I wish I could slip this book into the curriculum of every medical school in the United States of America (USA). Granted, at well over 400 pages, Elderhood – the second book by physician-writer Louise Aronson – wouldn't ‘slip’ easily. Yet, should its poignant stories of old patients, its well-laid critiques of medicine's failings and its paean to geriatrics insinuate themselves amid organ systems and pathophysiology … then her book might fulfil its ambitious subtitle: Redefining Aging, Transforming Medicine, Reimagining Life. Medical students aside, this book should appeal not only to practitioners, researchers and students, but to a very broad and general audience. Aronson has written it for all of us.

In Elderhood, Aronson seeks to convince readers of the need to re-envision the landscape of old age and particularly to rethink our medical approaches to old people. We tend to think of ‘old age’ as a monolithic category, but increasingly, it is a time of life that spans multiple decades. To see in old age only loss, marginalisation, isolation and dependency is equivalent, Aronson suggests, to seeing parenthood as only sleepless nights with a screeching infant or a reckless teenager: ‘Although the concerns are real, they represent just part of a much larger picture’ (p. 254). Aronson sets out to reclaim ‘elderhood’ as a final stage of the lifecycle on par with childhood and adulthood, and containing, like these other stages, multiple sub-stages of development. Popular culture and geriatrics alike have too often focused on old age as only a time of frailty and dependency, and overlooked the years, or decades, of vibrant, satisfying life in old age. To her credit, Aronson notes that we cannot champion a positive vision of old age at the expense of ‘worsened degradation’ when people face functional loss (p. 245). Elderhood encompasses all of these, and so must we.

What I find most novel in Aronson's argument is her insider critique of medical practice. Elderhood is most persuasive in its eloquent condemnation of the current health-care system in the USA, not only for how it is failing old people, but for how it is failing everyone, especially physicians. This focus bears similarities to Atul Gawande's (Reference Gawande2014) best-seller Being Mortal, which laid bare how the US approach to long-term care has championed health and safety at the expense of autonomy, purpose and meaning, and how we need to start asking some basic questions to align people's values with their dying and deaths. Like Gawande, Aronson writes in a compelling and accessible way fuelled by specialist insights, intermixing illustrative stories both personal and professional with well-supported argument. While this loose structure and repeated themes make the book hard to excerpt, her vignettes of patient care leave one wishing all of their old loved ones could receive a geriatrician's whole-person care. In one memorable example, she describes a largely unresponsive patient with end-stage Parkinson's for whom she discovers a ‘prescribing cascade’ – where a new medication's side-effects have led to another new medication, and so on – with her intervention resulting in the patient's awakening back to interactivity and mobility (p. 48).

Aronson also reveals her own experience of physician ‘burnout’, but she redirects our attention from discussions of ‘physician resilience’ to the structural injustices of the US medical system: ‘Nationwide, health care's medicine-as-business mentality, “death by a thousand clicks” electronic record systems, and antisocial priorities harm patients, waste money, and erode clinician morale’ (p. 345). From unneeded care to needlessly expensive care, to pill bottles, clinical trials and vaccine guidelines that utterly fail to consider the old, Aronson points to the ways the medical system translates its values and its blind spots into unnecessarily problematic experiences for old patients. While attentive throughout her book to the ways marginalisation and health disparities compound over an individual's lifetime, she calls our attention to another structural disparity in medicine, that of salaries among medical specialties where primary care ‘remains American medicine's second-class citizen’ (p. 236). Her point is not that front-line primary care doctors, and geriatricians highest among them, are underpaid, but that the hierarchies of medical specialties are ‘representative of the biases underpinning health care's often inefficient, always expensive, and sometimes nonsensical care – biases that harm patients and undermine medicine's ability to achieve its primary mission’ (p. 235).

Medicine, like US culture writ large, is broken, she argues:

We need nothing less than a paradigm shift. Embrace elderhood, Aronson tells us, for ‘when beliefs about elderhood change, the culture and experience of old age, in life and in medicine, will change too’ (p. 351).