In this in-depth follow up piece, Olivia Earl continues to address ageism in the healthcare industry (catch up with Part 1 on a general ageism overview here). Here, she evaluates general attitudes by providers and considers the multiple barriers someone older may face in receiving healthcare. Her thoughtful writing invites us all to identify our own biases and understand injustices in our system.
Written by Olivia Earl
Ageism and the Healthcare System: An Introduction
Do you know the famous anecdote of the 97 year old man? He goes to the doctors because he has pain in his left knee. The doctor takes the man’s history and performs a physical exam on the man. However, no sign of trauma appears to be present, no immediate reason for the knee to be in pain. The doctor says “Hey, the knee is 97 years old. What do you expect?” The patient says, “but my right knee is 97 and it doesn’t hurt a bit.”
“Recently, a distressed geriatrician colleague told me a story about grand rounds at a major medical center where the case of a very complex older patient brought in from a nursing home was presented. [Grand rounds are meetings where doctors discuss interesting or difficult cases.] When it was time for comments, one of the leaders of the medical service stood up and said, ‘I have a solution to this case. We just need to have nursing homes be 100 miles away from our hospitals.’ And the crowd laughed.” (Dr. Louise Aronson).
As demonstrated in the anecdotes above, ageism can happen in a healthcare context between provider to patient or between providers. Additionally, ageism related to and in healthcare can occur within a patient themselves. This is known as internalized ageism. Internalized ageism can result due to ageist beliefs, thoughts, and actions that individuals experience in their everyday lives. These experiences can develop various environments such as work, home, and as depicted above, healthcare. These experiences become internalized, and older adults may begin to hold ageist assumptions and beliefs against themselves. Unfortunately, both external and internal ageism can reduce healthcare seeking behaviours in seniors, negatively impacting their overall health.
Examples of Ageism in Healthcare
The anecdotes of the 97 year old man with a painful knee and the healthcare provider wanting long term care homes to be 100 miles away from the hospital demonstrate two ways of how ageism can exist in a Canadian healthcare context. While these examples are very unfortunate true scenarios, there are many other contexts and ways that ageism remains a prevalent issue for seniors. Below will discuss and analyze an example of both explicit and implicit ageism, how they impact the quality of services seniors receive, and how ageism impacts the healthcare system overall.
First, it is important to understand how ageism can occur in healthcare providers. Ageism can occur either implicitly or explicitly. Implicitly refers to beliefs, thoughts and judgements that individuals have without conscious awareness. In other words, implicit ageism is what we immediately think or believe about a person or circumstance. In a healthcare context, internal ageism can manifest as a healthcare provider immediately thinking that senior patients are incompetent, dependent, or unintelligent. It is thought that implicit ageism develops when ageist stereotypes that exist within a community are internalized within their population. This demonstrates how a society's beliefs and social norms have a strong influence on the unconscious beliefs that members of a community may hold.
The other way ageism may present itself in a healthcare context is explicitly. Explicit ageism refers to when there is conscious awareness in an individual: such as intention with their thoughts, actions, or feelings. As demonstrated in the first anecdote, this type of ageism can manifest as a physician simply writing off patients' pain due to the fact that they are a senior.
Explicit Ageism - “Bed Blocker”: A Damaging Colloquial Term
Ageist beliefs, actions, and terms perpetuate ageism both implicitly and explicitly in the healthcare system. The use of the term “bed blocker” is another example of explicit ageism that is pertinent within the Canadian healthcare context. While the term bedblocker is not an official medical definition, it is used colloquially by healthcare providers to describe older adults who may be unable to leave the hospital for a variety of reasons. These senior patients use beds in the hospital that ageist physicians believe younger patients could use and are more deserving of. The issue with using terms such as “bed blocker” to describe seniors is that it places the blame on them for not getting better, rather than addressing the root cause of what is impacting their health. Ageism then continues to be prevalent in the healthcare system, and the healthcare system continues to use resources inefficiently. If healthcare providers began to address their ageism, they could recognize their bias against senior patients. As a result, the discourse shifts from healthcare providers blaming seniors, to genuinely attempting to address the root cause of a “bed blockers” illness. This makes healthcare services more effective and efficient for all patients. By improving the health of “bed blockers”, physicians support them becoming more independent and leaving the hospital, and frees up hospital resources for other patients who need to access their services. It becomes clear to see how ageist beliefs from healthcare providers impact their behaviours in addressing senior health, which not only negatively impacts seniors, but the whole healthcare system.
