[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
    
    [GRAPHIC] [TIFF OMITTED] T8496.002
    
    [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.]

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