Waiting For Help

Years ago I was resting in the wonderful light of a fall afternoon, dozing and drifting; my true source of the relaxed state. In the quiet I heard a tap, tap, tap. I didn’t want intrusion and went back to my daydream. In a few more moments, tap, tap, tap. I did not get up.

I learned the next day that my 92 year old neighbor had struggled, crawling out of her apartment onto the balcony to get help. Help from me. I saw her in the hospital. She never came home. All I have are some baking tins her grand nieces wanted me to have.

I know the intellectual response would be: “I couldn’t have done anything. She’d had a fatal stroke.” We didn’t know about early stroke intervention at that time.

But this is a completely inadequate response. Each time an animal is loose from its owners wandering the street, or someone trips and falls in an intersection, they need help. Our help. My help.

There is never the right time, enough time but each day we can make that effort. Our unwillingness to do so is a weapon of social destruction.

Walking down the hall at the small rehab hospital I work at I’m either focused on the next three things I’m to do or those little white call lights blinking and beeping. . .little cries for help. If I’m stressed I try not to make eye contact with the room’s inhabitants, because all my efforts to be a patient advocate come to bear and the patient in need will ask me to help them with picking something up, going to the bathroom, getting a question answered. They need the help then, not when I’m available. Oh sure, there are aides on the floor who are busy helping others. There is no queue, no soft voiced operator that will talk them through the intervening minutes. Many can wait; there are provisions for an accident in bed. There must be an equation that describes helping and waiting that addresses attention, anticipation, and anxiety.

Research tends to focus on victim versus bystander. The hapless victim - an inadequate description for a person being pummeled while others walk by.

I’m sitting at Kaiser, waiting for my third appointment of the morning. Made two appointments in advance, but was able to sneak in the third and have a procedure done. I love making waiting time work. With my mini laptop I can write this narrative, with my cell discuss the contents with my brother. So, even though I should and could be emptying my bladder for my next appointment. I defer that bodily need because there is something more fun, compelling, or just plain accessible to do.

Frankly, I hate to wait. I like to help, most of the time I love to help. But I seem to have limits.

I know that talking at people about the whys of waiting: “you are next in line”; “Suzy went on break”; “Suzy is helping someone else” and so on. Our brain just can’t take in the rationale. Waiting, becomes impatience, begets irritability.

I’ve been waiting to continue with my blog. I’ve been diverted with other compelling activities. A full-time job; an annual event; vacations. Great stuff, so much so I was willing to defer something I wanted to do which was writing.

When visitors enter the rehab hospital and see elderly persons sitting in wheelchairs, there is a visible response, ‘there but for the grace of god go I’ sort of look. Just because Ruth is sitting in a wheelchair at 4:00 in the afternoon with her head down should tell the world that she’s worked out for two and half hours, had a full shower, met with her family and continues to recover from her total knee replacement, while she is contemplating her recent visit to the neurologist to determine the cause of her arm tremors. She has a lot to do, and she is busy. Ruth is not waiting at all, unless you think she is waiting for the other shoe to drop. In that way, we are all like Ruth.

I think there is a place for a study here. As people recover from their medical procedure whether at home or at a hospital is there a relationship between their use of the call button or requests for help and their state of mind, their functional status? On the surface it seems like common sense the better the person is, the less they’ll need others. But I’m not sure we understand what calls for help really are. Perhaps with better understanding we might be better able to help those who are waiting for it.

How does waiting for a bedpan compare to waiting for a transplant organ? What are the levels of anxiety during the pre-help process? And just who will respond to a request/plea for help? Someone who has attended an in-service on niceness? Do men respond less than women, do those of the same race respond more to each other? Are we expecting heroes or helpmates as responders?

For clinicians this is the rub. Patients seek help from us and what we want to do is assess and treat. Help may be derived from this, but they most certainly will need to wait to get it.

