It’s 10pm on a Sunday night and all of my family and I are watching and laughing at Gogglebox on Channel 4. Except for my teenage son, who is upstairs in his bedroom. He is studying hard because he has decided that he wants to be a doctor. He’s started his vocation early — he’s only 14.
I reassure him that he is only in second year and there is still plenty of time. But he has already decided that to do well, certain sacrifices (eg, Gogglebox) need to be made to get him over the line.
It is not like those who choose medicine are the only ones studying hard, but I’m already beginning to notice in him something that I hadn’t noticed about my own life in medicine: how a life in medicine marks us out as different from early on and how it can shape and define us from then.
The competitiveness for places in university is high, which demands a degree of focus, obsessiveness and perfectionism early on in those intent on making it. Those sacrifices will serve my son well but will need to continue throughout university training and post-graduate life if he is going to succeed.
After a few years of being surrounded by other over-achievers, he will probably assume that this is the norm.
His medical school training and life as a junior doctor will shape him further.
Like a novice entering a seminary, he will quickly become accustomed to the costumes, props and rituals that define it. He will be exposed to sleepless nights, illness and death in a way that few of his non-medical friends are, but medical training will encourage in him a degree of objective remove from his patients to help him survive. But he won’t notice because most of his friends will also be doctors.
He will also discover early on that society confers a special value on doctors and aspiring medics. Medical students are celebrated in families and society in a way that novice priests might have been in the past — ‘he’s going to be a doctor, you know’. It is well recognised that even the primitive tribal medicine man (who was also often a priest) was released from the obligation of procuring food for his tribe.
Society needs doctors to be different, and placing us on a pedestal is probably an expression of its need to bestow a kind of magic and infallibility on us. It is part of the way they acquire the necessary trust to surrender themselves to our care. Whereas it might help us get a table in our local restaurant (‘What time would you like to eat, doctor?’), that perceived specialness demands a price.
Doctors are seen by some of their flock, not as the flawed, vulnerable human beings that they are, but as separate, dehumanised, almost God-like versions of themselves. It makes certain people (especially those we have met professionally) behave awkwardly with us socially.
We become a bit like those lonely priests who are greeted exclusively by their title of ‘Father’ — as if they had no name or identity of their own.
Those who embrace their role too seriously (priests and doctors) have to give up part of themselves and will be set up for the inevitable and painful fall from grace when they (and their flock) realise that they’re not as God-like as they thought they were.
Gogglebox is nearly over and I’m tired and want to get to bed early — I have a busy clinic and a couple of important meetings tomorrow. But my wife reminds me that I still have important work to do tonight — tomorrow is bin day.
I call upstairs for my son.
It is usually at this time of the year — as chatter about the ongoing Leaving Certificate examinations reaches a peak — that the nightmares come back. I arrive late for my Irish exam, unable to recall a word of Irish or a single interesting thing that Peig Sayers might have once said. Or I’m rushing late, down a long corridor, unable to find the exam hall and then having done so (it is empty), unable to find my pen.
As if the nightmares aren’t enough, the masochist in me has been further reliving the Leaving Cert experience by entering my results into one of those online CAO points calculators. I fear (even allowing for some points inflation over time) that my rather modest 487 points (thank goodness for Home Economics) would hardly get me into medicine these days.
Getting into medicine is hard, but it should be. Just gaining the points for entry demands a degree of intelligence, sacrifice, hard work and resilience that will serve those embarking on the gruelling slog that medicine is. But it often comes as a disappointment to those who secured 600 points in the Leaving Cert (and a relief to those who didn’t) to realise that being good at doing exams doesn’t necessarily mark you as someone who will become a great doctor.
Patients in a 2009 Mayo Clinic study identified the best doctors as those who are confident, empathetic, humane, able to see their patients as individuals, forthright, respectful and thorough.
Despite the crudeness of the selection process (and it seems no-one yet knows how much the HPAT adds), most of those starting out in medicine that I have met tick many of these boxes and start with great promise. They are bright, enthusiastic, curious, compassionate and optimistic. Apart from the occasional psychopath or narcissist (a few still make it through), most who start off on a career in medicine do so for the right reasons — a desire to make people better. At least that’s how it starts.
But along the way something happens. The very processes that help us prepare for healthcare can diminish in doctors the very attributes that our patients value most in us. The study of disease tends to break patients down into their component parts and systems, and can make us sometimes forget that the patient with a disease is a person.
