Elder care as “frustrating” and “boring”: Understanding the persistence of negative attitudes toward older patients among physicians-in-training
Highlights
► We examine attitudes of physicians-in-training toward older patients. ► We use an ethnographic approach to understand student opinions. ► Physicians-in-training receive contradictory messages about aging.
Introduction
Preparing physicians to meet the needs of the “gray tsunami” (Kirchheimer, 2008, in Diachun, Van Bussel, Hansen, Charise, & Rieder, 2010) has emerged as a priority in US medical education. Although geriatricians generally report very high job satisfaction when compared with other subspecialties, the number of physicians choosing to pursue geriatrics as a career remains inadequate given the anticipated rise in numbers of older adults requiring medical care in the US (Adelman et al., 2007). In order to insure proficient treatment of older patients by young physicians, the Association of American Medical Colleges in 2007 instituted minimum geriatric competencies for fourth-year medical students (AAMC, 2007, in Eskildsen & Flacker, 2009).
However, despite much research on the topic, it is still not entirely clear what the “best” approach to geriatric-focused education entails. Efforts at reforming medical school curricula involve such interventions as introducing geriatrics-specific learning objectives and lectures, facilitating student encounters with older adults earlier in the process of medical training, encouraging longitudinal care of seniors that includes home visits, and encouraging the development of geriatric-specific communication skills (Diachun et al., 2010, Thomas et al., 2003). The impact of these revisions on students' attitudes and knowledge of geriatrics has been mixed (Adelman et al., 2007, Diachun et al., 2010, Eskildsen and Flacker, 2009, Kishimoto et al., 2005, Perrotta et al., 1981, Shue and Arnold, 2005), and negative perceptions of caring for older patients continue to persist among medical students, residents, and faculty (Krain, Fitzgerald, Halter, & Williams, 2007).
In the face of increasing education about the negative impact of ageism on care of older patients and the rising importance of providing competent geriatric care, why do ageist assumptions persist among physicians-in-training? This study specifically seeks to explore the attitudes of physicians-in-training toward older patients. Based on ethnography and narrative analysis, we found that the majority of physicians-in-training expressed a mix of positive and negative views about caring for older patients. We argue that physicians-in-trainings' attitudes toward aged patients are shaped by a number of heterogeneous, paradoxical and frequently conflicting factors, including both the formal and so-called “hidden”1 curricula in medical education, institutional demands on physicians to move patients through the hospital as quickly and efficiently as possible, and portrayals of the process of aging as both as a “problem” of inevitable biological decay, an opportunity for medical intervention, and a pathological state that can be slowed or reversed through “anti-aging” science. In order to navigate these ambiguities, uncertainties, and contradictions that surround aging and caring for the elderly in the U.S., we suggest that medical trainees must develop individual approaches to care that attempt to balance caring for and meeting the needs of older patients while also conforming to the structural and institutional requirements for efficiency and fast patient turnover.
Section snippets
Background
In America and in many other societies, biomedicine and the health care system have emerged as the dominant frameworks to both understand the process of aging and attempt to manage and treat the medical and social conditions associated with old age (Kaufman, 1994, Kaufman et al., 2004). The emergence of gerontology as a medical specialty in the early 20th century marks the separation of the aged into a distinct category of patients that are seen to require different types of care than other
Methods
This article is part of a larger anthropological investigation of how physicians-in-training are socialized to determine patient “worth” and how this determination shapes the time and effort spent on an individual patient's care. This study utilizes the techniques and methods of ethnography, a qualitative approach to research developed by anthropologists that includes participant-observation and semi-structured interviews. Fieldwork was conducted at two urban teaching hospitals in northern
Ageist assumptions
In this study, participants were asked whether older patients, as a group, were more likely to receive lesser care or be less enjoyable for staff to treat medically. Whereas some types of patients (i.e., drug addicts, non-adherent patients, the homeless— see [primary author] et al., in press) were described by participants with strong feelings of frustration, anger, or resentment, older patients, by comparison, were described as mildly frustrating, or simply less interesting. A few participants
Discussion
In all, most participants felt some combination of frustration and warmth toward older patients. Negative perceptions of the elderly by the study population, including that they were inherently ‘end of life’ patients, that they were cognitively impaired, that their medical problems were complex and unlikely to be resolved, and that they were socially ‘needy’ and ‘slow’ to interact with, were tempered by views of older patients as more accommodating, deferent, and more willing to listen to
Conclusion
While a large number of studies have focused on the broad issue of ageism in medicine, this paper seeks to understand how perceptions of aging patients as “boring” are both supported and contested by physicians-in-training and impact their approach to care of geriatric patients. This paper argues that it is the attitudes of senior physicians, the increasingly ambiguous and complex understanding of the process of aging in biomedicine, and the constraints, requirements, and organization of the
Acknowledgments
The authors would like to thank Sharon Kaufman, Nancy Burke, and Brian Dolan for their comments on drafts of this paper, as well as the anonymous reviewers. This research was made possible by a University of California, Berkeley Mentored Research Award [RH] and funds provided by the UCSF Department of Anthropology, History, and Social Medicine [RH and AT] and the UCSF Medical Scientist Training Program [AT].
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