Clinical Geriatrics

We received a letter from Ms. C, who describes herself as a relatively healthy 77-year-old woman. At her recent checkup, her physician recommended she have a screening colonoscopy. After expressing her “less than enthusiastic feeling toward the upcoming experience,” she was told by the physician that she should cheer up because a colonoscopy is recommended only every 10 years, and at her age, she shouldn’t have to undergo it ever again. Regarding being told so bluntly of her finite expected lifespan, Ms. C comments, “I am not exactly ready to leave in 10 years. In fact, I am descended from an Asian family where almost all my elders lived to be over 90. Is it too much to ask the medical profession to be a little more sensitive in their physician-patient communications?”

Attributes of interpersonal communication skills and professionalism are essential core competencies for medical trainees to be taught and evaluated on, similar to medical knowledge, patient care, and other required “tools of the trade.” Unfortunately, some skills are more difficult to teach and acquire than others. While the physician was factually correct in that Ms. C’s next colonoscopy would likely be her last—at least based on actuarial data, and assuming the test results would be normal and not require follow-up testing—he could not say this with certainty. Most importantly, he failed to demonstrate appropriate interpersonal skills in discussing her lifespan.

We wish Ms. C a long, healthy, and happy life, and clearly agree with her that her physician did not have a crystal ball and could not predict with any degree of certainty exactly how long she would live. In fact, the older an individual is, statistically, the older one can expect to live. While a baby girl born today has a life expectancy of 79.6 years, the 20-year-old woman can expect to live to 80.4 years, the 50-year-old woman to 81.91 years, the 70-year-old woman to 85.45 years, and the 77-year-old woman (the age of Ms. C) to 87.78 years, or 10.78 additional years, on average. This is a moving target with multiple variables and unknown influences. These data are based on actuarial Period Life Tables that are used by life insurance companies to calculate premiums. The data are clearly only an estimate of what one may expect based on large numbers of people, and do not take into consideration an individual’s unique genetics, health status, and environmental and societal factors. These additional variables may either increase or decrease this predicted age.

We need to always remember the importance of sensitive interpersonal communication when providing patients with “full disclosure,” and consider just how much information is necessary and how much is “too much.” The handbook in the following link provides practical information to assist clinicians to better communicate with their older patients: www.niapublications.org/pubs/clinicians2004/chap01.asp.

Send comments to Dr. Gambert at medwards@hmpcommunications.com

Dr. Gambert is Chairman, Department of Medicine, and Physician-in-Chief, Sinai Hospital of Baltimore, and Professor of Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.