Coming Out about Age

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When I was growing up, every 12 months I got one year older. But my mother, who turned 39 three months after my 7th birthday, remained 39. That puzzled me. My mother explained that for women, by magic, their age never clicked past 40! The French have long dealt with my mother’s reluctance to come out about advancing age with the decorous phrase – “d’un certain âge.”

Some years ago, a distinguished physician-colleague a few years younger than I am now, told me he’d experienced three phases in his medical career. Early on, potential patients would say “Who is Dr. X and what does he know?”  At mid-career they would say “I want to see Dr. X – he’s the best!” Then, in when he got to the over-65 phase, they asked “Oh – is Dr. X still alive?”

Teen agers worry about looking too young to get in to R rated films or the popular clubs. For over 65ers like Dr. X, the worry is about looking too old to be seen as relevant to ongoing life.

I recently conducted a small, unplanned experiment with “coming out” about age. I lead the Ethics Advisory Group at Harvard Pilgrim Health Care (HPHC), a not-for-profit New England health plan. The group includes HPHC staff, employers who purchase HPHC insurance for their employees, physicians who practice in the HPHC network, consumers (folks who have HPHC insurance), and public policy representatives. Our topic was HPHC’s inclusion and diversity program. Our aim was to identify values that would support the program and values that might impede its success.

The meetings are open, and the topic drew 45 participants, including a lot of “diversity.” I try to make the discussion informal, engaged, and personally meaningful. As a white male professional I wasn’t accustomed of thinking of myself as “diverse.” But in the run-up to the meeting I realized that age, like race/ethnicity, LGBT status, and other characteristics, is part of the concern with inclusion.

I made an enquiry to the human resource department, and confirmed my guess that I’m the oldest employee in the organization.

Prior to the meeting I’d circulated an article by Eric Schultz, the CEO, about his personal commitment to inclusion and diversity. After Eric opened the discussion, a staff member recounted how, as a newly out lesbian, she cried at her orientation session, when the speaker made clear that LGBT folks were genuinely welcome. I followed her comment by saying that perhaps I should have cried when Eric included age in his opening remarks. (I like our meetings to include laughter, and was happy that the group laughed.) Later in the meeting I commented that a friend in his 80s, who is there in the consumer role, and I, represented “chronological diversity” much as African American, Latino, LGBT, and folks with disabilities, who were participating, represented other forms of “diversity.” (The group laughed again.)

After the meeting some of the participants said they’d enjoyed my comments about age and asked me how old I am. In terms of the climate of openness I want to encourage in the ethics meetings, I took the direct question as a good sign. But later I felt some discomfort. What if some of those at the meeting had “ageist” attitudes? Was I relegating myself into a ghetto? I know from the lesson my mother taught me early in life that I’m not the only one with a concern of this kind.

When I did a Google search under “elderly people coming out about age,” all the links were about LGBT coming out, except for one to the Beatles, who nailed my concern in the Sgt Pepper’s Lonely  Hearts Club Band with their song “When I’m 64”:

When I get older losing my hair,
Many years from now,
Will you still be sending me a valentine
Birthday greetings bottle of wine?

If I’d been out till quarter to three
Would you lock the door,
Will you still need me, will you still feed me,
When I’m sixty-four?

In my psychiatric practice, I saw many gay & lesbian patients who were conflicted about coming out. Over the years, I got better at helping them distinguish between genuine external risks and internalized homophobia. Since the ethics committee meeting I’ve been doing the same differential diagnosis with myself. To what extent is my concern about losing respect in my work environment realistic, and to what extent does it reflect internalized “ageism”? I believe it’s largely the latter. But time will tell.

James Sabin, M.D., 74, is an organizer of Over 65, a clinical professor of psychiatry at Harvard Medical School, and a Fellow of the Hastings Center.


7 Responses to “Coming Out about Age”

  1. Carol Eblen

    I enjoy your comments, Dr. Sabin, because you aren’t afraid to reveal that you are human, and you have a sense of humor about “ageism.” “Will you still need me? Will you still feed me when I’m 64” should be updated to “when I’m 84” in view of the wonderful technology that supports healthy aging in the 21st Century.

    Somehow, we all survive getting older and our
    psych/ego is protected because we don’t even really remember our younger versions. This would be too painful! At 86, when I look at the old woman in the mirror with the white hair and sagging skin, I don’t really feel or remember that younger me at all. This would be too painful! When I try to recall the young “me,” and when I look at snap shots, I recognize her, but she isn’t living with me NOW and she is just a pleasing memory.

    We grow old around our essential selves and accept it until old age starts eroding our essential selves and we become “somewhat” disabled and dependent and often “invisible” in the busy world of the young and magnificent.

    But “ageism” in the Medicare/Medicaid healthcare Delivery System exists for both the old patient and for the physician, whether young or old, doesn’t it? Age is a co-morbidity factor, isn’t it?

    I heard William Buckley tell Charlie Rose that he was just tired of living and ready to go and that he sticks around for his family —and then look at Betty White, who is going to squeeze all she can out of life until the very end.

    I would hope that the Hastings Center would take a look at “ageism” as it exists in healthcare for the elderly/disabled on Medicare and disclose the connection of medical futility to fiscal futility and its connection to unilateral covert or overt DNR Code status that is extrapolated into the medical charts of the elderly/disabled when hospitals/physicians KNOW there will be no reimbursement for life-extending or life-saving treatments by Medicare and the private insurers.

