Elder care as "frustrating" and "boring": Understanding the persistence of negative attitudes toward older patients among physicians-in-training

Abstract

This study explores the attitudes of physicians-in-training toward older patients. Specifically, we examine why, despite increasing exposure to geriatrics in medical school curricula, medical students and residents continue to have negative attitudes toward caring for older patients.
This study used ethnography, a technique used by anthropologists that includes participant-observation, semi-structured interviews, and facilitated group discussions. Research was conducted at two tertiary-care academic hospitals in urban Northern California, and focused on eliciting the opinions, beliefs, and practices of physicians-in-training toward geriatrics.
We found that the majority of physicians-in-training in this study expressed a mix of positive and negative views about caring for older patients. We argue that physicians-in-trainings' attitudes toward older patients are shaped by a number of heterogeneous and frequently conflicting factors, including both the formal and so-called "hidden" curricula in medical education, institutional demands on physicians to encourage speed and efficiency of care, and portrayals of the process of aging as simultaneously as a "problem" of inevitable biological decay and an opportunity for medical intervention.
Efforts to educate medical students and residents about appropriate geriatric care tend to reproduce the paradoxes and uncertainties surrounding aging in biomedicine. These ambiguities contribute to the tendency of physicians-in-training to develop moralizing attitudes about older patients and other patient groups labeled "frustrating" or "boring".

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Elder care as “frustrating”and “boring”: Understanding the persistence of
negative attitudes toward older patients among physicians-in-training
Robin T. Higashi
a,
⁎, Allison A. Tillack
a
, Michael Steinman
b
, Michael Harper
b
, C. Bree Johnston
b
a
Department of Anthropology, History, and Social Medicine, University of California, San Francisco, United States
b
San Francisco Veterans Affairs Medical Center, Department of Geriatrics, United States
article info abstract
Article history:
Received 30 March 2012
Received in revised form 7 June 2012
Accepted 25 June 2012
Objectives: This study explores the attitudes of physicians-in-training toward older patients.
Specifically, we examine why, despite increasing exposure to geriatrics in medical school
curricula, medical students and residents continue to have negative attitudes toward caring for
older patients.
Methods: This study used ethnography, a technique used by anthropologists that includes
participant-observation, semi-structured interviews, and facilitated group discussions. Research
was conducted at two tertiary-care academic hospitals in urban Northern California, and focused
on eliciting the opinions, beliefs, and practices of physicians-in-training toward geriatrics.
Results:We found that the majorityof physicians-in-trainingin this study expressed a mix of positive
and negative views about caring for older patients. We argue that physicians-in-trainings' attitudes
toward older patients are shaped by a number of heterogeneous and frequently conflicting factors,
including both the formal and so-called “hidden”curricula in medical education, institutional
demands on physicians to encourage speed and efficiency of care, and portrayals of the process of
aging as simultaneously as a “problem”of inevitable biological decay and an opportunity formedical
intervention.
Discussion: Efforts to educate medical students and residents about appropriate geriatric care tend
to reproduce the paradoxes and uncertainties surrounding aging in biomedicine. These ambiguities
contribute to the tendency of physicians-in-training to develop moralizing attitudes about older
patients and other patient groups labeled “frustrating”or “boring”.
© 2012 Elsevier Inc. All rights reserved.
Keywords:
Ageism
Medical education
Ethnograpy
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;
Journal of Aging Studies 26 (2012) 476–483
⁎Corresponding author. Tel.: +1 415 225 7616.
E-mail address: robin.higashi@gmail.com (R.T. Higashi).
0890-4065/$ –see front matter © 2012 Elsevier Inc. All rights reserved.
doi:10.1016/j.jaging.2012.06.007
Contents lists available at SciVerse ScienceDirect
Journal of Aging Studies
journal homepage: www.elsevier.com/locate/jaging

Author's personal copy
Diachun et al., 2010; Eskildsen & Flacker, 2009; Kishimoto,
Nagoshi, Williams, Masaki, & Blanchette, 2005; Perrotta,
Perkins, Schimpfhauser, & Calkins, 1981; Shue & 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, institu-
tional 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.
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, Shim,
& Russ, 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 adults (Phelan,
2010). In addition, as Estes and Binney (1989) show, the
biomedical sciences characterize aging as a pathological
process that is best understood on a cellular level. This
“biomedicalization”has had a profound impact both on
medical and popular perceptions of aging, “fostering the
tendency to view aging negatively as a process of inevitable
decline, disease, and irreversible decay”(Estes & Binney,
1989: 594, in Kaufman et al., 2004: 731). Thus, medical
interventions have largely become the primary and most
“appropriate”means to manage the “problems”of aging
(Kaufman et al., 2004).
