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Ageism in Medicine: How It Appears, Why It Can Hurt You

Interview with gerontologist Mark Lachs

None of us wants to be stereotyped by age.

Yet all too often in the world of medicine, we are defined and labeled by our years on the planet — and treated according to preconceived notions about that age. Because of this, we can potentially miss out on the unique and individualized care we need for maximum health and well-being, says physician and gerontologist Mark Lachs, author of the new book, Treat Me, Not My Age.

Lachs asserts that none of us ages in exactly the same way. This is especially critical, he says, "because when we're looking at a tremendous increase in longevity among the population, we're also looking at more chronic illness among older people." We need to know what is at stake.

Ageism can start early and subtly — in our 40s, 50s, 60s, Lachs says. "If you're a young person who plays pick-up basketball, like our president, for example, and you injure your knee, your doctor might say, 'Well, take up golf.' That's a subliminal message to slow down that may have nothing to do with your particular situation. For people who are much older, it's actually a common form of ageism. You might go to the doctor for pain, and without a complete evaluation or an exam, the doctor may say, 'You should expect that. You're getting older.' And that's just crazy."

<p>'Patients should feel that their doctor is leaving no stone unturned.'</p>

Lachs is based at New York's Weill Cornell Medical College, and his research has appeared in the New England Journal of Medicine; his honors include an academic leadership award from the National Institute on Aging. He spoke to the AARP Bulletin about navigating the health care system. (Read an excerpt from Treat Me, Not My Age.)

Q. We're seeing more ageism among doctors and hospitals, you say. Why is this?

A. Medicine has become more and more hurried. We now have what I call "the incredible shrinking office visit." As a gerontologist as well as an internist, I see a lot of patients who have gotten a sort of drive-by treatment, and it's not right. Patients should feel that their doctor is leaving no stone unturned, that complaints are being fairly adjudicated, and that someone is really thinking about their issues. No ailment should ever be written off as an "old age" ailment. Treating patients based on their age means you can miss very significant, treatable situations.

Q. How so?

A. If you've seen one 70-year-old, you've seen one 70-year-old. We're all created equal, but as we get much, much older, we don't age that way. In my practice I have 90-year-olds who go to work every single day, and I also have 50-year-olds with multiple sclerosis who are bedridden. When you treat patients like a number, you run risks.

Q. What are those risks?

A. Let me give you some examples. What if you're a woman in your 40s who has fibroids and your doctor steers you toward a hysterectomy without asking whether you want to have more children? That's a form of age discrimination. Here's another example: An 88-year-old female patient of mine asked me recently if she still needed regular pap smears and mammography. She had been getting them routinely for many, many years, and she always had negative pap smears and negative mammograms. I looked very carefully at her history and assessed all of the risks of not doing the tests at that point. And I told her, "No. No. There is no reason for you to have these tests right now." Every patient is different, and I hate the way the health care system pigeonholes people based on a number, and it becomes more absurd as patients get to be 70, 80 and 90, with great variations in their functional ability.

treat me, not my age

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Q. What can patients do about it?

A. Among other things, outline your goals for any doctor's visit before you arrive. Then, try saying, "Doctor, today I'd like to cover three things — my knee pain, the results of my cholesterol test, and whether or not I need a mammogram." So the expectations are created at the beginning. That's reasonable, and doctors will appreciate it. Too many patients simply submit. You need to articulate your concerns. Ask questions. Ask why a test is necessary or not. Ask about the background.

Q. You're talking about much more than medical tests. You're talking about a game plan to get the best treatment. What else should patients be aware of?

A. We all know about the dangers of hospitalization, including the increased risk of infection. But lots of bad things happen when people move between physicians and institutions, or even within institutions. The world's become so specialized that information gets lost. In my book I tell a story from my days as a resident, when a primary care patient came in with a bypass scar on his chest. The bypass had been done at my own institution — yet nobody had told me about it. A patient can be handed off from a primary care doctor to an orthopedist and back again, and one guy doesn't know what the other is doing.

Q. What can a patient do about it?

A. Your default posture should be: Assume that information is going to get lost. Be the repository of your own medical information. And don't think that President Obama's push for electronic medical records (EMRs) will fix this.

Q. Why not? Isn't greater efficiency and transmission of your information among the promised benefits?

A. Someday that might be true, but we're not there yet. First, very few primary care practices have adopted EMRs because the cost of adoption is significant. Big, fabulous academic medical centers like the one where I work are very computerized; that's true. But if I care for you in my practice, and then you get chest pain and someone takes you to another medical center across town, guess what? The two offices don't speak to each other. So I tell patients to keep a "biggest hits" list with them. That includes your five or six major medical situations, such as diabetes or coronary artery disease. Obviously it's not practical to walk around with your entire medical record. But a few key pieces of paper can work.