Implicit Ageism: Doctors Dismissing Senior Patients
While referring to an individual as a bed blocker is a very apparent act of ageism, ageist actions can be less obvious. An example of implicit ageism is when doctors who are working with senior patients immediately go to speak to their family to discuss medical information instead of speaking to the patient directly. When a physician behaves in this manner it may reiterate beliefs in the patient, the patient's family, and in the physician, that older adult patients are not competent enough to understand their own healthcare. In fact, research has demonstrated that ageist beliefs about older adults, such as assuming that they are less competent, have influenced what kind of treatment options that are provided to them by physicians, as well as their recruitment for clinical trials. When seniors receive treatment that is less effective as a result of a physician's internalized ageism, this can place extra strain on the healthcare system. When provided less effective treatment, senior patients may need to more frequently use healthcare services, or it may even result in the senior having a health emergency, because their health issue was not properly addressed the first time. As a result, more healthcare resources are wasted due to physician ageism. However, if a physician is trained to unlearn their ageist beliefs, they can provide the best treatment options right away for their senior patients, therefore taking the most efficient course of action. This can lead to senior patients recovering faster, and less healthcare resources are wasted.
Furthermore, an issue that many older adults may face with their healthcare providers is a lack of communication of health information. Research has demonstrated that communication can be limited between health care providers and older adult patients, which can be worsened by a senior patient’s sensory deficits, cognitive impairments, and functional limitations. The decrease in communication between older patients and their healthcare physicians may be rooted in implicit ageism within the healthcare provider. In fact, research has shown that when healthcare providers have older adult patients, they may be less patient, less engaged, less likely to take issues seriously that the patient has brought to their attention, as well as engage in the ageist practice of elderspeak. Elderspeak refers to simplifying a concept and speaking slower than they typically would, assuming that older adult patients are incapable of understanding without these adjustments. This practice can result due to either implicit or explicit ageism, and it can negatively impact a seniors overall mental and physical wellbeing.
Ageism in healthcare settings is unfortunately a very relevant issue that seniors may experience on a regular basis. In fact, facing ageism in healthcare settings can contribute to decreased access to health services by seniors, negatively impacting their overall health. It is suggested that more training and awareness of implicit and explicit ageism for health care providers could help support better patient centered care and reduce the ageist barriers that seniors face in the healthcare system. A natural starting point for educating and training healthcare providers on the impact of ageism? Medical school. However, some health professionals think medical school is not providing enough geriatric studies for its students to provide them with enough foundational knowledge and experience needed to successfully work with and provide healthcare services to older Canadians.
Medical School in Canada: How Does it Perpetuate Ageism?
Multiple research studies and physicians themselves acknowledge the fact the Canadian healthcare system and how it functions sustains ageism. One aspect of the healthcare system that significantly contributes to ageism existing in health services, is how medical schools operate. Some physicians believe that addressing ageism in medical school when students are first studying may be beneficial to help lower the ageist beliefs and perceptions that doctors have when they begin practicing in the Canadian healthcare context. The issue with the Canadian Medical School system lies within the fact that at this point in time there is no compulsory geriatric education in medical school. Despite the push for it, there are challenges implementing it due to the already intense curriculum they receive. The Canadian Geriatrics Society has been advocating for an addition to the medical school curriculum that puts a focus on geriatric training, and developed 20 core competencies that guide the knowledge medical students should be taught regarding geratric medicine and care of older adults. Though these core competencies have not been mandated into any curriculum, medical schools in Canada have been teaching approximately 68% of the 20 competencies to their students. It is noted that the geriatric competencies that are addressed and the education students receive vary quite drastically depending on where one studies. At this moment, some of the best geriatric training that students receive is seeing older patients when they are on rotations in the hospital. However, Dr. Tricia Woo from McMaster University in Hamilton states that this is not enough education or exposure for the students. As a result medical students appear to be graduating from Ontario medical schools without the experience or knowledge truly needed to provide the care Canadian seniors need. This lack of understanding and experience in recent medical school graduates unfortunately perpetuates the ageism that seniors experience in the healthcare system, and until changes are made to address the issue, this pattern is likely to continue.
Dual Discrimination Against Seniors: Ageism, Hearing Loss, and LGBTQ+ Status
Despite the Human Rights Code stating that older adults have the right to access healthcare free of discrimination, it has become evidently clear that many older adults are impacted by ageism in a variety of ways when accessing health services. Ageism may interact with other forms of discrimination to make it more difficult for older adults to access health services. This is why it is essential to take an intersectional point of view when we address issues like ageism in healthcare. Namely, individuals may face dual discrimination because of their age, which languages they speak, hearing capabilities, and LGBTQ+ status. Being marginalized and facing dual discrimination may create access barrier to healthcare services in Canada.
