Ageism in Rheumatology
This year, I was invited at the last moment to participate on a panel at the American College of Rheumatology (ACR) meeting. The panel I was invited to join examined the issue of ageism in the practice of rheumatology.
I was thrilled to be asked to join the discussion.
What is ageism?
"Ageism is the practice of categorizing or limiting opportunities for people based on how others view one's age. An example of ageism might be limiting therapeutic options (which medications or treatments are offered) because of a person's age."1
An example of ageism in practice
An example might be if a patient is hurting and tells their rheumatologist. Then, the rheumatologist considers the situation and decides that the patient should be offered treatment. But the patient is not offered other treatments based on their age alone. In response, the rheumatologist might suggest increasing their dose of methotrexate but never discusses providing a biologic.
The rheumatologist might rationalize this choice by saying things like they are old, do not have that long, or would not understand how to use a biologic, or "No way am I going to explain biologics to someone that old."
This year ACR featured an entire thread regarding ageism, and I was part of the opening session. During the hour, between 60 and 80 viewers were present.
What does the research say?
Ageism has an audience among the rheumatology community, but is ageism a critical consideration? There may be some ongoing literature to support that a bias does exist.
In 2009 (now old research), a Dutch study was done and found that "elderly RA patients were less likely to receive anti-TNF-alpha treatment within an equal period of time compared with younger patients, taking disease activity, disease duration and comorbidities into account."2
Just to emphasize: elderly patients were prescribed anti-TNF treatments less often than younger people with similar disease progression. Meaning, they were in pain longer and lost more joint mobility. One might draw 2 conclusions: either they complained less or they were taken less seriously.
Other rheumatic conditions like PsA
On the positive side, in 2019, there was a study on bias among 93 patients in a single clinic dealing with psoriatic arthritis (PsA) in prescribing biologic agents. The study states as follows:
"There is no age or sex bias in prescribing practices for PsA. In accordance with the ACR, patients with controlled symptoms on [oral small molecules] are being appropriately maintained."3
One must discount that finding, however. It was done in 1 sitting, and I suspect if you are fortunate enough to be seen by a doctor in that setting, you might be assured that ageism is not a thing. But there are a lot of rheumatology practices in our country, and one can not make a broad statement about the nature of the situation.
Reasons that ageism may occur
So why does this happen? One reason might be that "overworked health care professionals see the same older patients again and again."4
It is this repetition that creates the stunted view of what age and illness look like. If you are trained to believe that some people will die soon anyway, it may allow doctors to justify their actions. Of course, there is no way to prove that, but it is an interesting possibility.
There are also structural reasons that ageism is prevalent in the United States. For all that Medicare does right, it also creates some issues. Among them is that rheumatologists are among the lowest-paid specialists within the Medicare system, and the very profession that spends the most time with patients reimburses those physicians the least.
Medicare also cuts patients off from the most advanced treatments. It is sometimes impossible for those who rely on Medicare to have access to leading-edge therapies because of its reimbursement structure. Those who get the best treatment only do so because their rheumatologists are willing to take enormous time commitment to gain approval for their patients. Frankly, who wants to spend that amount of time for so little reimbursement?
In the case of rheumatology, ageism may run along with sexism. Approximately 70 percent of the rheumatology population is female.5 If women's complaints are often dismissed because they are voiced by women, then older women face an exceedingly difficult path in having their issues addressed.
Ageism must be addressed
Regardless of where it is found, we must confront ageism when and where we find it. If we do not engage and rebuke it as seniors, we are destined to make matters much worse.
Have you ever confronted 1 of the ism's (among these: ageism, sexism, racism, for example) in your rheumatologist or other doctor's office? Let us know what happened.
After the past 2+ years, how do you feel about telehealth appointments to manage your RA?