[Senate Hearing 108-124]
[From the U.S. Government Publishing Office]
S. Hrg. 108-124
AGEISM IN THE HEALTH CARE SYSTEM:
SHORT SHRIFTING SENIORS?
=======================================================================
HEARING
before the
SPECIAL COMMITTEE ON AGING
UNITED STATES SENATE
ONE HUNDRED EIGHTH CONGRESS
FIRST SESSION
__________
WASHINGTON, DC
__________
MAY 19, 2003
__________
Serial No. 108-10
Printed for the use of the Special Committee on Aging
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WASHINGTON : 2003
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SPECIAL COMMITTEE ON AGING
LARRY CRAIG, Idaho, Chairman
RICHARD SHELBY, Alabama JOHN B. BREAUX, Louisiana, Ranking
SUSAN COLLINS, Maine Member
MIKE ENZI, Wyoming HARRY REID, Nevada
GORDON SMITH, Oregon HERB KOHL, Wisconsin
JAMES M. TALENT, Missouri JAMES M. JEFFORDS, Vermont
PETER G. FITZGERALD, Illinois RUSSELL D. FEINGOLD, Wisconsin
ORRIN G. HATCH, Utah RON WYDEN, Oregon
ELIZABETH DOLE, North Carolina BLANCHE L. LINCOLN, Arkansas
TED STEVENS, Alaska EVAN BAYH, Indiana
RICK SANTORUM, Pennsylvania THOMAS R. CARPER, Delaware
DEBBIE STABENOW, Michigan
Lupe Wissel, Staff Director
Michelle Easton, Ranking Member Staff Director
(ii)
C O N T E N T S
----------
Page
Opening Statement of Senator John Breaux......................... 1
Statement of Senator Ron Wyden................................... 4
Panel of Witnesses
William Faxon Payne, M.D., Retired Radiologist, Nashville, TN.... 5
Rabbi Zalman Gerber, Philadelphia, PA............................ 10
Daniel Perry, Executive Director, Alliance for Aging Research,
Washington, DC................................................. 14
James S. Marks, M.D., Director, National Center for Chronic
Disease Prevention and Health Promotion, Centers for Disease
Control and Prevention, U.S. Department of Health and Human
Services, Washington, DC....................................... 21
Robert N. Butler, M.D., President and CEO, International
Longevity Center-USA........................................... 40
Joel E. Streim, M.D., President, American Association for
Geriatric Psychiatry........................................... 47
APPENDIX
Testimony submitted by Henry Tomes, Ph.D., Executive Director,
Public Interest Directorate, of the American Psychological
Association (APA).............................................. 65
Toby S. Edelman, Center for Medicare Advocacy, Healthcare Rights
Project, Washington, DC........................................ 67
(iii)
AGEISM IN THE HEALTH CARE SYSTEM: SHORT SHRIFTING SENIORS?
---------- --
MONDAY, MAY 19, 2003
U.S. Senate,
Special Committee on Aging,
Washington, DC.
The Committee met, pursuant to notice, at 2 p.m., in room
SD-628, Dirksen Senate Office Building, Hon. John Breaux,
presiding.
Present: Senators Breaux, Dole, and Wyden.
The Chairman. The Committee will please come to order. I
thank all of our guests for being with us, and Senator Dole as
well.
OPENING STATEMENT OF SENATOR JOHN BREAUX, CHAIRMAN
The Special Committee on Aging is special in a sense, that
it also sometimes alternates between the chairmen of the
committee, and this may be the only committee in the U.S.
Senate where you have a Democrat chairing a committee today. So
we kind of alternate because it's really nonpartisan.
I think the committee has a very unique responsibility in
defending America's seniors. As we all prepare for the pending
wave of 77 million aging ``baby boomers'', our responsibility
is to help our country rethink and really to redefine so many
of the ways we think about growing older in this country.
Outdated thinking about aging leads to outdated public
policies, and also public health risk. Today's hearing is
important not just because seniors are falling through the
cracks in our health care system, but because it serves as a
brutal reminder of how ageism is presented in our country. We
must, in my opinion, rethink our attitudes and policies toward
the elderly.
Too many people assume that since seniors have Medicare,
their own health care system, that their health care needs are
being adequately met. I have said time and again that Medicare
is broken. In addition to the antiquated nature of the program,
the system designed to care for our seniors also discriminates
against them. Part of this discrimination is due to the lack of
doctors, pharmacists, physical therapists, or mental health
professionals who are trained in geriatrics.
But another reason is the underlying age bias in modern
medicine. We all know the stereotypes about seniors that say,
``well, they're difficult'' or ``they're all going to die
anyway'' or ``they're all a bunch of old geezers.'' This
afternoon we're going to explore that ageism bias in health
care, or as I refer to it as ``medical ageism''. Across the
spectrum of the United States health care system is a potential
to save more lives, to save millions in health care dollars,
increase access to better health care, and also to improve the
quality of life of seniors by removing the systematic bias from
our health care system.
This Committee has looked at the entire health care system
and identified specific areas where medical ageism exists: in
mental health, in preventative health screenings, in clinical
trials, and in treatment for hospital-borne infections. For
example, cancer continues to be the second leading cause of
death. Nearly 80 percent of all cancers are diagnosed at ages
55 and older. Yet most people do not receive the screening
tests that they should. In fact, only one in ten seniors are
up-to-date in their preventative Medicare screenings. In
contrast, 95 percent of 5 year olds are up-to-date on their
immunizations because we conduct immunization programs and run
major public awareness campaigns. Why not try to get something
similar done for our seniors?
While the Food and Drug Administration, the FDA, now
mandates that children be included in clinical trials for new
prescription drugs, seniors are almost always left out. This is
ironic because the average 75-year-old has three chronic
medical conditions and regularly uses about five prescription
drugs. Changes with aging can also alter how the body
metabolizes, absorbs and clears these drugs from the body.
Though much progress has been made to eradicate the stigma
and the shame of mental illness, seniors have also been left
behind in this area. Older Americans have the highest suicide
rate in our country, a rate four times the national average.
Many assume that symptoms of depression are a part of the
normal aging process, but they are not. In fact, over 70
percent of suicide victims saw their doctor within 1 month of
their suicide. They were not treated or referred for treatment
for their depression. Our health care system simply failed
them.
We found age bias in so many aspects of our health care
system that this hearing can really not address all of them.
Today is just a beginning. We plan to further investigate areas
where medical ageism exists and to use this committee to
highlight these areas over the next few months.
Now, today I learned of a terrible case of an elderly woman
in my State of Louisiana who died from oral neglect. Why?
Because no one bothered to look into her mouth. Gum disease is
treatable, not a death sentence for the elderly. I was
astonished to learn of numerous other egregious cases just like
this one. Apparently, many do not see dental care for the
elderly as a priority. Again, one questions why we should
bother with trivial things like dental cleaning. Cleaning is
too late for seniors. Oral disease can seriously compromise the
general health of seniors and place them at increased risk for
infection.
[The prepared statement of Senator John Breaux follows:]
Prepared Statement of Senator John Breaux
I believe this Committee has the unique responsibility to
defend America's seniors. As we prepare for the pending wave of
77 million aging baby boomers, our responsibility is to help
this country re-think and re-define how we age. Outdated
thinking about aging leads to outdated public policies and
public health risks. Today's hearing is important, not just
because seniors are falling through the cracks in our health
care system, but because it serves as a brutal reminder of just
how present ageism is in our country. We must rethink our
attitudes and policies toward the elderly.
