Normal versus Pathological Aging: Knowledge of Family Practice

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Copyright 1996 by

The Cerontological Society of America The Cerontologist

Vol.36

, No. 1,113-117 Famil y physician s ma y lac k discriminator y abilit y t o differentiat e norma l agin g fro m diseas e states . To assess such ability, 53 aging-related indicators or symptoms were presented to 65 physician s i n thre e famil y practic e residenc y programs . Respondent s classifie d eac h sympto m a s norma l agin g o r disease . O n average , resident s classifie d 73.4
% o f symptom s correctly . The y wer e mor e likel y t o classif y diseas e state s correctl y (80.0% ) tha n t o classif y sign s o f norma l agin g correctl y (66.8%) . Misattributio n o f norma l agin g sign s a s diseas e ma y promp t physician s t o overmedicat e an d overtrea t patients , resultin g i n advers e clinica l outcomes . Ke y Words : Medica l education , Geriatric s education , Aging , Knowledg eNormal versus Pathological Aging:

Knowledg

e o f Famil y Practic e Resident s S . Collee n Beall , DrPH, 1 Lori n A . Baumhover , PhD, 2 Ala n J . Maxwell , MD, 1 an d Rober t E . Pieroni , MD 3

Elderl

y patient s accoun t fo r 20 % o f al l outpatien t physicia n encounter s (Reuben , Fink , Vivell , Hirsch , & Beck , 1990)
, an d almos t 50
% o f thos e visit s ar e t o famil y physician s (Verno n & Worthington , 1992)
. I n comin g years , th e proportio n o f offic e visit s b y olde r peopl e wil l increas e rapidl y du e t o th e growt h o f th e elderl y populatio n an d th e hig h rat e a t whic h th e elderl y utiliz e healt h car e resources .

Althoug

h a n increasin g numbe r o f medica l educa - tio n program s hav e include d geriatri c component s i n recen t years , th e integratio n o f geriatric s conten t int o residenc y trainin g program s i s ofte n inadequat e (Reube n e t al., 1990). Furthermore, it is not clear that physician s are , o r perceiv e themselve s t o be , ade - quatel y prepare d t o trea t a n agin g patien t populatio n (Blumber g & Macpherson , 1992
; Drog e & Billig , 1992)
. Severa l factor s sugges t tha t preparatio n i s no toptimal: (a) recent studies indicate low preferences fo r workin g wit h elderl y patient s b y medica l student s and/o r physician s (Smit h & Wattis , 1989)
; (b ) criticis m continue s t o b e directe d a t th e inadequac y o f medi - ca l educatio n i n geriatric s - or , a t least , t o th e lo w priorit y give n t o geriatri c component s (Reube n e t al. , 1990
; American Geriatrics Society [ACS], 1991); and (c ) medica l professional s frequentl y d o no t ear n hig h score s o n genera l test s o f knowledg e abou t agin g (Intrieri , Kelly, Brown, & Castilla, 1993). O f mor e specifi c interes t i s physicians ' knowledg e abou t issue s relate d t o th e clinical , diagnosi s an d managemen t o f agin g patients , an d abou t aspect s o f norma l huma n agin g (ACS , 1991)
. Knowledg e abou t bot h shoul d b e a n importan t facto r i n determinin g•Address correspondence to Colleen Beall, DrPH, Center for the Study of Agin g - CCHS , Th e Universit y o f Alabam a Schoo l o f Medicin e - Tuscaloos a

