October 22, 2021
Dear Interested Readers,
Are You Old, Gray, And Only In The Way?
On Wednesday morning I was beginning to write this note when I had a sudden change in my plans. My working title was “I Am Concerned About The Future Of Healthcare. Are You?” If you are a regular reader of these notes, you might have noticed that recently there has been a less than hopeful tone to my writing. I think that my spirits have been undermined by the resistance of Joe Manchin and Krysten Sinema to President Biden’s proposed infrastructure bills and the resistance of Republicans to federal legislation that might ensure fair elections without barriers to minority voting.
I share the concern of many that much like it is possible for the Red Sox to blow a lead and lose in the late innings it is also possible that the Democrats will squander their opportunity to initiate a progressive program that addresses poverty, the need for improvements in infrastructure, the desperately needed development of adequate housing and transportation resources, the need for improvements in pre-K and post-high school education, the expansion of medical coverage that will give every American the care they need, and the initiation of meaningful improvements to mitigate the climate changes that are here now and are only going to get worse. I fear we are on the road to becoming a country with an impoverished majority.
I wish that the Democrats had the will to end the filibuster, but Manchin and Sinema also want to preserve that legislative relic that has been abused and has become a barrier to progress in ways that the “founding fathers” never imagined. The filibuster coupled with the electoral college and the compromise that gave every state two senators no matter how large or small they might be has created a perfect storm that has given us minority rule for most of the past three decades and may give us an authoritarian future that will make existing inequities much harder to rectify.
I share the concern of many other progressive Democrats that as the president’s initiatives are debated and the proposed legislation is defeated or diminished the likelihood of Republican control of both houses of Congress in 2022 increases, and the stage is set for Trump or some Trump clone to win the presidency in 2024. The end result of that nightmare would likely be a government for the privileged few that sees no need to invest in healthcare or in any improvement of the social issues that are problems that must be addressed if we are to see improvements in the social determinants of health. Trump’s first four years were only a prequel to the American version of How Democracies Die.
As I was pulling together some of the references that supported my increasingly dystopian image of the future, I glanced at my emails and saw the Kaiser Health News for Wednesday. One of the articles that KHN presented was entitled “‘They Treat Me Like I’m Old and Stupid’: Seniors Decry Health Providers’ Age Bias.” The title hit close to home and captured my interest. The article was written by Judith Graham. If you click on her name you will discover that she has written several articles about how age impacts healthcare, and that KHN regularly publishes Graham’s articles on aging under the banner of “Navigating Aging” and that there is a Navigating Aging Facebook Group that you might consider joining.
As I read her short article the words and melody of Louden Wainwright III’s version of Charlie Poole’s haunting song from the late twenties, long before we had social security or Medicare, entitled “Old And In The Way” began to play in my mind’s ear. I urge you to click on the title below and to hear the song as you continue reading its words. You’ll need to start the song and then minimize the screen with the song to pull off that trick.
When you walk along the street how oftentimes you meet
Some poor old man who’s gotten old and gray?
With age his back is bent, in his pockets not a cent
And for shelter he has no place to stay
His relations by the score, they’ll turn him from the door
They’ll see him on the street and pass him by
If you ask them why they do, they’ll turn and say to you
He is old, he’s gray, he’s only in the way
Now let us cheer them on, for they won’t be with us long
Don’t sneer at them because they’re old and gray
Just remember while you’re young that for you the day may come
You’ll be old and gray and only in the way
Now my message I am sure is for rich as well as poor
For take a rich man when he’s growing old
His relations ’round him stand and take him by the hand
They all want him to die, they want his gold
And what it’s truly worth to own the riches of this earth
He’ll discover at the closing of the day
After all he’s like the poor when his journey’s nearly o’er
He finds he’s old and gray and only in the way
Now let us cheer them on for they won’t be with us long
Don’t sneer at them because they’re old and gray
Just remember while you’re young that for you the day may come
You’ll be old and gray and only in the way
If you are not of my generation and have never heard of Louden Wainwright III, you may be a fan of his musically gifted children, Rufus Wainwright, Martha Wainwright, and Lucy Wainwright Roche. The mother of Rufus and Martha was the well-known Canadian singer-songwriter, Kate McGarrigle who died in 2010. Lucy’s mother is Suzzy (rhymes with fuzzy) Roche, one of the Roches. I think that you may need to go back to the country music pioneers, The Carter Family, to find a more impressive demonstration of musical talent in one family, and I am not forgetting James Taylor and his sibs.
