Rheuminations: Ageism Is a Threat to Quality Care

My gray-haired, heavily moustachioed patient shot me a wry smile and a very slight nod under his cowboy hat. I got the message loud and clear.

I reciprocated with a bit of a sigh. “Don’t worry. I’ll talk to him afterward.”

The three-way conversation quickly resumed between the stoic patient, the eager medical student and me. You may ask, what was this kabuki theater all about?

It was about the phrase “getting older isn’t always fun, but it’s better than the alternative.” Admittedly, it’s some­thing that I’ve also said a few times in one form or another, but the more I look at it and the more interactions I have like that one in clinic, the more I realize that there’s probably a better way to talk about aging. Why? Let’s rheuminate!

Ageism in the Rheumatology Clinic

You may have heard about ageism. Ageism refers broadly to the unfair treatment of individuals or groups based on their age.¹ We often think of ageism as an abstract concept that affects employees in the workplace or leads to social invisibility, but it is very much present in the world of clinical medicine.² It can sometimes be very obvious to bystanders, such as when patients are denied treatments because of assumptions about their age, or, it can be much more subtle, like the above statement about fun and aging that based itself on questionable assumptions.³

Rheumatology is a specialty that tends to a dis­proportionately senior population, so ageism pre­sents a particular threat to the quality of care.⁴ The older adult with lupus may be seen as an outlier, and not even diagnosed because “it’s a disease of young people.” But old people were necessarily once young people.

The octogenarian with polymyalgia rheumatica may be given high-dose glucocorticoid course after high-dose glucocorticoid course because “the 10-year risk of fracture is not relevant.” I saw this on a note once.

And of course, patients with osteoarthritis may be advised that nothing can be done for their wear-and-tear arthritis.

These subtle judgments, sometimes festering in the depths of our unconscious, can influence both diagnostic reasoning and management plans that we would not like to admit. The truth is that age can quickly become a shorthand for limitation, rather than a vital aspect of the patient’s context necessary to inform evidence-based practice.

Moreover, ageism can also distort our perception of disease. Perhaps because only a vanishingly few of us have the unique ability to reverse age, we don’t really know how it feels to be old. To put ourselves in somebody else’s shoes is harder when we have not experienced what they have gone through. We may downplay complaints of pain or fatigue in older adults, seeing it as expected rather than potentially treatable. Our perceptions of cranky old men yelling at children to get off their lawn can make it seem like being in a bad mood is a normal part of aging. As a result, if we are not careful, we can end up with diagnostic overshadowing, catastrophic undertreatment or a failure to offer the same standard of care we might to a younger person with identical findings.⁵

Worse yet, maybe we don’t want to think of the elderly. In general, we love to reminisce about our past as we long for our youth. We look back to our golden years, while dreading the onset of silver hair. Taking care of patients who are afflicted by geriatric syndromes is a profound reminder of our own mortality. Recognizing their frailty can bring us closer to acknowledging our own frailty. Maybe that’s why we are so reluctant to talk honestly about aging and why, among the different types of isms, ageism appears to be forever in the background.

As you can imagine, combating ageism requires recognizing its looming presence within ourselves and dragging those deeply held assumptions from the background to the foreground. That means challenging knee-jerk habits that are expressed within our language, such as jokes and idioms and witticisms. It means honoring the life experiences of our older patients and seeing them as full people, not merely caricatures we see on television or in movies. And it also means that we acknowledge that one day we will be old ourselves and that we need to pioneer better treatment for the elderly before we end up in their shoes.

Power Disparities

It is fair to say that most of us seek to make the rheuma­tology clinic an egalitarian space, where patients feel comfortable disclosing their health concerns and clinicians feel comfortable providing potential solutions. Regrettably, the reality is that we are far from that ideal.

A power differential exists, one marked by the stethoscope and the white coat, access to the electronic medical record and the healthcare organization’s ability to dictate the pace and structure of the visit. Due to this power differential, our words carry enormous weight, which is exactly why we must use them with utmost precision.

Even casual remarks can have unexpected con­sequences. A well-meaning joke about aging may be appropriate among friends, but, in the context of a clinician providing care to a patient, it may come off as minimizing or dismissive. This is especially true when discussing chronic conditions that intersect with complex dimensions of identity, function and autonomy. Words matter, and, because of these power differentials, the impact of our words may not reflect our intent.

Complicating matters is that there is no true list of preferred words or words to avoid. More important is the sentiment carried by each word. That is why it is critical to strike the right balance between authenticity and sensitivity. We want to be personable, spontaneous and relatable because that is how we see an egalitarian relationship, but in our clinic spaces, this natural drive cannot come at the expense of respect. Being mindful of how our words land, especially across lines of age, requires self-awareness and humility. Listening is certainly an important part of developing that self-awareness and humility, but it is only the beginning of how we can address ageism.