Program

, Box 870326, Tuscaloosa, AL 35487-0326. -Cente r fo r th e Stud y o f Aging , Th e Universit y o f Alabama . •'Departmen t o f Interna l Medicine , Th e Universit y o f Alabama . th e cours e o f car e tha t physician s prescrib e fo r el - derl y patients . Thi s researc h i s base d o n a metho d firs t use d b y Co e an d Breh m (1972 ) i n a surve y o f U.S . physician s i n whic h subject s wer e aske d t o classif y sign s o r condition s frequentl y observe d i n olde r patient s int o tw o categorie s base d o n whethe r the y resul t fro m (a ) norma l agin g processe s o r (b ) disease-relate d pro - cesses . I n conductin g thi s researc h w e wer e inter - este d i n (1 ) developin g a n up-to-dat e instrumen t whic h coul d b e use d t o asses s suc h knowledge ; (2 ) measurin g a n overal l knowledge-of-agin g score ; (3 ) measurin g abilit y t o correctl y classif y norma l agin g an d diseas e processe s i n th e elderly ; an d (4 ) measur - in g th e relationshi p betwee n knowledg e score s an d (a ) basi c demographi c factor s (e.g., gender, resi- denc y year) , (b ) geriatri c experience s (e.g., geriatric rotation , number of elderly patients), and (c) per- ceive d attitude s abou t geriatric s education . O f par - ticula r interes t wa s whethe r geriatri c experience s ha d a n impac t o n knowledge .

Method

s

Subjects

Questionnaire

s wer e distribute d t o famil y practic e resident s a t th e thre e campuse s o f th e Universit y o f

Alabam

a Schoo l o f Medicin e (UASOM) , t o director s o f residenc y program s affiliate d wit h th e Universit y o f Sout h Alabam a (USA ) Colleg e o f Medicine , an d wit h Pennsylvani a Stat e Universit y Schoo l o f Medi -cine. A total of 65 questionnaires was returned. Re- spondent s represente d i n th e fina l analyse s cam e fro m th e followin g programs : 3 fro m UASOM , Bir - mingha m campus , 1

9 from UASOM, Tuscaloosa cam-

pus , 23 from UASOM, Huntsville campus, 7 from US A Colleg e o f Medicin e (Mobile , AL) , an d 1 3 fro m Pen n Stat e (Washington , PA) .

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, No . 1,199

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Questionnaire

Th e instrumen t use d t o asses s knowledg e abou t norma l an d diseas e condition s wa s modele d afte r a

40-ite

m instrumen t develope d b y Dy e an d Sassenrat h (1979) . Fo r ou r study , a numbe r o f modification s wer e made : (a) items were updated or deleted to be more consisten t wit h curren t knowledge , (b ) th e distinctio n betwee n functiona l an d physiologica l item s wa s elim - inated , and (c) items were added to replace those deleted . In addition, a number of items were added in anticipatio n tha t som e item s woul d b e eliminate d i n th e proces s o f validatin g th e instrument .

Instrumen

t developmen t consiste d o f tw o phases : (a ) Th e fou r investigator s (on e geriatrician / internis t an d on e geriatrician/famil y practi - tioner , on e gerontologis t an d on e epidemiolo - gist ) reviewe d th e existin g instrumen t an d serve d a s a n interna l pane l o f developer s an d judges . Item s wer e retained , deleted , modi - fied , or added, resulting in a 55-item pool. (b ) Apreliminar y instrumen t consistin g o f thes e 5 5 item s wa s late r reviewe d b y a pane l o f nin e primar y car e physician s t o asses s th e fac e va - lidit y o f th e item s o n th e scale . A s a resul t o f thi s review , tw o items , on e relate d t o norma l agin g an d on e t o pathology , wer e omitted . Thi s articl e report s th e result s obtaine d usin g th e

53-ite

m instrumen t (2 5 item s o n norma l aging , 2 8 o n patholog y i n aging) . Th e questionnair e include d ad - ditiona l item s t o asses s demographic , experiential , an d attitudina l characteristic s o f th e sample . Interna l consistenc y o f th e resultan t instrumen t wa s accept - abl e [Cronbach' s alpha s = .8 7 (norma l aging) , .8 5 (patholog y i n aging) , .8 0 (overall)] .

Instructions

Instrument

s wer e distribute d t o th e director s o f th e residenc y trainin g program s describe d earlier .