Help with this article:

Eagly AH and Crowley M, Gender and Helping Behavior: A Meta-Analytic Review of the Social Psychological Literature, Psychological Bulletin Vol. 100, No. 3, 283-308, 1986.

Wegner DM, Crano WD, Racial Factors in Helping Behavior: An Unobtrusive Field Experiment, Journal of Personality and Social Psychology, Vol. 32, No. 5, 901-905, 1975.

The Good Samaritan Experiment http://www.experiment-resources.com/helping-behavior.html

Science of Generosity, University of Notre Dame, 2009

Wilhelm MO, Helping Behavior, Dispositional Empathic Concern, and the Principle of Care (abstract), Social Psychology Quarterly, March 2010, vol. 73, no. 1.

Nauman, SE, The Effects of Norms and Self-monitoring on Helping Behavior, Journal of Business Behavioral Studies http://www.aabri.com/jbsb.html

Maister D, The Psychology of Waiting Lines 1985 http://davidmaister.com/articles/5/52/

Medical Necessity

Some local university graduate students want to do something about the planned closing of the Adult Day Health Centers (ADHC) in California (1). Cry louder, stir up the heat and change the direction our health policies are going. They’ll replicate the many financial implications analyses; they’ll relay the human compassion by re-telling the stories of individuals receiving service. If they are lucky they’ll not only get an audience with an influential and interested legislator but also get to meet someone like Sylvia.

Sylvia is one of many who benefit from the ADHC system funded by MediCal and she will suffer a significant loss in quality of life, and maybe lose her life if her center closes.

To discuss Sylvia’s situation, we first need to explore the decision making process known as “medical necessity”.

The golden phrase of for-profit medicine is medical necessity. Medical necessity is the inverted pyramid on which reimbursement rests. Definitions are largely vague, tradition mediated standards of care. Here are some situations for the uninitiated.

A. You have an insurance plan; it says you are eligible for a procedure such as cardiac angioplasty. So you say to yourself “if I ever have heart problems, thank goodness I have that benefit”. If you were to develop heart problems the physician would write a statement demonstrating the procedure’s medical necessity. Plain and simple.

B. You have the same insurance plan and it says you can receive physical therapy services. So you say to yourself “I like physical therapy services, I should have some”. But you’d need to have a reason, a medical reason. Okay not so difficult to understand.

C. You are covered by MediCal (California’s Medicaid program) and, in the past, you did get dental services but due to past benefit reductions you can have dental services but only if you pay for them. We are all getting used to changing health plans.

D. You are a frail elder with hypertension, type II diabetes, depression w/ mild memory loss, osteoporosis of both the thoracic spine and right femur; you have mild loss of balance and need to get up at least once a night because of the diuretics you are taking for your high blood pressure. You are covered by MediCal and Medicare and you’ve been receiving nursing and therapy services at an Adult Day Health Service. But this has been a benefit of MediCal; Medicare does not pay for these services. By the summer of 2011 MediCal won’t either.

If you think you are getting the idea, hold that thought. In fact it’s worse than you think. I thought I might include one or more citations from Medicare - the arbiter of this type of definition - but chose not to. It is painful reading. To summarize simply, medical necessity is based on what those that pay believe providers of service should be doing. And because those that pay never see the patient they come to their conclusions based on reading some paper (the justification sent with the bill).

It was pointed out years ago that we cannot depend on what others do to ascertain standards of care. In 1992, Leape (2) chronicled how hysterectomies were being performed and paid for not because the procedure was indicated or that the patient wanted it but justified by an amorphous community standard of care. He went on and demonstrated how other surgeries such as tonsillectomies were routinely performed but not needed in his critical and critically acclaimed pamphlet “Unnecessary Surgery”. A significant percent of care delivered was considered unnecessary then and those figures remain today.

Many times we get what we need – physicians, nurses, technical specialists who are fantastic. I have received immediate and appropriate care; in fact I’ve received thoughtful and reflective care. But at times I had to demonstrate greater medical necessity than the physician concluded not for myself but for my patents. How do we know if we are doing too much, too little, or the right stuff at the right time?