I first heard the song “Old and Only In The Way” in 2009 when I heard Louden Wainwright III talking about his “Charlie Poole” project on an NPR program. Perhaps it was during an interview with Terry Gross. Charlie Poole was a North Carolina musician of the twenties and thirties, and Wainwright re-recorded many of his songs on an album in 2009 entitled “High Wide & Handsome: The Charlie Poole Project.” If you want to hear the original version of the song which is a little different, click here. I think that I may have written a piece at that time that connected the song to some activities at Atrius Health, but I am not sure. If you are old and gray, memory can fail you.
What comes through to me while I am listening to the song in versions from 1928 and 2009 is that “ageism” is not a new phenomenon. What is perhaps new is the impact of COVID on older people and the fact that our attention should be directed toward yet another problem that has gotten little effective attention in the past and is perhaps worse now and will surely become an even greater problem in the future. Not that we don’t have enough growing problems to test us without developing a heightened concern about the healthcare of all older Americans.
History and personal experience have shown that the needs and concerns of older Americans can be easily disregarded. Graham goes further and asserts that there is an implicit bias against the elderly. That bias is what I see as the core of the truth that the song presents. She uses stories, or to use medical vernacular, case histories, to make her points. The first story is an exceptional example of ageism in healthcare. I hope that it is also unique, but I am sure that it would not be hard to find other similar atrocities. I can imagine a similar scene in emergency rooms where I once worked.
Joanne Whitney, 84, a retired associate clinical professor of pharmacy at the University of California-San Francisco, often feels devalued when interacting with health care providers.
There was the time several years ago when she told an emergency room doctor that the antibiotic he wanted to prescribe wouldn’t counteract the kind of urinary tract infection she had.
He wouldn’t listen, even when she mentioned her professional credentials. She asked to see someone else, to no avail. “I was ignored and finally I gave up,” said Whitney, who has survived lung cancer and cancer of the urethra and depends on a special catheter to drain urine from her bladder. (An outpatient renal service later changed the prescription.)
Then, earlier this year, Whitney landed in the same emergency room, screaming in pain, with another urinary tract infection and a severe anal fissure. When she asked for Dilaudid, a powerful narcotic that had helped her before, a young physician told her, “We don’t give out opioids to people who seek them. Let’s just see what Tylenol does.”
Whitney said her pain continued unabated for eight hours.
“I think the fact I was a woman of 84, alone, was important,” she told me. “When older people come in like that, they don’t get the same level of commitment to do something to rectify the situation. It’s like ‘Oh, here’s an old person with pain. Well, that happens a lot to older people.’”
I am not aware of experiences of the elderly in emergencies rooms during COVID being quantitated, but I am sure that something like the experience of Joanne Whitney occurred many times as the tensions and demands peaked. Graham referenced COVID and then gives us her definition of ageism in healthcare:
Whitney’s experiences speak to ageism in health care settings, a long-standing problem that’s getting new attention during the covid pandemic, which has killed more than half a million Americans age 65 and older.
Ageism occurs when people face stereotypes, prejudice or discrimination because of their age. The assumption that all older people are frail and helpless is a common, incorrect stereotype. Prejudice can consist of feelings such as “older people are unpleasant and difficult to deal with.” Discrimination is evident when older adults’ needs aren’t recognized and respected or when they’re treated less favorably than younger people.
What Graham doesn’t say is that your problems are multiplied if you are old, gray, and Black or Brown. Graham informs us that ageism, not unlike other inequities, can sometimes be reflected in accepted policy. Intersectionality between ageism and other forms of inequality experienced by minorities can increase the harm experienced by these populations via multiple implicit biases. Ageism pushes buttons that we don’t understand as well as we think we understand other origins of inequality in care. Ageism can be both explicit and implicit as it contributes to outcomes in ways that we have not evaluated through a consensus ethical lens. Graham is specific:
In health care settings, ageism can be explicit. An example: plans for rationing medical care (“crisis standards of care”) that specify treating younger adults before older adults. Embedded in these standards, now being implemented by hospitals in Idaho and parts of Alaska and Montana, is a value judgment: Young peoples’ lives are worth more because they presumably have more years left to live.
Justice in Aging, a legal advocacy group, filed a civil rights complaint with the U.S. Department of Health and Human Services in September, charging that Idaho’s crisis standards of care are ageist and asking for an investigation.
Idaho, Alaska, and Montana are practicing explicit ageism. I think the most frequently experienced damage from ageism in healthcare arises from its presence as an “implicit” bias. Graham uses another story to make her point.
Emogene Stamper, 91, of the Bronx in New York City, was sent to an under-resourced nursing home after becoming ill with covid in March. “It was like a dungeon,” she remembered, “and they didn’t lift a finger to do a thing for me.” The assumption that older people aren’t resilient and can’t recover from illness is implicitly ageist.
