begin my day.
"In the meantime, I enjoy every cup of coffee, being in nature with my dog and my boyfriend" sounds pretty good to me. Thank you.
Adam
Wonderful article to remind me to reflect on the past, present and future. Thank you.
My husband's most recent way of coping with this fun and inevitable process is to constantly sing the late great Toby Keith's song, "Don't Let the Old Man In," a quote from the still inspirational Clint Eastwood, who continues to not "let the old man in."
Amen…!
I just read this sitting at my Friday place of work, a SNF (mixed rehab and long term care). This is my favorite of the eight buildings I visit each week. It’s my favorite not only because it’s the only large SNF I visit that still runs like a tight ship with a long time dedicated employee team, as it did prior to 2020.
But it’s mostly my favorite because when I’m here, not a day goes past where I can’t sit with my favorite 90-somethings. I plan Friday this way so this can happen. Yes they might have a SSRI or PRN anxiolytic that I follow (the scheduled ‘reason’ for the visit’ but it’s a chance to hear their stories, ask them how they’ve faced challenges, and provide a listening ear after a peer passes away. Yesterday in fact, I got to see some original photos of one resident’s father and siblings in their WWI uniforms. So very cool!
I feel most of my residents give me more than I give them. I feel blessed to have the privilege of being their psych NP as they complete their journey.
Thanks Dr Cifu for this Friday essay.
Wonderful.
Something I wish I had thought of when I was working in a SNF was connecting any local college / university Communication Department with facility to see is they would have students interested in documenting 80/90-somethings experience. Just thought I’d pass that along.
Win for the resident and student and the community
Chatting with a nonagenarian.
Whenever I see a person in their 90’s I try to get in a little conversation about their life experience. They have seen so much change in the world. One of my fondest memories is listening to a woman telling me about the history of her church dating back to the 1800’s. It was a church not far from where I lived at the time and I would drive by it frequently.
Her wit and mental clarity at 90 was fantastic. I was treating her knees for PT which unfortunately were severely arthritic. She was already out of bed, dressed and had breakfast in the cafeteria with the assistance of the nursing home staff. When I arrived at her room she looked at me with the great smile she always had and said, “Patrick. I just don’t have in me today.” I could hear in her voice this was not the day for me to use the powers of persuasion we therapist are famous for. I could tell the pain was just too much. I had a student with me that day so I ask her if she would just tell the student her “history” meaning medical. Which she did but the conversation continued onto her life which her church was the central part.
To this day I feel that that “PT” treatment was the best I’ve ever given to a person. I hope the student learned something that they could keep with them through their career. I know I have kept it with me (15 years now).
Almost forgot. Thank you for another reflection.
Thank you for your wonderful comment.
Such a great article. I was reminded when my physical health enforced retirement that nobody teaches us type A’s how to slow down! We spend half our lives acquiring things and building a sense of self; the other half getting rid of things and (sometimes quickly, sometimes slowly)a deteriorating sense of self. It’s in the acceptance where I find peace and serenity despite upcoming surgery #60 to repair a colon perf. Can’t wait to wave goodbye to the IR drain, but it’s saved my life! I still had a successful turkey season despite it. I’m doing the best with the limits my body has placed on me. What I’ve learned is as I age, I hope to continue to die living, not live dying.
Jim - Please think about writing something for us in the future! I think we could all learn from your journey and give and take with our field. Adam
Let me rephrase “love to” to I’d truly be honored.
Love to! Send me a topic 💜
The topic totally your call.
No rush at all, we are not going anywhere.