Too many people assume that since seniors have Medicare--
their own health care system--their health care needs are being
met. I have said time and again that Medicare is broken. In
addition to the antiquated nature of the program, the system
designed to care for our seniors also discriminates against
them. Part of this discrimination is due to the lack of
doctors, pharmacists, physical therapists or mental health
professionals trained in geriatrics, but another reason is the
underlying age bias in modern medicine. We all know the
stereotypes about seniors, that, ``They're difficult.''
``They're going to die anyway.'' ``Old geezers.''
This afternoon we're going to explore the ageism bias in
health care or, as I refer to it, ``medical ageism.'' Across
the spectrum of the U.S. health care system is a potential to
save more lives, save millions in health care dollars, increase
access to better health care and to improve the quality of life
of seniors by removing this systemic bias from our health care
system. This Committee has looked at the entire health care
system and identified specific areas where medical ageism
exists--in mental health, preventive health screenings,
clinical trials, and treatment for hospital-bourne infections.
For example, cancer continues to be the second leading
cause of death. Nearly 80 percent of all cancers are diagnosed
at ages 55 and older, yet most people do not receive the
screening tests they should. In fact, only one in ten seniors
are up to date in their preventive Medicare screenings. In
contrast, 95 percent of five year-olds are up-to date on their
immunizations because we conduct immunization programs and run
major public awareness campaigns. Why not try something similar
for seniors?
While the FDA now mandates children be included in clinical
trials for new prescription drugs, seniors are almost always
left out. This is ironic because the average 75-year old has
three chronic medical conditions and regularly uses about five
prescription drugs. Changes with aging can also alter how the
body metabolizes, absorbs and clears these drugs from the body.
Though much progress has been made to eradicate the stigma
and shame of mental illness, seniors have been left behind.
Older Americans have the highest suicide rate in America--a
rate four times the national average. Many assume that symptoms
of depression are a part of the normal aging process, but they
are not. In fact, over 70 percent of suicide victims saw their
doctor within one month of their suicide, but were not treated
or referred for treatment for their depression. Our health care
system simply failed them.
We found an age bias in so many aspects of our health care
system, that this hearing can not address it all. Today is just
the beginning. I plan to further investigate areas where
medical ageism exists and to use this Committee to highlight
these areas over the next few months.
Just the other day, I learned of a terrible case of an
elderly woman in Louisiana who died from oral neglect. Why?
Because no one bothered to look in her mouth. Gum disease is
treatable--not a death sentence for the elderly. I was
astonished to learn of numerous other egregious cases just like
this. Apparently, many do not see dental care for elderly as a
priority. Again, many question why we should bother with
trivial things like a dental cleaning, claiming it is too late
for seniors. But oral disease can seriously compromise the
general health of seniors and place them at increased risk for
infection.
I want to thank our witnesses for being here today and I
look forward to their testimony.
I want to now ask if she has any opening comments, Senator
Dole, our distinguished colleague from North Carolina.
Senator Dole. Senator Breaux, thank you very much for your
leadership in chairing the hearing today.
I do not have an opening statement, except to say, ``How
much I look forward to hearing the testimony of our panel
today,'' because my interest in these issues dates back
throughout my career in public service to my days on the
Federal Trade Commission, when I led several investigations at
that time, and because this week, my own dear mother celebrates
her 102d birthday. So I look forward to your testimony today.
Thank you.
The Chairman. Thank you, Senator Dole.
Senator Wyden, any comments?
STATEMENT OF SENATOR RON WYDEN
Senator Wyden. Thank you, Mr. Chairman. I am very pleased
that you're continuing these hearings and it's good to have
some old friends and passionate advocates, before us today
particularly Dr. Butler, who years ago was crying out in the
wilderness that our country get serious about these issues.
Like Senator Dole, I really come at these issues from
personal experience. For a number of years, I was Director of
the Gray Panthers before I was elected to Congress, so I have
taken a special interest in these concerns.
I believe that ageism is an immoral stain that cheapens our
country's health care system, and it's time to get some fresh
policies that wipe it out. Let me be specific about what I'm
especially concerned about, and that is something that Dr.
Butler has written about for years.
I think it really starts with medical education for so many
of the practitioners in the field. I remember years ago, when I
ran the legal aid office for the elderly, I was often invited
to speak at medical schools. I was struck at how few of those
who were studying medicine were taking geriatrics, or even a
course. We did a review of the current requirements and
apparently only 14 medical schools in the country require a
course on geriatrics. Most schools now seem to offer an
elective on the topic, but only 3 percent of the students are
even enrolling.
So my sense is, and to pick up on what Chairman Breaux is
talking about, the country is not going to be ready for this
demographic tsunami that is coming in 2010 and 2011. I hope
that some of you will talk to us about what it's going to take
to really shake up, once and for all, the system of how
students are educated for health care professions.
I was struck, when I was giving discussions on gerontology
and taught courses on the subject, that the medical education
model was simply out of sync for older people. It was almost as
if the ideal was to diagnose the problem, determine the cause,
treat it, and then cure it so that a young person would then go
on to play tight end for the Chicago Bears. That was sort of
the model.
Well, a lot of our constituents, and Mrs. Dole's 102-year-
old mother, isn't going to go play tight end for a football
team. There needs to be a medical education model that works
for those kind of people. We are going to have an extraordinary
number of people who are going to live to 100. The challenge
here is just staggering, and that's why I think it is so good
that Chairman Breaux is continuing this.
This committee has always worked in a bipartisan way, and I
remember Mrs. Dole's work on the Federal Trade Commission and
how helpful it was. So I look forward to working with my
colleagues.
The Chairman. I thank both of my colleagues, and thank the
very distinguished panel of witnesses who are going to be with
us this afternoon. We would ask that each of you try, to the
extent you can, summarize your statements and we will proceed
to questions.
Our first witness will be Dr. William Payne. Dr. Payne is a
retired radiologist from Nashville, TN, and we're delighted to
hear of his experiences.
Dr. Payne.
STATEMENT OF WILLIAM FAXON PAYNE, M.D., RETIRED RADIOLOGIST,
NASHVILLE, TN
Dr. Payne. Thank you, sir. Good afternoon, Senators.
I am pleased to be invited to appear here today and hope
that I can convince you to enact legislation to abolish aging.
We who are elderly could do without it. [Laughter.]
I am a retired radiologist and medical school professor
emeritus from Vanderbilt University. I turn 78 this month, and
I live in Nashville, TN.
On February 5, 1999, I was treated for an early cancer of
the prostate under general anesthesia. I was discharged that
day, and a few days later developed ``walking pneumonia.'' I
was treated with antibiotics, but as it turned out, the
treatment was inadequate.
Approximately a week after my surgery, I was up very early
to go to work at the hospital and was working a crossword
puzzle in our bedroom. I looked up and asked my wife who was
the man in the doorway. Since there was no man in the doorway,
she knew I was hallucinating. My brain was oxygen deprived.