Q. What would those be?

A. For my patients who have normal resting cardiograms, for example, I photocopy it and give it to them. It's a piece of paper the size of an index card, and it provides a baseline. As we get older we tend to accumulate not only conditions and diagnoses, but some abnormalities on medical tests, including x-rays, scans and stress tests. Also, keep a list of medications you're taking. A number of companies now, including Google Health and Microsoft HealthVault, have created tech-savvy online ways for patients to do this, depending on how you feel about medical privacy. You just never know where you're going to get sick or who's going to treat you.

Q. How does an older patient advocate appropriately for himself or herself, without overstepping the line?

A. That's the sweet spot, isn't it? You can advocate appropriately, and most physicians will respect that. Discuss your day-to-day activities with your doctor. Tell us how you move about, how you conduct your life, what you expect and hope to do in the future. The partnership is critical. But there is another issue here, and it has to do with the caregiver's role in the interaction. Very often, the caregiver accompanies the patient to the appointment.

Q. Right. So how should that be handled, ideally?

A. It's much more difficult, I think. On the one hand, you want to give the older patient space to have dignity. That person needs to be autonomous in the interaction. On the other hand, you're concerned. If you're like many boomers caring for older parents today, your parent comes back from the doctor, and you want to know how the visit went. You say, "Mom, Dad, what happened?" And like many people, they clam up. You can't figure out what went on in the visit.

Q. Why does that happen — what's at work here?

A. Boomers today are used to getting all kinds of things and all kinds of service, no matter where they go. Not true of their parents. I see many people in their 70s, 80s and 90s who are reverential to physicians to a fault. But we physicians are human beings. We're God's children, and we make mistakes.

Q. What do you suggest?

A. I tell the boomer child of an older parent to role-play with his or her parent before the visit. You might say, "OK, Dad, you're going to see Dr. Smith about your knee pain. He's probably going to ask you when the pain started, what makes it worse, and how about your other knee." This helps create a sense of what's going to happen at the visit. If the parent is willing to let the boomer child go with them on a visit, that's an opportunity to become a participant in the visit.

Q. But there are dangers to this as well.

A. Yes, because the physician can begin addressing the conversation to the child, without making eye contact or even speaking to the patient, which is another subtle form of ageism. If that's happening in the encounter, you need to gently redirect the physician to your mom or dad. You might say, "Dad, how does that sound to you?" You don't want to be rude, but you want to constantly make sure that your parent does not become the inanimate object in the room.

Q. You say that a doctor's bedside manner can actually lead to better medical care in some cases. How so?

A. It's an issue of doctor-patient fit. It's really important for patients and doctors to be able to talk to each other, really engage — not just cover the facts. There is also some data now that's starting to suggest that if you're engaged with your physician, you're more likely to adhere to medications, to follow up with recommendations. This is not about having your blood pressure taken correctly; it's about feeling doctored, feeling cared for and communicated with. That's always the fun of medicine for me, to get to know my patients and their stories and to grow along with them. People really see me as their physician but also as someone who can help them think things through. Think about how you respond to advice from someone whom you know and trust — versus someone you don't have much of a relationship with. You're much more likely to say, "Wow, this guy's truly concerned about me, I'm interested in what he has to say." And you probably adhere more to their advice and recommendations.

Q. You also talk about the profound benefits of aging in your book — that retirement can be better than people sometimes expect. Let's not neglect this important point.

A. Here's a quick history of retirement. Some people become rudderless in retirement, notwithstanding the current economic environment in which people have to work. But the overwhelming body of literature on retirement is that it's fabulous. There's independence, for one thing. And there's time. Most people tell me, "I don't know how I had time to work." That's a great thing to hear. If you have the resources, retirement can be an overwhelmingly positive experience.

Q. That's the goal!

A. And there's also the freedom to speak your mind, to not be tethered, which cannot be underestimated. I had a patient who was fired. He didn't like the boss, and he used a four-letter word with him. I told my patient, "That must have been terrible." He said, "No, it was fabulous! Do you know how many times when I was a younger man with four mouths to feed that I wanted to tell the boss to go take a hike? Now, I finally could." This was therapeutic for him.

Q. Clearly there are bright sides to getting older.

A. Marriages that survive are the most satisfying relationships. And sexuality can also persist until late life, which is fabulous. George Burns had a great joke: The key to late life is living to 100, because you rarely read about people who die after 100.

The science bears that out. Once you make it past a certain age without a disability, you keep going with less and less disability. And for boomers in their 50s and 60s, the foundation for that kind of existence is placed early on. Even with modest interventions like daily walking, or low-intensity weight training, or making sure to see friends socially — all of those affect longevity and quality of life.

Q. You see aging as such a hopeful time.

A. Rather than say, "I'm never going to get old," which is what Americans are being sold in so many places, say instead, "I'm going to get older."

Maureen Mackey is a writer and editor from New York.