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“As I age I become more me.”
– May Sarton
… More like me, but more unlike anyone else.
I am an 86-year-old male. Most 86-year-old men are dead. Not only am I not dead, I have absolutely another 14 years left to live, at least—after all, my tagline for years has been ‘Dare to be 100!’ I cannot shortchange the important things that I must do to fulfill my human potential.
I have been weathered by the winds of my 86 years. Like the lone cypress, I have become what I do and where I live. It is no different than you, of course, because time and environment put their stamp on all of us, intermingling with our physical bodies and our choices to leave a unique signature of who we are. Our wrinkles are the signature of the life we have lived.
Every cell in our bodies becomes what its task has been and how well it has performed that task. Our physical being is shaped by behavior. Choice overrides fate. Bones, arteries, and brains become what they do. We are plastic until we die, and our behavioral choices are the engine that creates that plasticity. Our moral duty then is to rise to the challenge of living fully.
Medicine has historically ignored the fact that our choices and our behavior run our health—except, of course, for medication non-compliance, a nuisance behavior to vexed healthcare professionals. But how we live, how we age, and how we die is largely driven by what we have chosen day after day.
Being a geriatrician, thinking about aging has consumed most of my life. I get it quite honestly. Aging was in my umbilical blood; my father was also a geriatrician. Dad was an alpha male throughout his life, always inspiring others towards their greatest potential. Like my father, I became a caretaker of the old, and my career has always been about exploring potential.
Now that I look back upon it, I question, what is the potential of medicine? When did my beloved field get off course? When did medicine lose its soul? My best answer is that the goals and the potential have changed. Some of the most heralded technologies have, in my opinion, taken us away from the path of wellness and potential, redirecting us instead to submitting to cold biological determinism. Let me give you an example.
In April 2003, I was in the packed Fairchild Auditorium at the Stanford University School of Medicine waiting with great excitement the announcement yet to come from Dr. Arthur Kornberg, one of our Stanford Nobel Laureates. He was anointed to deliver the proclamation: “We are gathered here today on one of history’s great moments, the completion of the Human Gene Project, two years ahead of schedule and on budget. We will have the human potential revealed. We will receive the Holy Grail of Life.” The date was chosen specifically to coincide with the 50th anniversary of the Watson/Crick paper on the structure of DNA.
It was a celebration of high moment. Hooray! Hooray!
At the conclusion, I immediately put my hand up, “Dr. Kornberg, I am a busy practicing physician and I am concerned about the fact that in my practice I don’t see any participation of genes in my patients’ problems. Their difficulties derive directly from lifestyle, but I do not see any mention of lifestyle in any of the major scientific journals such as Science. All I see is the gene for this, the gene for that.”
Arthur smiled benignly and responded, “Walter, that’s because there is no science in behavior.”
Discouraged, I gleaned that the future of medicine was to become genetics. When research advances in genetics are applauded, in my experience, people seem to overlook that the chemistry is always ultimately dependent upon environmental signaling. In other words, lifestyle behavior makes the genes express themselves or not. Behavior and choice are still directing the show. It turns out that there is only a small 15% contribution from genetic heredity.
Another Stanford encounter was three years ago when the administrator in charge of the remake of our hospital to the tune of $2 billion addressed us physicians. He regaled us about all the bells and whistles that we were going to have—we would have the fanciest hospital in the world. Everyone smiled to be part of this great enterprise. I raised my hand, “What are you doing to keep people out of the hospital?” No answer. Silence, in effect, was confirmation that we want people in the hospital so that we can empty their wallets.
What medicine today is supplying seems to be creating more of what we are getting: a sick population. We are robbing the self-efficacy of every patient that walks through the hospital door.
In my book Next Medicine: The Science and Civics of Health, I labeled six presenting symptoms of my sick patients: my profession, cost, injustice, harmfulness, inefficiency, and irrelevance. The greatest of these is irrelevance. Medicine lost its way by selling the wrong product—selling irrelevance. The traditional medical goal of preservation of health has been subverted by the insistence on cure. The evasive promise of cure transfers the primary responsibility for personal wellbeing from the individual to a usually remote and insensitive institution. Fate rules Choice, inappropriately. Prevention doesn’t occupy high visibility. Zimmerman’s Law asserted that nobody notices when things go right. Or as Szent-György observed, “Health to people is as water is to a fish.”
Medicine should be predominantly in the health business. Instead, it is in the disease business. Most of the monies directed to cancer, for example, gets sequestered into surgery, radiation, and pharmacy—treating the disease after the fact. However, most cancers are preventable. Were we to have the resolve to go down that route, the cancer story might be entirely different. It would be investing in health, not disease. But cancer treatment is a lucrative ROI to Medical Big Business.