My wife immediately called my internist and was told to
take me to the ER--now! When we arrived at the ER, I walked in
and collapsed in cardiac and respiratory arrest. I underwent
CPR for 10 minutes, then was placed on a respirator, where I
remained for the next 12 days in a coma. During those 12 days
on life support, I lost 30 pounds. I was treated with
antibiotics, blood transfusions, steroids, and both IV and tube
nutrition.
I had developed sepsis, or as we used to call it, ``blood
poisoning.'' Sepsis is an extremely serious and often deadly
bacterial infection. It can start with any common infection,
more often in the lungs, and rapidly progresses to multiple
organ failure. It must be recognized in its earliest stages for
treatment to be successful. Seniors are even more at risk of
contracting sepsis because the majority of people in the ICU
are above the age of 65. They must be treated aggressively
right away because their immune system response is reduced.
Dr. Wes Ely of Vanderbilt University medical center is a
physician who has done extensive research on sepsis. Luckily
for me, he just happened to be in the emergency room when I
collapsed. He recognized my condition as sepsis and immediately
began aggressive treatment for it. I was a lucky one. Other
seniors have not been so fortunate. Some doctors misdiagnose
sepsis in seniors, but worse yet are the doctors who recognize
it and don't treat it aggressively.
Luckily for me, I survived sepsis and lead a happy, active
and productive life. I work out daily at the gym and, with my
wife's excellent cooking, I now weigh 50 pounds more than when
I entered the hospital. [Laughter.]
Before I close, I want to share these thoughts with you.
Many times the health complaints of seniors are brushed off as,
``well, you should expect this at your age.'' Why? Why should
an older person not expect to have the same treatment as
someone half his or her age? We are still human beings with
feelings, and we have skills to offer society. We do not like
to be shunted aside as worthless hulks or has-beens. I think
all of the health profession should stop and think before
dismissing the health concerns of the elderly with comments
like ``you have to expect this at your age.'' Thank you.
[The prepared statement of Dr. Payne follows:]
[GRAPHIC] [TIFF OMITTED] T8496.001
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[GRAPHIC] [TIFF OMITTED] T8496.003
The Chairman. Dr. Payne, thank you very much for an
excellent statement. We will have some questions for you.
Next we're going to hear from Rabbi Gerber. He comes to us
from Philadelphia, PA. Rabbi Gerber will describe to us his
mother's experience with depression.
Rabbi, we're delighted to have you with us.
STATEMENT OF RABBI ZALMAN GERBER, PHILADELPHIA, PA
Rabbi. Gerber. Thank you.
I would just like to make a few points of what has happened
over the past few years in my mother's experience, that I think
will outline how it was more fate than attention to her needs,
luck more than attention to her needs, that actually helped her
back on the road to recovery.
My mother, in 1996, was about 70 years old. Don't tell her
that I don't remember exactly when she was born. She started to
suffer from depression. At that point she would go from time to
time to a doctor and the doctor at that point was not able to
aggressively treat her. Her condition deteriorated and they put
her on some strong medications but at that point there wasn't
much she really needed. Actually, in retrospect, we found out
she was suffering from an acute medical condition of
hypothyroidism, which many times leads to depression, but she
was going undiagnosed and untreated.
That started her to deteriorate, and then when my father
passed away in January 1999--he was very sick in December and
passed away in 1999--she sunk into a deep level of depression,
to the point of being completely non-communicative and was
unable to speak.
At that point, one thing that was extremely difficult--she
has quite a few children, and I'm one of them, and my father
had insights so as to ``squirrel away'' some money for her
care. But we were left at that point scrambling for what to do.
We felt at that point there was no real guidance, nowhere to
turn. We couldn't get any solid answers on what her problem was
and what should we do. So, for the lack of a better word--we
ended up finding a facility to put her in--but it ended up
basically of putting her in a warehouse. Her problems were not
being diagnosed, nothing treated, so she had to go somewhere.
We found an assisted living facility, which is actually a
facility that was not compatible to her condition. She needed
aggressive care, and no one knew that.
When that wasn't working--that was in California where she
lived--I and my wife ended up bringing her to Philadelphia and
we quickly decided to put her into a local hospital. There she
was treated for the medical condition, her hypothyroidism, but
still her mental condition, her depression, had basically gone
untreated. She was still unable to communicate.
From the hospital she was transferred to a nursing home,
where she became extremely depressed, to the point of being
self-damaging. She started to hurt herself. The nursing home at
that point, for lack of ability to--again, her mental condition
still going undiagnosed. The only alternative they had at that
point was to--she was misdiagnosed at that point in the nursing
home. They thought she was suffering from dementia and they
moved her to a dementia unit, which was basically the end of
the road. It would have been the end of the road for her. She
would be unable to communicate, unable to speak, and she was
deteriorating rapidly. She would have lasted for a short time
in the dementia unit.
At that point, because she was still self-damaging, still
hurting herself, the dementia unit didn't know what to do with
her. They were looking for more answers and, luckily, Dr.
Streim was able to step forward. They turned for a higher level
of expertise and they were able to correctly diagnose her. At
that point, when they were able to correctly diagnose her, it
turned out she was not suffering from dementia at all. She was
suffering from deep depression, so they moved her from the
dementia unit to a hospital at the University of Pennsylvania,
and she received intense care and treatment for her depression.
In the course of 6 weeks, the doctor who was in charge of
the ward said, ``That she was the worst case of depression he
had ever seen on his ward.'' Because of her correct diagnosis
and treatment, in the course of 6 weeks she was able to sit
down and have a conversation with me. She was able to recognize
me and stopped her self-damaging behavior. At that point she
moved back into my home and was able to start volunteering in
the local library, attending an outpatient therapy program.
She is now a functioning person. I feel that was the
turning point, that once she got the correct diagnosis and
treatment, we basically got our mother back. Until that point,
we could project that she would not have lived very long and
would have ended her days misdiagnosed in a dementia unit, in a
nursing home.
Now both me and my wife, and my siblings and her
grandchildren--she has 30 grandchildren--they have their
``Bubby'' back. They have their grandmother back.
The couple of points I wanted to bring out is that my
father had the foresight to ``squirrel away'' some money for
her, but even with--there's an old saying, ``That if there's a
problem, throw money at it.'' But even though we tried to throw
money at the problem, her money, at the beginning that wasn't
enough. When my sister and I were speaking before I came here,
she said that, you know, she had money, and still the diagnosis
was not there, so what would it be as with many elderly
citizens that don't have the money to throw at the problem?
What would it have been with them? That's my summary.
[The prepared statement of Rabbi Gerber follows:]
[GRAPHIC] [TIFF OMITTED] T8496.004
[GRAPHIC] [TIFF OMITTED] T8496.005
The Chairman. Thank you very much, Rabbi, for that very
personal story. It was very helpful.
Next we're going to hear from Dan Perry of the Alliance for
Aging Research. Dan, welcome back. He is Executive Director of
the Alliance and is here to tell us about the new report that
the Alliance is releasing today on ageism, how health care
fails the elderly. It's a very detailed and solid report and
we're glad to have you back.
STATEMENT OF DANIEL PERRY, EXECUTIVE DIRECTOR, ALLIANCE FOR
AGING RESEARCH, WASHINGTON, DC
Mr. Perry. Thank you very much, Senator Breaux. I also want
to extend my appreciation to the other members of the
committee, Senator Dole and Senator Wyden. Thank you very much
for bringing this issue to such prominence.
