Approaching 80

Approaching my 80th birthday is a psychological marker for me. It signifies that I have reached old age. This is completely personal. Not everyone views 80 as a marker. Actually, I read recently about an 86-year-old man who is still capable of running a marathon in less than four hours and about a 102-year-old man who completed a bicycle time trial averaging 17 miles an hour. That is truly remarkable, and there will be more people achieving results like that as life expectancy extends.  But for me. 80 signifies old.

I will reach 80 in a few months. I never expected to reach 80. The males on my father’s side of t he family all died in their 40s and 50s of heart disease, and I had coronary bypass surgery at 56, so I expected to be long gone. My experience will not be the same as others, although at some age, I think most will experience many of these feelings.  People age at different speeds, and some defy the norms. But for most of us, some point about 80, or slightly above, is a time of change in perspectives.

So, what does reaching 80 look like to me?

Well, it feels different from other birthdays. It is a point where it is difficult to deny that I am old and that I have some limited number of years left on this planet. Who knows how many, but it is probably a number less than ten. That’s okay. I doubt that it would be fun to live longer than that, but I feel exposed not having a decade between me and the hereafter. Nevertheless, I am starting to embrace my age; there is a certain pride in living this long. We live in such a youth-oriented culture that signs of aging are viewed as somewhat unseemly and something to be slightly ashamed of. Why else do we try so hard to maintain our youthful appearance and behavior? I am finally realizing that age, for all of its disadvantages, is something to be proud of.

As I’ve disconnected from my busy life of achieving and collecting, what I call the “noise of life”, and I have space to enjoy the perspectives and hopefully wisdom that comes with living a long time. I’m trying to get rid of “the shoulds” and spend my time doing the things I like or that challenge me in new and different ways. There is a constant temptation to fill all my time with tasks and activities that are familiar and that I know how to do. It is easy to fill a day or a week with chores, which I can do on automatic pilot and are not particularly satisfying. It has been necessary to release some of the things that have driven me and to tolerate the silence in order to find and create what comes next.

My time is sufficiently precious that I don’t have the inclination to carry grudges or to get angry at the things that I can’t control. It has always seemed good to me to accept people for who they are, even though I may not be attracted to some. (So far, our recently elected president is challenging that acceptance.) With people who are important to me, it seems much more sensible to respectfully say what may be troubling in the relationship and to avoid living in silent resentment. This can be difficult to do, and I’m not always successful, but at this point in life, I have only so much time to clear up misunderstandings and to express gratitude for the good things that have come.

I am confronted with the things that I just can’t do any more. Virtually everyone at 80 has some physical limitations. I love to be out of doors, to travel and see new things, to hike in the forest, and even to chop wood. Chopping wood would undoubtedly lead to days or weeks of back pain, and it just isn’t worth it. Hiking in the forest has to be calibrated with my Parkinson’s Disease to be confident that I can get back before I get exhausted. I’ve been fortunate enough to have had a lifetime of travel to exotic places, India, Africa, most of SE Asia, Bhutan, Nepal, South America. When my wife and I were traveling in the mountainous tribal areas of North Vietnam a couple of years ago, I became physically ill, and there was no doctor. It was not a serious illness, but it made me realize that I was at the end of my adventure travel. I need to be in places where there is reasonable medical care.

Whether we are extreme athletes or take more pedestrian risks, there are times when things don’t go smoothly or the unexpected happens. When that happens, one needs to fall back on reserve energy, strength and flexibility. People who climb mountains have told me there is no way to predict what will be encountered on a trip. They depend on the skills they have learned and physical fitness to find a way past their obstacle. To a lesser extent, unless one lives a very constrained life, our reserves of strength and experience allow us to explore the world with some confidence. For me at 80 those reserves are diminished.   There are things I would have taken on without thinking just a few years ago that I now need to carefully plan or forego for in order to avoid problems. In many ways, I am starting to understand the old person’s preference for predictability and routine.

Caution leads many seniors to live a severely constrained existence. One needs to find a balance between comfort and the thrill of adventures, no matter how small. I realize it is important to keep as active as possible and retain challenges even if modified to fit capabilities so that I don’t give up everything I enjoy. At 80, once you give something up, it is unlikely to come back. I’m lucky to have a supportive partner who encourages me and provides a safety net for trying new things.

At 80, I am no longer able to deny the presence of death. We spend a lifetime grappling with death in some way. When we are young, we ignore it. At other points, we are afraid of it. When we accept that it will occur to us, we wish that it will occur in a way that doesn’t involve too much suffering (not dementia, please).

Denial seems like a useful strategy for fending it off, but it doesn’t encourage coming to peace with one’s life, one’s accomplishments, one’s disappointments or with the people who really count in life. Preparing to accept death when it comes is a task of the elderly.

I recently saw the movie, “Fences,” in which the main character, Troy, sees death as an external force coming to get him. He challenges Death in his black robe with his sickle to come get him, and he is prepared to fight. I see death as more internal, as result of the inevitable struggle of a weakening body to deal with the challenges of living. If we are lucky enough to live until 80, death is a natural process of the wearing out of a machine. Plus, death is what makes life so precious. I think of the efforts of millennia to find the path to immortality. Major current research is devoted to extending life indefinitely. I think that it would be a bit boring after 100 years or so to keep hanging onto life. Knowing that it is all going to end motivates me to try to squeeze as much juice as possible out of the present and gives me the courage to try things that I might not do if I had infinite time.

“When signs of age begin to mark my body

(and still more when they may touch my mind),

when the ill that is to diminish me or carry

me off strikes from without, or is born within me,

when the painful moments come,

when I suddenly waken to the fact that I am ill or growing old,

and above all at the last moment when I feel that I am losing hold of myself

and am absolutely passive in the hands

of the great unknown forces that have formed me.

In all those dark moments, O God,

grant that I should understand that it is you

(provided only my faith is strong enough)

who are painfully parting the fibers of my being

in order to penetrate to the very marrow of my substance

and bear me away within yourself.”

Pierre Teilhard de Chardin

Senior Living Facilities

 

One of the worst fears for many people is that they will end up in a nursing home. If you are over 60, you probably have at least thought about whether at some point, you will have to move into a community designed for seniors. More often, this consideration occurs because something has changed, making living independently in you own home more difficult. It could be triggered by the death of a spouse or an illness that makes it difficult to function alone, or it could be due to advancing age and infirmity. Most people, like myself, don’t want to think about such a possibility, preferring to assume they will stay in their home, and consequently until the decision is thrust upon us don’t think about it and don’t know what alternatives there are. Fourteen percent of working people think they are likely to need such services at some point. In fact, sixth-six percent do.