Stamper’s son fought to have his mother admitted to an inpatient rehabilitation hospital where she could receive intensive therapy. “When I got there, the doctor said to my son, ‘Oh, your mother is 90,’ like he was kind of surprised, and my son said, “You don’t know my mother. You don’t know this 90-year-old,” Stamper told me. “That lets you know how disposable they feel you are once you become a certain age.”
At the end of the summer, when Stamper was hospitalized for an abdominal problem, a nurse and nursing assistant came to her room with papers for her to sign. “Oh, you can write!” Stamper said the nurse exclaimed loudly when she penned her signature. “They were so shocked that I was alert, it was insulting. They don’t respect you.”
I believe that ageism is real. I have experienced what seems like ageism to me in non-medical environments. More than once I have been in a retail environment looking for a product that I could not locate. Most of the clerks in the stores near me seem to be in their teens or twenties. I have experienced that if you are gray, a little hunched over from years of poor posture, septuagenarian, dressed in very casual clothes that are a little baggy, and if you are walking with a limp and using a cane, you may be invisible. I have stood and waited for service while other younger customers who asked for help after I initially approached the clerk got the attention that I needed. On other occasions, a younger person has inserted themselves ahead of me in a line waiting for service at the post office, as if I was invisible. Friends in my cohort tell me that they have had similar experiences. It is one thing to encounter implicit ageism and bias in a store, and a much more serious issue if it happens in a hospital emergency room. Graham adds some data to the discussion:
Nearly 20% of Americans age 50 and older say they have experienced discrimination in health care settings, which can result in inappropriate or inadequate care, according to a 2015 report. One study estimates that the annual health cost of ageism in America, including over- and undertreatment of common medical conditions, totals $63 billion.
I think that some of the risks that older patients experience from ageism arise from a lack of thought, a lack of sensitivity, a lack of attention, or defects in training that are exposed by the implicit bias of ageism. It may be true that older people just don’t seem to deserve the care and concern of people who are more obviously vital and have a longer life expectancy. I guess that healthcare professionals who harbor that opinion or bias could care less about older patients and give them less attention in the prioritization of their time that is forced by a shortage of medical resources. It takes time to “hear out” an older person.” Graham has a story for that concern:
Nubia Escobar, 75, who emigrated from Colombia nearly 50 years ago, wishes doctors would spend more time listening to older patients’ concerns. This became an urgent issue two years ago when her longtime cardiologist in New York City retired to Florida and a new physician had trouble controlling her hypertension.
Alarmed that she might faint or fall because her blood pressure was so low, Escobar sought a second opinion. That cardiologist “rushed me — he didn’t ask many questions and he didn’t listen. He was sitting there talking to and looking at my daughter,” she said.
It was Veronica Escobar, an elder law attorney, who accompanied her mother to that appointment. She remembers the doctor being abrupt and constantly interrupting her mother. “I didn’t like how he treated her, and I could see the anger on my mother’s face,” she told me. Nubia Escobar has since seen a geriatrician who concluded she was overmedicated.
The geriatrician “was patient,” Nubia Escobar told me. “How can I put it? She gave me the feeling she was thinking all the time what could be better for me.”
Graham suggests that if older people get less thought and attention at the hospital or in the doctor’s office, nursing homes can be even worse. It is frequently a challenge to maintain your dignity and identity in a nursing home no matter how much cognitive ability you retain.
Pat Bailey, 63, gets little of that kind of consideration [thoughtful reflection on her individual issues] in the Los Angeles County, California, nursing home where she’s lived for five years since having a massive stroke and several subsequent heart attacks. “When I ask questions, they treat me like I’m old and stupid and they don’t answer,” she told me in a telephone conversation.
One nursing home resident in every five has persistent pain, studies have found, and a significant number don’t get adequate treatment. Bailey, whose left side is paralyzed, said she’s among them. “When I tell them what hurts, they just ignore it or tell me it’s not time for a pain pill,” she complained.
Most of the time, Bailey feels like “I’m invisible” and like she’s seen as “a slug in a bed, not a real person.” Only one nurse regularly talks to her and makes her feel she cares about Bailey’s well-being.
“Just because I’m not walking and doing anything for myself doesn’t mean I’m not alive. I’m dying inside, but I’m still alive,” she told me.
I tell my friends who ask me for suggestions about whom they should pick for a doctor to look for a physician who is likely to be available for as long as they live. That may sound like an example of a “reverse implicit bias.” My advice is based on the difficulty I have witnessed as friends lose their doctor to retirement, pick a new doctor, and then have that new doctor decide to retire. Each transition creates emotional stress because one never knows what to expect from the new doctor. The last story demonstrates that reality:
Ed Palent, 88, and his wife, Sandy, 89, of Denver, similarly felt discouraged when they saw a new doctor after their long-standing physician retired. “They went for an annual checkup and all this doctor wanted them to do was ask about how they wanted to die and get them to sign all kinds of forms,” said their daughter Shelli Bischoff, who discussed her parents’ experiences with their permission.