Senator Breaux, it was a year ago that you held a similar
hearing on the ageist bias in other aspects of our society, and
especially as it surfaces in the media. Today's hearing
appropriately focuses on the health care setting, where older
patients tend to predominate and where the ageist assumptions
about what is good for them can have very deadly consequences.
As you know, Mr. Chairman, the Alliance for Aging Research
is a not-for-profit organization, working to ensure that older
Americans receive quality health care, informed by the best
geriatric practices, as well as to have access to the newest
and most effective medications, treatments, therapies, and
medical technologies, without any discrimination based on age.
Today the Alliance is releasing its new report, entitled
``How American Health Care Fails Older Americans.'' Ageism is a
deeply rooted and often unconscious prejudice against the old,
an attitude that permeates our culture. It is a particularly
apparent and especially damaging frame of mind that surfaces in
health care settings. Like other patterns of bias, such as
racism and sexism, these attitudes diminish us all, but they
can be downright deadly to older persons in receiving health
care.
In our latest report, we document with scores of citations
from the recent medical literature showing that older patients
too often do not receive preventative treatments, such as
vaccines and screening tests, that could potentially prevent
diseases from becoming life threatening.
Lack of generally accepted standards of care for geriatric
patients means older patients are more likely to face
inappropriately invasive procedures, such as multiple heart
surgeries, while others may be denied a life-saving surgery out
of the mistaken concern that the older person's age alone rules
them out.
Medical neglect of the aged begins with failures to screen
older people for the early signs of incipient disease. Very few
screening guidelines have been developed that even refer to
people age 65 and over, even though the vast majorities of
fatal heart attacks and cancer deaths occur after that age.
The short shrift that is given to older people begins even
earlier, in a sense, with the training--or rather the lack of
training--of America's health professionals in good geriatric
medicine. As you have stated, Senator, only about one in ten
U.S. medical schools require substantial course work or
rotation in geriatric medicine. It's not physicians' training
only. Our schools of nursing, pharmacy and other allied health
professions do no better, with less than one percent of
accredited professionals in those fields having advanced work
in geriatrics.
Scant exposure to the techniques of geriatric medicine can
foster ageist assumptions that ``it's too late'' to change the
habits of older people, or worse, that serious and chronic
health problems are somehow a ``natural'' part of getting
older.
Too little effort is made at preventive care in the
elderly, despite proven advantages for improving their quality
of life. In our report, we call attention to ageist defeatist
attitudes when it comes to counseling older smokers to quit the
tobacco habit, or to engage in regular physical activity. When
it comes to standard HIV and AIDS treatment and prevention
efforts, as well as substance abuse protocols, there is a blind
spot of ageism when it comes to people in their sixties and
older.
Our report also notes that older people are systematically
excluded or discouraged from participating in the clinical
trials that determine the safety and efficacy of the
medications for which Older Americans will be the largest end
users.
Ageist assumptions that distort the quality of health care
for such a large and growing group hurts everyone, because it
leads to premature loss of independence on a giant scale, and
it increases the mortality, disability and depression in older
adults who might otherwise lead productive, satisfying and
healthier lives.
Older people themselves unconsciously embrace unfounded
assumptions that to be old is to be sick, or that they
shouldn't bother their physician by bringing up their health
concerns, or that ``you can't teach an old dog new tricks'',
which gets in the way of adopting healthier behaviors.
The Alliance for Aging Research especially thanks this
committee for its attention to ageism in health care as the
threat that it is to the well-being of older Americans and to
all of us. Ageism is not something that we can just accept or
ignore, and unfortunately, it's not something that is just
going to go away. However, our report does submit these key
recommendations for getting at the root of the problem:
First, we should have reform in health professions'
education so that every doctor, nurse, and allied health
profession graduates with at least some exposure to geriatrics.
Researchers should target their studies on the benefits to
older people of common health screening protocols and
preventive measures, so that we have a baseline from which to
recommend more aggressive prevention and screening.
Congress and health agencies should raise the awareness, as
this hearing is doing, of the availability of experimental drug
trials and consider legislation creating appropriate incentives
to include older subject in clinical trials.
Last, we should all work to educate and empower older
adults and their families to be effective advocates in the
health care delivery that too often fails America's elderly.
Thank you very much, Senators.
[The prepared statement of Mr. Perry follows:]
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The Chairman. Thank you, Mr. Perry, and thank you for the
excellent report.
Our next panelist will be Dr. James Marks of the Center for
Disease Control. Dr. Marks is the Director of the CDC's
National Center for Chronic Disease Prevention and Health
Promotion. He will describe, as I understand it, prevention
measures for the elderly and whether they're being properly
utilized.
Dr. Marks, welcome.
STATEMENT OF JAMES S. MARKS, M.D., DIRECTOR, NATIONAL CENTER
FOR CHRONIC DISEASE PREVENTION AND HEALTH PROMOTION, CENTERS
FOR DISEASE CONTROL AND PREVENTION, U.S. DEPARTMENT OF HEALTH
AND HUMAN SERVICES, WASHINGTON, DC
Dr. Marks. Thank you, Senator Breaux, and members of the
committee, for this opportunity to address a critical priority
for CDC and for public health, preventing disease, and
preserving health among our Nation's growing number of older
adults. I would like to submit my full written statement for
the record.
The Chairman. Without objection.
Dr. Marks. The unprecedented aging of the U.S. population
will present societal and economic challenges unlike anything
our society has ever seen. We cannot begin to slow the
skyrocketing health care costs or control serious health
problems without much more aggressively working to prevent
disease, injury and disability among older Americans.
You've heard from Dan Perry that older Americans have not
been fully involved in disease research, and that treatment of
disease is not pursued as aggressively among older Americans as
it is among their younger neighbors. Likewise, and especially
in the areas of maintenance and promotion of health and disease
prevention, those areas have not been addressed as strongly as
they should among our older adults.
It is CDC's role and public health's challenge to see that
what we know is effective is much more broadly applied, and to
help conduct the research to learn more about what will work to
help older adults maintain an active, enjoyable life as they
age. Much of the research on prevention was conducted on adults
less than 65. Yet, increasingly, the science tells us that even
for older adults it is never too late to receive substantial
health benefits from improving health behaviors and from
receiving preventive health services. But they and their
providers have not been getting that message, and so their care
and their health have both suffered. Further, public health
practice in this Nation has not had an emphasis on older
adults, although that it beginning to change.
CDC has identified several critical priorities for
addressing the health of our Nation's seniors. First, we must
promote healthy lifestyles for our seniors. It is very clear
that healthy lifestyles are tremendously influential in helping
older people avoid the deterioration traditionally but
inappropriately associated with aging. Adults who are
physically active, maintain their weight and do not smoke,
delay the onset of disability by 7 to 10 years, a tremendous
improvement in a society where the costs of long-term care are
overwhelming each State's ability to provide basic services to
their poor and uninsured. Yet there is little systematic effort
to encourage these behavior changes among our older
populations.
Second, we must increase the use of clinical preventive
services, such as screening for chronic disease and provision
of flu and pneumonia immunizations. We know that older adults
are less likely to get cancer screenings, less likely to be
treated fully for high blood pressure and elevated cholesterol
than their younger neighbors. Despite coverage for flu vaccine
and pneumonia vaccine for the last 20 years, arguably the
simplest of our interventions, less than two-thirds of adults
over 65 get these as needed, and in African Americans, it's
less than 40 percent. Coverage is important, but it does not
ensure use. Education of providers and older adults themselves
is needed, and coordination of the services is important.
