This may be the first study to explore expectations regarding aging, as measured by the ERA-12, in a sample of practicing primary care clinicians. It is important to understand clinicians’ perceptions of aging because of the role clinicians play in supporting, diagnosing, and treating older individuals in the health care system. As social psychologists have long recognized (e.g., Blau, 1973
), what we think of a person influences how we perceive the individual, which in turn influences how we behavior toward the person, which, in turn, shapes that person. Clinician attitudes regarding aging may well affect the ways in which clinicians perceive their patients and selectively attend to and approach health care preventive and intervention practices. In fact, clinicians must rely upon their best judgment regarding normative and nonnormative behaviors in deciding what sorts of assessment, treatment, and follow-through are warranted by the symptoms patients present.
In our sample, 14.7% of the primary care clinicians reported that it was a normal part of aging to become depressed. Qualitative research by Burroughs and colleagues (2006)
indicated that primary care clinicians viewed late-life depression as a normal part of aging rather than an objective diagnostic category for treatment. Thus, Burroughs and colleagues
argued that these clinicians demonstrated therapeutic nihilism, the feeling that nothing could be done for this group of patients, and therefore, the clinicians did not attempt to address the condition. This finding is alarming in light of the fact that (a) depression is a treatable condition and (b) older adults are just as happy as their younger counterparts (Taylor, Morin, Parker, Cohn, & Wang, 2009
). Similarly, one third of the clinicians we surveyed agreed that as people get older they worry more, and one third agreed that every year that people age their energy levels go down a little more. Attitudes regarding these issues may moderate the degree and manner in which the clinicians elect to follow-up on patients’ complaints regarding worry and energy levels.
Although lower ERA may be detrimental to mental, physical, and cognitive health, it is also possible that expectations that are “too high” can have negative consequences if they cause older adults to have unrealistic expectations for which they will always fall short. Surprisingly, over 70% of our clinician sample disagreed with the statement that we need to lower expectations of how healthy we can be with age, which seems unrealistic given that 100% of aging adults experience declines in physical health across multiple physiological systems. Similarly, 55.7%–66.0% of respondents disagreed that trouble remembering names and forgetfulness is an accepted part of aging, despite extensive data showing that the ability of nondemented older adults to recall names declines with aging (American Academy of Family Physicians, 2009
Although various aspects of the “normal” aging process can be modified and minimized through attention to preventive health behaviors and healthy lifestyle choices around diet, exercise, personal habits, and psychosocial factors (e.g., Centers for Disease Control and Prevention and The Merck Company Foundation, 2007
; Peel, McClure, & Bartlett, 2005
), unrealistic clinician age expectations could contribute to patients’ feelings of inadequacy. Of course, unrealistically positive or negative assumptions regarding aging may also encourage the clinician (and others) to “blame the victim” (Ryan, 1976
), that is, blame the elder for a perceived failure to maintain certain health standards, rather than attend to contextual variables such as lack of intellectual, social, emotional, financial, or other resources that need to be addressed to support healthy aging.
Change is a part of aging; understanding and coping with how much, how quickly, and how fast is likely a key to successful aging. Goodwin (1991)
urged us to be careful regarding what we consider age-related “diseases” and what we do and do not consider to be preventable with advancing age. Clinicians with unrealistic views of aging may diminish rather than enhance their patients’ progress toward successful aging. Future research must help us understand the parameters of “realistic” expectations of aging, defined within the context of disparate societal conditions.
Our analyses identified a limited set of clinician characteristics that were associated with higher versus lower clinician ERA. As we review each, however, it is important to note that they actually explained a relatively small amount of the overall variance in clinician ERA-12 scores, leading us to speculate on other factors that may enter into these associations.
Respondent age was inversely associated with age expectations such that older clinicians reported lower scores on the ERA-12. Similar associations have emerged in studies of lay community members aged 60 years and older (Kim, 2009
; Sarkisian et al., 2002
; Sarkisian, Steers et al., 2005
). However, once we controlled for gender (women in our sample were disproportionately younger), age did not predict age expectations. Future research needs to examine age-related variation in ERA-12 scores, including the degree to which age expectations may actually decrease with age or, alternatively, may reflect a cohort effect. It is certainly possible that personal and/or professional life experience over the life span contribute to increasingly lower ERA. This receives some support from our finding that even after controlling for clinician age and gender, greater number of years a clinician had practiced was associated with lower age expectations (on the overall ERA-12 as well as on each of its subscales). It is possible that through additional years of medical practice, clinicians confront situations (e.g., as patients succumb to health problems they had worked to avoid) that convince them that there is less control over the aging process than they had originally anticipated.
In contrast, there is also good reason to expect that cohort effects contribute to lower age expectations among older clinicians. As noted earlier, there is evidence that attitudes regarding aging have become more positive over the past 30 years among the general population (Cook, 1995
; Quadagno, 2008
), and emerging knowledge and other resources have increasingly supported longer and healthier lives through recent history. Therefore, we might expect that younger clinicians have had less experience with negative images of aging and were exposed to more positive ERA during the formative years of their personal development and clinical training. In a related vein, the training of younger clinicians likely emphasized advances in, for example, neurobiological development that were not part of earlier training and that may contribute to more positive expectations among this younger cohort. Longitudinal research is needed to clarify the relative contributions of these and other developmental and cohort-related variables.