Long hours, sleep disturbance and the stress of working in ineffective or overburdened healthcare systems can strip those providing care of their own humanity and ability to empathise. And yet despite this process, so many make it through, a little bruised and shaken, but with some great battle stories and with their humanity intact.
Those who have done so will have developed a degree of self knowledge and awareness of their own vulnerability, an understanding of the importance of work-life balance, of having friends and lives outside medicine, by not taking themselves too seriously, by looking after their own physical health, and even understanding how exposure to the lives of others through literature, art, film and theatre enhances their understanding of their own lives and those of their patients. They will have realised that keeping up with themselves is as important as keeping up with developments within medicine.
If the raw substrate for good doctoring (a degree of intelligence, diligence and compassion) seems to be present in most of those starting out, perhaps the trick is to assist us all to develop skills that help maintain humanity in a system that frequently diminishes it.
Wish me good luck with my Leaving Cert repeats, by the way.
Now, where is my copy of Peig?
This article was originally published in The Medical Independent
Whereas I am long past the point where I have realised I can’t know everything, I like to think I’m good at keeping up to date. I keep abreast of the medical literature, attend conferences and tick all of the necessary CME boxes to keep the Medical Council happy. And yet, as I pass the mid point in my professional career, I have a sense that I may have reached a plateau.
I was reassured to read that I’m in good company. Atul Gawande, surgeon and well-known author of the The Checklist Manifesto, seemed to reach a similar peak in his mid-40s. Writing about it in The New Yorker, he describes a levelling-off of what had been steady improvement in his surgical outcomes for years.
Noting the transformative effect that an hour with a tennis coach had on his tennis game, he began to wonder why doctors didn’t use coaches to ‘up their game’ in a medical setting. Top-class athletes and opera singers don’t assume that they have achieved perfection once they finish their initial training, he observed. They are constantly reassessing, tweaking, and improving with the aid of a second pair of eyes and ears. If a tennis player like Rafael Nadal could benefit from a coach, then why couldn’t a doctor?
So Gawande decided to get himself one. He invited a retired general surgeon under whom he had trained to come and spend a morning observing him and coaching him in theatre. The effect was transformative. The 20-minute feedback discussion they had at the end of his operating list gave Gawande “more to consider and work on” than he’d had in the previous five years.
If it’s good enough for Gawande, I thought…
So last month I persuaded a colleague and long-time mentor to come and coach me. Hoping that he would tell me that I had already reached perfection (but also deep down fearing that I would be exposed as an out-of-date charlatan), I invited him to observe me for a morning in clinic. A full morning load was scheduled and the patients were notified in advance that another doctor would be present. There would be no specific agenda — he would give me feedback on anything he thought worthwhile throughout the course of the day.
He sat, much like a school cigire, at the back of the consulting room and remained largely silent, taking notes, occasionally approaching the examination couch to watch as I examined and performed procedures on my patients. This was the first time I had been observed in this way since I was a medical student. A little daunting, but after a while I largely forgot that he was there.
After lunch, he gave some feedback.
His most interesting observations related to my consultation style and the pace of the interaction. I have become very skilled (like many of us) at ‘keeping things moving’. As a result, I tend to leave almost no time for pause or reflection. Pauses, we agreed, allow us time to step back into ourselves, to try to re-gather a degree of objectivity after periods of more intense engagement during a consultation. Pauses also, of course, allow our patients time to gather their own thoughts and formulate questions. Missed opportunities to do so included the potentially quiet moments while a patient dressed or undressed, during a physical exam, or while washing my hands.
Additionally, whereas I always review patient notes immediately before I see them, this can be a slightly rushed affair when running behind. This results in an air of distractedness as I alternate my attention between my patient and the computerised medical record to double-check information. A suggestion to read through the notes of all patients before the clinic starts was made, allowing a more thorough assessment and freeing-up some time during the consultation.
I also received feedback on my examination technique, on my use of imaging (a tendency to over-rely on imaging findings in making certain diagnoses), my injection technique (“less stabbing, more distraction”), and the language I use to reassure patients (some patients require more of a ‘you will be fine’ approach than a ‘you’ll probably be okay’ one). We also discussed work-life balance, the redemptive powers of hard work, debt, death (ours) and planning for retirement.
It was hugely rewarding and fulfilling, a unique opportunity to get feedback from a peer and I’d be happy to recommend it.
Although at this stage of my career I’m not in this to win any competitions, it is still nice to aspire to an occasional personal best.
Anyone for tennis?