Since the early 1990’s there has been a major uptick in quality review mechanisms in healthcare organizations. Not just coincidentally to the start of broad reductions in healthcare funding. At first it was a few committees, some memos with mandates and the problem of meeting medical necessity with quality services was going to be fixed. But with more cuts, there were more quality review projects creating more findings and more fixes. The community standard keeps evolving.

Once services stop getting paid for, they are no longer the target for a standard of care, are longer medically necessary. Cutting and reducing and then cutting some more alters what was at one time essential good healthcare practice, albeit that needed to be tweaked. However, as much as we need to cut the care that is unnecessary, not appropriate and not healthful, we must not throw out the baby with the bathwater.

Let’s get back to Sylvia. Sylvia, who prefers “Sylvie”, is a 92 year-old pistol. She relishes conversations, actively listens to others and transcends reverie when read to. She can speak one of several languages she learned to survive growing up in central Europe, and has gracefully aged to just under 5’ in height.

Sylvie loves coming to her center, her Adult Day Health Center. Every day she is welcomed by name with hugs and inquiring looks. It is probably true that when Sylvie first started at the center 10 years ago her necessity was personal, not medical. A holocaust survivor, she is an immigrant to the U.S. dependent on a family that does not entirely want her. She found respite to offset the weariness of long life.

Her situation now is quite different. She has both hearing and visual deficits requiring others to be by her side. That warm and large heart has worked over time and is weakened limiting her exertion. Those knees, oh vey, her knees regularly cause disabling pain which leads to less walking only to lead to more problems. Nursing staff monitor blood pressure and medication usage. During the week on any given day she is seen resting quietly with her head back on a soft pillow, with a cool compress letting the headache of her body and life ebb. She asks for little and gives back royally.

Sylvia personifies “medical necessity”. The medical diagnoses of:

chronic cardiac failure, hypertension, osteoarthritis of the knees with acute episodes, depression, dementia (mild) with acute episodes, loss of peripheral vision, hearing loss w/ inability to use hearing aid and inability to self-manage, and not having appropriate care or assistance at home collectively qualify as medical necessity.

But that is only if the ADHC program exists and someone will pay for it. Sylvie’s family, like many others, can’t afford the $1500/month for the program. Even if Sylvie received Social Security payments, that amount would not cover the care. Only if admitted to a nursing home would MediCal be willing to pay over $4100/month because, of course, there is medical necessity (3).

(1) Assemble Bill 97 (California) http://www.leginfo.ca.gov/pub/11-12/bill/asm/ab_0051-0100/ab_97_bill_20110324_chaptered.pdf page 59-61.

(2) Unnecessary Surgery, Annual Review of Public Health, Vol. 13: 363-383 (Volume publication date May 1992) , Lucian L. Leape.

(3) http://www.efmoody.com/longterm/nursingstatistics.html

Looks

Evelyn by Susan Jansen

As people struggle with the challenge of physical disabilities, what part does feeling good about their appearance factor into their ability to work towards regained function?

We like to envision ourselves striding into a conference or social gathering with it “all together”: the clothes, the hair, the pose and the savoir-faire. Whether in informal business attire or street chic we love the power of looking good.

One day at a residential and out-patient specialty center I was introduced to an attractive and very well dressed mother and daughter seeking therapy services. The daughter who was 21 years of age had sustained a head injury during a motor vehicle accident the year before. As the mother spoke her daughter nodded with “yes, yes”. She had been attending a local private university and it seemed was on track for a very good life. Now the mother just wanted her daughter to appear pretty.

Seeing the young woman walk I understood the concern. She walked with a cane, a flexed arm and a stiff leg. From their point of view, like an ‘old person’. Not vibrant, attractive, sexy, not like a prospective wife and mother. Although treatment strategies have evolved since then, the desired results would still be unattainable.

