WRITINGS
Notes and essays on medicine, listening and the care of the patient.
On Listening
A consultation always begins the same way. With a trivial conversation. And then I ask the same question again — how are you? — but this time I remain in silence. And I listen.
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On Listening
A consultation always begins the same way. With a trivial conversation: how are you, how has your week been, some remark about anything of little importance. And then I ask the same question again — how are you? — but this time I remain in silence. And I listen.
As the person speaks, my attention begins to illuminate certain words, certain gestures, phrases that at first do not seem related to one another. I do not interrupt. I do not approve or disapprove with my face. I do not yet return any reaction that might condition what is to come. I simply listen, and allow those scattered signals to accumulate. There comes a point when they are so many that they begin to order themselves, to find one another, and then something emerges: almost always, within what is at times a highly elaborate discourse, there beats a message the person is not uttering directly. Often, one they did not know they carried within.
When the silence arrives — that particular silence which signals that all there was to say has been said — only then do I speak. And I do so with their own words, returning to them what they had expressed between the lines, adding nothing of my own.
For me, listening is precisely that: contemplating the vulnerability of someone who opens up to reveal something they may not even consciously see. Reading it without bias, without judgment, without the rush to respond. It is, probably, the most underestimated clinical act in all of medicine, and the one that has taught me the most.
· · ·
I think of a patient — one of those I most care for, and from whom I have learnt most over all these years. Young, of striking features, the kind that effortlessly meet the canons of beauty; elegant, articulate, possessed of a self-assurance that filled the consulting room. And yet, at first she spoke a great deal and said nothing. Everything sounded interesting, intelligent, impeccably argued: she wanted several procedures, each one lucidly justified. But beneath that architecture there was no ground. It was as if she were narrating a story to herself, one that had long ceased to represent her.
I told him at one point: do you realise that you speak a great deal and in fact tell me nothing? You have a strong presence, almost overwhelming, but everything sounds hollow. What is it that you truly wish to say?
He stared at me. And said: «I don’t know what I want. I just want people to keep loving me because I don’t see myself as pretty anymore.»
There it was, all of it. I told her that, before deciding what to do with her face, she needed to be able to name what she truly felt — to distinguish what she wished from what she imagined others expected of her. And on examining her calmly the rest appeared: hypothyroidism, weight gain, insulin resistance, several disorders linked together. Her skin, her expression, the sediment of fatigue on her face, were not a dermatological problem. They were the surface upon which an entire dysregulated system was writing its state with a clarity that only needed to be read. The face was not asking for a procedure. It was asking for someone to interpret what it was saying.
I proposed we begin there. To return to her body the equilibrium it had lost, and leave the aesthetic for later.
When that equilibrium returned, the skin returned with it: the texture, the luminosity, the expression, even the anxiety that had settled into her countenance and which she had come to confuse with her character. And then she understood something no procedure would have taught her. She was beautiful. She had always been. What she needed was not to simulate an absent beauty, but to recover the one the imbalance had been erasing. She ended up undergoing a fraction of what she had come to request, because the rest, quite simply, ceased to be necessary.
I have learnt more from her, over the years, than from many treatises. She has been a kind of living encyclopaedia of something difficult to teach: how the skin is the channel through which an organism expresses what it cannot say in any other way, to the point where the patient no longer recognises themselves in the mirror. And how the answer is almost never found in the surface, but in returning to the system what it lacks. When that happens, the skin once again expresses the equilibrium recovered, and the need to simulate is reduced to what is truly just and necessary — no more, no less. But that reading is possible only if one has first taken the trouble to listen.
· · ·
Why has medicine ceased to listen? In part it is time: ten or fifteen minutes are not enough for any of this. But it would be too easy to blame the clock alone. There is something deeper. The belief that everything can be quick and simple, that nothing has consequences, that if I do not do it, someone else will. Economic pressure. Competition. That silent slope along which a genuine interest in the patient slides, without anyone quite deciding it, towards commercial interest.
I do not blame the physician. The whole world pushed medicine into that territory of speed and surface, and the physician became trapped in an almost inhuman demand. Patients too are part of that current: many arrive persuaded that the procedure, the simulation, will make them feel better. The consultation becomes a transaction. And in the transaction what is essential is lost: the time to look at someone and understand what is truly happening to them.
· · ·
I do not have advice for the young physician. I have, rather, a conviction about what falls to us. Before intervening, to educate. Before offering, to understand what is a priority for the patient and what is truly best for them. Not from a moral position — the sermon does not interest me — but from science and from coherence.
It is not a matter of denying the procedure. Procedures, well indicated, improve people’s lives. It is a matter of knowing what, when, and how much. And that, almost always, is known only after having listened.
On aging
Patients arrive asking to look better, to take off a few years. Underneath there is something more precise: a discordance. They feel one way inside and see something else outside, and it is that distance —not their age— that brings them in.
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On aging
Nobody wants to talk about this.
We avoid it in a hundred ways: hiding our age, correcting the face, looking to a procedure to keep the years from showing. Every one of those manoeuvres says the same thing without saying it — that aging is something to escape. Youth confers dignity; old age, in the imagination we inherited, takes it away.
Medicine has not helped either. Faced with aging, our stance has almost always been palliative: we wait until the decline is established and only then intervene. We have never built a programme that begins early, that can actually be understood, that lets someone of thirty know what options exist and when it makes sense to use them. We ask patients not to fear old age while we ourselves treat it as an ending that can only be administered.
