Do Doctors Discriminate Against Older Patients?

Neil Chesanow

Disclosures

March 06, 2015

Are Doctors Neglecting Their Older Patients?

"Physicians are often accused of providing too much care to elderly patients at the end of life, but there's evidence that these patients also get far too little care before reaching that point," a recent Medscape article contended. "Years of skimpy treatment for elderly patients in their 70s and beyond impedes their health and may well hasten their death."

The article noted that Medscape's 2014 Ethics Survey showed that physicians were divided on whether older patients deserve as much care as younger ones. Whereas about one quarter approved of diverting scarce or costly resources away from older people, many more disagreed.

The article took as its starting point a controversial essay in The Atlantic[1] last October by oncologist Ezekiel Emanuel, MD, an architect of Obamacare. Dr Emanuel wrote that he had surveyed the literature on aging and concluded that, except in rare instances, a person's quality of life tended to nosedive after age 75, as chronic diseases, physical maladies, and chronic pain took their toll. As such, he wrote, he personally would decline medical treatment after age 75.

With that preamble, Medscape's article went on to discuss negative stereotypes physicians often have of older patients; the consensus among many doctors that scant resources should be diverted away from the elderly to younger patients who have their whole lives ahead of them; physicians' lack of curiosity about and knowledge of how to treat older patients; and the time constraints imposed on doctors by today's healthcare system, which often means that older patients, who require more time, get perfunctory and often inadequate care.

The article sparked dozens of comments from physicians, many of whom strongly disagreed with Dr Emanuel's logic and with our article's contention that many doctors give their elderly patients short shrift out of callousness, prejudice, or ignorance.

"When I was a young doctor in my 20s, I was planning to die happily at 65 without having to suffer the cruelties of old age," an anesthesiologist wrote. "Well, here I am, 71, healthy and still working. My patient population is 70% geriatric, many with serious health conditions but still willing to take care of themselves. If your health is fairly well-preserved, your brain is still functioning, and life is still enjoyable, why would a doctor decide that you are not a good candidate for, say, chemotherapy on the basis of your age?"

"How old is Dr Emanuel?" a pathologist demanded to know. "Perhaps too young and incapable of comprehending what it would mean to be 75, totally healthy, and functioning at the level of a 50-year-old, with many years of productive and enjoyable living left, yet hung out to dry on the basis of a doctor's personal conviction if confronted with a debilitating but fully treatable condition simply because of chronological age. My premature condolences to Dr Emanuel."

Dr Emanuel is 58 years of age.[2]

"Being 70 years of age, healthy, working, and enjoying it, this article makes me very sad for the elder population and those in our profession," a family physician commented. "It makes me want to take a course in geriatrics, quit my current practice, and help those in need in this over-70 age group."

But a number of doctors made the case for doing less rather than more for many elderly patients.

"I have far too many older friends who have suffered from the complications of 'replacement' surgery and useless biopsies and invasive 'tests,' when they could have led comfortable, alert, happy lives without it," a pediatrician observed.

"I would suggest that all practitioners read oncologist Atul Gawande's new book, Being Mortal: Medicine and What Matters in the End, which highlights the substantial discrepancy between what a physician believes the elderly patient wishes to be done near end of their life and what the patient actually wants after having a heart-to-heart discussion with the doctor," a cardiologist remarked. "Often, more is not better."

Several doctors pointed out that older patients themselves often prefer that their physicians offer minimal care.

"I have a new patient in her 60s with benign essential hypertension and a family history of some CAD, although not extensive, who was surprised and objected just a little when I told her we would do routine follow-ups with lab monitoring every 6 months," a family physician recalled. "She was quick to tell me her previous PCP only saw her once a year. Yet she changed to me because she liked the attentive care that I gave her very elderly mother! Go figure."

A family physician offered this perspective: "If a physician tells a patient that they are good for another year, I don't think of that as 'dumping.' I think of it as good news—you are doing well. Many patients complain if they are advised to come back in for a follow-up. They see it as a way of padding the bills. Of course," he added, "the doctor would see the patient if problems arose."

If older patients receive less care, thank the federal government, several physicians responded.

"In my practice, with the care I provide, treating Medicare patients financially is a loss," a neurosurgeon commented. "It does not even pay incremental costs, let alone cover overhead. I have continued to treat Medicare patients because it felt like the right thing to do and possibly was helping to keep referral pathways open. When I analyzed my practice financials for 2013, 60% of my cases were Medicare, yet this represented 3% of my gross income for that year. How many doctors will continue to treat elderly patients as charity work?"

Other doctors observed that older patients and their families often wanted to have it both ways: doctors who were willing to give them all the time needed without making them cool their heels in the waiting room until their turn came.

"Yes, money is part of the problem," a family physician agreed. "I feel sorry for the people who are seeing physicians who are not spending enough time with them. On the other hand," he wrote, "when I do spend the time, I then have to listen to the next person complain about the wait, as if I was spending time chatting and drinking coffee. It's impossible to have it all—get in today, not have to wait, be on time, yet get all your problems addressed, including the ones thrown in at the end of the visit."

A few doctors pushed back on the article's main contention: that older patients are often given short shrift by their physicians simply because they are old.

"I seriously doubt that most physicians consciously neglect seniors," a family physician opined. "Sometimes, when tests are not recommended, it may be because they have not shown to be of benefit. If a patient is out of the risk age for cervical cancer, for example, why do a Pap smear? Likewise, many of my patients have lived beyond age 85. They do not benefit from strict control of diabetes—in fact, they may be jeopardized."

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