The characterization in biomedicine of aging as pathological
decay and decline has yielded a number of “ageist”assumptions
about the care and treatment of older adults. Development of
the term itself is credited to Butler (1969), and refers to the
construction of negative, stereotyped, and dehumanizing
opinions and beliefs regarding older people (Phelan, 2010). In
societies such as the United States that put high cultural value
on youth, old age is associated with a limited or absent future
and a loss of personal identity (Phelan, 2010). Some typical
ageist beliefs include: older persons have limited sight and
hearing, have limited cognitive abilities that include poor
memory and are easily confused, are depressed or are
depressing to be around, are non-productive and rely on
“handouts”from the state, are repetitious and boring to interact
with, are lonely and isolated, and are asexual (Green, Adelman,
Charon, & Hoffman, 1986; Kaufman, 1994; Leibing, 2010).
Despite volumes of research that illustrate the importance of
assessing each patient's individual needs and capacities rather
than relying on stereotypes of aging and elderly patients when
providing care, these beliefs continue to characterize attitudes
toward older adults both in biomedicine and in society more
broadly (Adelman et al., 2007; Diachun et al., 2010; Eskildsen &
Flacker, 2009; Green et al., 1986; Kishimoto et al., 2005; Krain et
al., 2007; Leibing, 2010; Perrotta et al., 1981; Phelan, 2010; Shue
& Arnold, 2005; Thomas et al., 2003; Vincent, Tulle, & Bond,
2008).
However, recent increasing emphasis on anti-aging
research and regenerative medicine both supports and
contradicts the ageist assumptions so commonly found in
biomedicine. The “anti-aging enterprise”still character-
izes aging as a biological “problem”, yet also argues that
the processes of aging are not inevitable, but can be
slowed down or even reversed through science (Kaufman
et al., 2004; Vincent et al., 2008). Furthermore, through
advances in medical technology and practice, the age at
which certain medical interventions (for example, dial-
ysis and coronary angiography) are considered to be
appropriate, or “routine”is being steadily pushed back,
shattering notions of “natural age limits”for procedures
(Kaufman et al., 2004). Thus, Kaufman et al. conclude
that “at the same time that the relevance of age for
individual medical decision making is muted and denied
by clinicians, the urgency about age –especially the
desire to thwart its advancement by means of medical
interventions –permeates the social environment”
(2004: 736). Not fully socialized into the health care
system, physicians-in-training are both insiders and
outsiders to medical culture (Gaufberg, Batalden, Sands,
& Bell, 2010) and may struggle more acutely with the
paradoxes that characterize biomedical and social ap-
proaches to aging. Exploring how medical students and
residents both challenge and support ageist assumptions
and practices can reveal suggestions for revising ap-
proaches to aging in medical education and inform
efforts to change the professional practices of more
senior physicians.
1
We use the term “hidden curriculum”here to refer to the ritual
behaviors, assumptions, and commonly-held beliefs of physicians and
physicians-in-training (Hafferty & Franks, 1994). These behaviors, beliefs,
and practices are contrasted with the “formal”curriculum in medical
education, and are taught as students interact with older students and
instructors. Thus, it is through the hidden curriculum that students are
socialized to practice clinical medicine.
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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. Field-
work was conducted at two urban teaching hospitals in
northern California over a period of four months in 2005. A
total of ten medical teams were followed by the primary author,
each for a period of one week. A team typically consisted of: one
attending (clinical faculty member), one resident (second year
resident), one intern (first year resident), one fourth year
medical student, and one third year medical student. All
members of the team except for the attending were defined as
“physicians-in-training”and were potential study participants.
Interviews were conducted individually and observations
focused on activities in which physicians-in-training inter-
acted with other members of the medical team, namely
during rounds. Rounds consisted of going over the informa-
tion about patients gathered from the previous day (includ-
ing any physical exam findings, labs, or diagnostic or
therapeutic interventions), assessing patients' current health
status, and planning for future testing, treatment, or hospital
discharge. Rounds were observed each morning between
8:00 am and noon, and each afternoon was spent conducting
1 to 4 h of interviews and further observation.
