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Geriatric EM Ageism in the Emergency Department
Ageism in the Emergency Department
By Anita Chary, MD, PhD; Lauren Cameron-Comasco, MD; Anita Rohra, MD; Scott Dresden, MD, MS; Alden Landry, MD, MPH; Shan W. Liu, MD, on behalf of the SAEM Academy of Geriatric Emergency Medicine and the Academy for Diversity and Inclusion in Emergency Medicine
This article summarizes content from an inaugural webinar jointly sponsored by the Academy of Geriatric Emergency Medicine and the Academy for Diversity and Inclusion in Emergency Medicine. A recording of the webinar is accessible to SAEM members at: https://youtu.be/cJWO3fIf73I
Older adults, often defined as those aged 65 and older, represent a vulnerable patient population in emergency medicine. While many adults age healthily, others develop comorbidities that may limit their functional status and ability to independently perform activities of daily living. Physiologic changes that occur with aging lead to geriatric syndromes such as frailty, falls, and delirium, while changes in social position and relationships may lead to elder abuse and neglect. These issues necessitate a thoughtful approach to evaluation, treatment, and disposition of older patients in the emergency department (ED).
While older adults have unique clinical and social needs, we must also be wary of the differential treatment they may receive based on their age. Ageism is defined by the World Health Organization as “the stereotypes, prejudice, and discrimination towards others or oneself based on age.” While it can affect people of any age, in the world of medicine, we have particular concern about the impact of ageism on older adults. Clinicians may conflate increasing age with frailty, comorbidity, and disability. We may dismiss pathology due to old age, conceptualize physiologic changes associated with aging as disease, or make assumptions about our older patients that do them a disservice. Consider these examples: • A clinician omits a sexual history when interviewing a 74-year-old patient with dysuria, because the clinician doubts the patient is sexually active. • A clinician decides to shave the head of a long-haired older patient to repair a scalp laceration, neglecting the value the patient may place on their appearance. One strategy for combating ageism in emergency medicine is reflecting on and responding to our own biases. Implicit association tests and careful interrogation of our interactions with geriatric patients can reveal our unconscious biases about older adults. A common manifestation of ageism in medicine which implicates many clinicians is “elderspeak,” a form of communication that uses inappropriately juvenile and overaccommodating lexical choices. Examples include referring to older patients as “dear” or other terms of endearment, speaking slowly with short sentences, using an over-nurturing or high-pitched voice, or directing one’s gaze at a bedside caregiver rather than the patient. Elderspeak arises from implicit or unconscious bias. Those who employ elderspeak often intend to express care or facilitate communication. Instead, elderspeak works to exert a clinician’s control over the patient, reinforcing the old-age stereotype, and perpetuates negative self-perceptions among older patients. Studies show that older adults generally find elderspeak from health care workers patronizing and makes them feel incapable and impaired. Recognizing the negative impact that elderspeak can have on our patients, regardless of our intentions, can motivate us to change our communication styles for the better.
Category of Communication Examples
Content of Speech - Inappropriate terms of endearment:
“honey,” “dear,” “young lady” - Collective pronoun substitute: “Do we need to use the restroom?”
Delivery of Speech
Nonverbal Features - High-pitched vocal adjustments - Over-nurturing voice - Exaggerated intonations, smiles, nods - Short, slow sentences - Standing over patient - Yelling into patient’s ear - Patting patient on the head
Ageism operates not only at the level of interpersonal interactions, but also at institutional and structural levels. The COVID-19 pandemic, which has disproportionately affected older adults, has laid bare the ways that institutional policies can lead to disparate outcomes and decrease opportunities for advancement for people over the age of 65. One of the most obvious examples of institutional ageism during the pandemic has been the heavily weighted use of age in crisis standards of care, or standards used during emergencies to guide medical providers when rationing potentially life-saving treatments. Emergency clinicians have advocated against using age as a tiebreaker or relying on the concept of “life-years saved” to allocate ventilators and ICU beds, questioning underlying assumptions that devalue older adults’ contribution to and value in society.
A less obvious example of institutional ageism—but one that impacts our daily clinical practice—relates to masking. Hearing impairment affects approximately one-third of adults over the age of 65 and prevalence increases by decade. Mask mandates, while incredibly important as an infection control measure, can compromise communication with older adults who rely on reading lips or whose hearing aids are displaced by masks’ ear loops. Providing hearing amplifiers and masks with ties, rather than loops, represent simple solutions that can improve these patients’ ED experience. These forms of advocacy for systems-level change are crucial in mitigating ageism in medicine.
