A Third “Ism”: Ageism

As one of the physicians who has been in practice the longest, I am perhaps a bit oversensitive about issues related to age. Nevertheless, I recently had several annoying experiences that stimulated me to think about aging. Upon boarding a plane a short time ago, a young man offered to put my rollerboard in the overhead, something I was very capable of doing myself. While playing golf recently, I left a club on a hill near a green. The son of one of the other players offered to get it for me, implying that it would be very difficult for me to do it myself. I told him that I thought this was an “aging microaggression” and retrieved the club myself. I felt that both experiences were a bit belittling and patronizing, and they led me to think and read about ageism. Because many of the patients we deal with in structural heart disease are elderly, it seemed like a good topic for an Editor’s Page. The 3 characteristics that are most often applied to characterize individuals by society and science are race, gender, and age. While racism and gender discrimination are well recognized and publicized, less attention has been given to ageism. The term was first coined by Robert Neil Butler in 19691Butler R.N. Age-ism: another form of bigotry.Gerontologist. 1969; 9: 243-246Crossref PubMed Scopus (1007) Google Scholar and is generally defined in Wikipedia as the stereotyping or discrimination against individuals or groups on the basis of age. While agism can affect many age groups, especially very young children, it is usually expressed to the greatest extent and most associated with the elderly. Data indicate that ageism is very prevalent.2Nelson T.D. Ageism: Stereotyping and Prejudice Against Older Persons. MIT Press, 2002Crossref Google Scholar In fact, it is so common that it is often not recognized as such by those who are expressing it. A recent report found that ageism had been experienced by 93% of individuals in the United States between the ages of 50 and 80 years.3Allen J.O. Solway E. Kirch M. et al.Experiences of everyday ageism and the health of older US adults.JAMA Netw Open. 2022; 5e2217240Crossref Scopus (9) Google Scholar The fact that ageism exists at all is a bit surprising because everyone who is young will someday be elderly themselves, a condition that obviously does not apply to race or gender. The cause of ageism is uncertain but probably multifactorial. It has been argued that, as opposed to race and gender, the discrimination against age is socially acceptable. Even elderly individuals often joke about the limitations imposed by growing old. It has also been proposed that age represents a reminder of each person’s mortality and that ageism is a reaction to this reminder. Another possible contributor to ageism is the transition in society from the extended family to the nuclear family with less exposure to grandparents. All these conditions are likely amplified by the digital revolution and the divide that it has created between the young and old. Whatever the cause, it is clear that ageism is a reality and very prevalent in society. Age is a major risk factor for cardiovascular diseases, disorders which are most prevalent among the elderly. Therefore, it is not surprising that ageism is particularly relevant to the cardiovascular specialties. Given the prominence of heart valve degeneration in the field of structural heart disease, it is obvious that ageism would be an especially important potential factor there. It seems clear that, at baseline, ageism in medicine is a reflection of its state in the population in general. There is no evidence that physicians are less likely to be condescending or patronizing to the elderly. In fact, there is evidence that age-based bias permeates the education of medical students and house staff.4Stall N. Time to end ageism in medical education.CMAJ. 2012; 184: 728https://doi.org/10.1503/cmaj.112179Crossref PubMed Scopus (7) Google Scholar Microaggressions such as speaking to younger relatives rather than the patient or speaking slowly or using vocabulary that might be used for a child are not uncommon on the wards. Also similar to society in general, it appears that the medical profession is largely unaware of the ageism within its own ranks. There is evidence that the expression of ageism extends beyond just attitude to affect the manner in which health care resources are allocated.5Bowling A. Honour your father and mother: ageism in medicine.Br J Gen Pract. 2007; 57: 347-348PubMed Google Scholar Studies have reported that the elderly are less likely to receive thrombolysis or aggressive therapies for myocardial infarction, more likely to receive medical rather than surgical therapies for similar conditions, and even less likely to receive diagnostic testing such as echocardiography or lipid analysis than younger patients. The reason for this behavior is almost certainly multifactorial, and not solely due to ageism. There are obvious differences in biology between the young and the old that are major factors in clinical care, but a subtle, subconscious bias toward seniors likely also plays a role. An interesting potential aspect of ageism, and one I have not seen given much attention in prior literature, is the potential effect of such behavior by physicians to physicians. Although I am not aware of any data, I cannot see any reason why younger physicians should not harbor the same mindset toward their older colleagues as is prevalent toward older individuals throughout society. I have witnessed situations in which older physicians were given an inordinate amount of deference by younger colleagues and others in which their opinions were considered clearly passe and out of date. Both behaviors clearly seemed unwarranted. Perhaps the ultimate expression of ageism within medicine is the issue of mandatory retirement; an issue that deserves much more attention than can be given here. Suffice to say that the concept of ageism within the medical profession seems to warrant some serious investigation. There are clearly biological and lifespan aspects associated with old age that are undeniable and immutable. No one would argue against these factors being important considerations when dealing with patients. However, substantial evidence exists that a bias toward older individuals that is typically discriminatory permeates society, including medicine. This bias seems largely unrecognized by those of us who harbor it, appears to be socially acceptable, and, to some extent, seems appropriate and justified by the biological factors involved in aging. The line that divides appropriate consideration of age from an attitude and behavior that is discriminatory is probably very fine. The challenge to us in medicine, and to all of society, is to identify when that line is crossed and to ensure that such crossing is eliminated. The author has no funding to report.