Toward the end of each week, team members were asked to
participate in an individual, in-person interview to be con-
ducted in a private area of the hospital such as a conference
room or private office. A total of 21 formal interviews were
conducted, but the primary author observed and conversed
with all participants in more informal contexts, such as staff
meetings, or when team members were talking among one
another about certain patients. Each formal interview lasted
between 19 and 47 min; each was digitally recorded and later
transcribed. In these interviews, participants were asked if they
believed older patients, as a group, were more likely to receive
lesser care or be less enjoyable for staff to treat medically. While
the interview questions were pre-arranged, the format of the
interview was free-flowing and participants were able to
discuss related topics of concern. It should be noted that
students and residents attending the medical school associated
with the teaching hospitals where this research was conducted
had all been exposed to some kind of geriatrics-specific
training. Third and fourth year medical students had taken
part in required small-group sessions and lectures focused on
providing care to older patients, and the family medicine
clerkship in the third year contained one half-day a week of
geriatric training. Interns and residents in the internal medicine
program also had specific learning objectives and curricular
content focused on the care of older patients.
Results
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 went so far as to distinguish that it wasn't
older patients that were frustrating, per se, but rather the
characteristics that are assumed to accompany old age, e.g.
dementia, fragility, multiple chronic illnesses, and lack of
social support. Here we describe how physicians-in-training
may come to see caring for older patients as “frustrating”or
“boring”, and how ageist assumptions and messages, as part
of the clinical culture, affect participants' attitudes toward
care of older patients.
Generally speaking, older patients were assumed by study
participants to be inherently end of life patients. A fourth year
student admitted that, even before assessing an older patient's
condition, “I make more of an effort to get their code status [the
degree of resuscitation, if any, that patients want if they stop
breathing or go into cardiac arrest] and who will speak on their
behalf earlier.”In situations where an older patient was indeed
in the terminal stage of an illness, several participants seemed
surprised, and sometimes frustrated, when an older patient
wished to continue pursuing all possible treatment avenues,
instead of being transitioned to palliative care. “People assume
that they would not want to be full code or they assume that
they wouldn't want aggressive surgery. And you'd be surprised
what 80-something year olds are willing to go through.”Other
participants felt similarly, saying older patients“lived a full life”
and should “spend the rest of their time with family”(see
Kaufman, 2005 for an in-depth discussion of aging and end of
life care).
On one particularly memorable occasion, the primary author
witnessed a conversation among several physicians-in-training
in response to 2 different patients with very poor prognoses. One
was a 42-year old patient newly diagnosed with end-stage
pancreatic cancer, the other was an 84-year old patient with
end-stage lung cancer. When discussing the 42‐year old patient,
several team members expressed sympathy in visible ways: one
raised her eyebrows, one shook his head, and two others
verbalized notes of sadness. Comments were made about the
42-year old patient missing key life moments with his children
(two under the age of 12), and the word “tragic”was used more
than once. In contrast, none of the participants used the word
“tragic”when speaking of the 84-year old patient, and none
mentioned the patient's children or their ages.
Many participants also admitted that all older patients
are often assumed to be cognitively compromised at some
level. A fourth year student commented, “a lot of times
people make assumptions that someone is demented”,
and so sometimes staff “talk about their condition in front
of them without addressing them, and I think we do that
with a lot of patients.”Similarly, an intern explained,
“Sometimes people don't talk as much to older
patients as they would to a younger patient. People
don't explain as much to them, they kind of more just
reassure and tell them they're going to be OK and don't
explain the details of their illness. And sometimes
that's totally appropriate…but other times I think they
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want to know and they're sharp and they could
understand it and they're not really given the chance.”
Even older patients whose cognitive impairment is
confirmed are at risk of receiving lesser care. Another intern
reflected on why this might be the case.
“A lot of older patients are what we could traditionally call
‘poor historians’. So someone who's 85 comes in…and
can't recall his symptoms or when things started or the
precise characteristics of what's going on, and for a
physician that can be really frustrating. And I think there's
a certain amount of discrimination going on that those
patients may not get as good care as someone that comes
in with a similar problem who's 10–15 years younger, and
can describe the problem well and establish a better
rapport with the physician.”
Another assumption that may negatively affect the care of
older patients is that they are perceived to have a lot of
medical problems, most of which will not be resolved no
matter how much medical attention they receive. As one
intern said, “working with elderly patients can get frustrat-
ing…often times there's not a lot you can do.”A resident
stated more explicitly,
“It's always a bigger save when you help a 35 year old
woman with 2 kids than it is to bring an altered 89 year
old with a UTI [urinary tract infection] back to her semi-
altered state. So from that regard, it's a little bit less
rewarding.”Later in the interview he states, “It's hard to
admit somebody, fix one of their 22 problems, probably
their least significant problem, and then send them back.
That's not rewarding…Maybe you rehydrate someone
who's dehydrated or you give them some anti-nauseals
since they're vomiting…You've made them feel better in
the moment, but in the grand scheme of things, it doesn't
feel like you've done much, so it's frustrating for me.”