    Isn’t this the ugliest form of ageism?

    • Fer

      Of the three, Mortensen struck me as hanvig the smallest part in the film (granted it’s not like I was sitting there with a stopwatch). It could also just be the way Freud is handled within the story it’s more The Jung Show! with Special Guest Sigmund Freud! Could also be that people have come to expect one thing from Knightley, so when she brings something different it catches people’s attention

  2. Hope Reiner

    As much as I am trying to understand the new health care law and the ever present conversation on how expensive our health care system is compared to other countries, it never dawned on me that prolonging life would be a ‘luxury’ our system couldn’t afford.

    The thought terrifies me and the fact that this can happen makes me sick.

  3. Jim Sabin

    Dear Carol and Hope

    Thank you for your comments!

    I found Carol’s description of how the younger self recedes very interesting. It goes against an aphorism that was useful in my mental health practice: “maturity is a phase, but adolescence is forever.”

    With regard to Carol’s comment about unrequested DNR status and Hope’s fear that prolongation of life is seen as a “luxury” we can’t afford: that issue cuts both ways. Many elderly fear overly aggressive medical efforts to prolong life when the person feels “ready to go.” But as your comments point out, others fear that the medical establishment will “let go” too soon, or even take active steps to hasten an undesired death.

    Handling end of life care in a more comforting manner requires more conversation – within families and between patients/caretakers and health professionals. Unfortunately, the idea of conversation was made toxic when duplicitous politicians and media figures applied the term “death panel” to legislation that would have required Medicare to reimburse physicians for conversations about end of life care that were REQUESTER by their patients. Even though the “death panel” fantasy was at best a mistake but more likely a knowing lie, a substantial proportion of the population believed the claim.

    As Carol conveys, a vigorous older age can be experienced as a “blessing.”



    • Ollie

      Keep these arelcits coming as they’ve opened many new doors for me.

  4. Carol Eblen

    Yes, I agree! The death panel business was just artful nonsense by the Republicans to promote fear to cover up the fact that both “medical futility” and “fiscal futility” considerations often come to bear on the same patient, and that a type of “rationing” has been around a long time under both Republican and Democrat administrations because of Budget constraints.

    Of course, it cuts both ways, i.e. over treatment (for profit) and under treatment (for profit) because the 1991 PSDA has never been clarified at federal level and has been inadequately implemented at state level. Consequently, elderly patients have been hung out on a limb when they are over treated or are when they are the victims of non beneficial over treatment, errors and complications and are under treated.

    Because clinics and physicians’ incorporated practices were not put under the provisions of the 1991 PSDA, they believed that they had no legal duty to SEEK informed consent for either Curative Care OR Palliative Care, transition to Hospice, from their elderly Medicare patients suffering from diseases that would most likely kill these patient sooner or later. It is the treating physicians who didn’t want to have these end-of-life conversations with their patients, isn’t it?

    The reason may be because, under the law, physicians could treat and over treat elderly Medicare/Medicaid patients up to the diagnosis related group cap (DRG Cap) for the cancer/disease being treated (because of the federal age discrimination statute) and be fully reimbursed by CMS and the private insurers.

    Patients are “product” for profit under our system, are they not? There is much profit in curative care and only profit for the Hospice organization when patients ELECT to give up curative care and go onto Hospice.

    However, when, over ten or more years ago, CMS introduced Reimbursement protocols that started to punish physicians for non beneficial over treatments, mistakes, errors, and the complications, thereof, hospitals/physicians have had to EAT some of the costs of treatment when the treatment isn’t reimbursed by CMS or the private insurers.

    Physicians (mostly cancer specialists) are not seeking informed consent for palliative care as opposed to curative care in the OUTPATIENT setting and waiting too long to refer late stage patients to palliative care/transition to hospice. The patients, however, aren’t aware that they aren’t getting curative care, according to an article published by the NHI Library. Most outpatient cancer patients believe their outpatient treatments will or can cure them.

    Because the goals of the 1991 PSDA have been frustrated because of the physicians’ failure to cooperate with the goals of the 1991 PSDA, i.e. to prevent over treatment, to ensure patient autonomy, and to save money for Medicare and the Private Insurers when elderly terminal patients would elect to die sooner than later in order to shorten their suffering unto certain death, we have the MESS that exists today.

    Obviously, the trial planned by CMS in 2014 wherein Medicare patients will be eligible to be on BOTH Curative Care and Palliative Care/transition to Hospice at the SAME TIME is viewed as the new solution to stopping over treatment and to curbing the End-of-Life costs of dying of our growing population of elders.

    But, in the meantime, some pretty ugly stuff is going on, and elderly patients are being over treated for profit and passively euthanized for fiscal expediency, as necessary, with no recourse under current law.

    Doesn’t this worry you?

  5. Steve Moffic

    Remembering and processing our younger selves before the age of 64 can be mentally healthy and put our lives in perspective. Formally, this is called “Reminiscence Therapy”, but it can be done without a therapist. In a prior blog here, I tried to portray that process by going over my different names over my lifespan. Perhaps doing this kind of life review can even help us make end of life decisions.

    Steve Moffic