Addressing Ageism in Medicine

Authors: Anthony Hou, MD

“Why are you being so loud?,” asked Mr. E, after I had informed him of the physical therapy plan for the day.  The soft-spoken 80-year-old gentleman was my new patient at the skilled nursing facility.  He was about to embark on a course of physical therapy after having had multiple falls at home due to his advancing Parkinson’s disease.

“Come again?,” I asked, caught a little off guard by the combination of the whisper-quiet of his voice and the pointedness of the question itself.

“WHY are YOU speaking to ME SO loudly?,” he asked, this time with a much clearer intonation and more than a trace of indignation. This time, I heard him.

My initial mental reaction was defensive. After all, I had just wanted to be sure my patient could hear the quite important information I needed to communicate to him and didn’t he realize I was short on time and running late? Thankfully, within a few seconds, the better angels of my geriatric training took hold and I did what I should have done from the beginning.  Listen.

Mr. E was quite right that I had been speaking more loudly. I had wrongly assumed he was hard of hearing in my morning rush.  I quickly modulated my voice to its regular volume and, channeling my inner-Verizon, I asked “Can you hear me now?” 

Accordingly, Mr. E answered “Yes” in his regular, still very soft voice.  Perhaps not so surprisingly, I heard him easily, probably because I was now actually listening. I could only guess how many incidents throughout the day Mr. E dealt with people either talking loudly to him, talking over him, or not talking to him at all. 

We know ageism can be both insidious and blatant but, as with most “-isms”, the former may be the more damaging form, manifesting in an untold number of interactions elders have on a daily basis.  Stereotyping, patronizing, infantilizing exchanges may seem harmless in the moment but work to externalize ageism in the community and internalize ageism in ourselves. 

As my interaction with Mr. E proved, even a geriatrician with almost twenty years of experience can fall prey to unconscious ageist behaviors when self-awareness is compromised. It goes without saying that to combat ageism, it is necessary to have a basic knowledge of its existence. Correcting ageist behaviors starts with being aware of our own ageism.

As a generation of physicians comes of age in our rapidly graying post-pandemic world, the urgency to root out ageism in medicine has never been greater. Multiple studies have shown insufficient training regarding elder mistreatment for physicians on a national and global level. This lack of training manifests in physicians having lower suspicion for elder abuse, lack of confidence in the assessment and management of abuse cases, and confusion regarding the diagnosis and reporting of abuse. It is no wonder that cases continue to be missed every day in clinics, emergency rooms, and hospitals in every city in every county in every state in the country.

One seemingly simple solution would be to train more geriatric physicians to take on this work.  Unfortunately, at present time, there are just 7,300 board-certified geriatricians in the United States, which equates to 1 geriatrician per every 10,000 American elders. Even more alarmingly, just as our nation faces a rapidly growing older population with the entirety of the baby boomer generation joining the 65 and over age group by the year 2030, the number of physicians electing to specialize in geriatrics is declining. Just 41.5 percent of geriatric fellowship positions were filled in 2023, down from 43.1 percent in 2022. In this decade thus far, less than half of all geriatric training positions have been filled per year, with unmatched positions increasingly trending in the negative direction.

The reasons for this decline are many and unlikely to be reversed soon considering the current realities of our U.S. health care system, the focus of medical training programs, and the existing reimbursement structure for those who provide care for elders. As Dr. Sasha Lewicki, the associate program director for our Kaiser Permanente Los Angeles Medical Center Geriatrics Fellowship, notes, “All people in health care have taken care of aging individuals, but many haven't had the time or opportunity to take joy in actually getting to know them as individuals. There is a kind of dehumanization that happens when health care providers aren't able to connect with their aging patients and the patient's loved ones. This leads people to turn off their curious brain and try to avoid aging and death as much as possible. There is also a lot of ableism in our society, where individuals believe that loss of function means that there is no joy left in life. Many of our patients have this bias as well and very much fear and resist anything that would indicate or imply a loss of function. Health care providers absorb this ableist framework and end up wanting to avoid patients with disabilities.” 

Though the path forward is daunting, it is important that those of us who train future clinicians recognize these biases in our health care system and take steps to address them. We need to evolve our training to bring basic ageism and elder mistreatment education to a broader group, perhaps to college students interested in the health field, medical students, and residents of all specialties. 

For now, our Kaiser Permanente Los Angeles Geriatrics Fellowship program is committed to incorporating ageism education into our curriculum, including didactic training focused specifically on ageism in medicine. To this end, drawing from NCEA resources has been invaluable, including the recent infographic “What Health Care Students Need to Know about Elder Abuse” and the USC elder abuse curriculum for medical students and residents.  Our hope is that by calling out ageism as a very real entity in medicine, our learners will go out into practice with an advocacy mindset, ready to advance the discourse. 

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