To investors,

I have been reading one book per week this year. This past week’s book was Being Mortal: Illness, Medicine, and What Matters in the End by Atul Gawande. Highly recommend reading it. If you are interested in the individual highlights that I made in the physical book, you can read those here. Hope you enjoy these notes every Monday morning.

Book’s main argument:

No one wants to talk about the experience of dying, nor the days, months, and years that lead up to that moment. Old age used to be a revered status in a society — technology changed that. Rather than require our elderly to live the last days in institutionalized care away from their families, we now have a better path forward. Atul Gawande shares personal stories, and many different studies, that will make you think more deeply about medicine’s role in aging and the end of your life.

6 Big Ideas:

💡 Idea #1 — Doctors are well equipped to save lives, but they are not prepared for managing the last years of patients. This core problem is what Gawande sets out to solve, so he writes:

The purpose of medical schooling was to teach how to save lives, not how to tend to their demise.

And then he continues by saying:

Modern scientific capability has profoundly altered the course of human life. People live longer and better than at any other time in history. But scientific advances have turned the processes of aging and dying into medical experiences, matters to be managed by healthcare professionals. And we in the medical world have proved alarmingly unprepared for it.

This is backed up by data:

As recently as 1945, most deaths occurred in the home. By the 1980s, just 17% did.

Gawande also points out that the problem may not be exclusively pinned on doctors, but rather some of their tools as well:

Our reluctance to honestly examine the experience of aging and dying has increased the harm we inflict on people and denied them the basic comforts they most need. Lacking a coherent view of how people might live successfully all the way to their very end, we have allowed our fates to be controlled by the imperatives of medicine, technology, and strangers. 

💡 Idea #2 — Societies previously placed a premium on the oldest members of the group. They were believed to have wisdom and knowledge that was hard for the youth to capture or appreciate. Modern societies have gone a different direction. Gawande writes:

The dignity of old age was something to which everyone aspired. 

This was because old age was rare, so it was valuable. It appears that is changing:

Age no longer has the value of rarity. 

The transition is not merely measured in the aggregate number of people above a certain age though. There is a growing difference between the elderly and their younger peers:

As for the exclusive hold that elders once had on knowledge and wisdom, that, too, has eroded, thanks to technologies of communication — starting with writing itself and extending to the Internet and beyond.

Gawande explains that young people are not replacing the elderly as the top of a society’s hierarchy, instead independence has become highly sought after:

The veneration of elders may be gone, but not because it has been replaced by veneration of youth. It’s been replaced by veneration of the independent self.

💡 Idea #3 — Death is not an unfortunate, magic moment that happens late in life. Instead, it is the culmination of your habits, your experiences, and the wear and tear on your body. Gawande writes:

Increasingly large numbers of us get to live out a full life span and die of old age. Old age is not a diagnosis. There is always some final proximate cause that gets written down on the death certificate — respiratory failure, cardiac arrest. But in truth no single disease leads to the end; the culprit is just the accumulated crumbling of one’s bodily systems while medicine carries out its maintenance measures and patch jobs.

There are repercussions that accompany the fact that many of us are living longer:

The progress of medicine and public health has been an incredible boon — people get to live longer, healthier, more productive lives than ever before. 

In a sense, the advances of modern medicine have given us two revolutions: we’ve undergone a biological transformation of the course of our lives and also a cultural transformation of how we think about that course.

Gawande explains that we can’t see the small changes, but our body’s decay becomes obvious over a long period of time:

The body’s decline creeps like a vine. Day to day, the changes can be imperceptible. You adapt. Then something happens that finally makes it clear that things are no longer the same.

💡 Idea #4 — Most people don’t fear death as much as they fear what will happen in the days and months leading up to death. Both patient and caregiver is wildly unprepared for these moments. Gawande explains:

It is not death that the very old tell me they fear. It is what happens short of death — losing their hearing, their memory, their best friends, their way of life.

Gawande uses two quotes to summarize the barbaric nature of death:

As Felix put it to me, “Old age is a continuous series of losses.” Philip Roth put it more bitterly in his novel Everyman: “Old age is not a battle. Old age is a massacre.”

Since very few people know how to handle death and old age, society has created various “solutions” that likely are making the situation worse for many people:

This is the consequence of a society that faces the final phase of the human life cycle by trying not to think about it. We end up with institutions that address any number of societal goals — from freeing up hospital beds to taking burdens off families’ hands to coping with poverty among the elderly — but never the goal that matters to the people who reside in them: how to make life worth living when we’re weak and frail and can’t fend for ourselves anymore.

💡 Idea #5 — Young people tend to avoid thinking about old age because they believe life gets worse. People who spend significant time with the elderly report that the opposite may be true, which would mean that we can learn quite a bit from this population. Gawande writes:

Studies find that as people grow older they interact with fewer people and concentrate more on spending time with family and established friends. They focus on being rather than doing and on the present more than the future. Understanding this shift is essential to understanding old age. 

The focus on the present over the future can lead to more happiness:

Far from growing unhappier, people reported more positive emotions as they aged. They became less prone to anxiety, depression, and anger. 