Ultimately, decreasing ageism in emergency medicine will require a multipronged approach involving policy and educational changes as well as increased intergenerational interactions and exposure to adults who are aging healthily. As we clinicians consider our own knowledge gaps and implicit biases about older adults and work to fill them, we can take steps towards improving experiences and outcomes for our geriatric patients. Dr. Chary is an emergency physician and health services researcher at Baylor College of Medicine, Waco, TX. She is an anthropologist whose research focuses on health disparities and health care delivery for vulnerable populations. She is the resident representative on the SAEM Academy of Geriatric Emergency Medicine (AGEM).
Dr. Cameron-Comasco, is assistant professor of emergency medicine at Oakland University William Beaumont School of Medicine, Rochester, MI. She is the director of geriatric emergency medicine and the Geriatric Emergency Medicine Fellowship Director at Beaumont Hospital in Royal Oak, MI. She is the current president-elect of AGEM and has served on the AGEM Executive Committee since 2018.
Dr. Rohra is the director of simulation and assistant program director in charge of education for the department of emergency medicine at Baylor College of Medicine (BCM), Waco, TX. Dr. Rohra was lead faculty for diversity in her department from 2016 to 2019 and established a group promoting women in leadership within the department.
Dr. Dresden is associate professor of emergency medicine and director of Geriatric Emergency Department Innovations (GEDI) at Northwestern University, Feinberg School of Medicine, Chicago. He is the current president of the SAEM Academy of Geriatric Emergency Medicine (AGEM)
Dr. Landry is an assistant professor of emergency medicine at Beth Israel Deaconess Medical Center, faculty assistant director of the Office for Diversity Inclusion and Community Partnership, associate director and advisor for the William B. Castle Society, and director of health equity education at Harvard Medical School. He also serves as senior faculty at the Disparities Solutions Center at Massachusetts General Hospital
Dr. Liu is associate professor of emergency medicine at Harvard Medical School and an associate physician emergency medicine, Massachusetts General Hospital, Boston, MA. She serves on the research advisory committee and is aa principal investigator for the Mass General Research Institute. Dr. Liu is the immediate past president of the SAEM Academy of Geriatric Emergency Medicine (AGEM)
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About AGEM
The Academy of Geriatric Emergency Medicine (AGEM) works to improve the clinical care of older patients, prepare trainees to care for older patients, and advance the geriatric EM research agenda. Joining AGEM is free! Just log into your member profile. Click “My Account” in the upper right navigation bar. Click the “Update (+/-) Academies and Interest Groups” button on the left side. Select the box next to the academy you wish to join. Click “save.”
By Austin Lee, MD, on behalf of the SAEM Global Emergency Medicine Academy
The Global Emergency Medicine Literature Review (GEMLR) was started in 2005 and was intended to collate and highlight high quality research in international emergency medicine. The project, which is completely volunteer led, with no financial funding or support, has now been continuously running for over 16 years, with the 17th iteration currently underway. The review was never intended to be a comprehensive systematic review, but rather a platform to aggregate and discuss the most important research in global EM (GEM).
Inception
The international emergency medicine literature review initially was brought together by members of the Emergency Medicine Residents’ Association (EMRA) International Emergency Medicine Committee alongside several members of the Society for Academic Emergency Medicine International Interest Group (now the Global Emergency Medicine Academy). Starting in 2005, a small team set out to scope and summarize the most useful recent literature in global emergency medicine (EM). The
first year, 44 articles met the screening criteria and 10 articles were reviewed in detail. As the authors first year noted in their manuscript, one of the greatest obstacles for global EM researchers and practitioners “remains the lack of a high-quality, consolidated, and easily accessible evidence base of literature.” They went on to aspire that the review could “act as a forum for disseminating best practices, while also stimulating further research in the field of international emergency medicine.” Dr. Adam Levine, who spent 13 years as the editor-in-chief, was a part of that initial startup team, and reflects on the early days of the review: “At that time there was Journal Watch and EM Abstracts, but no one was really looking at the international EM literature.”
The GEMLR group has remained independent of ACEP, SAEM or any particular external group, while maintaining a symbiotic relationship with Academic Emergency Medicine journal, where the review has consistently been published.
Growth of GEMLR
For the first several years, the review team was composed of EMRA members and almost everyone was a resident physician. As the methodology and search strategy evolved, the literature search quickly expanded from a few dozen articles to several thousand articles. As the inset graphs show, the number of articles that are screened each year has grown precipitously, from a few thousand, up to nearly 36,000 in 2020, and there are now several hundred full articles scored each year. In the late 2000s and again over the past year, there have been significant increases in articles related to pandemic disease (previously H1N1 influenza and more recently COVID-19).