Today I confine my clinical practice to those who are 85 years or older - the elderly. If you haven’t reached that age yet, you might think folks should be pleased if they could walk at all. You would be wrong. There are several reasons older persons start to withdraw and become isolated – how they appear is part of that progression.

Currently I work with a delightful 88 year-old who has had several joint replacements, continuing degenerative joint disease and a few other assorted conditions. She is well educated, continues to be involved intellectually, a wonderful take charge and let’s do it sort of person. But she doesn’t like to mix and mingle much. She has been relegated to using a 4-wheel walker, useful but not elegant. She’d like to use a cane “more practical” she says out loud, but “more acceptable” to herself. To meet this concern, periodically, I have her perform walking trials with a cane – not only borderline unsafe, but inefficient, taxing and ungainly.

This past week when I greeted her with the requisite “how are you doing”, she responded “Fine, but. . .” and described how someone - a gentleman - she regards highly mentioned that her last knee replacement had not worked because she was “walking so badly”! Even with prompting about the accolades from neighbors - all women - who believe she is doing well, to her she is not doing well enough.

Although not a typical candidate I gave her instruction in using two canes (which luckily she had) and within the first 3 feet of using them she positively radiated. She wanted to walk down the hall, walk all the way down and back. Frankly, she looked aristocratic. She then enthusiastically performed the strength exercises she is supposed to be doing on her own; and willingly made an appointment to re-see her orthopedic surgeon about a lingering knee problem.

This is not a miracle or a feel good story. Physical therapists are frequently involved with gait training interventions. Sometimes the person has no residual impairment or altered pattern. But many develop a new pattern of walking and some find that acceptable and may even be grateful. Others will want to look good, as well. I was not able to help the college student twenty-five years ago. Today I have given my elder patient some hope, something to look forward to.

What I can’t control or even anticipate is the audience that each of these young and elderly woman have in their lives. There is a complicated interaction we have as we move through our day with those around us. Until we are good at something we may prefer to be by ourselves, but once proficient we want to show off. Trying to look good for others when one has a physical disability may be part performance, part learning. The late Robert Zajonc (1) put forward a literature review on social facilitation theory in the mid-sixties. It might be time to dust off this topic again. We have increasing numbers of people living with physical disabilities for longer periods of time. To face this challenge we need durable understanding about the person and their audience.

(1) Zajonc, RB, Social Facilitation, Science, New Series, Vol. 149, No. 3681. (Jul. 16, 1965) pp. 269-274.

Art courtesy of Susan Jansen. Ms. Jansen may be contacted at susanjansen@gmail.com.

Take It Easy

I spent my Sunday afternoon with 15 delightful women, most over the age of 80. I had been asked to speak on the importance of muscle strength as one gets older. The audience was attentive. I had handouts in large print, big photos - almost posters - to pass around and a portable microphone. They appreciated all of it. After the introduction, I reviewed the value of muscle strength training for older persons. Good review for this group.

Then I started with muscle strength and posture – it was a palpable response. I have an uncanny ability to alter my posture to exemplify altered function. When I “stooped” the group leaned forward, nodded their heads and some exclaimed under their breath “why, that’s me”, or “that’s how I look”. I demonstrated the muscles that control that part of our posture and immediately the attendees felt they’d gotten their monies worth (the session was free!).

There was more to the seminar: a self-assessment of functional decline to use when visiting their MD; physical assessment related to specific strength exercises; and tips on strength training itself. One of the first to break the ice asked “but my doctor told me to take it easy”. “How long ago?” I asked. “Years ago”.

Frankly the person asking the question didn't know how to interpret what was easy and what wasn't. Would they hurt themselves, do damage, set back their functional level, get sicker, or need more treatment? Better yet, could they self-determine what was their threshold for: motion, exercise, and amount of resistance?