Gawande describes the elderly in the same way that Robert Greene would describe Mastery or Brad Stulberg would describe groundedness:

If we shift as we age toward appreciating everyday pleasures and relationships rather than toward achieving, having, and getting, and if we find this more fulfilling, then why do we take so long to do it? The common view was that these lessons are hard to learn. Living is a kind of skill. The calm and wisdom of old age are achieved over time.

💡 Idea #6 — Medical care for the elderly is as much about understanding their psychological state as it is understanding the medical care that has been identified. Gawande explains how one assisted living manager, Bill Thomas, accidentally changed how the industry worked:

Bill Thomas believed that a good life was one of the maximum independence. But that was precisely what the people in the home were denied. 

…attack what he termed the Three Plagues of nursing home existence: Boredom, Loneliness, and Helplessness.

Thomas also discovered that the sense of belonging was incredibly important:

The only way death is not meaningless is to see yourself as part of something greater: a family, a community, a society.

This brings us to a key point — control of one’s life is incredibly important:

The battle of being mortal is the battle to maintain the integrity of one’s life — to avoid becoming so diminished or dissipated or subjugated that who you are becomes disconnected from who you were or who you want to be. 

The terror of sickness and old age is not merely the terror of the losses one is forced to endure but also the terror of the isolation. As people become aware of the finitude of their life, they do not ask for much. They do not seek more riches. They do not seek more power. They ask only to be permitted, insofar as possible to keep shaping the story of their life in the world — to make choices and sustain connection to others according to their own priorities. In modern society, we have come to assume that debility and dependence rule out such autonomy.

Memorable quotes:

1. Decline remains our fate; death will someday come. 

2. For most people, death comes only after long medical struggle with an ultimately unstoppable condition. In all such cases, death is certain, but the timing isn’t.

3. Death, of course, is not a failure. Death is normal. Death may be the enemy, but it is also the natural order of things.

4. “Eating alone is not very stimulating.”

5. The risk of a fatal car crash with a driver who’s eighty-five or older is more than three times higher than it is with a teenage driver.

6. With “assisted living,” the goal was that no one ever had to feel institutionalized. 

7. Medical professionals concentrate on repair of health, not sustenance of the soul.

8. The lesson seems almost Zen: you live longer only when you stop trying to live longer.

Pomp’s Takeaways:

My first big takeaway was the comparison between age and perspective. Atul Gawande posed the following hypothesis:

• A hypothesis: How we seek to spend our time may depend on how much time we perceive ourselves to have. When you are young and healthy, you believe you will live forever. When horizons are measured in decades, which might as well be infinity to human beings, you most desire all that stuff at the top of Maslow’s pyramid — achievement, creativity, and other attributes of “self-actualization.” But as your horizons contract — when you see the future ahead of you as finite and uncertain — your focus shifts to the here and now, to everyday pleasures and the people closest to you. 

This is fascinating to think about. If true, it argues that young people can actually increase the quality of their life, and in turn their happiness, by simply focusing on the present instead of the far-flung future. This lines up with Gawande’s line “It’s perspective, not age, that matters most.”

My second big takeaway was how important your environment can be. Gawande describes an experiment where an assisted living manager got approval to bring dogs, cats, birds, and living plants into the facility. There was a qualitative improvement (people were happier, more engaged, etc), but there was also a quantitative improvement in health outcomes too.

• Researchers studied the effects of this program over two years, comparing a variety of measures for Chase’s residents with those of residents at another nursing home nearby. Their study found that the number of prescriptions required per resident fell to half that of the control nursing home. Psychotropic drugs for agitation, like Haldol, deceased in particular. The total drug costs fell to just 38% of the comparison facility. Deaths fell 15%. The study couldn’t say why. But Thomas thought he could. “I believe the difference in death rates can be traced to the fundamental human need for a reason to live.”

It is incredible to see the impact that someone can have by simply thinking outside the box. This is on top of the learning that you can extend living by surrounding yourself with more life.

Lastly, there is a section of the book that mentions the relationship between where/how you die with the economic progress of the society you live in. Gawande explained it eloquently when he wrote:

• Scholars have posited three stages of medical development that countries go through, paralleling their economic development. In the first stage, when a country is in extreme poverty, most deaths occur in the home because people don’t have access to professional diagnosis and treatment. In the second stage, when a country’s economy develops and its people transition to higher income levels, the greater resources make medical capabilities more widely available. People turn to health care systems when they are ill. At the end of life, they often die in the hospital instead of the home. In the third stage, as a country’s income climbs to the highest levels, people have the means to become concerned about the quality of their lives, even in sickness, and deaths at home actually rise again.

This is a simple idea that exists in finance (ex: market selection is more important than asset selection) as well. The country you choose to live in, and ultimately die in, will have a profound impact on your experience. Choose wisely.

As I mentioned, this past week’s book was Being Mortal: Illness, Medicine, and What Matters in the End by Atul Gawande. Highly recommend reading it. If you are interested in the individual highlights that I made in the physical book, you can read those here. Hope you enjoyed these notes. Let me know if you would like me to continue writing these in the future.

-Pomp

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