Resident

s wer e requeste d t o complet e th e instru - ment s independently . The y wer e advise d tha t partici - patio n wa s voluntary , an d response s woul d b e anon - ymous . Assurance s wer e provide d tha t n o attemp t woul d b e mad e t o identif y individua l respondent s an d tha t response s woul d i n n o wa y affec t thei r evaluation s b y thei r preceptors , attendin g physi - cians , or faculty.

Analyses

Frequencie

s ar e reporte d fo r demographi c an d medica l educatio n variables . I n th e knowledg e tests , onl y correc t response s ar e counted . Missin g re - sponse s ar e treate d a s incorrect . T-test s an d one-wa y analyse s o f varianc e ar e use d t o examin e difference s i n knowledg e betwee n specifie d group s base d o n variou s variables .

Result

s A s show n i n Tabl e 1 , ove r two-third s o f th e sampl e wa s male , an d th e media n ag e wa s 29
. Eigh t respon - dent s wer e ag e 3 5 o r over , an d on e wa s younge r tha n Tabl e 1 . Characteristic s o f th e Sampl e

Characteristic

s Tota l Gende r Mal e Femal e Ag e 20-2 7 28-3
0 >3 0

Residenc

y yea r R 1 R 2 R 3

Complete

d forma l geriatri c rotatio n N o Ye s < 4 wks = s 4 wks

Expecte

d practic e settin g

Privat

e partnershi p

Multi-specialt

y clini c Healt h maintenanc e organizatio n

Academi

c o r researc h Othe rn 6 5 4 6 1 9 2 4 2 2 1 8 2 9 2 4 1 2 4 5 2 0 3 1 5 4 2 4 5 3

9Percent

100.
0 70.
8 29.
2 37.
5 34.
4 28.
1 44.
6 36.
9 18. 5 69.
2 30.
8 4. 6 23.
1 66.
7 6. 3 7. 9 4. 8 14. 3 Note: Frequencie s ma y no t ad d t o 6 5 du e t o missin g data . 26
. Almost half were in their first year of residency training . Over two-thirds reported that they had not complete d a forma l rotatio n i n geriatrics . Amon g thos e havin g complete d suc h a rotation , th e mos t commo n lengt h reporte d wa s fou r weeks . Two-third s o f resident s indicate d tha t the y expecte d t o ente r a traditiona l primar y car e sol o practic e o r partnership .

Resident

s wer e aske d bot h abou t th e numbe r o f nursin g hom e patient s an d tota l elderl y patient s ac - tivel y followe d a t th e tim e the y wer e sampled . Tabl e 2 indicate s tha t a larg e majorit y o f resident s wer e activel y followin g elderl y patients . Seventy-fiv e per - cen t wer e seein g a t leas t on e nursin g hom e patient , bu t onl y 15 % wer e followin g thre e o r more . Th e resident s wer e muc h mor e likel y t o b e attendin g t o elderl y patient s i n othe r settings , becaus e mos t re - porte d tha t the y wer e followin g 10-2 0 age d patients . Seve n resident s wer e followin g 2 6 o r more . How - ever , thes e result s ma y b e misleading , becaus e 1 9 resident s faile d t o provid e a n estimat e o f th e numbe r o f olde r patient s i n thei r caseload .

Contrar

y t o som e expectations , genera l attitude s towar d th e elderly , a s reporte d b y th e residents , di d no t deteriorat e o r becom e mor e negativ e throug h th e residenc y experience . Ove r one-thir d o f respon - dent s reporte d tha t thei r attitude s becam e mor e pos - itive , while over half reported no change. Most re- spondent s perceive d tha t th e facult y relate d t o elderl y patient s i n muc h th e sam e manne r a s t o younge r patients . Ther e di d no t appea r t o b e an y bia s i n th e treatmen t o f patient s base d o n age . Hal f th e resident s viewe d problem s o f th e elderl y a s ade - quatel y addressed ; 19 % reporte d the y wer e not . 11 4 Th e Gerontologis

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Table 2. Current Patient Load and Perceptions of Geriatric TrainingTable 4. Percent of Correct Responses by Item