A fourth year student voiced similar frustrations by
stating, “[doctors] assume that when an old person comes
in there's going to be a ton of problems and it's going to be a
pain to address all of those issues.”Responding to a question
about whether she received negative messages from her
colleagues about nursing home patients, she said, “Our gut
reaction is when you hear that [a patient is from a nursing
home] you cringe a little. It's not that you're speaking
negatively about them, it's just that you know that generally
they have a lot of medical problems and that's why they're in
the nursing home. So while I can't guarantee that it doesn't
affect their care –I'm hoping it doesn't –I'd like to think we
give good care to everyone.”
In response to the same question, a resident said that
older patients, and especially patients from nursing homes,
have “complicated histories. They're considered to be more
potential for disaster.”Thus, in addition to feeling frustrated
by the fact that the patient's problems can't be resolved, she
felt additional frustration and anxiety from the possibility
that she might miss a problem.
Another assumption commonly voiced among participants
was that older patients were more “needy”in a way that made
interactions slow and frustrating. Several participants felt that
interactions with older patients took more time and felt less
productive. For example, participants said that they often had to
repeat themselves and speak more slowly, and that older
patients took longer to “get the words out”, wanted to talk a
long time about unrelated things, and sometimes complained
about things that participants felt were petty or irrelevant. As
one intern put it,
“Eventually you have to disengage and just leave the
room, even if they have five other complaints they
wanted to talk to you about, like the food wasn't good,
the nurse kept waking them up in the middle of the night
to take their blood pressure and they didn't like that, and
they think their home medication is a little bit different
from this…[in a diminutive voice, acting like he's the
patient] they're the blue ones, you know, a little bit bigger,
you know they're kinda like this shape.”In sum, the intern
says, “I'd like to be able to talk to people all day, but when
you have seven other people to see, you don't care if the
little blue pill is this big or this shaped or what.”
One resident felt especially frustrated with older patients.
“They are just very tangential and happy to have someone
around to chat with, and I don't have a ton of time for that.
And I also sometimes don't have patience for it.”He described
them as “not particularly interesting”, and felt less rewarded
by interactions with them because he was typically only able
to “fix”a couple of minor problems, while there was usually
little that he could do to resolve their underlying major
medical issues. For this resident, and a few other participants,
the likelihood that a patient could be restored to a state of
robust health was a significant motivator to spend time and
energy with that patient. Thus, resolving a urinary tract
infection in a patient with heart failure, kidney failure and
dementia felt unsatisfying as compared to, for example,
finding a tumor in an otherwise healthy patient who, as a
result of early diagnosis, stood a good chance of making a full
recovery, a scenario more likely to be encountered in
younger patients.
As these narratives reflect, many participants felt that it
was more rewarding to “cure”than it was to “care”for a
patient. One fourth year medical student commented, “The
whole thing about ‘curing’a patient, or doing everything you
can for a patient —that kind of gets thrown out the window
when you realize you work within a system and you have
limitations on what you can do. So you just learn what you
can do for the patient at this time [original emphasis].”
Others expressed their frustration more bluntly, saying they
perceived geriatric care as primarily involving low-level medical
maintenance, which they felt was “nurse's work”or “social
work”, and that they “didn't go to medical school for four years
to do this.”As one intern commented, “It gets frustrating when
it feels like you're doing a lot of social work but you're not
helping anybody. You feel like you're not doing anything for
them in the long term.”Note that in this quote, “helping”people
is equated with making significant health interventions, and less
with providing routine, basic care.
Some participants' comments revealed that their frustration
stemmed less from the patients themselves than it did from the
recognition that patients with progressive or chronic illnesses,
especially as they were older, simply did not have a lot of
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alternatives for better care within the health care system. One
intern commented that it was common for older patients to not
have enough social and economic support, which left him
helpless to set up better, more continuous care outside the
hospital. “It's hard when you don't necessarily have a great plan
for them when they leave the hospital…It's a sense of
disappointment in oneself and the system in not being able to
provide a better outcome.”
As these narratives show, the physicians-in-training in
this study tended to view both older patients and geriatric
care with frustration, a feeling of disappointment at the lack
of help they could offer, and with a broad characterization of
geriatric patients as somehow “less interesting”than others.
However, most students recognized that their ability to care
for this patient population was hampered by the health care
system, which attempts to provide medical solutions to what
are often social problems.
