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88–496 PDF 2003

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

(

SPECIAL COMMITTEE ON AGING 

LARRY CRAIG, Idaho, Chairman 

RICHARD SHELBY, Alabama 

SUSAN COLLINS, Maine 

MIKE ENZI, Wyoming 

GORDON SMITH, Oregon 

JAMES M. TALENT, Missouri 

PETER G. FITZGERALD, Illinois 

ORRIN G. HATCH, Utah 

ELIZABETH DOLE, North Carolina 

TED STEVENS, Alaska 

RICK SANTORUM, Pennsylvania 

JOHN B. BREAUX, Louisiana, Ranking 

Member 

HARRY REID, Nevada 

HERB KOHL, Wisconsin 

JAMES M. JEFFORDS, Vermont 

RUSSELL D. FEINGOLD, Wisconsin 

RON WYDEN, Oregon 

BLANCHE L. LINCOLN, Arkansas 

EVAN BAYH, Indiana 

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 CenterUSA ....................................................................................................................... 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) 

(1)

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 

2

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 

3

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 yearolds 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. 

4

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. 

5

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, 

6

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:]

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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 

11

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:]

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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 reVerDate 0ct 09 2002 12:19 Sep 30, 2003 Jkt 000000 PO 00000 Frm 00018 Fmt 6633 Sfmt 6633 C:\DOCS\88496.TXT SAGING1 PsN: JOYCE
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quire 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 

22

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 twothirds 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. 

41

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 welltrained 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. 

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stance, 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, 

57

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. 

58

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 

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bursed—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? 

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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 

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tive 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. 

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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 

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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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