Aging through the eyes of a doctor

Nothing in Marc Agronin’s medical training had quite prepared him for what he was to discover in a Miami nursing home at the beginning of his career. It was there that he learned that the true scales of aging aren’t one-sided. Drawing on personal experiences and in-depth interviews with pioneers in the field, Agronin takes a look at what aging means today. Here's an excerpt.

Introduction

For nearly every doctor, the very first encounter in medical school with an old person is with a corpse. I discovered this fact on the first day of gross anatomy class when our instructors led us up to the dissection lab and introduced us to the rows of human cadavers that would serve as our teachers and companions for the next six months. Everyone was a little uneasy that morning, and I welcomed the nervous glances and smiles of classmates as we filtered through the room searching for what we hoped would be the perfect body. "Look for a thin woman," my labmates Steve and Jimmy each whispered to me, recalling the sage advice of an older classmate trying to steer us toward an easier dissection experience. "Who can tell?" I shot back, staring out at the dozen black slate tables in the room, topped off with human forms wrapped in heavy white gauze and covered with translucent plastic sheets. I reasoned to my labmates that it was like trying to find King Tut among a room full of mummies, and so we quickly abandoned our original plan and went for a table near the window. Even in the few short minutes we had spent in the room, the fumes of the formalin solution used to preserve the bodies were overpowering, and so I hoped that at least an open window would provide some respite from the smell.

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"Please help your labmates remove the plastic coverings on your cadaver," the professor called out, "and then strip off all of the gauze to expose the entire body." A shudder went through my own body, and I cringed. The entire body? "Yes, the entire body," the instructor continued, as if she were reading my mind, "and then pick it up and flip it over — get a good look." This was surely a technique not meant to teach as much as to flood our psyches with the glory of gross anatomy, dispensing all mystery and anxiety in one fell baptism of formalin. Entering the room had been unsettling enough, but at least then the cadavers had been covered. I had honestly never seen a dead body before and was hoping to put off the experience as long as possible. But within minutes I was surrounded by teams of sweating medical students piling up strips of smelly, greasy gauze and struggling to pick up rigid and very heavy formalin-logged bodies. I remember one particularly surreal moment as I watched four classmates bearing the strangest of grins as they hoisted the cadaver off the table, grunting at its weight and struggling to grip the slippery, leathery skin.

How the body ages: A guide to the ravages of time

The unmasking of the face of our cadaver unnerved me the most. I had hoped in vain to skip that altogether and heed the words of the second anatomy instructor, who was strutting through the room and cautioning against removing too much gauze so as not to dry out the body. He argued gruffly with the first instructor that her shock treatment was unnecessary, finally shouting, "If they can't stand looking at the body, they shouldn't be in medicine!" My labmates were more obedient to the initial instructions and summarily removed the plastic bag from the head and began to unravel the gauze. I stood back and envisioned seeing what archaeologists had discovered in the mummified faces of pharaohs — coal-black visages with bony physiognomy and time-scorched skin that resembled cracked china. Those ancient, royal faces looked more skeletal than human and lacked all of the machinery of expression that might have betrayed a final emotion.

When the last strip of gauze was peeled away, I looked down on the face of our cadaver, mesmerized by her silent, still expression, her upper cheek muscles and eyelids slightly scrunched as if a puff of air had been blown into her face at the moment of death. The face appeared inert, like a totem permanently carved into clay or stone and so different from the blushing, breathing face of a living person. And yet this had been a person, I realized, who once had walked the earth and lived a life like everyone else in the room — working, loving, running, eating, perhaps bearing and raising children. Although the identities of and any biographical information about the cadavers used in medical school anatomy courses are never revealed to the students, the unmasking of our cadaver revealed numerous deep facial wrinkles and a few thin strands of silver hair matted on her head that betrayed one critical fact: She had been quite old when she died. We later learned that she had been 98 at the time of her death from a heart attack.