And yet we know a great deal. We know enough about how people age —what accelerates it, what slows it, what can be acted upon and when— that it should be uncomfortable to keep regarding this stage of life as the tragedy everyone must pass through before dying. We also know something that ought to change the entire conversation: what moves the needle most is not expensive. Strength. Aerobic capacity. Sleep. Enough protein. Human connection. None of it depends on costly technology or on being born in a wealthy country. It is within reach of almost anyone, at almost any age.
So what is missing is not knowledge. What is missing is that it arrive in time, in order, and reach everyone: in medical training, in schools, in public programmes that put it within reach of those who will never afford a private consultation. As long as the most effective thing is also the most accessible and still goes untaught, the problem stops being technical. It is an omission — and omissions have people answerable for them.
· · ·
Patients arrive asking to look better. To take off a few years. That is almost always how they put it, and underneath there is almost always something more precise: a discordance. They feel one way inside and see something else outside, and it is that distance —not their age— that brings them in.
The first thing I do is unsettle the request. Nothing is gained by simulating youth if we have not first looked at what is happening inside: how their weight is, how their metabolism is, how their hormones are working, how many hours they sleep. This is not a detour on the way to the procedure. It is the underlying question, because the process that troubles them in the mirror did not begin in the mirror.
When a patient understands that what they call aging was assembled out of small habits sustained over years, something settles. They stop asking how to appear young and begin asking how to recover the health that makes youth possible in the first place.
· · ·
I think of a patient in his early sixties. Life had gone well for him —he had achieved what he set out to, and more— and he came into the consulting room dispirited, asking for something to freshen up his face. He wanted to look better.
He came with insulin resistance, obesity, hypertension, dyslipidaemia, benign prostatic hyperplasia, disc herniations. A list of medications and a calendar of check-ups. What he told me was none of that: he told me he could not enjoy what he had built. That he lived so preoccupied with his health that a lifetime of effort had turned into administration. And that he consoled himself thinking his children and grandchildren might enjoy it in his place.
We talked for a long time. What he had to understand was not complicated: that decline had not fallen on him from above, it had been assembled over years of poor habits, sustained stress and self-neglect while he pursued his goals. And if it had been built that way, it could be dismantled on the same ground. Not with a procedure that simulated wellbeing, but by attending to the body producing it.
The process was hard. It was not aesthetic: it was a change of attitude, of habits, of the way he thought about himself. In time his metabolism normalised, he lost twenty kilos, came off nearly all his medication and built a routine he now sustains on his own. He says this is the period in which he has felt best in his entire life.
I did not give him back his youth. Nobody gives back youth. What he recovered was coherence: for the first time in years, what he saw and what he felt said the same thing. By the end of treatment almost everyone arrives at the same conclusion — it was not youth they were after, it was feeling well.
· · ·
None of this means aging is optional. Aging is the one thing absolutely all of us share, and much of the process is governed by factors nobody chooses: genetics, environment, the social and cultural conditions of the life each of us was handed.
What can be decided, to a considerable extent, is the pace. Aging is not a state one arrives at: it is something that happens at a speed, and that speed can be acted upon. Two people of the same age can be carrying years of difference between them, and that is not a figure of speech — today it is measured. Much of what we take to be natural —loss of strength, broken sleep, sustained inflammation, frailty arriving ahead of schedule— answers less to the calendar than to small decisions repeated across decades. And if so many people travel that road without knowing there was another, it is not carelessness: it is that the paradigm they grew up inside had already settled the matter. Patients in their forties arrive with some information; those past sixty often arrive resigned to a decline they take as written, convinced each year must be worse than the last. That is not negligence. It is what they were taught, and nobody troubled to teach them otherwise.
· · ·
Nor do I want to write this as though it always works. For years I was wrong in believing anyone could do it. There are people who understand everything, who fill themselves with knowledge, and still change nothing: they were not willing. Knowledge opens the door. It pushes nobody through it.
And there are requests I do not accept. Fantastical transformations, the ones that will not hold to the reality one is starting from. Attending to longevity at thirty is not the same as beginning at seventy, and promising the same in both cases would be a lie.
It matters little what brings them in. Many arrive out of fear rather than conviction, and the process is identical: the changes of the first weeks transform the way they think long before the laboratory results move. None of this is easy; taking charge of one’s own body is not easy. But once someone confirms that what they are doing has an effect, the effort stops weighing. The best indicator that a treatment is going well was never a number — it is how the patient feels, and they recognise that change before I do.
· · ·
There is a scene that repeats. The patient comes in and studies me carefully before speaking. Sooner or later the question arrives: and do you do this yourself? How old are you? One of them put it without ceremony: it would be strange to treat excess weight with an overweight doctor, or hair loss with a bald one.
He was right. In this, a physician cannot preach from the outside. What I ask of a patient —consistency, judgement, coherence between what they say they want and what they do every day— I owe first to myself.
· · ·
I would like aging to stop being thought of as a loss to be administered and start being thought of as a stage one prepares for. It is probably the most agreeable effort there is: not adding years to a life, but giving life back to the years that already cost so much to live.
The old idea of aging —the one of inevitable decline— collapsed a long time ago. It remains for us to know it, and for someone to take on the work of teaching it.
The scientific grounding of what is claimed here —epigenetic clocks, the hierarchy of interventions, GLP-1 analogues— is developed in Aging is not a state. It is a speed, published on Cléfôre.
Other writings will be added, without haste.