What follows are brief descriptions of the major alternatives that represent different needs and levels of care.   It is useful to know the choices whether for yourself or a family member or a friend. If nothing else, it is worth being acquainted with the vocabulary. The choices are arrayed from the least intense to the more intense services.

Senior Communities: These are residences set up for seniors. They may be arranged as town houses or as an apartment complex. They are appropriate for relatively independent seniors who are ambulatory and have little in the way of disability.   Often, they have recreational facilities, such as a gym or swimming pool, and they may offer services such as housekeeping and dining, but they don’t offer nursing care or help with “Activities Of Daily Living” (ADLs such as independently ambulating, dressing. bathing, self feeding, personal hygiene and grooming, toilet hygiene and continence). Therefore, these communities are for high functioning seniors, who will have to move elsewhere if they become unable to care for themselves.

 Home Health Care: Home health services are adjunctive services that can be brought into a home of someone who is unable to travel to receive care, and which are essential to a person who wants to remain at home rather than in an institution. The services are generally adjunctive to the care provided by family or friends. They include, intermittent skilled nursing care (such as physical evaluation, wound care, IV administration), physical and occupational therapy, speech therapy, medical supplies and devices. Medicare parts A and B will pay for most of these things. Medicare does not pay for 24-hour home care, meals, homemaker services (laundry, shopping, house cleaning, personal care). To receive Medicare coverage, a doctor must certify that the person is housebound and must order the services, and the nursing services must be intermittent, not continuous. Often, home health care is supplemented by a home health aide who takes care of the more custodial tasks and is paid by the patient or family. Other services that can be added to home health services are senior day care centers, meals on wheels and senior transportation services.

Assisted Living Facilities: For some, it may be too expensive or difficult to remain at home. In the last two decades, there has been an explosion of alternative care facilities, sparing seniors the agonizing choice between home and nursing home. The alternative is an Assisted Living Facility where the person can live in a group setting in which they have a room and can get assistance with ADLs, such as dressing, bathing, grooming and has someone available on site 24 hours a day. The individual must be ambulatory and generally takes meals in a communal dining room. The facility usually provides services such as house keeping, shopping, assistance with medication, ambulating outdoors, but does not provide medical or nursing services. Board and Care facilities are another form of Assisted Living, but it is provided in a private home.

Skilled Nursing Facility (SNF): SNFs are one step up from assisted living and one step down from a hospital.   In fact, a SNF is often used following a hospitalization as a transition to going home. A SNF can provide full time nurses, a doctor who rounds daily. In addition to help with ADLs, they can provide medication management, wound care and a variety of rehabilitation services such as physical therapy and speech therapy. The differences between Assisted Living and a SNF is the availability of these nursing and rehabilitative services. Medicare provides coverage for a SNF, for up to 100 days after an acute hospitalization.

Nursing Homes: What is the difference between a SNF and a Nursing Home? Unfortunately, the terms are sometimes used interchangeably. In fact, some facilities may have both SNF and nursing home sections. Basically, a SNF must be licensed by Medicare and usually meets a higher standard of care than that required of a Nursing Home. Nursing homes are usually licensed by the state. Nursing homes are staffed by nurses and nursing assistants who can provide assistance with ADLs, meals, medication and management of minor wounds and catheters.   Generally, they provide care that a healthy person could manage on their own. They generally don’t provide rehabilitative services or care of more complicated problems. A nursing home may be the permanent residence of handicapped (physically or mentally) or frail individuals, and such is considered to be “custodial care”. The cost of a nursing home can run $100,000 to $200,000 per year depending on location and the facility. Medicare will not pay for custodial care. Medicaid will pay, but the person must spend down their financial resources to qualify for Medicaid.

Continuing Care: These facilities provide multiple levels of care, independent living, assisted living and skilled nursing, and a person moves up the scale as they age and need more care. They generally require a person to be independent when they enter. They are a good choice for someone who is still independent and wants the security of knowing that they can remain in the same facility when their needs become greater. These facilities usually provide various forms of recreational facilities, meals and transportation. They are expensive and not affordable for most. There is usually a substantial fee to buy in ($100,000 to $1,000,000, depending on what is covered, the desirability of the location and the facility) and a significant monthly charge ($1,000 to $6,000).

Other resources:  Long-term care insurance is a policy usually purchased while one is working, which will defray a proportion of the things not covered by Medicare.  Aging Life Care Professionals, or Geriatric Care Managers, are individuals who are expert at knowing the resources available in their geographic area. They can help guide a client and/or their family to the local resources, examine the alternatives, help assess costs and be an ombudsman for the person involved. If they have been certified as an Aging Life Care professional by the ALCA, it guarantees a level of knowledge and training.

Obviously, this is a cursory look at a very complex subject. It is a starter kit. If possible, it is worth consulting with an Aging Life Care Professional if one is in the process of considering alternatives.

Views Of Aging

For this posting, I thought that I would share some of the pithy quotes that people wiser than I have written. Enjoy.

“You don’t stop laughing when you grow old; you grow old when you stop laughing”.     George Bernard Shaw

“And the beauty of a woman with passing years only grows”.                                    Audrey Hepburn

“Your face is marked with lines of life, put there by love and laughter, suffering and tears. It’s beautiful”.                                                                                                             Lynsay Sands

“I wish the time hadn’t gone so fast. And sometimes I wish that that I had enjoyed it more along the way and worried about it less”.                                                                         Neil Gelman

“I’m not opposed to aging – though society is kinder to men than women when it comes to growing old. How can I look at aging as the enemy? It happens whether I like it or not, and no one is set apart from growing old; it comes to us all. Youth passes for everyone, so why deny it? I’m proud of my age. I’m proud that I have survived this planet for as long as I have, and should I end up withered and wrinkled and with a lifetime of wisdom, I would trade a few years of youth for the sophistication of a great mind.. for as long as it lasts”.   Donna Lynn Hope

“We don’t age out of singing or eating ice cream, why should we stop making love”?Ashton Applewhite

“Stop whining about getting old. It’s a privilege”.                                                             Amy Poehler