I can speak from direct experience over the course of a now 60+ year career. The medical profession has witnessed the total transformation from a gentle, harmless cottage industry to a corporate giant, from house calls by GPs to armies of accountants. I still strain to maintain my idealism in the face of the degradation of my profession.
Among the field of medicine, geriatricians are an endangered species. In my career of promoting geriatrics the perpetual lament has always been financial. How can geriatrics compete for young talent with oncology or cardiology when the recent medical school graduate is in debt of $100,000? Cures have high profile. When I was in medical school in the 1950s, the US spent 2% of the GDP on health-related expenses; now it is 20%, with no apparent letup in this crescendo. Medicine has become Big Business. From the beginnings as a little humble cottage industry, it is now a monster corporation with minimal oversight.
The future healthcare needs of our world will experience a pitiful shortfall because there are not enough doctors of my persuasion to address the coming epidemic of old people. Margaret Thatcher observed, “I know that it is coming. I just hope that it doesn’t happen on my watch.” The chilling prospect of being unable to care for all our older selves is spooky, so scary that it is an institutional blind spot, even as the population grays year after year.
But aging is not pathology.
The mission of my life has been to care for people as they age, and through this process I strive for an understanding of what aging really is. The year 1970 was the inflection point that would most dramatically change how I was to age and how my mind was to contribute to the field of geriatrics. Dad died and I became a runner because I knew that exercise was the best treatment for depression. There have been 45 subsequent marathons, including the tragic bomb-shattered run at Boston in 2013. But an even bigger change came when I moved to California to join the Stanford Medical School as the designated geriatrician.
As a result of this wonderfully fortuitous professional challenge it has been my privilege to care for a large percentage of the grand old populace of my community. I have made hundreds of house calls, nursing home visits, and ICU oversights, and I have signed many hundreds of death certificates. I was the identified old person doctor of my special community.
But times have changed. Medicine is now Big Business.
Stanford Medical School, like all medical schools, is expensive. It costs lots of dollars to balance the books. As a result, it is constantly searching for new profit centers; bariatric surgery is my most egregious example. Dollars trump idealism every time. The industrialization of medicine puts caring for patients in a precarious position. When I was visiting dozens of nursing homes to attend the most blighted of our fellow citizens, I always insisted that on rounds I touched every patient. There were no untouchables in my medical practice.
But now the industrialization of medicine leaves patients untouched and even unseen.
I once had the amazing opportunity to spend an hour with Mother Teresa in her convent in Calcutta. I explained myself that I was there to get her opinion on how I could reconcile the awful inequities of our modern medical system and do right by my patients.
Without hesitation she replied, “Don’t worry about that, Dr. Bortz. Just love them.”
On reflection, I realized that the word ‘love’ was never included in any medical curriculum.
Intrinsic to my perspective on the practice of medicine has been my conviction that we choose to be who we are, and what we choose is substantially more important than what happens to us. Choice has replaced Fate as the major determinant of health. Intrinsic is more powerful than extrinsic. This conviction extends to my proposition of an equation that quantifies the determinants of health that I published in the American Journal of Public Health. Lifestyle (behavior) is the predominant exponential that far exceeds all extrinsic components.
In addition to my patient care responsibilities, I have also been honored to serve in various administrative and editorial roles for the field of geriatrics. I have served as president of every local aging-related organization and eventually was president of the American Geriatrics Society in 1981. It was my honor to have presided over the emergence of this specialty.
For many years, geriatric medicine was very much a backwater of the medical enterprise. First, there was not much of a constituency—not many old people when I was in early training—and only miniscule support of research activities into the basic principles of aging. The science of aging was a blank slate. Clinicians like me were guided by our everyday observations more so than the pages of esteemed research journals.
As pioneering geriatricians then, our lives were often our laboratories. It was a totally serendipitous event that led to my intellectual commitment to aging. When I was in my early practice years in the 1960s and producing four wonderful kids I endured the unceremonious event of pulling my right Achilles tendon off at Stowe, Vermont while skiing. My children were giggling to see their clumsy father being carted down the mountainside on a sled. My distress was eased by several big shots of scotch.
When my surgically repaired right leg emerged from its cast six weeks later, I was aghast. It was withered, painful, and purple. It was an old leg. But the cause of this distress was not aging because the other leg was just as old and it was fine. Nor was it because the leg had been operated on because the surgeon could have put the cast on my good leg and the same thing would have happened.
Why did my leg grow old in a cast? There was nothing in the medical literature to explain it. There was no disease. It became old simply because it was in the cast. In an effort to tease out this observation, I consulted all of the textbooks in the Stanford medical library about aging and also those having to do with inactivity. My intellectual sleuthing was enriched by having easy access to the local space adventures at Moffett Field by NASA. The discipline of Space Medicine was just being born. We all recall seeing John Glenn, Neil Armstrong, and the other astronauts emerge from their capsules staggering and beat up, even though all they had been doing was fiddling with a bunch of dials and switches. It turned out that space travel represents the prototype of accelerated disuse.