Third, we must reduce hazards and risks for injuries.
250,000 people are hospitalized for hip fractures each year,
and about half will be unable to go home or live independently
afterwards. Simple measures in homes, like reducing furniture
and throw rugs that increase their risk of tripping, or
installing grab bars in houses can greatly reduce this risk of
injury.
I would like to highlight a small local program that CDC is
helping to support, that offers evidence that we can close
these gaps between what we know works and what we actually do
in our communities.
The Sickness Prevention Achieved through Regional
Collaboration project, or SPARC, is conducted by a non-profit
organization serving a critical role as a local bridge between
health care providers, aging services providers, and seniors in
a four-county area at the intersection of Connecticut, New
York, and Massachusetts.
SPARC has shown remarkable results. It increased pneumonia
vaccine in Dutchess County, NY by 94 percent, doubled the use
of breast cancer screening among women attending flu clinics,
where SPARC made mammography appointments also available, and
it doubled the rate of pneumonia vaccinations in Litchfield,
CN, an increase that was twice as large as that in surrounding
counties. It's an outstanding example of a successful science-
based program that should be happening in communities
nationwide.
I would like to thank the committee for inviting me to talk
about this issue of critical importance to the American people,
the public health, and the CDC. It is in all of our best
interests to assure that the golden years are healthy, quality
years, and that older adults get what they want most--their
best chance for staying independent, active members of society,
for as long as possible.
We, as a society, must recognize that the increasing number
of older adults makes the urgency of this vision much more
compelling than it has ever been before.
Thank you very much.
[The prepared statement of Dr. Marks follows:]
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The Chairman. Thank you very much, Dr. Marks, for those
remarks.
We will now hear from Dr. Robert Butler of the
International Longevity Center, a good friend of the Aging
Committee. He is going to talk about the under representation
of seniors in clinical trials.
Dr. Butler, welcome back. It's good to see you.
STATEMENT OF ROBERT N. BUTLER, M.D., PRESIDENT AND CEO,
INTERNATIONAL LONGEVITY CENTER-USA
Dr. Butler. Thank you, Senator Breaux, and Senator Dole and
Senator Wyden. I would like to speak briefly and then submit my
full statement for the record.
Ageism, pervasive in our culture and within medical
practice, affects all of us who plan to grow old. Today,
however, I will just focus upon under representation in
clinical trials and leave with you also a report which the
International Longevity Center recently completed on this
topic.
The consequences of under representation are more than
considerable, with an impact with respect to adverse drug
reactions, the inappropriate dosage and the misperception that
older persons cannot tolerate certain medications, or perhaps
not even benefit from them.
There is ample evidence that there is inadequate
representation in clinical trials. For example, in one large
cancer trial with 16,000 patients, only 25 percent were of the
65-plus representation, and yet, 50 percent of everybody who
develops cancer is over 65 years of age. Similarly, only 9
percent of one sample with breast cancer were represented.
With respect to heart disease, the other great killer in
old age, in one study of the 75-plus population, only 9 percent
were of the older age group, although 40 percent of all heart
attacks occur among those 75 years of age and older. Of course,
the complexity grows with age, in particular in the 85-plus
population.
It is very important to note also that the National Center
of Health Statistics has estimated that, in any given year,
something like 17 percent of all persons over 65 years of age
wind up in a hospital with the very strong possibility that
drug reactions were involved. This is staggering. There have
been estimates that this costs our country and people $20
billion a year.
So why aren't older people included in these clinical
trials? For one thing, there is the notion they do not want to
participate, which we know is not true, and also it should be
pointed out they constitute a huge pool of some 35 million
people to whom investigators could turn.
Second is the notion that the confounding variables of
complex illness would make the findings too difficult to
interpret. But, in fact, the world of reality is the number of
older persons with complex illnesses that are on so many
medications, as you indicated, Senator Breaux, in your opening
remarks. Therefore, we are, in a sense, protecting from the
fruits of research individuals whom we really need to know more
about, for both quality of life reasons and with respect to
cost.
Moreover, physicians do not refer older people, perhaps in
part because they, too, do not comprehend the extent to which
it is valuable to do so. There are no regulations to require
appropriate representation. I think back on the days in which
that was true also of women and of minorities, and there are
always explanations. For example, in women it was explained
because of the menstrual cycle, and it would simply be too
confounding and too complicated. There has also been the
misunderstanding that Medicare will not cover the clinical
costs associated with clinical trials.
So what might we do? Briefly, we have advanced the idea,
borrowed actually from a senatorial suggestion some number of
years ago, that it might be well now to have a national
clinical trials and evaluation center. It might be divided into
ten Health and Human Services regions, with competition among
medical centers to carry out such studies, that the funding
would come from conventional sources--NIH, the Federal
Government, pharmaceutical companies, academia--and also would
provide great opportunities to follow patients after a drug has
entered the market. For example, on average, only about 5,000
patients have been studied when a medication is available, and
yet, the population base that might make evident the extent of
untoward side effects is considerably more. So a national
clinical trials and evaluation center is something that should
be considered.
Moreover, regulation, so that just as women and minorities
have required representation, so will older population. Then
the provision of some incentives--for example, motivations to
pharmaceutical companies perhaps by extending patents.
Finally, the importance of medical education. If we have
well-trained physicians, well-trained nurses and other health
providers, they can play a much more significant role in both
mobilizing the representation of older people within clinical
trials and undertaking the appropriate observations necessary
to note untoward and other side effects.
Thank you very much.
[The prepared statement of Dr. Butler follows:]
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The Chairman. Thank you, Dr. Butler, once again for some
very important remarks and a great contribution.
We will hear from our final panelist this afternoon, Dr.
Joel Streim, President of the American Association for
Geriatric Psychiatry. He will discuss the effects of age
discrimination against the elderly in the arena of mental
health.
Doctor, we're glad to have you.
STATEMENT OF JOEL E. STREIM, M.D., PRESIDENT, AMERICAN
ASSOCIATION FOR GERIATRIC PSYCHIATRY
Dr. Streim. Thank you.
Mr. Chairman and members of the committee, I appreciate the
opportunity to testify here today about the effects of age
discrimination in our health system on older adults with mental
disorders.
We know that psychiatric illness in older persons is a
serious public health problem. Research has shown that mental
illness is associated with poorer health outcomes and increased
costs for elderly patients with co-occurring medical conditions
that are highly prevalent in late life, such as hip fractures,
heart attacks and cancer. In older adults, the interaction of
concurrent psychiatric and medical conditions causes excess
disability and increased mortality, creating unique treatment
needs that have been largely ignored by our health system.
Geriatric mental illness brings together two of the most
damaging elements of discrimination in America: the stigma of
advanced age, and the stigma of mental illness. These twin
discriminatory burdens are evident not only in a lack of
research, but also in inadequate access to treatment and
appropriate services. Community mental health facilities often
lack age-appropriate services and staff trained to address
medical needs; and Medicare, with its primary mission of
funding health care for seniors, perpetuates the bias against
mental health care by requiring a 50 percent copayment for most
mental health services, rather than the 20 percent copay that
applies to all other medical conditions. That's not just an
insurance carrier's coverage decision. It's the law.
