We’ve all heard the saying, “age is just a number.” Nowhere is that more important than in the hospital setting. Over the years I’ve become more and more aware of ageism in healthcare – a bias against full treatment options for older patients. Assumptions about lower capabilities, cognitive status and sedentary lifestyle are all too common. There is a kind of “senior profiling” that occurs among hospital staff, and this regularly leads to inappropriate medical care.
Take for example, the elderly woman who was leading an active life in retirement. She was the chairman of the board at a prestigious company, was an avid Pilates participant, and the caregiver for her disabled son. A new physician at her practice recommended a higher dose of diuretic (which she dutifully accepted), and several days later she became delirious from dehydration. She was admitted to the local hospital where it was presumed, due to her age, that she had advanced dementia. Hospice care was recommended at discharge. All she needed was IV fluids.
I recently cared for an attorney in her 70’s who had a slow growing brain tumor that was causing speech difficulties. She too, was written off as having dementia until an MRI was performed to explore the reason for new left-eye blindness. The tumor was successfully removed, but she was denied brain rehabilitation services because of her “history of dementia.”
Of course, I recently wrote about my 80-year-old patient, Jack, who was presumed to be an alcoholic when he showed up to his local hospital with a stroke.
Hospitalized patients are often very different than their usual selves. As we age, we become more vulnerable to medication side-effects, infections, and delirium. And so, the chance of an elderly hospitalized patient being acutely impaired is much higher than the general population. Unfortunately, many hospital-based physicians and surgeons — and certainly nurses and therapists — have little or no prior knowledge of the patient in their care. The patient’s “normal baseline” must often be reconstructed with the help of family members and friends. This takes precious time, and often goes undone.
Years ago, a patient’s family doctor would admit them to the hospital and care for them there. Now that the breadth and depth of our treatments have given birth to an army of sub-specialists, we have increased access to life-saving interventions at the expense of knowing those who need them. This presents a peculiar problem – one in which we spend enormous amounts of resources on diagnostic rabbit holes, because we aren’t certain if our patients’ symptoms are new or old. Was Mrs. Smith born with a lazy eye, or is she having a brain bleed? We could ask a family member, but we usually order an MRI.
My plea is for healthcare staff to be very mindful of the tendency to profile seniors. Just because Mr. Johnson has behavioral disturbances in his hospital room doesn’t mean that he is like that at home. Be especially suspicious of reversible causes of mental status changes in the elderly, and presume that patients are normally functional and bright until proven otherwise.
Last month I hit a new age record at my rehab hospital – I admitted a charming, active, 103-year-old woman after a small stroke caused her some new weakness. She was highly motivated in therapy, improved markedly and was discharged to an independent living center. I bet she will live many more years. When I joked that she didn’t look a day over 80, she winked and told me she had stopped counting birthdays years ago. She said, “It doesn’t matter how old you are, it matters what you can do. And I can do a lot.”
“Most physicians are competent and able to take care of most of the problems patients present with. The standards for getting into medical school are high and for getting out are higher. I think this call for patients to become experts in picking their doctors is overstated.” – David Rovner, MD, Professor Emeritus, Michigan State University
Most? What does “most” mean? Can most doctors treat me for the flu? How about pancreatic cancer? Must I conduct the same type of research to choose a doctor to set my broken arm that I do to find one to treat my mom’s congestive heart failure? Is the same level and type of research necessary to find a good surgeon as for a primary care clinician? Read more »
*This blog post was originally published at Prepared Patient Forum: What It Takes Blog*
From the department of “Credit where it’s due,” in the comments of my post on the Lewin Group
, Nurse K pointed out the following:
Come on Shadowfax, you’re blogging about this stuff and you stand to make A TON of money if it goes through…for awhile…until insurance companies decrease your compensation since you’re making more per patient. I know you mentioned this before in like a comment or something, but ER docs stand to benefit (temporarily) probably more than anyone else. HUGE bias on your part.
Much as I (really, really) hate to admit it, she’s absolutely right. In fact, I’ll go one further: I first got interested in this part of medicine policy because I was mad that I was seeing all these uninsured patients and wasn’t getting paid a thing for my efforts. I started keeping track of the number of uninsured I saw every day, just as a pet obsession. It was a sobering number. After that I started getting a little perspective, talking to patients and seeing their bigger picture, understanding why they were uninsured, learning the particular challenges they faced getting health care, etc. For me, this cause became something beyond the personal a long time ago and became a moral imperative.
But K is right to note the potential for bias, and it’s fair for me to acknowledge it. I hope that my integrity on this point is evident. The fact that I argued in the New York Times for an increase in primary care compensation, with an attendant decrease in the compensation of specialists, including Emergency Medicine, should speak well for my ability to see beyond personal self-interest. (God knows it didn’t make me popular in EM circles!)
This is something which struck me yesterday, reading the med blogs reaction to Obama’s presser. Quite a few docs mounted their high horse and with great indignation denounced this:
Doctors are forced to make decisions based on a fee payment schedule that’s out there. So they’re looking… if you come in with a sore throat or your child comes in with a sore throat, has repeated sore throats, a doctor may look at the reimbursement system and say to himself, “I’d make a lot more money if I took this kids tonsils out.” Now that might be the right thing to do, but I’d rather have that doctor making those decisions based on whether you need your kids tonsils out…
Now it’s a clumsy clinical scenario written by someone who has no clue about medicine. But it’s a damned fair point. Bias comes writ large, as in the Walter Reed orthopod who pocket $850K and falsified his research to benefit Medtronic, and it comes writ small, as in the ER doc who sees a small lac and has to decide whether to use a band-aid or a stitch, knowing that the stitches will pay 10x more. It comes with the cardiologist who has to decide whether to take a low-grade troponin leak to the cath lab. It comes with the surgeon seeing a patient with unusual abdominal pain and a slightly enlarged appendix on CT (you can observe or just take out the appy; guess which pays more).
Whether there’s a “fix” for that in the current reforms is debatable. It harms our standing, however, to deny the possible existence of bias and to claim a moral purity that, as a profession, is not justified. I think and hope that most of us in these ambiguous situations are able to come to the right decision for the patient the vast majority of the time regardless of our economic interests. The best way to remain credible is to acknowledge the mere potential for bias and move on and debate the salient point. Making counter-factual arguments that biases do not exist or that we physicians are too awesomely altruistic to ever be influenced by them does nobody any good.
*This blog post was originally published at Movin' Meat*