“No age in life is inglorious. Youth has its merits; living to a ripe old age is a true statement of value. Aging is the road to take to discern our character. Fame and fortune may elude us, but character is immortal. We must encounter a sufficient variety of experiences, including both failure and accomplishments, in order to gain nobility of character”.       Kilroy J Oldster

“If we counted wrinkles like pages in a book, some of us are fast approaching ‘epic’ status”.                                                                                                                             Jo Ann V Glim

“When Dr. Jung said we must be able to look forward in old age to the next day, and to look forward to the next adventure that is ahead, he was stating life’s imperative, to grow, personal. As long as we are alive, we must be able to dream of the future, of better ways of life. We are also invited by our better Self to dream new dreams of creativity and fresh ways of expressing ourselves, as many great artists have into their nineties”.                 Bud Harris

When you are distressed with your aging and want to go back to your youth, think of algebra”.                                                                                                                   Unknown

“None are so old as those who have outlived enthusiasm”.                                         Henry David Thoreau

“Grow old with me, the best is yet to come”.                                                               Robert Browning

Genes: Masters of Health and Disease

The science of genetics has changed so much over the last 50 years that it is hardly recognizable to someone like me who took my last genetics course in medical school. At that time, we were taught that an individual’s basic characteristics are inherited from his/her parents by means of genes that are carried on 23 pairs of chromosomes, twisted strands of DNA that carries the code for life in the nucleus of all of our cells. Genes were thought to be immutable, fixed for life, except for the occasional mutation. Identical twins were thought to be exactly alike because they carried exactly the same set of genes. So your (phenotype), physical size, skin color, eye color, basic physical structure, susceptibility to various diseases etc. are determined by your genetic make-up (genotype), and this wasn’t thought to change. It was clear, however, that there were other influences on the development of a person. Even identical twins with the same genetic makeup (nature), particularly those raised separately, developed some differences in their characteristics, such as intelligence, athletic ability, health, preferences and accomplishments depending on influences from their environment (nurture).

It was recognized as far back as Aristotle that parents contributed “messages” that led to the formation of a new child. This was a big step from the earliest theories that the male contributes a tiny miniature person to the female who in turn nurtures it in her body until the time of birth. The state of knowledge about inheritance remained pretty much the same until the mid-1800s and the observations and experiments of Darwin and Mendel. The work of these two men began almost a century of observations and experiments to try to determine what accounted for the formation of new life and inheritance. It wasn’t 1944 until that DNA was recognized, through a series of imaginative and exhaustive studies, as the substance that carries the genetic code and that structurally similar RNA reads the DNA genetic template and carries the message from the nucleus to the mitochondria in the cells which in turn manufactures proteins that implement the structures and functions of the body.   What has followed is a deep understanding of the structure of DNA, how genes are arrayed on the various chromosomes and how it carries out its functions. We have also learned the effects of genes, far from being static, can be amplified, diminished, activated or turned off that this is the primary mechanism mediating changes in the body’s health and functioning throughout our life time from fetus to old age.

Humans have somewhere in the neighborhood of a billion genes. The numbers which are active at any point in time are a few thousand. In other words we have many sites on the genome that seemingly aren’t doing anything. A discovery of the last decade is that many of these seemingly blank spots are actually switches that turn on and off other genes largely as a result of challenges encountered from the environment. These are called epigenes. So we have many more genes than those that are active at any point in time. In fact, we have vast warehouses of inactive genes that can respond to new or different challenges. We don’t know what all of them are doing, but it has become clear that many of the functional changes that occur during our life times are mediated through epigenes switching on and off the genes that control functions. One example of a functional change that is turning out to be related to changes in gene function is the development of cancers. We have come to understand that many kinds of cancer (perhaps all) are related to genetic functional changes probably through the activation of genes that previously were silent. The development of the body’s many different kinds of cells (liver, blood, heart, etc.) is probably related to which genes have been activated. Since all cells of an individual have the identical gene complement at birth, something has to instruct the cell to become a liver cell or a blood cell, and this is likely to be mediated through epigene activation of the appropriate structures as the embryo develops.

There are many diseases that appear to have a genetic basis. Some genetic diseases show up at birth.   In these cases, if you have the causative genes in your cells, the disease develops soon after birth. The metabolic defects that cause sickle cells, cystic fibrosis and inherited immunodeficiency are present and manifest from the beginning. However, there are no apparent problems at birth for those who carry genes for type 1 diabetes (onset usually in childhood), schizophrenia (late adolescence), manic-depressive disorder (adulthood), depression or Parkinson’s disease (late life}. The gene or genes have been present from birth, but they apparently don’t have an effect until they are “turned on”. In some instances, as with the case with cancers, environmental factors interact with genes or epigenes to act as triggers for activation. So the exposure to chemicals, smoking, radiation, stress, nutrition and some habits may be, at least in part, mediated through the activation of genes by epigenes, rather than mutation. One can see how the effects of diet, exercise and a variety of other environmental factors can be mediated through activation or inactivation of genes. What this says is that genetic makeup is much more plastic than we imagined when genes were thought to be immutable, and it opens the door to therapy based on blocking or activating genes.

Genetic research has accelerated. Scientists are discovering ways of identifying specific gene abnormalities and of plucking out disease related genes and replacing them with normal versions. Cancer may turn out to be a genetic disease with a cure that can be achieved by manipulating the genetic code. It is also possible to generate stem cells, cells that are undifferentiated and can transform into anything (heart, liver, kidney, etc.). The hope is that it will be possible to infuse these cells and have them replace damaged or lost functions, like dopamine producing neurons in Parkinson’s Disease or heart cells in someone who has had a heart attack. We are still a long way from being able to turn these theories into active therapies, but it is an area where it seems there are almost an infinite number of possibilities.

For those who want to go from this cursory summary to a more detailed understanding, an excellent book written for the lay public is “The Gene, an Intimate History” by Siddhartha Mukherjee.

Reducing the cost of Care

Two months ago, I summarizing the main drivers of the health care costs in the United States, which make health progressively less affordable. I promised to write a subsequent post with some suggested changes to reduce costs or, at least, slow the rate of health care inflation. This is an enormously complicated and arcane subject about which volumes have been written, so my “solutions” will necessarily be simplified. My goal is to give the reader a sense of what might be necessary to slow the runaway costs that now consume 17.5 percent of our GDP.