With demonstration, feedback and guidance several of the women experimented with their ability to perform a movement with and without resistance. They were able to detect their limits and what they could do on their own. It took a few minutes.

We clinicians do not know how people will interpret our cautionary instructions. One of my elderly patients was told to keep her head straight due to extensive degenerative changes in her cervical spine. She heard “keep your neck stiff” and she complied. This resulted in reduction in head turning, muscular tightness and lingering pain. She thought it came with the territory.

We can not, nor should not, abandon the use of precautions. We can give simple tips. We can explain that this instruction should be reviewed. This is one of the times I recommend that a physical therapist’s input should be sought.

Trailhead

My town is embarking on an opportunity for change. But we have been misled before. So much so, that we aren’t easily swayed. We want change, and we want to work on it now. But underneath and all around us are those damn crevices, towers of great information that are difficult to break down or break through, systems that prevent serendipity. (1)

There is nothing like a really good idea. An idea that makes sense, builds on itself, allows for adaptation. I start with an idea trail. It begins with one thought, and then another. Some link, some don’t. Eventually I apply smart program development criteria. But in the mean time, I talk it up with folks from different paths and places. Then I suggest we have coffee somewhere near where the idea has the greatest meaning. Frankly, here is the secret. With putting the right folks together, a wonderful set of ideas will be created which can become a working concept. Inclusion of all these disparate sectors results in: buy-in, feedback and self-evaluation and, of course, best methods of implementation.

Here is an idea. A pediatric specialist changed positions. She worked at a community based center providing needed and (essentially) free services to children with developmental and orthopedic problems. Now she works in the neo-natal intensive care unit (NICU) literally down the street where all the kids she had been working with started out in life. Right away she was able to share with them what ‘what happens if’ feedback, e.g. prolonged position of the child for feeding and airway protection causes residual impairments. This interaction should be going on without large-scale initiatives.

The idea trail. Given information about the local healthy community initiative, I wondered along with my dear colleague that there might be a connection not only between high risk NICU infants and lifelong disability but societal problems as well. Without hesitation, a list was generated: post-traumatic stress syndrome (PTSD) of the parents, the emotional delays and latent inappropriate teen drug use, severe funding cuts along with a void of strategic education and support for the high risk infants’ ‘first responders’ - their parents. Well, she shared the opportunity with her colleagues and they got inspired and the trailhead is established.

Now let’s apply some creative analytic thinking. What information might help the idea? Discard it, embrace it, or change it? It would be great if we could answer some assumptions, such as, is parental PTSD also related to income and residence or culture? How about the social sequelae of having been in the local NICU? Do most of the kids go to college, or have families of their own? What are the essential needs of the child after discharge, and are these services accessible and affordable, or even used? There are more questions, and questions beget questions. What would families of the children share? Why, the teachers in pre-school! As is turned out, the rehab facility down the road hadn’t shared their insights with their nearby colleagues until happenstance occurred.

This process doesn’t cost much, if anything. It certainly can happen quickly. Many who sit in organizational charts are comforted by lots and lots of detailed data; others just know the problem and need for it to be articulated. But we all suffer from lack of connectedness.

(1) Meyers, Morton A.: Happy Accidents: Serendipity in Modern Medical Breakthroughs, New York: Arcade Pub., Distributed by Hachette Book Group, c2007.

Old

How old is old? When you are 30, 55, 62, 65. . .dare I say 85? Well, I’ve never met an 85 year old who didn’t know they were old. What do 85 year olds know that we don’t? That after an accumulation of time, impairments (loss of hearing and vision the most likely) and cultural bias, they know that time has passed.

I have a dear friend whose career was consulting with specialty medical practices around the United States on how to improve their business. One might think the job entailed how to bill more while doing less, or maximize billing, or promote the latest medication or procedure, but this was not what he spent his time doing. He spent his time reminding the personnel in the physicians’ offices - including the M.D.’s - who the patient was. I had the opportunity to observe him at a very large ophthalmology practice located in a well to do senior retirement community. A critical stumbling block to patient use of the practice was that the forms were all printed with small 8 point type size. True, every question was on the page but of course the ophthalmology patient had a tough time reading and then completing it. My friend the consultant knew to look at this, as he’d found this many times before.

