An Age-Old Dilemma


Marilyn R. of Philadelphia remembers the day she was told a lump in her breast was malignant: "I was almost in shock for days," she recalled.

A family meeting was held with a surgeon, and Marilyn was advised that a lumpectomy with subsequent radiation therapy would be just as effective as a mastectomy.

"This is what I would suggest," he said, "but the decision is yours."

Quite conflicted, 64-year-old Marilyn decided to consult her family physician. "I wanted his opinion," she explained. "After learning the details of my problem, to my surprise, he told me he would prefer I have a mastectomy. Now, I had a hard choice to make."

The family physician had said to Marilyn's husband, "I think a mastectomy is recommended; after all, at her age, she isn't going to nurse any babies, and does she really need those breasts?"

After much deliberation, Marilyn decided to have a lumpectomy. "And, today, 14 years after that procedure, I have had no recurrences; I am fine – and still have my body intact."

In this age of so-called geriatric awareness, it is still alarming to realize that older patients are not always treated the same as younger patients in today's health-care system.

More than 30 years ago, Dr. Robert N. Butler, the founding director of the National Institute on Aging, coined the word "ageism" – the term for discrimination against older people. Over the past three decades, Butler has seen little change in the widespread bias against older people within the U.S. health-care system.

Butler now heads the New York-based International Longevity Center-USA, and notes, "The ageist view of older people has persisted, despite a significant body of evidence, dating back to the 1960s, that older people can tolerate powerful drugs and interventions to treat many diseases.

"There is no reason to assume that a person would not benefit from a drug or treatment based simply on his or her age."

The nonprofit Alliance for Aging Research located in Washington, D.C., published a recent report listing serious shortcomings in caring for the senior population. The report outlines five key areas of concern:

• Health-care professionals do not receive enough training in geriatrics to properly care for many older patients;

• Older patients are less likely than younger people to receive preventive-care treatments;

• Older patients are less likely to be tested or screened for diseases and other health problems;

• Proven medical interventions for older patients are often ignored, leading to inappropriate or incomplete treatments;

• Older people are consistently excluded from clinical trials, even though they are the largest users of approved drugs.

"This is often true," says Dr. Martin Frank, a retired cardiologist, former chief of cardiology at Abington Memorial Hospital. Frank also feels that today's health professionals (unlike older physicians, whose training in this area may have been minimal), do receive proper training in geriatrics to care for many older patients.

"Yes, there is some discrimination, also, against African-Americans, Hispanics … and women," he adds.

Unfortunately, health-care providers miss out on millions of opportunities every year to prevent, treat and enhance the lives of older Americans by viewing many serious medical conditions in older people as simply a natural part of getting old.

Ageism bias comes at a cost to everyone in society. Poor medical attention often results in premature dependence on family or the government, increased earlier mortality and disability, as well as depression, despair and isolation among many older adults who might otherwise continue having a wholesome, productive life.

As Dr. Kenneth Brummel-Smith, professor and chairman of the department of geriatrics at the Florida State University College of Medicine, says, "When you say nothing can be done, nothing happens [on the research front], but when you say let's look at [this condition], that's when research begins. That's what happened with Alzheimer's disease and other conditions."

Many doctors have only limited training, if that, in the care and management of geriatric patients. Only about 10 percent of U.S. medical schools require coursework or rotations in geriatric medicine.

While many more medical schools do offer geriatric courses as electives, the annual survey by the American Association of Medical Colleges shows fewer than 3 percent of medical-school graduates choose to take these courses.

The United States lags behind other developed countries in geriatric training. This startling fact is reflected by the greater presence of geriatric departments throughout Europe and Japan. A special course in geriatrics is mandatory in all medical schools in France.

A serious component of the ageism problem is the relationship between physicians and their older patients, in addition to the decreasing reimbursement physicians receive from Medicare for treating patients over the age of 65.

A recent survey by the American Medical Association found that 61 percent of primary-care physicians and 44 percent of specialists plan to impose new or additional limits on the Medicare patients they treat, while 71 percent of the physicians intend to make changes in their practices that could adversely affect patient access, such as discontinuing certain services and referring complex cases.

Dr. John W. Rowe and Dr. Robert L. Kahn, authors of Successful Aging, published in 1999, expose many ageist myths with research suggesting that "humans possess far greater powers for health, resilience, adaptability and positive change than is often assumed by health providers and older patients alike.

"We like the term 'convoy of social support' to describe the pattern of supportive relationships with which an individual moves through life. A convoy is a dynamic entity; the ships that make it up are in motion, en route to a destination. They are protected by being part of the convoy, but each also provides a degree of protection to the others."

The metaphor of all this, write the physicians, is that "the convoy seems to fit the personal networks of stability and change on which we depend for support as we move through the life course."


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