Note: Thanks to the ever-wise Dr Maurice Barry, Consultant Rheumatologist, Connolly Hospital, Blanchardstown, for his time and counsel.
This article originally appeared in The Medical Independent
The hedonistic lifestyles of certain musicians will be familiar to many readers, but the unexpected dangers of playing a musical instrument may not.
Aware that I have an interest in musicians’ health, last week a medical colleague alerted my attention on Twitter to an interesting article in the October 2013 edition of Der Hautarzt (German dermatology journal), describing a condition I hadn’t heard before of called ‘fiddler’s neck’.
Fiddler’s neck is a condition where the afflicted violin (or viola) player develops an unsightly mark on the neck — just beneath the angle of the jaw. Although not that well recognised among dermatologists, it is better known among musicians as ‘violin hickey’ because of its resemblance to a more common condition (of quite different aetiology) seen in teenagers. The abnormality is due to an area hyperpigmentation and lichenification of the skin due to the rubbing of the instrument on the neck (erythema, scaling, cyst formation, scarring and inflammatory papules or pustules also occur). The article describes the development of a ‘violin hickey’ in (an undoubtedly embarrassed) 72-year-old lady.
Reading about this curious affliction prompted a ‘knight’s move’ wander through the literature on instrument-specific afflictions — and there’s lots to choose from.
Violinists who succumb to violinist’s hickey are also, presumably, susceptible to a condition known as ‘fiddler’s jaw’ (a condition akin to temporomandibular joint disorder, which comes about because of the way the violin is ‘clamped’ between the angle of the jaw and the shoulder), ‘fiddler’s finger’ (Garrod’s pads of the dorsal interphalangeal joints of the left index and middle fingers) and ‘pizzicato paronychia’ (infection in the nail-fold in string players secondary to pizzicato playing). A similar condition can also develop in pianists.
‘Fiddler’s neck’ is better known among musicians as ‘violin hickey’ because of its resemblance to a more common condition seen in teenagers
Jazz aficionados will immediately recognise the ballooned-cheeked appearance of ‘Satchmo’s syndrome’ in trumpet player ‘Dizzy’ Gillespie. The condition, originally named after Louis ’satchel mouth’ Armstrong, occurs in trumpet players, trombonists and French horn players comes about as a result of rupture of the orbicularis oris muscle (due to high pressures generated while playing high notes). Pressing the hard metal mouthpiece hard against the soft tissues of the lips without warming up can also cause injury; Freddie Hubbard, the well known jazz trumpeter, allegedly tore his lip during an “ill-advised high-note cutting contest” with another trumpeter, according to the Jazz Times in 2009.
Other hidden dangers of playing wind instruments include ‘flautist’s chin’ — a dermatological condition brought about by irritation from saliva and possibly nickel allergy, and ‘clarinetist’s cheilitis’ (perhaps explaining the ubiquity of the ‘jazz goatee’ in certain musicians). The spread of herpes, HPV and hepatitis have also been described due to the use of instruments that have not been cleaned properly (again, much like ‘violin hickey’, other aetiologies may need to be considered).
Both ‘guitarist groin’ (lower-limb DVT due to the pressure of a guitar held in the classical posture for long periods on the flexed thigh) and ‘guitar nipple’ have also been described. The latter is a form of ‘traumatic mastitis’ and was originally described in a letter to the BMJ in 1973. The case series describes a series of younger female guitarists, who all developed a cystic swelling about the base of the nipple. The cause, it seems, was the playing of full-sized guitars (by younger musicians) and direct trauma to the nipple area by the instrument.
Shortly after the ‘guitar nipple’ report was published, the BMJ published a letter describing an intriguing condition known as ‘cello scrotum’. The eight-line letter, published in 1974, describes the case of a professional cellist who developed an inflamed scrotum which, the author suggested, came about as a result of playing the cello for several hours a day.
Whereas the accuracy of the report was later questioned by other commentators (one suggesting that scrotal friction against the supporting chair was more likely to be responsible than direct cello trauma, per se), it was frequently cited in the literature over the years until the original author finally wrote to the BMJ in 2008, admitting that the case had been fabricated. The original letter had actually been signed and submitted by the Chairman of a brewery in Suffolk (the husband of a doctor) as a practical joke — never expecting that it might be published.
Hopefully there’s no practical jokers among the authors of the reports of the other conditions described.
This article was originally published in The Medical Independent
When was the last time you went to the funeral of one of your patients?