History:   To briefly set the stage, it is important to understand the traditions of medical practice. Until the early 1940s, medical care was delivered overwhelmingly by solo practitioners or small groups of two and three physicians. There was no health insurance to speak of, and the government programs of Medicare and Medicaid didn’t exist. The technology of medicine was very limited and was largely what a doctor could do in his or her office. Doctors were closely tied to a community, and payment was negotiated between the doctor and patient, largely through the exchange of cash or “in-kind” services. There were few insurance payments, group practices, few specialists, and hospitals were largely for dying patients. The good things about this model were the strong personal relationship between doctor and patient and also doctor’s freedom to determine how he wanted to run his practice. It is what many seniors remember about the good old days of personalized attention from the family doctor.

The disadvantages were that there were no limits to physician hours, no oversight of quality, and no ability to scale up to the advanced technologic world of medical and hospital care. The entry of insurance into both the private and government worlds brought more reliable payment but also greater complexity and administrative costs to doctors’ offices. While physicians complained about the changes in medical practice, they began to slowly gravitate toward larger group practices often with others of the same specialty and sometimes in very large multispecialty practices. The other segments of the health delivery industry also had to scale up. Hospitals began to supply more than nursing care; they have become purveyors of vast technologic resources, sites of highly specialized care, and, in many instances, became owners of physician practices. The pharmaceutical industry had dramatically expanded with an array of drugs that were unimaginable in 1940. And so on with the rest of the health care establishment, the surgical centers, the device manufactures, the nursing care providers, the laboratories, the insurance industry, etc..

One of the problems with this growth is that it has been in silos, each segment independent of the others, each jealously guarding its prerogatives and income. It has resulted in inefficient practices, duplication of effort, incentives to do more or sell more even if it has no benefit to patients’ survival or well-being. I believe that most people in health care are ethical and well motivated, but they are imbedded in separate systems that have no incentives to organize, to be efficient, to do only what is proven by evidence to provide benefit or to be guardians of limited resources.

Solutions:

Absence of an organized system of care: It is difficult to contemplate solving other problems without solving this first. Integrating doctors practices into a system that includes hospital care, diagnostic testing, pharmaceuticals and the various types of needed ancillary care is, I think, the path is to develop systems that are not competing for the patient’s dollar and have incentives to work together to find efficiencies. The oldest, but not the only, integrated care system of care is Kaiser Permanente health system. The Kaiser Permanente Foundation owns the facilities within which the doctors practice. They control the hospitals, the technology, the insurance products, the information systems and most of the back-office administration. They negotiate a contract for services with Permanente Medical Group, the doctors who deliver the care. The two entities work closely together. Customers pay Kaiser a specified each month, and Kaiser must provide all of the needed services for that fee (prepayment). Freed from fee-for-service, they can plan their services any way that they deem most advantageous to the patient and the institution. They are a system of care that can design strategies to avoid overlapping and unnecessary services. For example, they can utilize nurse practitioners and other ancillary personal to perform tasks for which they are qualified without worrying about whether they will be denied payment. Kaiser physicians are paid a salary competitive with what they could earn in their own office, so that there is no reason to churn out extra visits to generate more income. Patient education is encouraged to avoid unnecessary illness and hospitalization.

Other medical groups are organized differently. There are administrative entities that contract with many medical groups in many different locations, giving doctors more freedom to design their practice. However, they generally share an information system and are still held to standards for quality and service. The Sutter Health System in California operates in this fashion. Whatever the mechanism, the goal is to assemble all of the resources (hospital, laboratory, radiologic, outpatient care) under one financial roof to encourage sharing of information and to design more efficient processes.

Most young doctors finishing their training are not interested in opening an office on their own. They desire a more reasonable life style, readily available resources, the stimulation of colleagues to and be freed from administrative hassles. The trend is obvious. Most medical care is going to be provided large entities, which, at least in theory, can deliver comprehensive, efficient care of high quality. There is a cost to this. Care will be far less personalized and will require the patient to learn how to work within what can be a bureaucratic system.

 The current system incentivizes overuse:  I have already written about the perverse incentives of the fee-for-service system.  It encourages churning, the overuse of procedures, and it stifles innovation.  Doctors have little incentive to spend time developing new streamlined methods, which may reduce the number of visits and services if they are being paid fee-for-service. That could, in fact, reduce their income.

Medicare is experimenting with the creation of Accountable Care Organizations (ACOs), entities made up of groups of physicians and hospitals that are responsible for providing all needed care for a for a fixed monthly payment. These are HMOs by another name, but with the difference that patients can choose any physician in the insurer’s network and that there are strict quality controls on the care delivered. HMOs in the 1990s got a bad reputation because of overly restrictive limitations on physician networks and, in some instances, skimping on care. The downside to prepayment is that it reverses the incentives, potentially incentivizing underuse. Quality and satisfaction must be closely monitored.

Expansion of the use of technology: The technologies that have been introduced in the last 50 to 60 years are truly amazing. Technology companies have been booming, and it is clear that there is a lot more to come. In some instances, new technology can save resources, for example doing a CT or MRI scan of the abdomen rather than exploratory surgery. The difficulty is the temptation to overuse these wonderful, but very expensive technologies rather than older but reliable technologies combined with clinical judgment and the passage of time.   In many instances, the new technology is used before it is proven to be better. New products should be studied to show when they are clinically effective and cost effective. Currently insurers have the unenviable task of deciding when a new technology is ready for prime time and should be covered.

Patient demand for services: As I noted in my earlier post, this factor is often cited as a cause of the riding cost of health care. It is unclear to me how much of the rising costs can be attributed to this. Because the payment for service is usually done by an insurer (private or government), out of sight of the patient, it is easy for some to abuse the system and demand excessive services. There is some evidence from a study from the Rand Corporation many years ago that people who had zero financial responsibility for their medical bills used services more readily than those who pay a co-payment and have a deductible. This seems less relevant now when most policies are sold with substantial patient co-pays as employers offload costs to their employees through greater co-payments and deductibles.

Patients’ demands can be increased by the introduction of marketing and advertising.  The pharmaceutical companies in particular have perfected so called “direct to consumer” advertising. There was a time when pharmaceutical companies were prohibited from advertising drugs on public media. That restriction no longer exists, and pharmaceutical companies spend untold amounts touting the benefits of their product on television.

I won’t discuss aging of the population, but it is very real and only going to accelerate in the future. We have visions of life spans getting to be 90 to 100 for the Millennials rather than 70 to 80 as it is now. We have dreams of curing cancer and developing custom drugs and therapies for each patient. That could make health care an impossible burden to carry unless we can figure out ways of making a more efficient and cost-effective system.

