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msJAMA
April 1, 1998

Ageism in the Preclinical Years

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JAMA. 1998;279(13):1035. doi:10.1001/jama.279.13.1035-JMS0401-3-1

I recently worked in an infectious disease clinic where I met a patient in her late 60s who was infected with the human immunodeficiency virus (HIV). My surprise at seeing an older woman with HIV, an infection associated with unprotected sex or injecting drug use, made me realize I had preconceptions about aging and the elderly. Uninformed generalizations about a certain group are the basis of prejudice, and in my case, my attitudes could be construed as being ageist in nature.

Exactly what prejudices and misconceptions about the elderly do students have? Some studies have indicated that medical students perceive older people as being dull, disagreeable, inactive, and economically burdensome.1,2 Although other data are more positive3,4 ageism in medicine is a cause for concern. Medical educators are attempting to identify the source of age bias and devise means with which to address it.5 Engendering positive feelings about older people will presumably lead to better geriatric care. Interactions with the elderly in and out of the classroom help students understand the needs of the elderly and could prevent them from developing ageist attitudes.

The American Geriatrics Society has called for training in geriatrics in each year of medical school,6 a challenge that has been accepted by curriculum planners at University of Kansas School of Medicine (KU), where I am a second-year student. KU does not pretend to be a model for geriatric education. Efforts here are probably typical of other institutions, where age-sensitive curricula are evolving. For example, our program recruits older people in the community to join students in small-group discussions on aging. Courses in physical diagnosis and pharmacology also devote special sections to caring for older patients. In addition, a new faculty position in physiology funded by the Center on Aging ensures that topics on aging are incorporated into the basic science curriculum.

Year 1 now includes a year-long Clinical Science course with a life-span format, examining life issues from cradle to grave. Four weeks are devoted to aging, end-of-life care, and the historical evolution of societal attitudes toward the elderly. For example, we learned in a discussion of cultural roots of ageism that before the 16th century, for example, most people did not know their exact age. Instead, most identified with a stage of the "life course"7 that often corresponded to cycles seen in nature. Similarly, William Shakespeare opines that the 7 stages of a man's life end as it began "sans teeth, sans eyes, sans taste, sans everything."8 By the mid-16th century, people began inferring social position from age. Artists depicted the beginning and end of life as ascending and descending staircases. Middle age towered above as the pinnacle of achievement and status.

These images still prevail. We tend to think of our lives in discrete stages by which we chart our "progress." When people say, "Act your age," they are asking that you conform to a cultural expectation of a stage in life. Not coincidentally, these stages often are linked with economic power. Those in their 40s or 50s are considered to be at the top of their game not only because they enjoy better health, but also because they often have the most financial resources.

At KU, students are encouraged to use the term "life course" rather than "life cycle" because there is little that is cyclical about life. The human life course may be better thought of as the course of a river or the branching of a mature tree.9 By the time we see elderly patients in clinic, they have developed complex networks of life decisions: whether to marry, to have children, to leave college, to enter military life, to relocate, or to stay near one's place of birth—all choices apparent in the stems that have flourished and those that have withered away. And for most, the branching continues.

The older people who joined our small-group discussions surprised me with their candor about life choices. We asked how they felt about dying. A retired pastor, Henry Croes, said simply that he had learned in physics that no matter is created nor destroyed; therefore, dying must just be a conversion of sorts. Another woman described losing her child to illness. Another told of a lifetime of physical abuse. These confessions may not be so different from those we hear from younger people with one exception: with age comes perspective and wisdom that cannot be taught except through living.

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Article Information
The author would like to thank Stephanie Studenski, MD, MPH, Center on Aging at the University of Kansas School of Medicine, and David Ekerdt, PhD, University of Kansas, Lawrence.
References
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Shakespeare  W As You Like It. Act 2, scene 7, line 165.
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