Most older adults with mental illness receive their care in
primary care settings. The problem with this can be summed up
with one stunning statistic, which you referred to before,
Senator Breaux: one-third of older adults who commit suicide
have seen their primary care physician in the week before
completing suicide, and 75 percent have seen their doctors
within the prior month.
Because of the disconnect between primary care and mental
health care, older adults are too often misdiagnosed or
improperly treated. Research has demonstrated that older adults
are more likely to receive appropriate mental health care and
to have better clinical outcomes when mental health services
are integrated with general medical care within the primary
care setting. Multiple appointments with multiple providers in
multiple settings add up to an unacceptable burden to persons
for whom chronic illness and physical disability are serious
constraints.
There is also less stigma associated with receiving
psychiatric services when they're an integral part of general
medical care.
There are other research advances in geriatric mental
health that, in practice, could and should have life-altering
effects. For instance, it's been clearly demonstrated that
symptoms of pain and depression are treatable, even in old age,
even in the face of chronic disease and disability, and even
for those living in nursing homes. But our health system hasn't
done enough to translate this scientific knowledge into
clinical practice.
The pervasive attitude among clinicians, and among many
patients and society at large, is that getting old means living
with pain and depression; and so older adults don't get the
treatment they deserve.
Beyond the failures of recognition, diagnosis, and
initiation of treatment, recent research has revealed the next
generation of problems facing older adults with mental illness:
poor quality of follow-up care. Studies have shown that among
elderly nursing home residents who are receiving antidepressant
medication, approximately half continue to have symptoms, yet
they don't get needed changes in their treatment to ensure that
they get well.
In 1999, the Centers for Medicare and Medicaid Services
introduced a quality indicator for depression care in nursing
homes that unwittingly recognizes the simple prescription of
antidepressant medication as a reflection of good care, even
when failure to provide proper follow-up care leaves the
patient with unremitting symptoms.
There are few areas where there is a more serious dearth of
research and services than in the area of late-life alcohol and
substance abuse. The standard definitions of alcohol abuse
don't adequately reflect the problems of older adults. Older
adults who are abusing alcohol may not be driving cars or
fighting in bars, making them less likely to be identified as
having a problem by the usual social or legal parameters that
typically bring younger drinkers to attention.
Some older adults consume alcohol in quantities or patterns
that don't usually suggest abuse or dependence, but their
drinking may be causing falls, with the attendant risk of hip
fractures and other injuries, institutionalization, and even
death. Yet this category of ``at-risk'' drinking doesn't even
exist in current definitions; so the problem in older adults
goes unnoticed.
In the area of treatment, we don't have age-appropriate
services in settings acceptable to seniors. Existing approaches
to the treatment of alcohol and substance abuse are geared
toward younger adults, and don't address the problem of
comorbidity from medical illness and depression, as commonly
seen in the geriatric population. This is yet another example
of neglect of older adults and their unique needs, both in our
national research agenda and in the design of clinical
services.
In conclusion, mental disorders of late life are treatable.
However, ageist attitudes and health care policies that
discriminate against older adults prevent those individuals
from getting the treatment they need and deserve. This is a
shameful tragedy, and the time has come to right the wrongs
against so many older Americans.
I would like to thank the committee for the opportunity to
testify here today, and will be happy to answer any questions.
[The prepared statement of Dr. Streim follows:]
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The Chairman. Thank you very much, Doctor, and I thank all
of the members of the panel. I think you all have been very
helpful in pointing out what this hearing is all about, and
that is the fact that ageism discrimination exists and it
exists in the health care area in particular, which is one of
the biggest concerns, obviously, of seniors and older
Americans, whether it's in psychiatric care, clinical trials,
or whether it's in the recognition of a problem that is more
typical perhaps in older Americans, and they don't recognize it
because there's not enough attention being paid in the medical
profession to some of these problems.
Dan Perry, you had given us some suggestions. We know
there's a problem. I think you all made the case that there's a
serious problem of discrimination in America against seniors in
how they get their health care and how they don't get their
health care, because of a lack of concentration on particular
problems.
The question then becomes, if we've got the problems and we
know what they are, what do we do about them? You have given us
some recommendations which maybe we can elaborate on. You can
pass a law not to discriminate in health care against seniors,
but obviously that's not enough to solve the problem. So the
question really becomes, what can Congress do? How do we
approach this?
I will ask you first, and if anybody else has some ideas
about this, I would like to hear them.
Mr. Perry. I think raising this to this issue of ageism in
health care level of attention is a good first start. It is how
we've dealt with other forms of bias in our society. We have
thrown the bright light on it and we have shown how this
diminishes all of us. We have made it so that people think
twice in our society about indulging in sort of easy, sloppy
thinking when it comes to what an older person can do. So I
think that's an excellent first step.
Then let's realize that it's the Federal Government that
does provide the health insurance coverage for this whole
population. That's a pretty big stick to wield when it comes to
reforming health care. That includes medical education. As a
number of us have pointed out, the way we train, the way we
orient health providers in our society, has a lot to do with
their expectations of what an older person can or can't do when
they're out there actually practicing. Suggestions such as Dr.
Butler and others have made about changing the population of
those that are part of the clinical trial, these are very
doable, whether it's offering incentives to manufacturers or
creating national clinical trials and evaluation center under
some Federal leadership.
These are all levers that you, as policymakers, have at
your disposal to try to identify the evil that is ageism, as
with other forms of prejudice, and to make some structural
changes in how we teach, how we develop our new drugs, and how
we encourage people to get into trials and to use the testing
that's available.
Last, the part that is somewhat more ephemeral is this
business of empowerment. It's a matter of speaking to people
and telling them it's all right to be a ``squeaky wheel'' in
the system, and, in fact, that's the best way to make sure that
you're going to get the attention that you deserve, and not for
the patients themselves to have these attitudes that ``I'm 85,
I have no right to feel any better, and why am I going to push
back on the system''. So I think you're taking a big step in
the right direction.
The Chairman. If you look at the statistics--I mean, I
don't know how we got into the situation that we're in, because
we didn't do it overnight. But the numbers, by the year 2010,
50 percent of all doctor visits in the United States are going
to be made by Americans over the age of 65. Yet, only five of
the 125 medical schools in the country have full-time geriatric
departments. There is simply not enough geriatricians in the
country, in the Nation. Out of 650,000 physicians, only 9,000
are geriatricians, compared to about 42,000 who are
pediatricians for children.
It seems like society is ignoring this huge group of people
that are going to be older Americans. Yet the doctors are not
moving in that direction, and not utilizing clinical trials to
look at this huge growing population. Yet it happens not only
in health care, but in everything else, and advertising and
everything else. There is a huge group of people that are
getting ready to be here for a very long period of time and we
are not prepared, professionally, from a health standpoint, to
address what's going to happen unless some changes are made.
I don't know how we do that. Do we pass a law that we need
more geriatricians? We tried to do that with specialists and we
ended up with too many specialists and not enough general
practitioners, and now we have 42,000 pediatricians and only
9,000 geriatricians, and that's where the numbers are going to
be increasing.
Dr. Butler, do you have any thoughts on this?