Aging As An Adventure

It is easy to assume that aging is not going to be a pleasant time of life. Many have heard the now famous quotes, “Aging is not for sissies,” (Bette Davis), and “Too old to work and too young to die (Unknown).” It does at times feel like a one-way road downhill without redeeming features.   As parts of your body start to fail, and your capabilities begin to diminish irreversibly, dying ceases to be an abstraction, and you know that it lurks in the not too distant future. I had my awakening at the relatively young age of 56, when I was admitted to the hospital with chest pains, which proved to be caused by a substantially blocked coronary artery. I had a procedure called an angioplasty where a long catheter is passed from an artery in my groin into my coronary artery and a balloon is inflated to expand the area of blockage and restore circulation.

The morning after the procedure, the catheter was removed and the artery almost immediately shut down. I developed severe chest pain, and I knew that I was having a heart attack. My call brought the cardiac team into the room, and there was the bustle that I was so familiar with, hooking up the EKG, taking blood pressures, starting IVs and calling out instructions. At some point, someone said the EKG showed 5 mm of S-T elevation, an indicator of a severe heart attack in process. While this was going on, I felt strangely detached, like I was watching this happen to someone else. Within minutes, I was rushed back to the catheterization lab, and the catheter was threaded back into my coronary artery, and it was reopened.

In retrospect, I realized how close I had come to a fatal heart attack. Had this occurred outside of the hospital, I might not have made it. It made me realize that dying wasn’t something theoretical   I was going to die, perhaps relatively soon. As it turns out, I’ve been very fortunate. That was 22 years ago. Since then, I have developed Parkinson’s Disease, another chink in the armor of perceived immortality. So, I write this from the perspective of how important it is to see the world as one of possibilities and to use my time well. I don’t know how much time I have, and I want to go out with the feeling that I have lived and grown as much as I can.

Several authors have written about the stages of life, from childhood through establishing a life’s work to finding a partner, raising children, reaching the peak of one’s career and retiring to a quieter life. However, there has been relatively little written about the last stage, after retirement. It is not surprising given that until 40 to 50 years ago, life expectancy was slightly north of 60 years, and the average person often worked until they were disabled or died. Improvements in life style, disease prevention and treatment have led to dramatic increases in longevity, and the creation of Social Security and Medicare has given many people the means to make a life beyond retirement age. Having the time and health to pursue new goals has only become common in the last few decades and has activated questions about what makes for a more fulfilling latter stage of life. Given the potential of 10 – 20 years after retirement, what does one do with the time? This is still only partially explored territory.

Interestingly, many seniors view their later years as the best time of their lives. With a little luck, one has lessening responsibility for producing, meeting goals, earning money and raising a family. I realize that is coming from someone who has been relatively privileged and blessed with the means to retire from work and to have free time. However, time can be the curse or the blessing of getting old.   Time can be a void that longs to be filled or an opportunity to create something new. Some people dread the prospect of retirement. I don’t begrudge anyone the opportunity to continue to do work that they love. However, it is my view that when one scales back on one’s career, there is an opportunity to discover neglected or unrecognized parts of oneself.

Work that we like and a fulfilling career are blessings to be appreciated, but I believe that work satisfies only certain aspects of one’s life and neglects others, by necessity. Work satisfies our ambition and needs for competence, skill, the sense of making a difference and the ability to maneuver in a particular world, but it suppresses other important domains. It is difficult to satisfy the demands of succeeding at work and, at the same time, explore our unfinished business and neglected opportunities. All of us have bruises and regrets from our past. They may be disappointments, relationships left untended, or there may be potential passions that we’ve left unexplored. In that sense our lives are incomplete. For most of my life, I didn’t think about my potential other aspirations or my unresolved questions, because I was busy with the necessities of working and maintaining a life. Work can substitute for dealing with our basic conflicts and desires, the unfinished business of life. It may sound sophomoric but we deserve time and the opportunity to explore our passions and our disappointments from the past.

So you might ask, “Who wants to explore the potentially painful and difficult aspects of their life when I am relatively satisfied doing what I am doing”? I would say, it’s not all painful. There are many satisfactions to be had, new worlds and interests to be explored and pleasant surprises to be gained. There is an opportunity for a new creativity and a chance to give back to the world in which we have been raised.

I’ve been impressed with the richness of peoples’ lives when they get off the work treadmill and start to explore. People become writers, musicians, artists, tutors, community activists, students, competitive athletes and volunteers of all kinds. You don’t need to be world class to get great pleasure from exploring new parts of yourself. But it takes courage to stop doing something that you are comfortable with and to take a chance on the unknown, and it is difficult to take the risk of doing something that you might not be good at. The blessing is that there is no penalty for trying something that you may not be great at. It’s not like your life depends on it. I’ve related before that I started out learning something about photography, and by habit, I immediately wanted to be professional grade. When I acknowledged that I wasn’t at that level, I enjoyed it more.

So I encourage people who ask me about retirement to think creatively and to take risks.   Let your interests lead you to something that you have never done before. This is an opportunity to explore worlds that are new to you. The good news is that you will bring to it all of the wisdom that you have acquired in a long life.

If any of this makes sense to you, there are two books that address the subject of the challenges and satisfactions of late life in more detail. One is “The Third Chapter, Passion, Risk and Adventure in the 25 Years After 50” by Sara Lawrence-Lightfoot.   For the more “new age” inclined, “The Second Half of Life” by Angeles Arrien is a good discussion of the successive challenges of aging.

Hospital Hazards for the Elderly

Most people know that being a patient in a hospital can be dangerous while, at the same time, providing critical care. This post catalogs the dangers of hospitalization, particularly for older people and recommends some ways of lessening the hazards. The next three paragraphs are a direct quote from an NPR report on the program “All Things Considered.”

“Until March of this year, Janet Prochazka was active and outspoken, living by herself and working as a special education tutor. Then a bad fall landed her in the Zuckerberg San Francisco General Hospital.

Doctors cared for her wounds and treated her for pneumonia, but Prochazka, who Is 75, didn’t sleep or eat well in the hospital, and she became confused and agitated. Then she contracted a serious stomach infection.

Patients over 65 tend to be less resilient during a hospital stay than younger patients, research finds, and more vulnerable to mental or physical deterioration, even if they recover from the illness or injury that brought them there. One study, published in 2011, found that about a third of patients older than 70 and more than half of the patients over 85 left the hospital more disabled than when they came.”