Whereas I have had patients with whom I developed strong relationships over the years, whose funerals I might have attended had I known them in any other capacity than as their doctor, I tend not to go. Like many doctors I tell myself I’m too busy.
Although the death of our patients is (in some ways) inevitable, its timing can be difficult to predict. Cancelling or rearranging our working days to attend funeral services is hard to do at short notice, and even though an out-of-hours appearance at a local early evening removal is logistically possible, it is always easier to head on home. It is better to use our time catering to the needs of those above ground, we convince ourselves, than to those below.
But apart from logistics, there may be other reasons why doctors don’t attend the funerals of patients who have died.
Dr Danielle Ofri, writing in The New York Times, suggests that funerals make doctors feel awkward: “Now that the medical care chapter has closed, we’re not quite sure how we fit into the patient’s life. We were so recently actively directing the medical care — doing something — and now we are the awkward bystanders.”
And also, being faced with the reality of the death of a patient hurts. “It hurts to keep seeing the bodies of your patients — bodies with whom you have been intimately familiar — laid out in stone-cold carriage. It hurts to see the face of someone with whom you’ve had deeply personal conversation, now rigid with that oddly blank expression. It just hurts.”
For some of us, turning up at a funeral may also feel like returning to the scene of a crime, with the attendant fear of ‘being lynched’ by angry, grieving relatives. Whereas it is possible that this feeling may occasionally be justified, most of us, on some level, will feel that we have failed our patients in some way when they die. Facing up to this perceived failure can be a difficult part of doctoring in general.
Most of us, on some level, will feel that we have failed our patients in some way when they die
It is not surprising therefore — given the practical and metaphysical realities of attending — that most doctors don’t.
And yet, attending funerals may have unexpected benefits for those who make the effort. Thomas Lynch, a Michigan-based undertaker, poet and essayist, gave some advice to doctors about the benefits of attending. Speaking at a dotMED conference, he told the audience: “As humans, being present at a funeral forces us to look into the abyss. It presses us against the ontological and the existential, and makes us ask the important human questions. Is that all there is? Can this happen to me? Am I all alone? What comes next?” He also suggests that for doctors in particular, facing the human realities of a death among our patients reminds us that not only are we fallible but also that death is an inevitable. “You spend your lives trying to stop the sky falling. But the sky is falling.” Most of those who end up on his embalming table, he points out, are also very likely to have recently attended a doctor.
“Lead with your humanity,” he says to those of us uncertain how to proceed when the time comes. “I encourage you to be among the people of the dead when the time comes — as it always does. You will be improved by it. You can do some really good medicine by just being part of that, when you can, to the extent that time allows — a phone call, a bereavement letter, five minutes at the wake, a cameo appearance at the funeral, a handful of dirt over the grave.”
Whereas our continued involvement and communication with a patient’s family and loved ones after death is not expected, sometimes the smallest sparks of kindness at the darkest times are the ones that illuminate the most. These kindnesses, Lynch says, “are the stuff of good medicine — these ordinary miracles we do for one another”.
Sometimes healing can come about in unexpected ways.
This article was originally published in The Medical Independent
In the 1999 movie The Matrix, the story’s hero Neo, played by Keanu Reeves, learns how to slow down time. With special training, our hero’s perception and reflexes become so highly attuned to his environment that he is able to anticipate and dodge bullets, blows and kicks — while remaining unflinchingly calm.
There are days in medicine where we all wish we could be like Neo.
Despite the fact that consultation times have increased over the past few decades, our patients are frequently dissatisfied with the amount of time we spend with them. Increasingly complex and sophisticated medical options and rising patient expectation both dictate that we need more time. But decreased funding and increased pressure to see more patients mean that it’s not always available. The race to keep up has resulted in doctors running faster and faster just to stand still — resulting in what Dr Richard Smith, writing in the BMJ, calls ‘Hamster Healthcare’. It is a style of practice that leads to a reduction in professional (and patient) satisfaction and to burnout.
Whereas one possible solution is to allow enough time for every patient by allocating the necessary resources to do so, this will not be seen as an attractive solution to those paying the bills. An alternative solution to ‘Hamster Healthcare’ will come, according to Smith, from “getting off the wheel, not running faster”. He suggests a fundamental redesign of the practice of medicine to meet the patient needs within the economic constraints that exist. This approach will be music to the ears of those in the Department of Health and health insurers, no doubt.