Variable

sNumberPercent

Nursin

g hom e patient s Non e 1 5 23.
4 1 2 1 32.
8 2 1

8 28.1

3 o r mor e 1 0 15. 6

Elderl

y patient s Non e 4 8. 7 1- 5 8 17. 4 6-1 5 1 9 41.
3 16-2 5 8 17. 4 2 6 o r mor e 7 15. 2

Change

s i n attitude s towar d elderl y Mor e positiv e 2 4 37.
5 N o chang e 3 4 53.
1 Mor e negativ e 6 9. 4

Attitud

e o f facult y towar d elderl y patient s Mor e positiv e 1 3 20. 3 N o differen t 4 7 73.
4 Mor e negativ e 4 6. 3

Problem

s o f th e elderl y adequatel y addresse d Ye s 3 2 50.
0 No t sur e 2 0 31.
2 N o 1 2 18. 8 Note: Frequencie s ma y no t ad d t o 6 5 du e t o missin g data . Tabl e 3 . Mea n Score s o n Agin g Knowledg e

Variabl

eMean Scor ePercentage

Correc

t SD Norma l agin g scor e 16. 7

Diseas

e state s scor e 22.
4 Tota l scor e 39.
166.8
80.
0 73.
75.7
4. 7 6. 6 Tabl e 3 display s th e averag e numbe r an d percen t correc t response s t o item s relate d t o norma l agin g ("norma l aging") , item s relate d t o diseas e condition s ("diseas e states") , an d tota l item s i n scal e ("over - all") . The average scores for the normal and overall scale s represente d les s tha n 75
% o f th e item s cor - rect , indicatin g tha t knowledg e deficit s abou t agin g d o exis t amon g thes e residents . Resident s wer e bet - te r abl e t o identif y item s associate d wit h disease s o f th e elderl y (mea n scor e = 22.4
, representin g 80
% o f th e item s correct) . Th e correlatio n betwee n score s o n norma l agin g an d diseas e stat e item s wa s smal l (r = .22) . Tabl e 4 provide s percentage s correctl y respondin g t o eac h item . Knowledg e wa s bette r fo r disease - relate d tha n fo r norma l agin g items . Th e mos t fre - quentl y misclassifie d condition , decreased pro- prioception, wa s correctl y classifie d a s norma l b y onl y 35
% of residents. In contrast, decubitus ulcers, a pathologica l condition , wa s th e mos t frequen t cor - rec t classificatio n (97 % o f respondents) .

Difference

s i n knowledg e level s betwee n norma l agin g an d patholog y ar e als o suggeste d b y a compari- so n o f frequentl y misse d items . Eigh t item s wer e misclassifie d b y 40
% o r mor e o f respondent s (hig h Ite m 1 . Compression fractures 2 . Elevated prothrombin time 3 . Fewe r tast e bud s 4 . Bacteria in urine 5 . Dizzines s 6 . Increase d adipos e tissu e 7 . Decrease d bon e mas s 8 . Interrupte d slee p 9 . Decubitu s ulcer s 10 . High frequency hearing loss 11 . Anxiety 12 . Increased transaminase levels 13 . Pedal edema 14 . Decline in speech discrimination 15 . Perseveration 16 . Slowed colonic transit 17 . Yellowing of lens of eye 18 . Decreased temperature regulation 19 . Decreased tactile sensation 20 . Sedimentation rate of 40 21
. Decreased response to antigens 22
. Graying of axillary hair 23
. Post void residual > 100 cc. 24
. Reduced response of heart to work 25
. Global loss of intellectual capacity 26
. Albumin < 3 27
. Increased residual lung volume 28
. Loss of central vision 29
. Decline in stature 30
. Tinnitus 31
. Reduced renal function 32
. Depression 33
. Decreased proprioception 34
. Decreased vital capacity 35
. Incontinence of urine 36
. Impaired adaptation to dark 37
. Loss of sex drive 38
. Increased irritability 39
. Rigidity on physical exam 40
. Hemoglobin < 11 41
. Decreased olfactory acuity 42
. Osteophytes on vertebrae 43
. Contractures 44
. Painful, hard stools 45
. Delayed tumescence 46
. More withdrawn 47
. Diminished far vision 48
. Prolapse of bladder 49
. Decreased response to (3-blockers 50
. Reduced febrile response 51
. Less rapid learning 52
. Heart rate > 85 53
. Decreased skin turgorNormal (%) 86.
2 86.
2 83.
1 66.
2 73.
3 47.
7 81.
5 58.
5 70.
8 55.
4 66.
2 78.
5 67.
7 61.
5 64.
6 70.
8 35.
4 61.
5 61.
5 75.
4 46.
2 50.
8 81.
5 66.
2 76.