The sobering case described is not unusual. In fact, hospitalization can be the beginning of a downward slide for an elderly person, followed by declining function, reduced quality of life, placement in a skilled nursing facility or nursing home, and death. This post shares some of the common factors that cause complications and how they can, where possible, be prevented.

Conceptually, all of us have physiologic reserves that we call into play when there are challenges to the body’s well being. However, reserves decline with age due to loss of muscle strength, heart and lung capacity, immune function, cognitive function and general physiologic resilience. At the extreme, there are the “frail elderly,” who are most likely to do poorly in the hospital. Add the challenges that greet people in a hospital to the underlying loss of reserves, and it is a recipe for disaster. What are those challenges?

Immobility: It is surprising how many complications can be caused by the inability to get out of bed and ambulate. In no particular order, immobility can lead to pressure sores, rapid development of muscle weakness (which in turn contributes to falls), under expansion of the lungs (contributing to pneumonia), blood clots that can break loose and go to the lungs and loss of orientation.

Hyper-stimulation: Patients in hospitals must endure the almost constant noise, lights, machines, waking to be checked and other interruptions to sleep and rest. This is particularly true for patients in an ICU. Adding this to an unfamiliar environment can cause disorientation or a delusional state complete with hallucinations. Over medication can be another contributor to this set of events.

Infections: Hospitals are associated with many factors that lead to infections. Breaking our first line of defense, the skin, and invading the body through surgery, bedsores or procedures that puncture, reduce the body’s natural defenses. Similarly, organisms can invade the body through catheters placed in the bladder and through the air that is breathed, particularly if tubes are used for ventilation. Urinary infections are very common in people who have catheters in their bladder for more than a couple of days. Recumbence, pain and loss of muscle strength can make it more difficult for a person to fully expand their lungs, and partially collapsed lungs are a setup for pneumonia to develop. Add to that the proliferation of “super bugs,” virulent and resistant to antibiotics, any of the above sites can be susceptible to life-threatening infection. These organisms are carried from patient to patient primarily by the hospital staff, such as physicians and nurses who don’t always wash or disinfect their hands when going from patient to patient.

Our bodies are home to literally billions of organisms with which we live in harmony. These organisms are kept in check through barriers to entry, the skin, the lining of the gut and respiratory tract, through secretions like saliva and mucous and by the immune system. Patients who are sick, and particularly the elderly, have depressed immune function and less able to fight off microbes. When they have a chance to invade through breaks in the normal defenses, even ordinary cohabitants can become the cause of serious infection.

Errors: Medical professionals are subject to errors. They are caring for a large number of very sick patients in a complex environment, and it is easy to become distracted, overlook something or make an outright mistake. Some mistakes are egregious, like removing the wrong limb. Some are easier to understand, like misreading a doctor’s order and giving the wrong dose of medication. The elderly generally cannot tolerate medication doses that are standard for younger patients. Many errors are preventable by using standardized procedures and protocols and by putting in safety checks. Quality hospitals are implementing the tools of modern industry in the hope that like modern industry, errors can be reduced to one in a million.

Accidents: Falls are the most common accident occurring in a hospital. A combination of weakness and disorientation are usually responsible. After that, accidents can be caused by equipment malfunctioning, by a medical procedure gone awry or by failure to adequately supervise a young professional.

So to what end this litany of medical woes associated with hospitalization? What can we do to lessen these dangers given that although they are best avoided, hospitals can be life saving and are absolutely necessary at some points? I would give the following advice to someone entering a hospital and to their significant others who may need to be on guard if the patient can’t be. It is easy to be passive and compliant in the confusing setting of a hospital, but it is important to be one’s own advocate.

Avoid immobility: Even seriously ill patients including patients with recent surgery or on a respirator can be gotten out of bed to sit in a chair for a while, and preferably to walk short distances. My wife was hospitalized in an ICU for several days after a biking accident. She complained bitterly about how uncomfortable she felt when she sat up in a chair, but the staff persisted in getting her out of bed for short periods.

Advocate for periods of uninterrupted rest: It is difficult to avoid the consultations and monitoring of vital functions, particularly with patients in an ICU. However, protecting some time to sleep quietly is essential to avoiding exhaustion and disorientation. Talking to the staff about scheduling events in bunches, leaving time for rest, can help the patient recover.

Understand what is being done and why: It is difficult to get physicians’ attention in the hospital. They are usually in a rush when making rounds, and getting them to stop and answer questions can be a challenge. When my wife was in the hospital, doctors seemed invisible. They made rounds at 6 or 7 am, and they were often in the operating room or somewhere else during the day. I had to be persistent to get someone to talk to us. Other than in an emergency, you should understand the rationale for major tests and treatments, the benefits and the risks.

Be your own (or family members’) best advocate: When things are going well, compliments go a long way. However, if you are concerned about something, respectfully speak up; it may be a clue that something is awry. Know what medications you are being given and what they look like. I’ve had nurses bring a medication to my bedside that was actually intended for another patient. In the extreme case, chemotherapy has been given to the wrong patient.

Don’t be intimidated by the technology or staff: At times, the hospital procedures seem bewildering, and the staff may seem busy and brusque. As a patient, it is your right to know what is happening and as a visitor, you provide an important function, namely, being a friendly point of reference reminding the patient of who they are outside. If a patient can’t be their own advocate, it is best if one person speaks for the family so that the staff is not getting repeated or conflicting questions. Hospital staffs are usually concerned human beings who want to do what’s best for the patient, but they are busy and working in a complex environment. It’s often best to begin your inquiry with the nurse, who can bring in the physician as needed.

Hospitals can do miraculous things, and at times they are absolutely essential, but they can be dangerous. It is best to know where the dangers lie and to take steps to prevent them.

Why does Health Care Cost So Much?

Health care costs in the US continue to rise at an unsustainable rate. I remember studying this subject when I was early in my career, when health care costs represented about 8 percent of GDP, and reading predictions of it rising to 15 percent over the coming decades.   It is now 18 percent of GDP and predicted to rise to 20 percent in the not too distant future. Make no mistake, rising costs are a problem throughout the world, but it is a uniquely American problem in that the US spends about double the amount per capita that other developed economies spend and has inferior outcome measures. It is clearly a problem that affects what we earn and can spend as well as the competitiveness of the country as a whole.