The rate of hearing loss in those of us over the age of 65 is one in three (1). And the likelihood is that we will need services - social, medical, or legal - is undoubtedly 100%. But almost no one is expected to accommodate this loss of hearing. I walked into a nursing home’s therapy department a few weeks ago and saw one of the clinicians talking to their patient using a microphone. That was unusual. The patient wore a headset, and offered those who spoke to him a microphone. He couldn’t hear without it, but could hear fine with it. Simple, cheap, let’s order them for everyone!

We are getting older. And we will achieve the status of being old. But the duration of old age seems so much longer because the world keeps behaving as if we are aging in the opposite direction – as if our vision is more acute as our medical needs become more complicated, and as if our hearing gets sharper in new and noisy surroundings.

Failure to accommodate for one’s capabilities seems likely to continue unless, of course, those of us in our young adult and middle years begin to observe how one’s time is spent differently. In other words, experience a moment in time from another’s point of view. Otherwise, life gets old fairly quickly.

(1) Surveillance for Sensory Impairment, Activity Limitation, and Health-Related Quality of Life Among Older Adults -- United States, 1993-1997, Morbidity and Mortality Weekly Report, Vincent A. Campbell, Ph.D., John E. Crews, D.P.A., David G. Moriarty, Matthew M. Zack, M.D., M.P.H., Donald K. Blackman, Ph.D.

Relax

“Just relax, this won’t hurt” and then the skin is pierced, the tissue squeezed or the joint twisted. The word relax is related to the word laxative which is related to the word many say after the doctor, nurse or therapist say “just relax, this won’t hurt”. A person might just be reluctant to participate in further care.

Although, I’m not an etymologist, I do wonder about the words we choose and the expressions we depend on when treating patients. Another is, “don’t worry”. To worry is to think about the future as in, what will happen if I have this test, or take this medication. Naturally, most of us do not want to be in a chronic state of worry but given what life presents us, to worry may be an appropriate response.

And then the movie-like dialogue “you’ll never walk again”. I had a patient over 30 years ago, whose pelvis was partially severed along with multiple crush injuries due to an accident on a freeway shoulder. While she and her husband were outside their parked car, on a slope adjacent to the freeway trying to figure out what caused the breakdown another vehicle rammed through them.

I met Eleanor approximately two and half weeks later after she’d coded and been resuscitated numerous times. I was a weekend therapist, the first P.T. to have seen her. When I introduced myself she forthrightly stated, “I’ve been told I won’t walk again, but I will. Do you want to help me?” A marvelous person, determined, willing, knew things would be difficult, knew things would hurt.

Now my work is devoted to keeping the frail elderly in my community mobile. For some, they want to drive a car; others want to use a 3-wheel rather than a 4-wheel walker when attending a luncheon outing. Each knows – at some level - that they may not achieve their desires and they know they don’t have much time. To tell them “not to worry” would be disingenuous but to tell them “to worry” would be thoughtless, if not cruel.

A few decades ago there was discussion in my profession about what skills or behaviors were found in a master clinician. Distinct attributes would be culled and analyzed to replicate in future generations. A part of my definition of a master or effective clinician is one who develops a basis for trust with each of their patients by providing useful information. When I move this leg, Mrs. Connelly it may be uncomfortable; let’s try to avoid that by doing it this way. Or, I know Mr. Grant you want to return to driving, here are some things you need to be able to do to drive safely.

As a doctor, nurse or therapist you say you don’t have the time to prepare your patient for a test, treatment or decision? How would you rather spend your time?