Technology will help
The creative use of technology in medicine is likely to play a significant role in improving the continuity of care, eg, the use of secure email, text messaging, telemedicine and the use of online communities to share relevant healthcare information and support between visits. By using technology to deal with routine tasks and information-related exchanges, it is hoped that more time can be allocated to more meaningful face-to-face visits, when necessary.
Rethinking the consultation
It has also been suggested that rather than focus on the amount of time spent with patients, we should put some thought into changing how that time is spent. A study of patient satisfaction published in 2002 suggested that a patient preference for “more time” in the consultation correlated with patient dissatisfaction about the “emotional aspects of the consultation”. The study concluded that “a doctor who listens and tries to understand their patient may make the patient feel more satisfied with consultation length and subsequently more motivated to follow any recommendations for change”. This can be a hard task to pull off in 12 minutes, the average duration of a GP visit.
“In our clockwork analogy of the universe, we have an idea of time as something rigid, punctuated and inflexible. This sense of time is reinforced when our care becomes nothing more than a series of tasks.” “But the human experience of time is quite different,” he writes. “In moments of connection, time stands still.”
He also suggests a number of practices which will help us to use our time with patients more effectively; The importance of building a good rapport early in the consultation and of the importance of a good introduction. He advocates the use of mindfulness; the ability to pull our fragmented, distracted selves together to help us pay careful, non-judgemental attention to our patient, and to our reactions to them.
He emphasises the importance of compassion, for ourselves and for our patients, the use of humour and the usefulness of allowing our patients to set their own agenda.
Whereas it is important that we take advantage of whatever technological and metaphysical tricks we can use to maximise the efficiency of our time with our patients, no-one, even Neo, can slow down time.
This article was originally published in The Medical Independent
If you are a doctor who (despite your best efforts) often runs behind, and consequently has to deal with a waiting room full of unhappy, anxious or angry patients, you will be glad to hear that help is at hand. Some familiarity with the science of waiting may help you take practical steps to improve the waiting experience of your patients — even in situations where a medical wait may be inevitable.
The reassuring finding from the literature is that overall patient satisfaction correlates poorly with the amount of time spent waiting.
A study from patients waiting in a busy Chicago emergency department showed that patient satisfaction was better predicted by other (modifiable) factors, such as satisfaction with information delivery (regarding tests, procedures and reasons for delays) and the courtesy, friendliness, and professional attitude of the doctors and nurses.
Additionally (and although it may seem obvious), patient satisfaction was also higher where the actual waiting time was less than expected. Unfortunately, this rarely occurs in practice — unless scheduling is engineered to give that appearance. Deliberately misleading patients is not recommended — but at the very least, offering them a realistic expectation of what to expect in terms of waiting times can do a lot to placate an anxious patient.
Some other potential contributors to consumer dissatisfaction that may also be relevant include…
Occupied time feels shorter
Boredom, it seems, results from being attentive to the passage of time itself, so anything that can be done to distract those waiting may help — reading material unrelated to the medical agenda, for example.
Unfortunately, out-of-date copies of Hello magazine or Horse and Hound can give the reader the impression that he or she has moved back in time rather than forward, but suppliers can provide waiting rooms with an up-to-date selection of magazines on subscription (and at a significantly reduced cost).
Some restaurants will provide a library of books for customer perusal in the waiting area — an increasing number of doctors’ surgeries are creating similar libraries of books for use by their patients. A UK charity ‘Poets in Waiting Rooms’ provides packs of cards of poetry of suitable length and content for this environment.
There is also emerging science to support the anxiolytic effects of music and radio played in waiting rooms. In a study which explored the preference of patients awaiting radiotherapy, ‘easy listening’ seemed the most popular, with jazz being the least popular. Staff potentially subjected to repeatedly listening to Engelbert Humperdinck and Roger Whittaker may need to be consulted.
Get them started
People like to get started, or at least feel that they have started the process of their medical consultation. This is one of the reasons that customers are handed menus while waiting to be seated in restaurants.
Although there may not be a menu equivalent to this in most medical practices, handing the patient a questionnaire to complete or somewhere to write down questions that they would like to ask the doctor may help pass a few minutes. It implies ‘service has started. We know that you are here’.
Whereas waiting even a short while for something of perceived little value can feel unbearable, the converse is also true — the better they perceive their doctor to be, the more patient the patient will be.
Whereas we can’t always control how patients perceive us, providing good-quality care (even if that means spending extra time with patients that results in delays to others) may help keep patients calm in the waiting room.