In our sample, female clinicians reported higher age expectations than their male counterparts. When clinician age and gender were both included in the analysis with total ERA-12 scores, the associations between gender (but not age) and ERA-12 remained significant. However, because women in our sample tended to be younger on average than men (M
= 43.4, SD
= 9.6, and M
= 51.7, SD
= 11.6, respectively), it is likely that these variables are collinear. Previous studies have not reported on the associations between ERA-12 scores and gender, and additional research with participants matched on age, gender, and sociodemographic characteristics is necessary to determine the nature of this gender association. The bases of these gender differences are likely complex, potentially relating to variations in motivations for and experience in clinical training, attitudes regarding patient–practitioner interaction, and gender-associated patterns of practice, to name just a few possibilities. For example, research has found that female (vs. male) physicians recommend more preventive services, attend more to emotional issues, spend more time with their patients, and have greater patient satisfaction (Bertakis, 2009
). Although we do not suggest that these gender-related patterns among physicians necessarily contribute to or reflect differences in ERA, they suggest that gender may be associated with a variety of behaviors and attitudes that may also be engaged in expectations of and interactions with aging patients.
Contrary to our hypothesis, we found no strong associations in our sample between a clinician’s personal health behaviors (i.e., reported fruit and vegetable consumption, exercise, perceived fitness, perceived health) and ERA-12 scores. This may be explained, in part, by the fact that only 7% of our sample was older than 65 years and other factors such as activity availability or competing priorities with work and family may be more prominent barriers to the performance of health behaviors than views about aging for younger populations. Moreover, there was quite limited variation in our respondents’ health behaviors, with most reporting high levels of healthy activities and fitness. This fact diminishes the potential to identify significant associations between health behaviors and age expectations.
Although not comparable samples, it was striking that primary care clinicians in this study had a mean score of 68.2 (SD
= 14.5) on the ERA-12, considerably higher than the means of 23.5–39.7 of community-dwelling elders reported in previous studies (Joshi, Malhotra, Lim, Ostbye, & Wong, 2010
; Kim, 2009
; Sarkisian, Steers, et al., 2005
). Future research needs to examine how factors such as culture, education, age, and socioeconomic status may influence age expectations both within and beyond clinician populations. For example, as noted earlier, it may be that younger adults have higher age expectations in general as a result of their limited experience as well as the cultural context in which they have lived. It is also possible that more affluent members of society are buffered from some of the challenges of aging that afflict the impoverished or underserved. Relating to culture and ethnicity, Sarkisian, Shunkwiler, Aguilar, and Moore(2006)
found that after adjusting for health and sociodemographic characteristics, Latinos had lower age expectations than non-Latino Whites and African Americans. However, when the authors added education to the model, being Latino was no longer significant (Sarkisian et al., 2006
). Exploring the etiology of age expectations across the life span may inform interventions to modify age expectations in both young and older adults from diverse backgrounds.
A limitation of the current study is that it relied on only one measure of views regarding aging. Future studies should explore the associations between ERA-12 scores and other standard measures of attitudes and stereotypes toward the aged and aging, and provide normative data for comparisons between the three subscales. In addition to those noted previously, the demographic, training, and health characteristics explored in the present study explain a small portion of the variance in ERA-12 scores. Future research should consider other constructs we did not measure that might explain variation in clinician ERA-12 scores such as believing health outcomes are modifiable versus fixed, optimism, self-efficacy, depression, and happiness. In addition, experiences such as working in a nursing home might influence age expectations. Longitudinal (rather than cross-sectional) ERA data from larger and more diverse populations of clinicians (and nonclinicians) would enhance our ability to more fully understand the role of the variables we examined as well as to identify other characteristics that predict the content of and change in age expectations over time. Qualitative research with primary care clinicians and with other medical professionals may help identify characteristics that need to be explored in subsequent quantitative work.
Implications for Practice
Primary care clinicians play an important role in promoting primary, secondary, and tertiary preventive health care and facilitating successful and productive aging across the life span. Our research provides important baseline data regarding the expectations of young, middle-aged, and older primary care clinicians regarding aging and it identifies some of the clinician characteristics that are associated with variation in clinician age expectations.
Because personal views of aging have been linked to subsequent health behaviors among older adults, it is quite possible that clinicians’ expectations about the aging process are associated with differential diagnostic, treatment, and referral patterns as well as contribute to patients’ expectations and health behaviors. It is critically important that future research examines how clinicians’ age expectations influence personal behaviors and health care delivery. Studies on clinicians’ age expectations may help guide the development of interventions to “optimize” clinician views of aging so they can offer appropriate care that is likely to make a difference in meaningful health outcomes without medicalizing the aging process itself, facilitate personal opportunities for aging well, and support patients’ ability to age successfully.