9Disease (%)

87.
7 70.
8 76.
9 80.
0 96.
9 86.
2 80.
0 90.
8 69.
2 70.
8 87.
7 83.
1 87.
7 75.
4 87.
7 90.
8 83.
1 75.
4 75.
4 81.
5 95.
4 41.
5 93.
8 81.
5 84.
6 41.
5 87.
7 73.
8 erro r rate ) (Tabl e 5). Of those, only two were signs or condition s associate d wit h disease . I n contrast , fiv e item s relate d t o pathology , a s compare d t o n o item s relate d t o norma l aging , wer e correctl y classifie d b y 90
% of respondents (low error rate in Table 5). Tabl e 6 display s knowledg e score s tha t wer e sig - nificantl y differen t amon g groups , a s wel l a s score s considere d b y th e researcher s a prior i a s mos t likel y t o sho w differences . Onl y tw o o f th e independen t Vol

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Table 5. Symptoms and Conditions with High and Low Error Rates Norma l Conditio n a s Pathologica l

Conditio

nPercentPathological Condition as Normal

Conditio

n Percen t Hig h Erro r Rate s

Decrease

d proprioceptio n

Delaye

d tumescenc e

Declin

e i n speec h discriminatio n

Decrease

d respons e t o bet a blocker s

Decrease

d tactil e sensatio n

Yellowin

g o f len s o f ey e65 5 4 5 2 4 9 4 5 4 1

Diminishe

d far vision

Osteophyte

s o n vertebrae58 5 8 Lo w Erro r Rate s

Decubitu

s ulcer s

Hemoglobi

n < 1 1

Contracture

s Peda l edem a

Depressio

n Note: Hig h erro r rat e = a

t least 40% of residents incorrectly identified a condition; low error rate = fewer than 10% of residents

incorrectl y identifie d condition . Tabl e 6 . Analyses of Variance. Aging Knowledge Scores b y Characteristic s o f th e Sample

Characteristi

c

Geriatri

c Rotatio n Ye s N o Ye s N o Ye s N o

Elderl

y Patient s 0- 5 6-1 5 1 6 o r more < 5 6-1 5 1 6 + < 5 6-1 5 1 6 +

Residenc

y Yea r R 1 R 2 R 3 R 1 R 2 R 3 R 1 R 2 R 3

Practic

e Settin g

Private/clini

c Othe r

Private/clini

c Othe r

Private/clini

c Othe rQuiz

NormAg

e

PathAg

e

Overal

l

NormAg

e

PathAg

e

Overal

l

NormAg

e

PathAg

e

Overal

l

NormAg

e

PathAg

e

Overal

lMean Scor e 17. 4 16. 4 23.
1 22.
1 40.
4 38.
5 17. 4 16. 1 20. 5 21.
3 24.
6 21.
5 38.
8 40.
7 42.
0 16. 1 16. 3 19. 1 22.
7 23.
3 19. 7 38.
8 39.
6 38.
8 17. 0 16. 0 23.
3 20. 2 40.
2 36.
2 F . 6 . 8 1. 1 4. 0 4. 7 1. 1 1. 3 2. 7 . 1 . 6 2. 5 2. 4P .5 5 .4 4 .2 8 .0 2 .0 1 .3 3 .2 8 .0 8 .8 8 .5 4 .0 1 .0 2 variable s ha d a significan t effec t o n scores . Resident s wh o ha d a highe r numbe r o f elderl y patient s di d scor e significantl y highe r tha n thos e wit h fewe r pa - tient s o n th e norma l agin g item s (F = 4.0 ; p = .02 ) bu t thos e wit h man y elderl y patient s performe d wors e o n th e diseas e state s item s (F = 4.7 ; p = .01) .