While all those sitting in a waiting room need to feel they have been noticed and not forgotten by office staff, this needs to be balanced with their need for privacy. One way of keeping patients abreast of progress in hospital environments is a paging system, which will allow a patient to go for a stroll or a coffee while waiting. A company who provides this service to Irish hospitals is SS Communications.
Barcelona-based design company Fuelfor (www.Fuelfor.net) specialises in the systemic redesign of the medical waiting room experience, including: special patient-friendly signage; customisable modular furniture; integrated play areas for children; acoustic separators for privacy; mobile phone apps (which update patients on appointment delays); and printed notepads for patients to prepare questions for their appointment.
This approach has been shown to improve the perception and effectiveness of healthcare service delivery.
With increasing pressure on doctors’ time, it seems likely that medical waits are going to continue, if not worsen. Although there are certain types of delays that no amount of information, reassurance or distraction can prevent, quality medical treatment or heart-felt apologies will make it bearable. There is something we can do to ease the wait.
This article was originally published in The Medical independent
I’ve just returned from my specialty’s annual scientific meeting in Boston. The meeting truly is the ‘Virgin Megastore’ of our specialty, with over 15,000 delegates, 3,000 scientific abstracts, hundreds of oral presentations, ‘meet the professor’ and review sessions.
Whereas very few unexpected medical breakthroughs are ever revealed at the meeting, it is a unique opportunity to catch-up with all of the latest developments in our specialty and always worth the trip.
Here’s some of my highlights from this year’s meeting.
Year in review
Location: Forum (bar-restaurant), Boylston St, Boston MA
Format: Dinner and a beer with many of my Irish specialty colleagues whom I don’t see from one end of the year to another.
Topics discussed: Getting older, managing complex disease, medical gossip, how to get a neurosurgical patient admitted to Beaumont Hospital, the future of our specialty, vasectomies, politics, cookery courses and box-sets.
‘Meet the professor’ session
Location: Main entrance to exhibition area, MCCA Convention Centre
Format: One-on-one intimate mentoring session with an expert in the area of life, rearing teenage kids and rheumatology.
Topics for discussion: Retirement planning, the art of the perfect holiday, keeping cool with teenagers and making the best of downtime at conferences (without succumbing to feelings of guilt).
I’m here. This time, as I say goodbye to my wife and kids, I know that it will be for the last time. My mind drifts inevitably to the fatal accident that will take me, the tears of my wife and children as they attempt to identify my charred and mangled remains, and even what selection of music might be played at my funeral. My teenage children look at me strangely as I hug them and tell them how much I love them before I leave. “You’re being weird, dad. We’ll see you next week. Enjoy the conference.”
Of late, I have become rather obsessed with the idea of my own mortality. A previously unnoticed small lymph node in my neck fast-forwards me (despite the firm reassurance of my GP) to the lymphoma and failed bone marrow transplant that will take me away prematurely. Some short-lived palpitations after drinking too much coffee remind me that the differential diagnosis includes a fatal cardiomyopathy.
I have always been one for a bit of drama, but thoughts about my own death are relatively new to me.
In my youth, the idea of dying never really occurred to me. Death was an inevitability, and despite my frequent exposure to it though work, it was always somehow beyond the horizon. Life seemed an endless list of possibilities and the relentless momentum of their pursuit kept me looking forwards.
Longing to grow up, get a job, fall in love, travel, to fulfil my (ever-changing) dreams and aspirations. Always moving, looking forward, never back.
Many older people spend their time looking back — longing to be young vigorous and healthy again, back in the throes of first love, reliving memories of the best parts of their lives
The reverse is true for many in old age. Many older people spend their time looking back — longing to be young vigorous and healthy again, back in the throes of first love, reliving memories of the best parts of their lives and even dwelling on the bad choices they might have made.
A few of my friends have had dalliances with serious illness and it has made my inevitable demise more real. Whereas I’m healthy, I tire more easily, have slowed-up physically and have to work harder to lose weight. I also keep missing bits around my chin when I shave because it is less taut than it used to be (less of a square jaw, more of a hammock). Now that the inevitable, un-ignorable signs of ageing are upon me, I can see things more clearly. And I’m rather enjoying myself.
I’m in the middle. Without the pushing forward of youth or the pulling back of old age, I’m at a point that writer (and undertaker) Thomas Lynch describes as “balanced between infancy and decrepitude”. It’s a point which allows you a good view of what went before, what lies ahead. It allows a balance and perspective that shows you the importance and wonder of how things are now.