It is a problem that is getting surprisingly little attention in this crazy presidential campaign of 2016. Donald Trump promises to abolish Obamacare, and Hillary Clinton wants to expand coverage to more of the poor, neither of which will help to control the cost problem that is the driver of many economic concerns. This brief post will not contain all the answers to a tremendously complex problem, but I will try to summarize the main issues. First, I’ll focus on the principle drivers of increasing cost.

Aging of the population: It ‘s well known that providing health care for older people is much more expensive than the young. Our population is aging, and calculations project that this is some of the cost increase, but it is nowhere near the total problem. Besides, it doesn’t explain the US costs as compared to other developed countries, since their populations are aging too.

Expansion of the use of technology: In the last 30-40 years, there has been bonanza of new technologies that have vastly increased our capabilities and improved outcomes. Imaging (CT scanning, MRI, PET scan), minimally invasive surgery, new drugs for the treatment of cancer and other diseases, genetic diagnosis and improved treatment modalities (targeted radiation therapy, joint replacement, microsurgery) are some of the things that have improved what we do.   The problem is that each of these innovations is expensive, and once they are available, their usage expands to problems where they have no incremental value. It would be great if they substituted for other less effective, costly procedures, but they tend to be incremental. No one is going to suggest forgoing a valuable new tool, but our payment system (next section) encourages their overuse.

A system of payment that clearly incentivizes doing more: The following is complex but important. In fact, if I had one thing that I could do to control costs, I would change the reimbursement system. With some notable exceptions (such as Kaiser), health care in this country is paid for on a fee-for-service basis. In other words, a doctor or a hospital provides a service, and they are paid a fee, usually pre-negotiated, for that service or procedure. The main thing that insurance companies, Medicare and Medicaid negotiate are the fees, and providers of care are paid sharply discounted fees as compared to their “usual charges”. If you are unlucky enough to not have health insurance, you will be charged the full fee. In other words, you will be charged the retail price, not the wholesale that everyone else is paying.

The perverse problem with fee-for-service is that it controls unit price but not volume. So what has happened is that providers have increased the volume of services that they provide. By doing more procedures, providing more services and seeing patients more quickly, doctors, hospitals, laboratories, etc. have been abLe to maintain a high level of income. The effects of this are obvious to most. Visits tend to be brief and rushed. Unable to take the time for a careful history and physical exam, doctors send patients for multiple scattergun tests, and physicians have a strong incentive to do more procedures, such as surgery, because it pays well. Young physicians are gravitating to specialties that are more procedure oriented, in part for life-style reasons, but in part because procedures pay better and take less effort than talking to a patient. Consequently, there is a growing shortage of primary care physicians to coordinate care, because it is hard work that doesn’t pay well. It is difficult to make changes that might make healthcare more efficient and rational, because the payment system holds everything in place. There are no financial incentives to do it better, only to do more.

Patients’ demand for services: A colleague of mine, spent a year in Europe studying the health care systems, particularly the British National Health Care System. He said that one of the contrasts between there and here is that the British are much less demanding about their care and more accepting of limitations. The average American expects to have the latest care technology and care available immediately, and can be very impatient with advice that it may not be needed. Until recently, comprehensive health insurance shielded them from the cost of  care.  Health insurance was designed when the costs were an order of magnitude lower and was often given away by employers as a way of avoiding wage increases. It wasn’t unusual to total coverage with minimal to no co-pays and deductibles. That is changing with high deductible policies that don’t pay until the patient has paid a $3,000 – $5,000 deductible, thereby giving the patient a reason to hold down costs. It appears to have had some effect, but to a great extent, we are spoiled and expect to have access to the most expensive technology without having to pay for it. As a country, we have not had to balance the tradeoff between access and cost. That is true except for the poor and uninsured who have limited access.

Absence of a system of care: The fundamental problem is that we don’t have a system of care. We have many silos, physicians, nurses, hospitals, insurers, pharmaceutical companies, laboratories and the government each trying to optimize the care process to enhance their own incomes and leverage. There are no villains and no heroes. Each is trying to turn a profit within their own domain without considering the effect that it has on another silo or the overall product. No one is in charge of the quality, efficiency or the rationale of the enterprise as a whole. It makes it very difficult to assess what needs to be done no less bring about a fundamental change.

In a subsequent post, I’ll discuss solutions that have been suggested and my own ideas.

Can We Prevent Cancer?

Status

A recent Op-Ed in the New York Times by a physician, Aaron E. Carroll asked the question, “Are we helpless to prevent cancer?” Although it causes fewer deaths than heart disease, cancer is the most feared affliction for most people. When and if cancer strikes seems like pure bad luck, putting aside the few people who have a known genetic predisposition. There has been so much progress in the prevention of heart disease that it feels more controllable whereas cancer seems like it strikes out of the blue.

Dr. Aaron’s message is that many forms of cancer can be significantly reduced or prevented by attention to the risk factors that contribute to its developing. Our medical system is very physician centered. Since most physicians are usually not focused on disease prevention, they pay most attention to testing for early detection of relatively few cancers for which there are effective screening tools and the treatment of already established disease. The public tends to mimic this medical model and puts off doing the things that can reduce its risk of cancer. Thus cancer is often discovered at a stage requiring treatment, resulting in much less chance of success in becoming disease free, much more arduous treatment with many more adverse effects on the patient. Obviously, it is far better, cheaper and less uncomfortable to prevent the disease if at all possible.

It is difficult to assess the impact of behaviors or the percent reduction of cancer risk. Most of these suggestions do not come from controlled studies where people are randomly assigned to implement the behavior or not. More often they are the result of observational studies that note the number of times a cancer is associated with a particular behavior. For example, 80 percent of people with esophageal cancer smoke, much higher than the general population. There are geographic locations where the incidence of a particular cancer is much elevated, and people from low risk areas acquire the elevated risk when they move into a high risk area. These observations strongly support the presence of extrinsic factors that influence how often cancer occurs, factors that can potentially be controlled.

The following lists the five behaviors for which the evidence is strongest that there are risks that we can reduce in the formation of cancer:

Avoid tobacco – Strongest evidence of risk. Cancer of the lung, esophagus, stomach, throat, larynx, kidney, pancreas, bladder. Substantial risk with second hand smoke, and risk of cancer of the mouth, tongue and throat with chewing tobacco

Protect skin from sun exposure – Skin cancer, melanoma, squamous cell, basal cell, particularly if fair skinned. Evidence well established

Drink alcohol in moderation – Cancer of the breast, colon, liver, mouth, throat, larynx . Moderation is 1-2 drinks per day.