Resisting ageist assumptions
While many study participants expressed ageist assump-
tions and negative feelings about older patients, some
participants felt more positive and more competent about
the care they provided to the aged, and felt especially
rewarded and appreciated by them. One resident reflected
on her experiences with older patients, saying,
“I feel like I've had a really positive experience and am
feeling more positive about geriatrics from my training…
Two of my patients, one is 81 and one is 74, just dealing
with their chronic illnesses and talking about what's going
to happen in the future, about fall risks, social supports,
their home life –I just really enjoy that, and I feel more
and more comfortable…I've been thinking about it more –
how comfortable I feel as their doctor, and they listen to
me. And my patient yesterday, the 81 year old, he said,
‘you know, you really take care of me, you really take care
of me’[subject smiled], and I was like yeah, I know how to
do it, I know what to tell him and what to help him with…
It was nice.”
When asked what she learned from her older patients,
one intern seemed more empathetic and understanding of
their behaviors that typically frustrated her colleagues.
“They're so used to routines that being in the hospital is
really hard on them [original emphasis]…it takes them
out of anything they know that's normal and it kind of
takes away their feeling of control…Younger people are
more adaptable, can vary their schedule day by day. But
older people are more likely to get up at the exact same
time and eat at the exact same time and go to the same
restaurant, and have their routine. And they know
which pill they're taking at which time of day, and
suddenly they're in the hospital and they don't have
control over their medications, they don't have control
over their meal times, nothing around them is familiar,
and I think they're a lot more likely to get confused and
upset. And so I think I've learned it's good to reorient
them as much as possible and that's just something to
think about, especially if patients get hostile some-
times, to sort of give them the benefit of the doubt
because it's a lot harder for them than it would be for
me or someone else my age.”
Despite this intern's assumption that older people are less
flexible and more reliant on routines than other adults (a
common misperception discussed by Leibing, 2010), it is
clear that rather than being annoyed or frustrated, this
physician-in-training tried to understand and address the
special needs senior patients in the hospital might have.
Other participants felt that their young age (most
physicians in training being in their mid to late 20s) was
less of a problem for older patients as it was for younger and
middle aged patients. One resident speculated that perhaps
this was because “everyone seems young to them so they
actually don't mind it as much. Or maybe they're used to
being treated by people who are younger than them…It's
been less of a barrier.”One intern appreciated that older
patients tended to treat physicians in training with greater
respect as professionals, whereas younger patients typically
questioned their assessments. “When I take care of a 30-year
old patient, and I'm a 26-year old doc, they're like ‘oh you're
the resident’[using a dismissive tone].”But with older
patients, “even if you're a medical student, if you're taking
care of them then you're the doc. They'll listen to you…Older
people have that ‘you're the doctor’kind of attitude.”Other
participants agreed that older patients tended to have a
different idea of the doctor's role, and were more likely to
defer to the doctor's opinion in decision-making. This
deference, however, could sometimes be a liability for older
patients if the staff did not adequately take the time to
explain all options and ramifications as they would for
someone who was known to ask questions or question the
staff's assessments. In fact, one participant told us that his
attending specifically instructed him to review all the options
on two or three separate occasions with older patients in
order to avoid a potential misunderstanding and make sure
that the elected course of action was truly what the patient
wanted.
Another trainee remarked that her family medicine
clerkship helped her prepare to take care of older patients
in the hospital, saying that initially,
“I felt really intimidated by older patients because they're so
complex and are usually on a whole bunch of drugs and have
a lot of different medical problems. But then in my family
medicine clerkship, we had one day every week that was
dedicated to learning about geriatrics, and we'd learn about
things like how long-term care insurance works, and how the
Medicare and Medicaid systems work, and figuring out how
to pay for home care, and stuff like that. And we'd make home
visits with the geriatrician, and see how seniors live outside
the hospital, and meet families that were caring for an older
relative and find out about their problems. So when I did my
medicine clerkship a few months later, I was much more
comfortable with older patients and felt like I could actually
suggest ways to make their care better inside the hospital and
when they were discharged.”
In this instance, the view that characterizes elderly patients
as “frustrating”or “less worthy of care”and geriatrics as a
discipline as “boring”is challenged by the formal medical school
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curriculum. This curriculum exposes students to geriatrics and
focuses on educating them about the challenges seniors can face
as well as providing them with knowledge of the medical and
bureaucratic systems that seniors and their caretakers must
navigate. Home visits enabled students to see the aged in the
broader context of life outside the hospital, and encounter them
in situations other than acute illness.
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 student physicians. Similarly,
study participants expressed that they were both bored and
challenged by geriatric care overall, characterizing the
discipline as less rewarding than ‘regular’medicine because
it involved “more social work than actual medical care.”At
the same time, participants expressed frustration about the
difficulty of achieving geriatric goals of care in a system that
values efficiency of practice and ‘cure’rather than ‘care.’