Dr. Butler. Yes. My view has always been that no one, but
no one, should graduate from medical school, or any residency
program or, in fact, be in practice, and be subject to
continuing medical education, without properly trained teachers
in geriatrics. If we don't have the teachers, we're at a loss.
So our Center came up with a very simple algorithm, which
is extraordinarily inexpensive. We know that it takes roughly
ten physicians for every one of the 145 allopathic and
osteopathic schools of medicine, to create a teaching cadre, a
core group, that can assure us of proper teaching. We calculate
that between now and the time the ``baby boomers'' reach 65 en
mass, about 2022 to 1923, it will only cost the country about
$22 million a year. Since there are 100,000 faculty members in
medical schools, and we're talking about 1,450 academic
geriatricians, it's really a very modest proposal.
It's doable and a running program already exists within the
Federal Government. You do have, within HRSA, the Health
Resources and Services Administration, the Geriatric Academic
Career Award.
The Chairman. Can anybody give me an answer as to why
medical schools have not tried to keep up with where the
population is going?
Dr. Butler. For this very reason: there haven't been the
teachers. If you don't have the leaders, the academicians, then
you don't have the figures for students to emulate, you don't
have the knowledge base to do the teaching. If you said to an
obstetrician or a urologist, ``you've got to teach
geriatrics'', it wouldn't really be very constructive. So you
have to have the teacher base.
When the Heart Institute started, it was fortunate to be
able to train, in the first 22 years of its existence, 16,000
cardiologists, which is probably why we have excellent training
in cardiology and a 60 percent reduction in deaths from heart
disease and stroke. But we've had nothing comparable in the
field of geriatrics. You have to have teachers in order to
really transform the schools.
The Chairman. Is geriatrics a profession? Some may make the
argument that, ``all right, we don't need to have a geriatrics
department. We have a cardiology department and we train heart
doctors, and heart doctors see a lot of elderly people. We're
training specialists in disease areas that older Americans are
going to be suffering from, so we don't need a specialty for
older Americans because we have all these specialties in
medical diseases that, in fact, older Americans get. So we
don't need a geriatrics department. We have a cardiology
department.''
Dr. Butler. That confirms my point, that you have to have
the teachers to make sure those cardiologists or urologists or
whatever have a proper understanding of the nature of the older
person.
The same issue arose in the 1920's with respect to
pediatrics. The view of organized medicine was that children
were just miniature adults, and we certainly did not need
pediatricians. We overcame that. So we have to have that
teacher base. Once we have that, we can be sure then that,
whatever field one goes into in medicine, they've had proper
training.
The Chairman. I think we certainly have the ability to move
in that direction, I would say to my colleague, Senator Wyden,
because the teaching hospitals are funded through Medicare.
Yet, Medicare has never insisted that the hospitals that train
doctors that are funded by Medicare, which is for older
Americans, have any requirement whatsoever that a certain
percentage of the operations deal with older Americans.
Dr. Butler. Absolutely, although Medicare does provide,
fortunately, fellowship programs, supported by the graduate
medical education money, but only for one year, when it should
be a 2-year program to really launch the young academic
geriatrician.
The Chairman. But it's also optional. You can ignore it.
Dr. Butler. You can. You're absolutely right.
The Chairman. Dr. Streim.
Dr. Streim. Actually, we have a ``catch 22'' here, because
if we are going to be successful in training the geriatric
educators who will train the generalists and the specialists in
issues related to aging, we have to first attract early cohorts
of medical students and residents to geriatric fellowship
training. The problem is, because of ageist attitudes, it's
very difficult to recruit some of the best and brightest to
choose careers in geriatrics, to become the teachers of the
future.
There are some legislative remedies that I think can help.
One is, to address the cap that CMS has placed on GME positions
at medical centers. That cap was introduced primarily to limit
the number of specialists we train. A few years ago, provision
was made so that, instead of only paying for half of a FTE for
specialty training in the fellowship years, there was an
exemption made for geriatrics fellowship training, so that
those trainees would be reimbursed--that their salaries would
be supported at a full FTE. That's helpful----
The Chairman. What's the FTE for, non-Washingtonians?
Dr. Streim. The full time equivalent salary for residents
in a teaching hospital, which is part of graduate medical
education funding that comes from the Medicare program.
But the fact is that all medical centers that have teaching
residency programs are still capped at their 1996 levels, again
to limit specialty care training. Many medical centers are
therefore reluctant to increase the number of physicians
available to train physicians in geriatric medicine and
geriatric psychiatry because of that cap. This is an area where
I think we can help medical centers encourage or create more
opportunities for clinical training in geriatrics.
The Chairman. A very good suggestion.
Dr. Streim. There is one other suggestion I would like to
make at this point, too, if I might.
The fact that we really aren't attracting enough people to
pursue training in geriatrics has to do with misconceptions
about careers in geriatrics and what geriatrics is all about,
and that's where trying to teach this to medical students in
the earlier stages of their training is so important. The
Bureau of Health Professions at HRSA can play a major role in
helping us to train those who will go to medical schools and
really make the case for careers in geriatrics to those who are
in the earliest years of training.
That's really what we need to do to prime the pump, so that
we can get trainees attracted to geriatric careers, to become
the teachers of future medical students and residents.
The Chairman. Thank you.
Senator Wyden.
Senator Wyden. Thank you, Mr. Chairman. You asked so many
key kind of questions, I just want to amplify a number of the
points you made.
It seems to me that the acute lack of practitioners is a
very serious problem, but what seems even more serious to me is
how little has changed in really a couple of decades. I think
about this panel, and going back to the days when I was
Director of the Gray Panthers, most of what you all have said
today is very similar to what was said 20 years ago.
Dan, would you disagree with that?
Mr. Perry. No, you're absolutely right. The big difference
is that we're now a little more than 7 years away from when the
first ``baby boomer'' is going to join the Medicare rolls.
Fifteen or 20 years ago, it might have been a bit abstract, but
there is literally no time left to delay.
Senator Wyden. So we could have had this debate 20 years
ago. I think what is really needed is a revolution in medical
education, and that nothing short of that is really going to
turn this around.
I share Chairman Breaux's view. You can't just wave your
wand and, by fiat, decree from Washington, DC, that this is all
going to happen, that people are going to flock to geriatric
education.
Has anybody asked medical students recently, through some
kind of survey or other kind of exercise, what it would take to
get them to be serious about geriatrics? Have they been asked?
Dr. Butler. I think they've been asked indirectly by the
electives, which only----
Senator Wyden. By who?
Dr. Butler. Indirectly through the electives they've been
asked. Namely, only 3 percent apply, and that's because they
don't have the teachers, they don't have----
Senator Wyden. That's the result, Bob, and we know what the
result is. I'm curious whether anybody has like shown up at the
Harvard Medical School and said, ``Look, here's the bottom line
here. Nobody is going into geriatrics. What would it take to
get you folks into this?''
Dr. Butler. I don't think anybody has done that, except as
I've said, in a way, that they've voted with their feet by
virtue of not even taking the electives, which is an expression
of their sense that it's too depressing, that the rewards are
minimal because there are no high-paying aspects in terms of a
procedure, there are no teachers that will really lead them.
They don't see the positive aspects because they haven't been
taught because they haven't had the teachers to do so.