Eat a healthy diet – Fruits and vegetables, 5 servings per day, is associated with reduction of many forms of cancer. There is some evidence that cooked red meat increases cancer incidence, but it is not yet strong enough to recommend. Healthy diet can help reduce obesity, which is independently associated with many kinds of cancer.

Exercise regularly – (150 minutes of active exercise per week) Aside from the many cardiovascular benefits, there is also linkage to lack of exercise to breast, colon and endometrial cancer as well as longevity.

I can’t vouch for the accuracy of the number, but it is estimated that 40 percent of the incidence of cancer can be reduced by following these five suggestions. Obviously, there is much that is unknown, such as the mechanisms of the effects and other risk factors as yet unproven or undiscovered. Of the thousands of chemicals to which we are exposed, there are undoubtedly many that are going to prove causative to developing cancer. For any who want to read more detail about the strength of evidence related to the above behavioral factors and some that are less proven, a reference on the Internet is www.nap.edu/read/10263/chapter/5 . It is from the National Academy Press, “The Behaviors Contributing To The Burden of Cancer”.

So knowing all of this, why don’t we follow more healthy behaviors? Well there is some evidence that we have improved. The incidence of smoking is down substantially, exercise seems more common, and there is some evidence that people eat healthier diets (beef consumption has dropped dramatically in recent decades). However, most of us fall short of addressing all five behaviors. Unfortunately, there is no pill to take for any of these, and behavioral change is hard. As many times as I have reminded myself, I routinely forget to apply sunscreen. I recently had my first basal cell carcinoma removed.

There are also five screening tests that have been proven to be of benefit in finding cancer at an early enough stage to reduce mortality. Screening is tricky because it tests a large population most of whom do not have the of cancer being screened for. Even with a very good test, the result is often more false positives than true positives. (If a test is 98% specific, then 98 % of the time when the test indicates disease, it is, in fact, present. Obviously, 2% of the time, the test is a false positive.) If 1000 people are being screened for cancer that occurs in 1% of the population, then ideally 10 people will have a test result that indicates disease. However, false positive results will occur in 20 people, so that only one third of the people with positive results will have the disease. This results in a large number of follow-on tests or treatments that are not needed.

The U.S. Public Health Service Task Force (USPHSTF) has looked at all of the evidence on the benefits and risks of screening, and they recommend five screening tests to be promoted to the general population. Other tests may be indicated depending on a person’s unique situation, but these five have been proven to reduce mortality.

Pap Smear – For the early detection of cervical cancer in women, screening should begin at age 21 and continue to age 65. Screening should begin yearly but once there has been 2-3 negative tests, screening should proceed every 3 years.

Screening for Human Papilloma Virus (HPV) – Should be done in conjunction with Pap smear at age 30 to 65. HPV is the putative cause of most cervical cancer and genital war ts. It is more sensitive than Pap Smear in finding early stage changes, and, consequently, a positive test should be followed up with colposcopy. Negative results on both tests indicates that screening can be done every five years.

Mammography – for women between the ages of 50 to 74. Negative results mean that screening can be done every two years (This does not apply to women who are being followed for an abnormality or who have had previous breast cancer.) There is controversy over whether screening should begin at age 40, the USPHSTF has left the choice up to women and their doctors.

Colonoscopy – Recommend this being performed at age 50 and every 5 years thereafter until age 75 for the detection of colon cancer.

Skin Examinations – There is only fair evidence for the effectiveness of having a doctor survey your skin every year or two. The purpose is to look for skin cancers including melanoma. As I have gotten older and lesions are more common, I personally have seen a dermatologist every year for an examination.

Most of the guidelines recommend the cessation of screening at age 65 – 75. However, as people live to an older age, this will need to be re-evaluated. The question to ask yourself at that age is, “Would I do anything about it if I found an abnormality?” If you are healthy enough to say yes, then you and your doctor should consider continuing screening.

 

Falling into a New Age

The following post was written by Diana, reflecting on her experiences recovering from a bicycle accident and its physical and psychologic aftermath.

Two years ago, I had a bike accident that – literally and figuratively – threw me for a loop. I recovered physically and then found myself in a psychological quagmire that took me a much longer time to sort out. I was 68 years old and vigorously healthy at the time, and I wasn’t thinking of myself as anywhere near old. The accident changed all that.  I no longer felt sure of how to regard myself on axes of age or health.

Now I am turning 70, grateful to be alive and healthy, still enjoying my work although at a lesser pace than before, and I know for a certainty that although I am full of energy and gusto and knowledge, that I am a senior, and the future is uncertain. I have trained myself to enjoy the present, to do as much as I can, and not to look at the future as an inevitable downhill slide. (Of course it is an inevitable downhill slide, but I don’t have to focus my energy on it all the time.)

Four of my good friends or family members – all in their seventies and reasonably healthy – have each taken a fall within the last year. Fortunately, their physical injuries were relatively minor. But for each of them it has revealed a trajectory that I recognize only too well, and each of them has experienced a psychological reckoning. Each of them either tripped over some small ‘bump in the road’ or lost his/her balance. On getting up, each one felt embarrassed first and only gradually realized he/she was injured and needed medical care. Physical recovery has been smooth for all of them, but each has had a deeper reckoning as a consequence. Not everyone was willing to talk about his or her own recognition of frailty as a fact of life.

I too have tripped and fallen recently, fortunately without injury. But I know that my balance is imperfect, a factor of simple aging. The recognition that we can no longer take for granted navigation with our own feet is (forgive me) a first step. I can hike at least as far as I could ten years ago, but now I will happily use a walking stick on uneven ground. The second step is not to feel diminished by this.

I have eliminated from my life certain physical sports and risks I used to enjoy, with the conscious recognition that I don’t want to invite injury. And I enjoy, at least as much as before, all that I can see and do. I admire those of my peers who are more physically adventurous and adept than I, without wishing I could still compete with them. Losing the sense of competition is one of the under-celebrated blessings of this time of life. Another is abandoning any striving for perfection, a perennial frustration best left to the young.

This sense of wellbeing has been a gradual acquisition over the past two years. Each of us finds our own way through this labyrinth of growing older. It helps that my friends and I can laugh about our frailties of memory and balance. It helps immeasurably that we can share with each other the beauty that surrounds us, and the inspiration of the young people in our lives. My sense of dread has been replaced with these gifts.