Ageism in Medicine Must Stop, Experts Say

Deborah Brauser

March 19, 2018

HONOLULU, Hawaii — Ageism is not only prevalent in society, it's also widespread in medical education and in the clinic. This situation, say leading experts, results in substandard care and poor outcomes for older patients.

A symposium here at the American Association for Geriatric Psychiatry (AAGP) 2018 Annual Meeting focused on this problem and possible solutions.

Kirsten Wilkins, MD, associate professor of psychiatry and psychiatry clerkship director at Yale University School of Medicine, West Haven, Connecticut, told meeting attendees that thinking of older people as innocent, cute, adorable, or fragile and in need of protection may seem positive but in fact reflect stereotypes. Such attitudes, as well as infantilizing elderly patients, may seem helpful but are aspects of inherent bias.

"This can lead to some paternalistic prejudice. These patronizing behaviors may seem benign, but they've actually been associated with negative health outcomes," said Wilkins.

Unlike racism and sexism, "ageism is the only 'ism' that is socially sanctioned and considered to be normative," said Susan W. Lehmann, MD, associate professor of psychiatry and behavioral sciences at Johns Hopkins Medicine, Baltimore, Maryland.

"We don't really acknowledge ageism, but it's in medical education settings. It's in the hospital where we're training our residents and where we're training our medical students," said Lehmann, who is also director of the Geriatric Psychiatry Day Hospital Program at Johns Hopkins.

Seeing Beyond the Stereotype

In her presentation, Wilkins cited examples of benevolent ageism, including using pet names, such as "hon" or "honey," using slow speech or a sing-song voice, and using plural pronouns, such as, "We're going to get you dressed now." It also includes using patronizing speech and behaviors, which can lead to loss of self-esteem, motivation, and feelings of control.

Although society has long used terms such as "old fogeys" and "geezers," emergency departments have commonly used the terms GOMERs, meaning "get out of my emergency room," and LOLs, meaning "little old ladies."

"We're trying to teach our trainees to speak up when they hear something like this. But instead of trying to school people, and they get defensive, maybe it's pointing out something unique about the patient, like, 'Did you know Mrs Smith is a retired physician?' or other details. Reframing might help people to see beyond the stereotype," said Wilkins.

In a second presentation, W. Bogan Brooks, MD, psychiatry clerkship director, University of South Alabama College of Medicine, Mobile, noted that previous research has shown that ageism can lead to undertreatment, particularly for complaints of pain, fatigue, depression, sexual disorders, and cognitive impairment, as well as overtreatment, with needless tests, procedures, medications, and admissions to the intensive care unit.

"On the average, an older adult goes to see the doctor about 12 times a year. These doctor visits represent a lot of opportunities for physicians," said Brooks. But past research has shown that "because of ageist attitudes, doctors can be guilty of undertreating conditions if they attribute patient complaints to ordinary aspects of aging.

"Alternatively, doctors can be guilty of overtreatment if they label expected changes as a disease," he added.

Creating Cultural Change

Ageism is also reflected in medical education, as evidenced by the lack of geriatric training, said Lehmann.

"Geriatrics is really the one area where there is absolutely no requirement from accrediting bodies, which is unbelievable," said Lehmann.

She added that the Liaison Committee for Medical Education only requires teaching across the lifespan. There is no mention of a focus on aging.

"We're not teaching complex care or how to prioritize, so we shouldn't be surprised when [students] feel overwhelmed or demoralized by an older patient," she said.

Lehmann had the following recommendations to help change the culture of ageism, starting with medical trainees:

  • In medical school, increase focus on geriatrics, including exposure to older patients in community vs acute settings at initial presentation.

  • Anticipate medical students' potential discomfort with elderly patients. Ask about their previous experience with this population and acknowledge that when they work with older patients, they may feel anxiety, frustration, and/or sadness.

  • Address the fact that there may be implicit, unconscious bias against older patients and look for opportunities for connection and advocacy.

  • Discuss negative consequences of ageism, such as missing a diagnosis, jumping to incorrect conclusions, and creating a poorer quality of life for patients.

  • Encourage medical students to recognize ageism in clinical settings and to reframe the bias, and lead students to see ageism as a social justice issue.

  • Change behaviors by teaching best practices for communicating with older patients, and refrain from using condescending words or tones.

  • Review medications to reduce polypharmacy.

  • Model interprofessional, team-based approaches.

"Perhaps more than any other time, we're living in a very interesting, historical moment. Attitudes that are so entrenched in society are now being challenged, and people are saying, 'Maybe we can change culture.' And that's what I'm talking about: a culture change in our hospitals and in our physicians," said Lehmann.

"I'm optimistic because I think being in this historical moment, we have an opportunity to talk about these issues that maybe wouldn't have resonated earlier."

Importance of Role Models

"This was a powerful presentation, and it's true: implicit bias is really out there," Francis G. Lu, MD, professor of clinical psychiatry and director of cultural psychiatry at University of California, Davis, said during the question-and-answer session following the presentations.

All of the suggestions for combating ageism "are very powerful drivers. And if you focus your efforts there, I think that will help with success," added Lu.

Adam Rosenblatt, MD, director of the Geriatric Psychiatry Program at the Medical Center at Virginia Commonwealth University, Richmond, told Medscape Medical News that it's difficult to get people interested in working with this population, but that it's actually "fun and challenging."

"I had no intention of being a psychiatrist, let alone a geriatric psychiatrist, when I showed up in medical school and did not have a positive attitude toward older people."

However, "it was the existence of role models that really turned it around for me," said Rosenblatt. Because of one mentor in medical school, "I saw that it was possible to do good for these people and get positive outcomes, and he was enjoying himself." Other role models reinforced these messages, he added.

"I'm skeptical about interventions where we teach people to be more sensitive. But if we paid geriatricians more and started more programs to train more of them, I think it would make a big difference," he said.

Kenneth Sakauye, MD, is professor emeritus of psychiatry at the University of Tennessee Health Sciences Center College of Medicine, Memphis, and has been chair of the Council on Aging for the American Psychiatric Association (APA).

He reported that the APA is about to release its newest version of its guide to cultural competence. He edited the first version "about 20 years ago."

"What we're finally doing in this version is looking at the whole issue of education" when it comes to identifying and fighting biases, said Sakauye.

He noted that at the University of Tennessee, there is now a mandatory course in geriatrics for all fourth-year students to "get them into areas that we thought would provide them with a positive experience" working in geriatrics.

Session moderator Dennis Popeo, MD, New York University School of Medicine, New York City, noted that this is an important topic "that is not getting a lot of traction" in the field.

"Some of the points made today, such as that aging is a part of cultural competence and the importance of role models, are really important for medical students and all students in general," he told Medscape Medical News.

The presenters have disclosed no relevant financial relationships.

American Association for Geriatric Psychiatry (AAGP) 2018 Annual Meeting. Session 108, presented March 15, 2018.

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