Resident

s wh o planne d t o ente r a solo or partnership practic e di d scor e significantl y highe r bot h o n th e overal l qui z (t = 2.4 ; p = .02 ) an d o n th e diseas e state s qui z (t = 2.5 ; p = .01) . Neithe r th e numbe r o f nursin g hom e patient s no r th e perceive d adequac y o f geriatric s trainin g wa s relate d t o diseas e o r norma l agin g knowledge . Althoug h student s wh o ha d a for - ma l rotatio n i n geriatric s tende d t o hav e highe r over - al l knowledg e score s (mea n = 40.4
) tha n thos e wit h n o suc h rotatio n (mea n = 38.5)
, th e differenc e wa s no t significan t ( p = .28) . Som e finding s wer e no t anticipated . Havin g facult y wit h mor e positiv e attitude s towar d agin g patient s tha n towar d patient s i n othe r ag e group s wa s signifi - cantl y negativel y relate d t o residents ' overal l knowl - edg e o f agin g (t = 2.3 ; p < .02) . Althoug h no t significantl y different , third-yea r resident s ha d lowe r score s o n th e diseas e state s qui z (mea n = 19.7 ) tha n eithe r first-yea r o r second-yea r resident s (mea n = 22.
7 an d 23.3
, respectively) ; bu t the y ha d slightl y highe r score s o n norma l agin g item s tha n di d resi - dent s i n thei r firs t tw o years .

Discussio

n

Substantia

l knowledg e deficit s abou t th e agin g proces s wer e observe d amon g resident s respondin g t o thi s survey . Overall , resident s answere d abou t 75
% of the items correctly. Despite increased inclu- sio n o f geriatri c conten t i n medica l schoo l curricula , thi s resul t suggest s tha t medica l educatio n ma y no t hav e greatl y improve d level s o f knowledge . Som e resident s ar e no t takin g advantag e o f availabl e train - in g i n geriatrics , althoug h i n thi s sampl e th e geriat - ric s rotatio n wa s probabl y no t availabl e befor e th e secon d yea r o f th e residenc y program . 11 6 Th e Gerontologis

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The evidence regarding the efficacy of geriatrics

