Memo from the Editor's Guest: Medicine, after

Quit smoking, I always told my patients. Of course I said that; every physician says it. Exercise; eat fewer calories. Take your medicines. Get these tests done.

I was so full of advice. I knew so much about how people should live. But that was before Sept. 11. That was before we all watched the world change forever. And if the world has changed, then surely the practice of medicine must change, also. Surely my practice must change.

Four weeks earlier, exactly, I had given a lecture about aging to a group of older women. I talked about normal aging patterns, about how some organ systems lose their ability to restore homeostasis after an insult, while other functions do not change much at all.

I also tried to put that information into perspective. I gave figures on life expectancy now and a century ago, here and around the world. I tried to show that our long lives are not a natural and inevitable aspect of human existence, but something exceptional, a gift.

I expect my audience knew this, just as I did—intellectually. We all know that we could die this evening in a car accident, or tomorrow show the first symptoms of disease. We know this, but we live as though we believe bad things will not happen to us, as though we will not suffer intolerably, as though we will just go on living.

Since Sept. 11, it has become more difficult to go about living with the conviction that bad things will not happen to us, should not happen to us—or at least that they will not happen to us today.

I find that I am no longer so sure how people—my patients, for instance—should live in the face of the tragedies that have come to them, unexpected and undeserved. I am no longer so sure how people should live now that we can feel in our bones that we may not be alive and well tomorrow.

We do not know, either, if or when we will be called upon to be heroes. The people who took over an airplane from its hijackers did not wake up that morning knowing that they would have the chance to run headlong to meet death in order to turn it away from other people.

And besides tragedy and heroism, there is wisdom. We desperately need it, but wisdom is not something we can count on, if history is any indication.

But I do not know where heroism comes from, or wisdom, or the ability to turn tragedy into either of these. I don't know that nonsmokers, or well-controlled diabetics, or abstinent alcoholics, are any more likely to be heroic, or wise, or any more likely to show others the way to heroism or wisdom, than the people who ignore all of their doctors' instructions with the classic rejoinder, "You gotta die sometime."

I don't know that they are less likely to, either. I don't know.

So this is how I think I will carry on the practice of medicine in spite of not knowing these things that seem so important: I won't stop talking to my patients about smoking, or about their exercise regimens, or their alcohol use. Those are part of my job. But I think that I might give people less advice. I will ask what they think.

What, now, do you think about smoking cigarettes and controlling your diabetes? Is it just as important as ever; more important? If so, I'm ready to work on it with you, if you'll help me to understand where we should be trying to go. If not, tell me what has changed, what has become more urgent, more important, or what has always been more urgent and more important.

Tell me about it. Tell me why you want to come to see me, but not follow my suggestions. Tell me why you do not take the easy way out, why you choose to make sacrifices, why you choose to live this difficult life that other people try to avoid. Tell me what you are thinking. Tell me more.