Another aspect of addressing ageism is having a willingness to apologize. Ageism is so ingrained into our being that it is impossible to imagine that we can completely avoid its entry into our relationships. We will need to apologize when we inadvertently cause distress to others. An apology does need not be dramatic or self-flagellating. Neither does it need to be defensive. Sometimes a simple, “Thank you for pointing that out. I hadn’t thought about it that way,” can be transformative, so long as it comes from the heart.

In this case, because of my long-standing relationship with the patient, saying “I’ll talk to him afterward” seemed to be enough. It may feel awkward, but admitting fault catalyzes growth, and growth is all that we can ask for as we literally grow older.

Role-Modeling Change

For all that we talk about words, what is unspoken is often just as important as what comes out of our mouths. Precisely because of that power differential in clinic, we are being closely watched and our reactions are being monitored. How we listen to patients, how we talk with colleagues and how we reflect on our own behavior are key components of the encounter, and we can use these to role model change.

As many wise people have said (but notably not Mahatma Gandhi), we must “be the change [we] want to see in the world.” This necessitates being intentional about language, including body language. It means consistently engaging in positive, open, pro­social body language that mirrors our words and affirms the worth and complexity of our older patients. This is even true when there seems to be only two people in the room.

Seems to be is the key phrase here because we are, in truth, the products of thousands of encounters before us. When we have the discipline to consistently role model respect for older individuals, we are having a multiplicative effect on the encounters that we will have in the future. Truthfully, a one-time moment of political correctness is unlikely to make a meaningful difference. But repeated, quiet acts of dignity and thoughtfulness accumulate over time.

All of this requires deliberate self-reflection. We must interrogate our own biases, examine our automatic responses, and be honest about the ways in which we fall short. In the end, we must be willing to change, not because someone is watching, but because it’s the right thing to do. Integrity matters, as it always has, and always will.

To What End?

So what if we do all this? What if rheumatology becomes more attentive to ageism and power disparities? What happens when we choose our words with care and prioritize the dignity of our older patients?

One outcome is better communication. When patients feel heard and respected, they are more likely to be honest, engaged and proactive. This leads to richer clinical data, potentially better adherence to treatment and, ideally, improved health outcomes. Words, after all, build the bridge between knowledge and trust.

This communication builds deeper connections. By being mindful of ageism, we show our patients that they matter—not just as bodies to be diagnosed, but as people to be understood.

A therapeutic element exists in all this connection. We reinforce that their lives (and our lives) have value, regardless of age, and that those voices are worth listening to. Most importantly, deep and lasting connections build purpose, and that enables both clinicians and patients to thrive.

Ultimately, this empathic approach makes us better clinicians. It sharpens our ability to take in perspectives, thereby deepening our insights and aligning our practice with our values. While a lot has been done on administrative levels to promote the use of standardized surveys and questionnaires, this approach of deep listening and connection may be more meaningful and purpose driven.

Conclusion

So what happened with the medical student?

After the patient left, we sat down and began an open-ended conversation. Almost immediately, the medical student realized the patient had not taken his words very well and disclosed to me that he realized that misstep “as soon as those words came out.” Surprisingly, I talked very little since our student was rightfully doing the lion’s work of self-

reflection. I was impressed that he didn’t feel a sense of shame, but rather a sense of gratitude that the patient had pointed this out. Perhaps that is one of the privileges of being a student, and one mindset we should all try to cultivate and retain as we grow older.

As for the patient, he came back six months later. He saw me from across the waiting room, grinned, and said, “Doc, you’re looking older and wiser.”

I laughed. This time, nothing was mentioned about the alternative. I simply said, “Thanks. I’m having fun.”

Bharat Kumar, MD, MME, FACP, FAAAAI, RhMSUS, is the director of the rheumatology fellowship training program at the University of Iowa, Iowa City, and the physician editor of The Rheumatologist. Follow him on X (formerly Twitter) @BharatKumarMD.

References

1. Chang ES, Kannoth S, Levy S, et al. Global reach of ageism on older persons’ health: A systematic review. PLoS One. 2020 Jan 15;15(1):e0220857.
2. Burnes D, Sheppard C, Henderson CR Jr., et al. Interventions to reduce ageism against older adults: A systematic review and meta-analysis. Am J Public Health. 2019 Aug;109(8):e1–e9.
3. Coelho-Junior HJ, Calvani R, Picca A, et al. The influence of ageism on the hallmarks of aging: Where age stigma and biology collide. Exp Gerontol. 2024 Oct 15;196:112575.
4. Poudel P, Yu J. Geriatric rheumatology: The need for a separate subspecialty in the near future. Cureus. 2020 Jun 6;12(6):e8474.
5. Yarahmadi S, Soleimani M, Gholami M, et al. Ageism and lookism as stereotypes of health disparity in intensive care units in Iran: A critical ethnography. Int J Equity Health. 2024 Jun 3;23(1):114.