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I am a planner. I didn’t used to be. I never planned anything in my 20s. Maybe it is kids and marriage that made me that way. But I tend to think more about how to prepare for the future and what I can do now to avoid a crisis later. It always amazes me how some people don’t think about the future, as if it will never arrive. It always does. “Everybody gets old if you live long enough” is a favorite line. I see it with finances – some people continue to spend more than they bring in despite it clearly being unsustainable. You can do it for a while, but there will be a day of reckoning and it will be major and sometimes irreversible. How can you avoid the day of reckoning? By recognizing the risk factors and decisions that lead to the crisis point AHEAD OF TIME and doing whatever one can to alter the course well in advance. 

The same is true for health. A day of reckoning may arrive by way of a heart attack or stroke. It may arrive by way of type 2 diabetes. It may arrive by way of a hip fracture, dementia, cirrhosis of the liver or terminal cancer. Now those problems did not arise out of nowhere, just as the financial crisis did not. In most cases these crisis points are the culmination of decades long processes. In some cases, such as terminal cancer, the crisis may have been avoided with early detection by screening. In other cases the cancer could have been avoided altogether through better decisions such as avoiding cigarettes. 

As I got further along in my medical career I saw more and more end-stage problems that were incurable despite very aggressive, expensive interventions such as chemotherapy. I saw end-stage obesity, diabetes, cardiovascular disease, and cognitive and physical decline that were past the point of salvage. Some of these people lived another decade for sure, but had years of poor-quality life. They were simply unable to do the things that made them happy, whether it be fishing, golf, gardening, cooking, or a crossword puzzle. Some were no longer able to travel to see family. 

As my career progressed I became more and more cognizant of the fact that most of what we do, and almost all of where healthcare dollars flow, is directed towards treatment of illnesses that may have been avoidable with early intervention and planning. What we really do should be called “sickcare” rather than healthcare. It turns out that sickcare is very, very expensive. Unsustainably so. 

So what can we do to alter the course? So many things. Education, diet, exercise, understanding risk factors for cardiovascular disease. Addressing osteoporosis. Managing sleep. Understanding early signs of declining mental health. We do some of these things in medicine but not always well. Education and counseling about these things take time. Doctors don’t often have that time. Moreover, our medical insurance reimbursement schema do not pay doctors for helping patients avoid sickness like they do for treating sickness. 

What is clear is that we have made a lot of strides towards treating sickness, and as such we are able to extend lifespan of chronically ill patients. However, for many in the throes of chronic disease, quality of those extra years is poor. Death is always sudden – you are alive and then you are dead. But unfortunately the dying part can be quite slow. 

There is a lot of talk about putting less emphasis on lifespan and more on healthspan, or quality of life. We all want to enjoy the second half of life. We want to be productive, active, happy, and feel well. We want to be able to play with our kids and even grandkids. We want to be able to do what makes us feel alive. 

Take a look at the graph above. The three lines represent different three examples of quality-of-life trajectories over a lifetime. The orange line is a typical demonstration of declining physical and mental abilities beginning in 30s-40s as is often seen with progressive chronic illness. Modern medicine may allow this person to live into his 70s. However, ability to perform the activities that bring him pleasure decline over time, and in his last decade he is likely incapable of performing at even a marginal level. Quality of the later decades is poor even if longevity is average. The gray line depicts the life of a person who lives an average life expectancy but is able to enjoy his years much later into life. Anybody would choose the gray line over the orange line. Many people would even choose a shorter life with more quality years, although you should not have to accept that trade-off (unless you derive all of your pleasure from high-risk hobbies).

 Now, quantity of life and quality of life are rarely independent of each other. A person who identifies and addresses risk factors is likely going to live longer AND with much more vitality and enjoyment in the later years. The yellow line represents the ideal scenario – a longer, more enjoyable life.

In a future blog, I am going to give examples of specific strategies that can improve BOTH quality and quantity of life.