Interestingly, however, the physicians-in-training we
talked to and observed did not draw clear distinctions
between frustrating patients and frustrating care. Instead,
opinions about the challenges and rewards of caring for older
patients were intertwined with perceptions of the positives
and negatives of geriatric care as a whole. This is significant,
as generalizations of geriatric care as uninteresting could
then lead to assumptions that all elderly patients are
uninteresting, and vice versa. Indeed, this finding was
echoed more broadly in the research project overall. We
found that, for many groups of patients characterized by
physicians-in-training as ‘frustrating,’including the elderly
but also substance abusers and the homeless, certain
individual traits quickly became generalizations that impact-
ed participants' overall perceptions of and approaches to
subsequent individuals in “frustrating”patient groups. While
it is understandable that physicians-in-training would learn
to anticipate certain commonly shared characteristics of
medical pertinence (e.g. older patients are typically on
over a dozen medications), this study demonstrates that
physicians-in-training adopt moral pre-judgments about
certain categories of patients as well, and that this may be
negatively impacting attitudes and approaches toward older
patients.
As this study demonstrates, complex and often conflicting
attitudes by physicians-in-training toward older patients
result from a number of heterogeneous and paradoxical
conceptualizations of and approaches toward aging within
medical education, the requirements of health care institu-
tions, and society more broadly. One source of ambiguity and
confusion for physicians-in-training can be found by exam-
ining the approach to aging within many ‘formal’medical
education curricula. While some geriatrics-specific course
content stress views of older adults as active, productive
members of the community that have much the same needs,
questions, and concerns as younger patients, other course
content portrays patients of older age as more “complex”and
“dependent”and requiring distinct and specialized knowl-
edge, skills, and approaches (e.g. Diachun et al., 2010;
Kishimoto et al., 2005; Shue & Arnold, 2005; Thomas et al.,
2003). Indeed, as Kaufman points out in her examination of
geriatric assessment, “geriatric medicine defines old age as
normal and nonpathological yet ironically stakes its identity
on the claim that old people are best served by specialists
trained to view them as separate from other adults (i.e., not
normal) with different problems and medical needs”
(Kaufman, 1994: 431).
Furthermore, as noted above, the dominant biomedical
discourse on aging characterizes it as a biological process
involving disease and decay where older patients are
assumed to be inherently “end of life”patients. Many of our
interviews with physicians-in-training reflected this per-
ceived link between aging and death. The frequent pairing of
geriatric courses with units on palliative care and dying in
medical curricula may help to reaffirm this view (e.g.,
Eskildsen & Flacker, 2009). Similarly, while medical curricula
often have lectures or small group activities focused on
defining ageist assumptions and illustrating how these
assumptions can negatively impact care, these learning
goals are often contradicted by the use of case studies
focusing on “typical”complaints of older patients, such as
issues of continence, depression, or dementia (e.g. Adelman
et al., 2007; Eskildsen & Flacker, 2009).
While efforts are ongoing to revise medical school formal
curricula to improve students' perceptions of and approach
to geriatric care, the “hidden”or informal curriculum remains
a powerful influence on how physicians-in-training learn to
practice medicine and form opinions about different types of
patients (e.g., Cribb & Bignold, 1999; Gaufberg et al., 2010;
Hafferty & Franks, 1994; Lempp & Seale, 2004). Research has
shown the importance of the attitudes and behaviors of
senior physicians on shaping how physicians-in-training
perceive certain tasks, types of patients, or goals; for
example, Diachun et al. found that “teachers' biases regarding
the importance of geriatric education can negatively affect
students' interest in geriatric course content”(2010: 1222).
In addition, Hafferty and Franks show that even before
medical students begin classes, “acceptees arrive for their
first classes with rather well-defined ideas about what
constitutes meaningful medical intervention (“treatment”)
and what clinical activities (“maintenance”) are less highly
valued within the culture of medicine”(1994: 865).
As the above narratives illustrate, many study participants
viewed older patients as requiring more time and effort to care
for, and that care more frequently involved “maintenance”rather
than “cure”— all things that directly conflict with the hidden
curriculum's emphasis on efficiency, detachment, and the lesser
“value”of routine care. Yet, these physicians-in-training also
acknowledged the potential benefits of working with older
patients, including a higher level of respect for students, “nicer”
interactions, appreciation of the care team's efforts, and
increased adherence to physician instructions. Interestingly,
however, physicians-in-training were also quick to recognize
that the institutional requirements of the health care system
often overshadowed efforts to provide quality and appropriate
geriatric care. The difficulty of caring for older patients in the
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“real world”emerged as a frequent source of frustration for our
participants.