trainin g i n improvin g agin g knowledg e is , however , mixed . Among residents at the UASOM, though not amon g resident s a t Pen n Stat e o r Sout h Alabama , resident s wh o ha d complete d a geriatric s rotatio n score d significantl y highe r tha n thos e wh o ha d n o suc h rotatio n (dat a no t shown) . Geriatric s rotations , therefore , ma y b e a valuabl e thoug h no t sufficien t conditio n fo r improvin g agin g knowledge . Th e famil y practic e resident s i n thi s stud y wer e bette r abl e t o identif y physica l sign s an d condition s associate d wit h disease s tha n thos e reflectin g nor - ma l agin g processes . A large r knowledg e defici t fo r norma l agin g item s als o wa s observe d b y Co e an d Breh m (1972 ) an d b y Dy e an d Sassenrat h (1979) . I t i s no t entirel y clea r tha t thes e score s reflec t genuin e differences , fo r a numbe r o f reason s relate d t o th e constructio n o f th e instrument . Som e word s use d t o describ e physica l sign s an d condition s virtuall y identif y th e agin g conditio n a s pathological . Thes e includ e term s suc h a s "edema, " "decubitu s ulcer, " "fracture, " "prolapse, " etc . Item s associate d wit h suc h item s wer e (correctly ) associate d wit h diseas e a t a hig h rate . Th e investigator s sometime s assigne d numerica l value s t o item s i n orde r t o avoi d confu - sio n (e.g. , hemoglobin < 11; post void residual > 10 0 cc ; se d rat e = 40
; albumi n > 3) . I n ever y cas e th e correc t classificatio n wa s "disease, " an d mos t o f thes e item s wer e correctl y classified . I t appear s tha t whil e issue s o f ambiguit y wer e successfull y avoided , clue s ma y inadvertentl y hav e bee n give n abou t cor - rec t responses . I n retrospect , a bette r approac h ma y hav e bee n t o phras e suc h item s t o eliminat e th e numerica l valu e (e.g. , "lower range of normal he- moglobi n values" ) o r t o hav e provide d som e norma l numerica l values . O n th e othe r hand , th e directio n o f result s foun d her e i s consisten t wit h th e tw o othe r studie s (Co e & Brehm , 1972; Dye & Sassenrath, 1979). This may be du e t o th e fac t tha t medica l educatio n i s mor e ori - ente d towar d identifying , diagnosing , an d treatin g diseas e state s tha n norma l (healthy ) states . Bot h i n thei r undergraduat e medica l educatio n an d i n thei r residencies , physician s ar e expose d t o sic k elderl y patient s i n bot h acut e an d long-ter m car e facilities . Man y o f thes e patient s hav e multiple , usuall y chroni c condition s whic h ma y ten d t o overshado w th e les s obviou s norma l agin g changes . Becaus e change s i n hearing , eyesight , an d balanc e ofte n ar e no t a s life-threatening or as amenable to treatment as othe r symptoms , the y ar e no t a primar y focu s o f medica l education . Eac h typ e o f erro r investigate d i n thi s stud y i s associate d wit h treatmen t decisions . Whe n a symp - to m o f diseas e i s incorrectl y attribute d t o norma l aging , physicians may fail to respond to the symptompromptly and aggressively. As a result, a treatable conditio n ma y deteriorat e t o a poin t wher e treat - men t i s n o longe r a s efficaciou s a s i t ma y hav e bee n earlier . O n th e othe r hand , i f a norma l age-relate d chang e i s erroneousl y considere d symptomati c o f a n underlyin g pathology , a physicia n ma y prescrib e un - necessar y test s o r procedure s i n orde r t o identif y a nonexisten t patholog y o r prescrib e unnecessar y medicatio n t o trea t a nonexistent disease. The results o f th e curren t stud y sugges t tha t overdiagnosi s an d overtreatmen t o f olde r patient s i s a mor e likel y out - com e tha n underdiagnosi s an d undertreatment . Al - thoug h error s i n judgmen t ar e unlikel y t o resul t i n failur e t o trea t a n il l patient , a n incorrec t diagnosi s ma y caus e emotiona l trauma , unnecessar y proce - dure s ma y b e invasive , ofte n causin g discomfor t o r physica l trauma , prescriptio n drug s ma y hav e harm - fu l sid e effects , an d healt h car e cost s wil l b e need - lessl y inflated . Th e curren t stud y suggest s a nee d fo r improve d geriatri c conten t i n th e medica l educatio n o f famil y practic e residents , particularl y i n recognizin g symp - tom s associate d wit h norma l aging . Becaus e geriatri c patient s ar e likel y t o constitut e a larg e an d increasin g proportio n o f famil y physicians ' patien t panels , knowledg e abou t norma l agin g i s critica l t o provid - in g optima l level s o f car e a t reasonabl e costs . Whil e improve d medica l educatio n wil l clearl y benefi t pa - tients , it also is in the physician's financial self- interest . I n a manage d healt h car e syste m wher e profit s ar e drive n b y preventio n an d cost-effectiv e patien t managemen t rathe r tha n fee-for-service , medica l educatio n mus t incorporat e informatio n abou t health y norma l agin g t o avoi d unnecessar y procedure s an d thei r associate d costs .

Reference

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Received

March 15, 1995

Accepted

October 7, 1995 Vol

. 36, No. 1,1996117Downloaded from https://academic.oup.com/gerontologist/article/36/1/113/612954 by guest on 15 August 2023

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