“They were very upset and told him, ‘We don’t want to talk about this,’ but he wouldn’t let up. They wanted a doctor who would help them live, not figure out how they’re going to die.”
The Palents didn’t return and instead joined another medical practice, where a young doctor barely looked at them after conducting cursory examinations, they said. That physician failed to identify a dangerous staphylococcus bacterial infection on Ed’s arm, which was later diagnosed by a dermatologist. Again, the couple felt overlooked, and they left.
The Palents finally found the kind of doctor who had the approach that made them comfortable. Graham ends her piece describing the care that the Palents eventually found:
It’s the opposite of ageism: It’s “We care about you and our job is to help you be as healthy as possible for as long as possible,” …It’s a shame this is so hard to find.
We all have “numerator experiences.” None of us have a way of knowing if what we are experiencing is characteristic of the experience that is most common in our population. The group that I am a part of, my demographic, is mostly old and gray if they have hair at all. In the last 18 months, I have lost three close friends, one woman, and two men, to various forms of cancer. All three had excellent healthcare coverage and received their care from world-class medical institutions. All three expressed significant dissatisfaction with the care they received. In particular, they noted substantial defects in the “caring” of physicians, nurses, and other staff. Was that because they were old, gray, and in the way?
I still get most of my care in the organization where I worked. When I am known as a retired colleague, the care and caring that I feel are exceptional. I have received some care at medical facilities near my retirement home where I am just an older man with gray hair. When I get care where I am not known I appreciate a significant discount in the quality of the service. Is the difference an expression of the inherent bias of ageism? I don’t know, but I certainly witnessed defects in the care that both of my parents experienced in their later years. Sometimes the defect in care was “overuse.” They were subjected to procedures that were not needed and had little potential benefit to them or anyone else other than as a teaching experience or as a revenue opportunity,
Maybe the sense of inherent bias that I imagine is something that I should tolerate or expect. There are other inherent biases against other populations that are much greater concerns and perhaps deserve more effort at fixing than the inherent bias of ageism. Another alternative view would be that we should commit to providing every person, no matter what their age or the other descriptors of who they are, with the equal care that was described earlier by Graham.
“We care about you and our job is to help you be as healthy as possible for as long as possible…”
That attitude, if put into wider practice, might go a long way toward simultaneously fixing all the forms of inherent bias in healthcare. Equity is one of the six domains of quality described in Crossing the Quality Chasm. It would seem to me that if we set the goal of caring about maximizing the health of every person we could solve many problems simultaneously.
I don’t know what will happen to the president’s agenda or if we will ever get rid of the barrier that the filibuster creates for removing the adversities and inequities that undermine the health of so many Americans. Adverse social determinants of health may be a permanent reality in the future of healthcare, but it is within your control to treat everyone who gets care from you with the respect they deserve even if among all the elements that define them they seem old and gray, and only in the way.
A Most Unusual And Somewhat Disappointing Fall
More leaves are down, and I am getting a little nervous. The fall is not evolving in its usual way. I still see many green leaves that should have turned by now. Many of the leaves that were colorful last week are now on the ground turning brown. They were brought down by some overnight wind and rain last weekend. The superspectacular banquet of color that I was so eagerly anticipating for this week seems unlikely to happen.
I am not giving up on the Red Sox, but I know they face a huge challenge tonight and hopefully again tomorrow in Houston. They face a win or go home reality over the next two games. The bats that were so hot in games two and three of this series were like fragile icicles in games four and five. I am trying to emotionally prepare for the worst. I will admit to an implicit bias against anything associated with Texas that stems from the fact that the state seems to be the epicenter of some of the most heinous attitudes in our society. A small compensation would be for their baseball team to flounder.
One bright spot for me is in my front yard. We are lucky to have a Japanese maple that was planted by a previous owner. This brave little tree always puts on its best color every fall, even when other trees fail to do their best. I just had to share a picture of it with you as an emblem of fall since like the Sox my favorite large-scale fall vistas have gone from possibly spectacular to most likely disappointing.
Despite my disappointment, and even for my readers who are Astros fans in Texas, I hope that fall is living up to its best possible form wherever you are. I will try to remember that baseball is just a game, and there are many positive Americans who through no fault of their own live near neighbors who seem gullible to misinformation and are plagued by their inherent biases.
Be well,
Gene
