Reviewed Book
Old & Sick in America: The Journey through the Health Care System. Muriel R. Gillick, Chapel Hill: University of North Carolina Press, 2017, 300 pp.
Aging, I often tell my students, is changing the world. Never before has such a large proportion of people lived so long. At the same time our social worlds, and especially the social world of medicine, is changing experiences and meanings of both aging and dying. Muriel R. Gillick’s Old and Sick in America: The Journey through the Health Care System offers readers an insider’s tour of the U. S.’s complex systems of care for older adults with a keen eye toward the social, economic, and policy drivers of this imperfect system. With over 30 years of experience as a geriatrician caring for older adults, Gillick is an expert guide to the major changes shaping contemporary elder care.
Thanks to medicine and public health efforts that have radically decreased infant and child mortality while converting formerly fatal conditions into chronic illnesses, in many places old age has become the period of the life course most associated with death and dying. Gillick’s book joins a growing conversation addressing vexing questions arising from the preponderance of medical intervention now directed toward sick and dying older adults. For example, why are so many resources spent on heroic, expensive, and often traumatic treatments in the last months of older peoples’ lives? Why do older adults often return from hospitalizations more vulnerable than before? Why do so many people receive care and die in places other than their homes? These questions are especially troubling because it appears that many attempts to treat older adults’ illnesses worsen their daily experiences without substantially lengthening their lives. Gillick’s aim is to provide a better understanding of the elder care system through the perspective of a deeply concerned physician who recognizes the systemic ways that these practices harm older adults.
Gillick understands the U.S. health care system from a Durkheimian “complex systems theory” perspective, and views its various components as working together to maintain prevailing relationships and adapting over time in ways that tend to “preserve the status quo” (p. xvi). Thus, Gillick argues that medical care for older adults as currently practiced is not centrally focused on the overall well-being of older patients. Rather, disjointed treatment systems, incentives created by the capitalist economic structure of medicine, and a variety of federal policies have built a system that better serves the needs of health care providers, insurers, and drug/technology companies than it does older patients. This system promotes the intensive use of expensive and often invasive medical technologies, poor coordination between health care providers, and it leads to suboptimal—and often deadly—outcomes for older adults.
As indicated by the book’s subtitle, Old and Sick in America is organized to follow a typical older adult’s journey through the health care system, starting with the doctor’s office, proceeding to the hospital, and ending at the skilled nursing facility (the current term for what most people call a “nursing home”). In each part of the book, Gillick begins with a short case study that effectively illustrates the kinds of experiences that older adults might have at each site. Later chapters in each section describe the different kinds of providers within each category (i.e., small group doctors’ practices vs. multispecialty groups) and provide key historical background explaining how this array of providers came into being. Each section also analyzes the current economic and policy pressures incentivizing specific forms of elder care and discouraging possible alternatives. Notably, the focus on formal health care excludes from Gillick’s analysis several sites of non-medical elder care that nevertheless play a crucial role in older adults’ experiences of care and physical health, including assisted living facilities and home-and-community-based care. Across the chapters, readers learn how specific aspects of Medicare policy, pressures created by the market-based provision of care, and the interests of drug and medical technology companies directly and indirectly influence the ways geriatric medicine is practiced in the United States.
One strength of the text is that Gillick forthrightly advocates for a number of changes that, based on her decades of experience, she believes will refocus geriatric medicine on the wellbeing of older people. Across chapters, Gillick points out that medical specialization, electronic records systems, and insurance policies often promote the treatment of single conditions, though treatment for older adults is more likely to improve well-being through holistic analysis of overall functioning and interactions between bodily systems. Gillick persuasively argues that this will be best accomplished through the use of integrated, interdisciplinary, and multispecialty care teams both within hospitals and across care settings. To be effective, such systems require large cadres of geriatric specialists trained in the distinct physiology, treatment outcomes, and needs of older people. When possible, medical appointments and care would be conducted at home, enabling more accurate assessments of older adults’ full functioning and reducing the risks posed by hospitalization.
Not necessarily written for academic audiences, Old and Sick in America does not directly describe Gillick’s methodology. Much seems drawn from personal observations of how geriatric care has changed over her many decades of experience. Gillick often illustrates broader points using concrete case examples from across the United States. The rationale behind selecting these cases is not explicit; however, they are effective at showing that many aspects of the health care system are at least partly the result of historical contingency and economic interest rather than some kind of purely detached “best practice.”
Old and Sick in America beautifully complements two other recent texts addressing the care of older adults in an era of lengthening lifespans. Sharon Kaufman’s Ordinary Medicine (2015) draws on a decade of ethnographic research around the country to consider the cultural values within which more medical treatment and longer lives have come to be unquestioningly understood as preferable. Atul Gawande’s Being Mortal (2014) is a personal meditation, drawing on his experiences as both a physician and family member, on how to live better with aging, rather than simply pursuing longer lives for their own sake. To this conversation, Gillick contributes a behind-the-scenes analysis of the political and economic forces shaping health care settings and actors and the ways that these directly impact older adults’ experiences of care. Together, the three texts form a solid foundation for scholars studying health care at the end of life in the United States. I can easily imagine assigning Old and Sick in America as a concrete illustration of the intersections of policy, political economy, and medical practice in any applied medical anthropology classroom. Clear writing and concrete details will appeal to both undergraduate and graduate students, including those in professional and applied degree programs. Beyond the classroom, I recommend this text as an excellent primer for anyone who finds themselves or a family member anticipating engagements with the byzantine U.S. health care system toward the end of life.
References Cited
Gawande, A. 2014. Being Mortal: Medicine and What Matters in the End. New York: Metropolitan Books.
Kaufman, S. 2015. Ordinary Medicine: Extraordinary Treatments, Longer Lives, and Where to Draw the Line. Durham: Duke University Press.