One of the main priorities of hospitals is to “move things
along”; that is, to limit the length of patient stays in the
hospital and encourage physicians to discharge patients as
soon as possible (Kaufman, 2005). However, the current
model of appropriate care for older patients requires
in-depth coordination with family members, consulting
physicians, and other kinds of care providers (PT, social
workers, in-home help, etc.). Not only does the institutional
requirement to “move things along”severely limit physi-
cians' time and ability to make these kinds of arrangements,
but also the current system of hospital reimbursement does
not reimburse or incentivize for this kind of coordination
(Thomas et al., 2003). As Thomas et al. point out, the “lack of
appropriate reimbursement clearly influences physicians'
attitudes toward caring for older patients; affects the ability
of physicians to model appropriate geriatric care to residents;
and contributes to the high rate of specialist referral for
geriatric patients, even when internists know the best
practice”(Thomas et al., 2003: 631). In this instance, it is
clear how the structure and organization of medical in-
stitutions can impact not only physicians' behaviors, but also
encourage the modeling of less-than-optimal attitudes and
behaviors toward specific patient groups. As we have argued,
such practices and approaches are an important influence on
physicians-in-training as they learn how to provide care, and,
as one resident told us, “to learn which corners are ok to cut.”
Yet, in addition to being influenced by the formal and
informal curricula of medical education and the institutional
demands of the health care system to “move things along”, the
knowledge and attitudes of physicians-in-training toward
geriatric care are also constructed through ever-changing
interactions with communities and organizations beyond the
medical sphere. As Kaufman et al. point out, the biomedicaliza-
tion of aging and the increasing popularity of regenerative
medicine have resulted in an ambiguous and uncertain
discourse in U. S. society where “the aged body tends to be
viewed now as simultaneously a diseased entity, a site for
restoration, and a space for improvement”(2004: 736). Thus,
physicians and physicians-in-training are at the same time
presented with cultural discourses that view chronologic age as
irrelevant when considering medical intervention and the view
that older patients are inherently “end of life”patients.
Furthermore, despite the efforts of some geriatricians and
aging experts, older individuals continue to be marginalized by
society and associated with economic, social, and physical
dependency (Phelan, 2010). These wider cultural trends (that
are constantly shifting) both shape and are shaped by
biomedicine.
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
medical system that shape students' approaches to older
patients. Efforts to educate medical students and residents
about appropriate geriatric care tend to reproduce these
paradoxes and uncertainties, which then contributes to the
tendency of physicians-in-training to develop moralizing atti-
tudes about older patients and other patient groups labeled
“frustrating”or “boring”.
Yet, students are not simply passive recipients of medical
curricula (whether formal or hidden) but are active agents,
“pushing back against and transforming the structure, even
as they operate within its constraints”(Davenport, 2000:
324; Good, 1994). In addition, educators cannot examine or
alter the hidden or formal curricula of medicine in isolation
from one another. As Hafferty and Levinson (2008) rightly
point out, medical schools are complex systems where
multiple learning environments interact and influence one
another. “Thus,”they write, “the learning that takes place in
the classroom or at the bedside is shaped by what takes place
within the formal social interactions among and between
faculty and students…and vice versa”(Hafferty & Levinson,
2008: 609). Like other kinds of learning, medical student
training is dynamic, interactive, and interdependent, and
educators should be aware that efforts to change one part of
the curriculum will impact other parts as well.
Therefore, as the medical education system continues to try
and prepare physicians-in-training to meet the needs of an
expanding population of older patients, it is important to
acknowledge that curricular changes must go beyond simply
adding lectures on geriatric topics or encouraging physicians-
in-training to develop new skills. As these narratives of
physicians-in-training show, efforts to change behaviors or
attitudes must, as Thomas et al. point out, be achievable in
clinical practice (2003).
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].
References
Adelman, R. D., Capello, C. F., LoFaso, V., Greene, M. G., Konopasek, L., &
Marzuk, P. M. (2007). Introduction to the older patient: A “first
exposure”to geriatrics for medical students. Journal of the American
Geriatrics Society,55, 1445–1450.
Association of American Medical Colleges (2007). Geriatric competencies for
medical students: recommendations of the July 2007 geriatrics consen-
sus conference [on-line]. Available at http://www.aamc.org/newsroom/
presskits/competencies.pdf Accessed October 11, 2011.
Butler, R. (1969). Ageism: Another form of bigotry. The Gerontologist,9,
243–246.
Cribb, A., & Bignold, S. (1999). Towards the reflexive medical school: The
hidden curriculum and medical education research. Studies in Higher
Education,24, 195–209.