As the project grew over time, the process became increasingly formalized with positions such as managing editor and assistant editors. The literature search also began to be split into two separate tranches covering six months, to give reviewers time to sort through the large number of screening and scoring articles. The language of the journal articles included has been an evolving target, with different languages meeting the inclusion or exclusion criteria based on the fluency of the review and editorial teams. Further, the methodology for determining the “top scoring articles” for a full review (which includes both a summary and commentary) has evolved over time.
Dr. Tom Becker, the current GEMLR editor-in-chief and review member since 2008, notes that the editorial board has developed a number of committees and has several avenues for both formal and informal feedback: “Over time, we have added new instructions or policies to address emerging issues or to standardize aspects of the review.”
Former managing editor Dr. Indi Trehan highlights how the editorial team considers the impact of potential protocol changes: “As ideas and problems come up, the committees are tasked to explore different solutions, which often means rerunning prior years’ reviews to see how outcomes might change”
Systematic Review Group
About six years ago, the GEMLR group also spun off a systematic review subgroup, which expanded the number of people able to participate with the project, while looking to answer more targeted questions in a systematic review format. The GEMLR group produces about one systematic review per year on a specific topic; this team is working to broaden the global EM evidence base while also increasing the exposure of GEMLR. To date, reviews have looked at pediatric nutrition interventions in humanitarian emergencies, bystander assistance for trauma victims in LMICs, the effectiveness of interventions for responders’ mental health in responding to disasters, and mobile health technologies and EM care LMICs.
Challenges
As the GEMLR has grown, there have been obstacles. Current GEMLR Managing Director, Dr. Sean Kivlehan, has observed the challenging task of managing the “ever growing number of articles that are reviewed each year.” Dr. Trehan expanded on this theme, remarking that many of the current data
management steps feel a bit clunky, from the manual extraction of abstracts from PubMed, to cutting and pasting large amounts of text, to the large spreadsheets with numerous data columns.
There has also been a growing recognition of the need for geographic and practice environment diversity among the reviewers, editors, and GEMLR leadership. Historically, the GEMLR team has been predominantly represented by volunteers from the global north, with a small minority living and working in the low- and middleincome countries (LMICs).
Dr. Levine has observed that GEMLR has not yet fulfilled its full potential to serve as a forum for disseminating best practices into the LMIC clinical environment. The full benefit that could come from better communicating the findings and highest quality research from the annual review to EM providers in LMICs is yet to be realized. Similarly, the goal of the review to stimulate research from international EM providers in LMICS indicates that more needs to be done. Dr. Trehan points out that despite a growing number of research articles each year, the predominance of funding from and to institutions in the global north perpetuates the colonization of global health research. Consequently, “the questions being asked are often not the questions that frontline LMIC providers are actually interested in as they won’t really help improve their clinical practice or patient outcomes.”
Successes and Future
“We have benefited greatly from the hard work of so many motivated volunteers, and I think many of them have had the chance to learn how to better appraise literature, as well as to develop and critique a literature review,” remarked Dr. Levine.
Dr. Becker makes light of the fact that the growth and consistent approach from the working group has made the GEMLR a “household name” in the global emergency medicine (GEM) community. He reflects on the joy he and many others have gained from the “networking and lifelong friendships that have evolved among members of the group.”
As described by Dr. Kivlehan, “the biggest success has been to build a major network of academic GEM practitioners across the globe. This network has led to extensive mentorship arrangements and collaborations outside of GEMLR.”
Over the past several years, the GEMLR leadership team has focused on expanding the global participation and representation among the pool of reviewers and editors. As GEM is growing as a field and more people are interested and there are more fellowships, the leaders have put term limits into place for editors to create scheduled turnover and allow others to contribute and move into leadership roles.
Among the growing population of EM practitioners in LMICs, as well as medical students, residents, and global EM fellows, the GEMLR serves as a very useful way to better understand the strengths and weaknesses of the current research and is a great tool in finding articles to discuss for a journal club or scholarly presentation. For those who are interested in joining the Global Emergency Medicine Literature Review group, there is an annual call for applicants (historically due in July or August).
As noted in the 2010 publication, the GEMLR continues to grow, and hopefully it can continue onward in its aims to “foster further growth in the field, highlight evidence-based practice, and encourage discourse” around global EM.
ABOUT THE AUTHOR
Dr. Lee is a senior reviewer for the GEMLR, and currently is a fellow in global emergency medicine at Brown University. He is interested in strengthening emergency care, particularly in low- and middle-income settings. @gemlrgroup
Global Emergency Medicine Literature Reviews Online 2005 – 2020
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