Senator Wyden. It's been a while since I got an invitation
to speak at the Oregon Health Sciences Center, and we had Dr.
Chris Cassel until recently, who, of course, was a leader in
the field. But because of what you all are saying, I'm going to
go back to the Oregon Health Sciences Center shortly and really
start asking the students what it would take to get them
interested in this, not just the medical students, but the
nursing students and a whole host of them, because clearly,
what's going on now, isn't working. The recommendations today
are good and useful, but they really aren't very different
than, as Dan said, those made years ago.
Dan, do you want to chime in here?
Mr. Perry. I would add to what Dr. Butler said, that there
is nothing that attracts and succeeds like success. Just a few
years ago, we had a grand total of one department of geriatrics
that really did interdisciplinary work and was really a
success. Dr. Butler happened to head that at the time.
Now, in the last 4 or 5 years, we're up to five. Out of 145
allopathic and osteopathic medical schools, five out of 145
still is not a great success, but it's something.
If we had more examples, such as those being funded by
private foundations--the Donald W. Reynolds Foundation has
funded these full departments at the University of Arkansas,
the University of Oklahoma, and they're attracting people into
the field. They are cross-fertilizing between physicians,
nurses and social workers. If we had more examples of that,
physicians, nurses and others in training would see that this
is an attractive field and they would be attracted to success,
in my opinion.
Senator Wyden. How are these associations doing in terms of
making this a priority? Say AAMC, the Association of Medical
Colleges, are they using their bully pulpit to make this a
priority?
Dr. Streim. Not sufficiently.
Dr. Butler. Not to my knowledge. I think it goes back,
unfortunately, to finance. They do not have the financial basis
upon which to operate, and there hasn't been that type of
public/private initiative which I think we've enjoyed with the
Reynolds department, that I enjoyed at Mount Sinai with the
Brookdale Foundation.
You need to have the funding in order to be able to support
the physical space, the teaching equipment, the faculty
salaries, and that's where the geriatric academic career work
in HRSA that Dr. Streim mentioned is so vital and important.
Senator Wyden. How are the medical school presidents doing?
I haven't seen a medical school president, a dean, the leaders,
speak out about this in any significant way. Am I missing
something? Maybe I'm not reading the literature----
Dr. Butler. I think Dr. Cassel did, Dr. Rowe, both at Mount
Sinai in the second instance and Chris Cassel in the first at
Oregon. But again, there are so few geriatricians that very few
of them have achieved the status of becoming deans or becoming
the presidents of medical centers.
Dr. Streim. The leadership is sitting in this room,
unfortunately. It doesn't go much beyond.
Senator Wyden. I think what you all have had to say, in
terms of recommendations, is important.
I hope we can set in place now, through legislation and
through the work that you're doing, something that's going to
really jar a system that has changed very little in the last 20
years. I think what Dan was talking about is a relevant point.
Certainly it was harmful that the situation didn't change over
the last 20 years, and I think it produced the kinds of
accounts that the Rabbi and others have talked about.
If it doesn't change now, and it doesn't change quickly, we
are going to get engulfed by these problems. When that
demographic tsunami hits, then you are going to see the
extraordinary price that this country pays for what I call the
immoral stain of ageism.
Mr. Chairman, I guess we have several who want to comment.
Dr. Butler. The revolution I would suggest is that, just as
there are national cancer centers, Alzheimer's disease centers,
that the Federal Government, in cooperation with the private
sector, initiate departments of geriatrics within American
medical schools. That would be the revolution. There would be a
revolt, people would be upset, but in the long run, it would be
the kind of result that I think you're speaking to.
The Chairman. Dr. Marks.
Dr. Marks. I would like to comment a little bit and refer
to Senator Wyden's question, the first one. When I was
training, I trained in pediatrics, but you see that I'm
speaking on the issues of aging because I recognize how
critical it is to our society. The areas that people were
staying away from was oncology, because there wasn't much hope
in it. I think that's part of the sense of what people feel
about an aging population.
Part of what we have to recognize is framing that hope is
going to be critical. That is not just about repair work on
badly damaged bodies, but it's about, in fact, helping people
to stay healthy and active as long as they can.
I saw a gentleman on TV who had finished last in his race.
It was a 100 meter race. He was 102. He wasn't discouraged by
this because the oldest age category was 75 to 79. That's a
very different view of the next 20 years after age 80 than most
of us have.
We do not have to have the outcomes we currently have, and
if we just train people to treat those outcomes and not to
prevent, them we will have limited ourselves as a society and
we will have limited our view of what older age can be. That is
part of what we think public health needs to bring. Just like
you talked about no geriatrics programs in medical schools,
almost every school of public health has a maternal and child
health program. Very few have any programs for dealing with an
aging population.
When we see what can happen in a program like the SPARC
program, we see that we can dramatically change the preventive
services and the attitudes of community agencies around an
older population.
The Chairman. Thank you very much.
Dr. Payne and Rabbi Gerber, these other gentlemen have been
commenting on how to resolve the problem. You have given two
excellent examples of the problem and what the problem is, a
lack of recognizing clinical depression in a somewhat older
American which led to a lot of problems over a number of years,
and Dr. Payne, fortunately for you, you had someone in the
emergency room who just happened to recognize it, but you
almost died because of what you got.
Did you indicate that that particular problem is more
serious perhaps with the elderly?
Dr. Payne. Yes, I think it is, because of the reduced
immune system response in the elderly.
The Chairman. It's easier for them to be susceptible to
that.
Dr. Payne. Sir?
The Chairman. It's easier for them to be susceptible to
that because of their age?
Dr. Payne. Right.
I think there is one other thing, Senator, that hasn't been
touched on very well. I think there should be some public
education, which is fairly cheap, insofar as the elderly are
concerned, that they should seek medical help when they first
need it, not when they desperately need it. I don't know how
you get this done, but maybe through public education, like
we've had with smoking and alcoholism, et cetera, that when
you're sick, go to your doctor.
The Chairman. One of the most exciting things in medical
care is the whole concept of preventative care. Everybody says
we have to have more preventative care. People don't see a
physician until they're sick. In reality, we ought to have a
complete analysis and profile on every American, looking at
their case history, their parents, their genetic makeup, to
determine what they're susceptible to later on in life, so that
a proper course of preventive medical care can be instituted
earlier to delay the inevitable results of what that person may
likely develop later on in life, whether it's coronary heart
disease or diabetes or any of the diseases that affect so many
of us. That really is what preventative care is, not waiting
until you're sick to go get treated, but to do the things that
are necessary now to prevent that sickness from ever occurring
and delaying it later and later.
This has been a terrific hearing. I thank all of our
witnesses for being here. Your suggestions are good, your
examples are so very important for us to be able to take to the
general public and begin the next step.
This is a huge problem, but it's also a huge opportunity.
It's a huge opportunity for our medical schools to begin
looking at institutes on aging and to do more, like you all are
doing in your areas. This is something that really represents
the future in health care.
Speaking of Senator Dole's mother being 102, we would like
to recognize today the clerk for our committee, Patricia
Hameister, that it's her 100th hearing. She's not 100 years
old. [Laughter.]
This is her 100th hearing, and we want to congratulate her
for her great service as well.
With that, our committee will stand adjourned.
[Whereupon, at 3:12 p.m., the committee adjourned.]
A P P E N D I X
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