Davenport, B. A. (2000). Witnessing and the medical gaze: How medical
students learn to see at a free clinic for the homeless. Medical Anthropology
Quarterly,14(3), 310–327.
Diachun, L., Van Bussel, L., Hansen, K. T., Charise, A., & Rieder, M. J. (2010). “But
I see old people everywhere”: Dispelling the myth that eldercare is
learned in nongeriatric clerkships. Academic Medicine,85(5), 1221–1228.
482 R.T. Higashi et al. / Journal of Aging Studies 26 (2012) 476–483

Author's personal copy
Eskildsen, M. A., & Flacker, J. (2009). A multimodal aging and dying course
for first-year medical students improves knowledge and attitudes.
Journal of the American Geriatrics Society,57, 1492–1497.
Estes, C. L., & Binney, E. A. (1989). The biomedicalization of aging: Dangers
and dilemmas. The Gerontologist,29, 587–597.
Gaufberg, E. H., Batalden, M., Sands, R., & Bell, S. K. (2010). The hidden
curriculum: What can we learn from third-year medical student
narrative reflections? Academic Medicine,85(11), 1709–1716.
Good, B. J. (1994). Medicine, rationality, and experience: An anthropological
perspective. Cambridge: Cambridge University Press.
Green, M. G., Adelman, R., Charon, R., & Hoffman, S. (1986). Ageism in the
medical encounter: An exploratory study of the doctor–elderly patient
relationship. Language & Communication,6(1/2), 113–124.
Hafferty, F., & Franks, R. (1994). The hidden curriculum, ethics, teaching and
the structure of medical education. Academic Medicine,69, 861–871.
Hafferty, F., & Levinson, D. (2008). Moving beyond nostalgia and motives
towards a complexity science view of medical professionalism. Perspec-
tives in Biology and Medicine,51(4), 599–615.
Kaufman, S. R. (1994). Old age, disease, and the discourse on risk: Geriatric
assessment in U. S. health care. Medical Anthropology Quarterly,8(4),
430–447.
Kaufman, S. R. (2005). …And a time to die: How American hospitals shape the
end of life. Chicago: University of Chicago Press.
Kaufman, S. R., Shim, J. K., & Russ, A. J. (2004). Revisiting the biomedicalization of
aging: Clinical trends and ethical challenges. The Gerontologist,44(6),
731–738.
Kirchheimer, B. (2008). A gray tsunami cometh. Long-term care is challenged
by the onslaught of the baby boomers, but concern is muted by lack of
immediacy. Modern Healthcare,38, 22–23.
Kishimoto, M., Nagoshi, M., Williams, S., Masaki, K. H., & Blanchette, P. L.
(2005). Knowledge and attitudes about geriatrics of medical students,
internal medicine residents, and geriatric medicine fellows. Journal of the
American Geriatric Society,53, 99–102.
Krain, L. P., Fitzgerald, J. T., Halter, J. B., & Williams, B. C. (2007). Geriatrics
attitudes and knowledge among surgical and medical subspecialty
house officers. Journal of the American Geriatrics Society,55, 2056–2060.
Leibing, A. (2010). Inverting compliance, increasing concerns: Aging, mental
health, and caring for a trustful patient. Anthropology & Medicine,17(2),
145–158.
Lempp, H., & Seale, C. (2004). The hidden curriculum in undergraduate
medical education: Qualitative study of medical students' perceptions of
teaching. British Medical Journal,329, 770–773.
Perrotta, P., Perkins, D., Schimpfhauser, F., & Calkins, E. (1981). Medical
student attitudes toward geriatric medicine and patients. Journal of
Medical Education,56, 478–483.
Phelan, A. (2010). Socially constructing older people: Examining discourses
which can shape nurses' understanding and practice. Journal of Advanced
Nursing,67(4), 893–903.
Shue, C. K., & Arnold, L. (2005). Changing medical students' attitudes about
older adults and future older patients. Academic Medicine,80(10 Suppl.),
S6–S9.
Thomas, D. C., Leipzig, R. M., Smith, L. G., Dunn, K., Sullivan, G., & Callahan, E.
(2003). Improving geriatrics training in internal medicine residency
programs: Best practices and sustainable solutions. Annals of Internal
Medicine,139, 628–634.
Vincent, J. A., Tulle, E., & Bond, J. (2008). The anti-aging enterprise: Science,
knowledge, expertise, rhetoric and values. Journal of Aging Studies,22,
291–294.
483R.T. Higashi et al. / Journal of Aging Studies 26 (2012) 476–483