Eleanor not only walked – but devoted her life to volunteering at a hospice near her home. I was teaching a course on the Psychology of Disability a few years after working with her, and was able to renew contact. I asked her to visit the class. Not knowing she would be a guest, I’d prepped them about the accident event, the extent and nature of her injuries, the rehabilitation effort. I played an audio tape that I’d asked her to make at the time about her near death experience. And then, she walked in the room, sat down and spoke to the group about what it means to own one’s life.

Broke

Students at the school in my neighborhood who are without health insurance can’t get fractures fixed. The scene: the child comes running in from the playground cradling his arm, goes to an adult who directs him to the nurse’s office, but because there are school cuts she’s not in so the principal calls the parents. The parents arrive quickly and take the child home. They apply warm compresses and salves. No, they do not go to an emergency room. No way to pay.

Plans are underway to gut Medicaid, our societal safety net for healthcare. It’s going to be broke and once cut, there are no plans to fix it. We can fight in many ways- or can we? After letters voicing our outrage, what can we really do? If we are health professionals we could start voicing alternatives, best ways to use a shrinking budget, strategic and tactical methods to spread the budget effectively over the largest number of people. In addition, we could attend planning and action meetings in our community and voice concerns and options. We can volunteer to sit on panels and commissions. State health departments could help some of us remobilize to perform critical community based services.

Some of us already do this; some of these methods are in place. Now we need to link them together as a cohesive service. Who are “we”?

View

I’m still taken aback, that after 38 years in practice as a health professional, that what a patient tells me is not what they report to their family. It is not because they have two faces or a peculiar cognitive condition. It may be that the patient has become the interpreter of medical events to their outside world. Isn’t that worth pondering?

The trajectory of medical and health services begins with the point of view that the person (the “patient”) seeking those services has also given them high priority. The healthcare professional proceeds on the following:

• Once in a patient-clinician conversation we think that the person believes we know more than they do.

• And, because we are knowledgeable we believe our corrective procedures will solve the problem.

• The problem solved?

If in the conversation of treatment the patient balks, changes subject, or dismisses the topic what is our response? Become more emphatic, offer mild threats or do we check to see if we are in the ball park?

Imagine what they are telling their family, friends, and neighbors. That the solution was a one-week stay in a place that neither speaks their language or serves their food and comes with a 2-hour surgical procedure that it will takes weeks to heal from. Or, that they will need to secure transportation, have family take a loss of half-day’s pay, travel to an unfamiliar place and repeat 3 times a week for months. Everyone shakes their head and then offers their suggestions.

Arthur Kleinman, psychiatrist and medical anthropologist lays out eight questions to prevent us from continuing to miss the boat. Many other sages remind us that we need to change our ways and not measure compliance but the degree to which we can have a meaningful conversation and where that will lead us in clinical practice.

The patient as interpreter, the patient as conversationalist, the patient as source of wisdom is not a frightening prospect. Even with significant cultural, language, historic differences the patient almost always wants you to succeed.

Waiting

With the sea change of baby boomer demographics, marketing efforts are underway to seize the day: how to make money in the population bubble of those over 65. Our response to the success of our culture lacks the sensitivity and romanticism found in studies such as Blue Zones. We do look at what our elders will tell us – although they have been for decades – we want to “play elderly”, a version of playing “grown-up”, and then get individuals to change their behavior.

It has been said that our older years represent our greatest time of personal change. We fear the probable altered physical, mental, emotional states that vary randomly. Decisions are made that change our life: where we live, who we live with, where the remains of our monies will reside.

What would happen if on our 45th birthday we each made a statement about where we’d be at 85? What if scholars developed a happy aging index, a test that monitors not just personal financial success but those indicators that have been cited repeatedly as critical to optimum health and mental health over the life span? What if we had in-home units that told us not only our body weight, but stress response status, need for a check-up or education? What if we accepted that we will age earlier in our lives?

How could we change in mid-life for a more successful late-life? What are we waiting for?