Healthcare services, as designated by the Supreme Court of Canada, must be provided in a way that reduces barriers faced by marginalized populations. Unfortunately in Canada, there are many groups that still face barriers that make accessing healthcare services more difficult, even with the legislation from the Supreme Court. These groups of people may include older adults who are hearing impaired as well as LGBTQ+ older adults. Older adults in these groups can face increased barriers while attempting to access health services as dual discrimination becomes prominent.
Hearing Loss, Language, Ageism, and the Healthcare System
Hearing loss and languages spoken by the patient are two factors that can act alongside ageism to create access barriers for seniors in the healthcare system. One barrier that may exist for both seniors with hearing loss and those who do not speak the same language as their health care providers includes the lack of access to hospital translators and being left with no one to assist in the translation process, or having to utilize family members to translate health information between patient and provider. The lack of access to proper translators can create uncomfortable and dangerous situations for the patients involved in the situation. For example, a family member translating on behalf of the patient may become uncomfortable with sharing the patient's private medical information, and they may not provide the healthcare worker with accurate information. This type of situation may be more likely when young children are forced to translate on behalf of their parents and are uncomfortable or are unfamiliar with the health topics being discussed. There may also be circumstances where a family member acting on behalf of the patient as a translator may get confused about medical information, and they do not disclose this to the healthcare provider. In these instances, a patient or healthcare provider may not receive proper medical information, leaving the patient in a vulnerable position.
Without the provision of proper translators for older adults who experience hearing loss or face language barriers in healthcare settings, the healthcare system continues to act in a manner that does not prioritize older adults and treats them as less important than those who can receive services without extra assistance. This example of ageism acts in a manner that continuously and negatively impacts older adults and their health.
The barriers older adults who have hearing loss and language barriers face negatively contribute to their overall health. While seniors already face significant barriers as a result of ageism, hearing loss and language barriers create secondary barriers that make accessing healthcare even more difficult. Research from the Hearing Foundation of Canada demonstrated that around 10% of Canadians, or 3 million people, deal with hearing loss. When looking at the older adult population, 50% of those with hearing loss are over the age of 65. Furthermore, out of the three million Canadians who experience hearing loss, only 1 in 6 wear hearing aids. Healthcare facilities need to be able to provide accessible services to individuals of all ages, but they especially need to address and remove barriers that hearing impared older adults face. The removal of these barriers will help support the development of a healthcare field that is less ageist, and more accessible.
LGBTQ+, Ageism, and the Healthcare System
Older adults who are apart of the LGTBQ+ population also face dual discrimination in healthcare environments. This discrimination can occur in many forms, being very subtle to being very blatant. Homophobia, both conscious and unconsciously, will negatively impact LGBTQ+ older adults' experiences in healthcare settings. For example, CHJ is an older lesbian woman who is seeing a new gynecologist. This gynecologist begins to question her about her sex life - and immediately assumes that she has a husband. While the physician may not have poor intentions, the assumption of heterosexuality can create a hostile and uncomfortable environment for LGBTQ+ older adults receiving healthcare. These types of assumptions can take a severe toll on the wellbeing, both mental and physical, on older adults. Assumptions of heterosexuality in older adults may also occur from healthcare professionals due to an association of LGBTQ+ with younger individuals. These assumptions are particularly ageist and harmful, as they can be rooted in the belief that older adults do not know or understand what it means to be apart of the LGBTQ+, or that they themselves are homophobic because of their age. It is essential that healthcare providers begin to recognize their own unconscious bias against older adults and LGBTQ+, if health services are to provide safe and inclusive environments to promote health and wellbeing of all patients.
Similar to the experience of CHJ, other older LGBTQ+ individuals may expect to face discrimination and homophobia, both because of their age and their gender or sexuality, from healthcare providers. Unfortunately, this dual discrimination can create avoidance of healthcare services in LGBTQ+ populations. Furthermore, research demonstrates that many healthcare providers may lack professional education on working with older LGBTQ+ adults, which can lead to acts of ageism, as well as other forms of discrimination against particular groups within the community. For example: biphobia, transphobia, homophobia. The lack of awareness and education that healthcare providers receive on older LGBTQ+ adults is a blatant example of the dual discrimination that exist within the healthcare system, and that negatively impacts the health of older LGBTQ+ adults.
Ageism in a healthcare context is a prevalent issue that needs to be addressed to improve the health of Canadian seniors. Discourse within the healthcare system has allowed offensive and ageist terms like “bed blocker” to be used, and it has allowed healthcare providers to regularly engage in elderspeak. These discourses of ageism within the healthcare system contribute to worsening health outcomes for seniors. With an intersectional point of view, it becomes clear how marginalized senior populations face even more barriers when accessing health services, contributing negatively to their overall health, and reducing the likelihood of accessing health services in the future for fear of discrimination.
Edited by Saloni Gupta
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