As I arranged hundreds of research articles on the effect of aging on bones, arteries, sleep patterns, blood coagulation,
etc. on one table, and then arrayed a similar spread of articles about the consequences of inactivity on the same parameters on another table, the two lists were identical. Lack of use and accelerated aging were superimposed. The result of this fascination became an article in the Journal of the American Medical Association in 1982 called “Disuse and Aging,” which concluded that much of what is commonly attributed to the effects of aging per se in older persons was instead due to disuse.
The state of the body is a result of behavior!
When my wonderful Dad was queried, “Dr. Bortz, how do you stop aging?” he responded with an inspirational quip: “I am not interested in arrested development.”
Aging is not to be stopped or cured. Aging is as natural an event as gravity or magnetism. Everything in the universe ages, from canyons to Chevrolets. Aging, like miles on a car, is simply wear and tear. Unlike the car, we are wonderfully capable of self-repair. But in our rush to repair we forget that it is the body itself that is programmed to heal. The healer within has never been acknowledged by the medical profession.
Acknowledging the universality of aging, what are the essential basic components? They are three: time, matter, and energy. Where are these three exponentials codified? Time, matter, and energy are codified within the Second Law of Thermodynamics. The First Law on the conservation of energy states that there is a constant amount of energy in the universe. The Second Law concerns its inevitable redistribution.
To provide terminology of the explosive growth arising from the science of molecular biology, I have built upon these laws and have proposed the new term Metabolic Field to encompass the vast information from our reductionistic explorations into molecular biology. The prior classical fields of magnetism, gravity, strong and weak nuclear forces, and quantum forces are insufficient. Further, they do not include time in their rubric. Therefore, I propose the new term Metabolic Field to fill this vacuum.
This terminology hopefully exhibits what Mother Nature has given to her progeny. The infinite number of variables with their infinite number of contingent relationships seems vastly paralytic in their scope. How can we compute the universe? It takes a pretty big program. Einstein said something to the effect of not everything that is important can be measured and not everything that can be measured is important. The Metabolic Field proposal addresses this comprehendability of expression.
The color of truth is not black or white—it is gray. As unsatisfying as this is intellectually, it inevitably represents the basic realities. The Nobel physicist Philip Anderson in his important Science paper observed that ‘more is different.’ This is a restatement of Mr. Aristotle who recognized that the whole is more than the simple assemblage of the parts.
The term Metabolic Field seeks to encompass the parts and their system in an ongoing recognition of Nature’s majesty. I proposed the term Metabolic Field as an appropriate addition to the previously described classical fields of gravity, magnetism, the strong and weak nuclear forces, and quantum. Together, they represent a more complete description of Nature’s wonders.
The process of aging is an expression of these fundamental rules. Aging is not determined lockstep. While Schrodinger opened the door to what is life, I hoped to be able to open the door a little wider by injecting the feature of time into life’s equations.
We are the first generation in the history of mankind that knows how long a life could be, should be. Our biological birthright is 100 healthy years. We should do the best we can with them. Behind us we leave ripples of our endurability. None of us humans can cope with the idea of oblivion—a world without us is essentially unthinkable. Although our atoms and molecules disperse into the dust from which we arose, what remains are the ripples of our life, the currents that we have caused to happen because of our efforts.
I realize that for the great part of my investment in learning about growing old my search has been strictly objective, but now at age 86, with my wife now deceased and my body starting to show a few cracks, my perspective becomes subjective. Aging is not simply something that happens to someone else—it is finally happening to me.
We have previously lived too short and died too long—until now—but with our new comprehensions we have created a new moral imperative. We now know what the human potential is, its extent and its content. And it is up to us to heed the imperative.
This do for me: As you age, be an exclamation point, not a comma.
Walter M. Bortz II, MD is a Clinical Full Professor of Medicine at Stanford University School of Medicine. His history of service includes former seats as Co-Chairman of the American Medical Association’s Task Force on Aging and former President of The American Geriatric Society. Widely recognized as one of America’s most distinguished scientific experts on aging and longevity, he has published 150+ peer-reviewed medical articles and authored numerous books, including We Live Too Short and Die Too Long, Dare to Be 100, Living Longer for Dummies, Diabetes Danger, and Next Medicine. He is currently working on his latest book, Aging is Negotiable. He is a compulsively reliable blogger each week for the Huffington Post. Dr. Bortz is 86 years old, still runs up to 18 miles per week, and encourages everyone at any age to stay engaged and keep moving!
Fall | Winter 2016