***

For many months after completing the gross anatomy course, I continued to wrestle with my experiences of working with a dead person. I would hearken back to a particularly vivid memory from class when the dissection required the corpses to be sitting upright on the slate table. Despite a somewhat human pose, everything sacred about both the body and its persona seemed stripped off the cadaver. Any small fantasies or fears of rejuvenation or zombification of the body that I still harbored by that point in the class faded away completely, and I said to myself, "There's no coming back." I now understood what the words "from dust to dust" meant. But this understanding did not bring satisfaction. I was particularly worried about how my growing lack of sensitivity toward the corpse could easily creep one step back to the extremely debilitated, aged patient. The two seemed, at times, to merge into one. I asked myself, "How does a doctor — how does anyone, for that matter — maintain a positive regard toward aging while simultaneously having to witness the loss, suffering, and utter degradation that it brings?"

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I have learned since then that these dismal equations of aging with decrepitude along with the rigid and defensive attitudes that they inspire are only one side of the story. The other side is too often overlooked in our dread of aging. This realization first came to me several months after completing gross anatomy when I began volunteering at a nursing home down the street from the medical school. I was assigned to visit Esther, a one-hundred-year-old woman who, I must admit, looked uncannily like the cadaver I had just spent the previous six months with! Surprisingly, this realization was not eerie but comforting. And Esther could not have been more of a delight to be with. Her mind and wit were sharp, she smiled constantly, and she reveled in our time together. One day she described to me in detail the births of her three children, then extended their life stories over decades to the present. One moment I was hearing about her beloved young children, and the next moment I was meeting them in person — then in their seventies! There were many moments when I closed my eyes and simply listened to Esther, losing track of the nearly 80 years between us. And I began to see age in a different context: Someone living with the daily infirmities of aging and approaching death could still enjoy most of the same human experiences we find so precious in younger years. Unfortunately, we often fail to see these positive elements in the lives of our elders because we are so focused on the physical or mental decline of aging. The body will certainly reach its limits, with death beyond our ability to predict or control. But the true failure here is not old age; rather, it is the failure of our own creativity and willingness to conceive that life up until its last moments has its own ways and meanings.

In the spring of my second year in medical school, Esther died several weeks after suffering a stroke. During our last visit, she struggled to talk and reach out to me despite the loss of speech wrought by a small clot in her brain. As with so many of the older patients with whom I had grown close over the years, I had put the possibility of her death out of my mind, imagining that she was actually my own age but just looked a little different. In fact, I have often employed such mental gymnastics to deal with aging and death in my own family. Shortly after my grandparents passed away, I compressed much of my grief into an odd fantasy that in the afterlife they had moved down to Miami Beach and were experiencing eternal bliss together, with endless sunny beaches and Early Bird Specials. Florida, I imagined, was actually some form of Shangri-La where all of our deceased elderly could be found happily wandering around if we just looked hard enough.

As fate would have it, I currently live and work in Miami as a doctor for old people — the very profession so derided in my early years of training. In this location, I frequently encounter several unique groups of elders, including aged Holocaust survivors and Cuban exiles, who have exerted a disproportionate influence on my clinical work and have inspired so much of my writing. To be more specific, I am the psychiatrist at the Miami Jewish Health Systems, the site of one of the largest nursing homes in the United States. Although people sometimes call my place of work "God's waiting room," they miss a much bigger picture. True, the average age of my patients is about 90 years old, meaning that I see a lot of people close to 100. The 80-year-olds who come to see me are like teenagers on my scale of things and the 70-year-olds — babies! And true, my job is to tend to all of the maladies and infirmities of aging. But as I first learned from Esther and then from countless others, the true scales of aging are not one-sided; the problems of aging must be weighed against the promises. In my work as a geriatric psychiatrist, I have learned that aging equals vitality, wisdom, creativity, spirit, and, ultimately, hope. And for an increasing number of aged individuals, these vital forces are growing by the day.

From “How We Age: A Doctor’s Journey Into the Heart of Growing Old” by Marc E. Agronin, M.D. Copyright © 2011. Reprinted by permission of Da Capo Lifelong Books.