Mr. Jones is a 68-year-old Black man and Mrs. Baker is a 68-year-old White woman. Both see you for severe depression. You think voluntary hospitalization for ECT is optimal for both patients. However, Mr. Jones replies, “Doc, I’m not getting hospitalized! ECT? They experiment on Black people with that!” Later, Mrs. Baker similarly replies, “Doc, I can’t get hospitalized! They mistreat people there! And I might lose my employment—my boss targets older folks!” Given your patients’ concerns, you want to better navigate ageism and racism during clinical encounters. 

A changing patient population

As America ages and becomes more racially diverse, mental health clinicians are increasingly facing two common inequities: ageism and racism. Ageism independently contributes to health inequities (Chang ES et al, PLoS One 2020;15(1):e0220857). Medical racism shows up in various ways: unequal access to care, disparities in quality of treatment, biases in clinical decision making, and mistrust between patients and clinicians (Hamed S et al, BMC Public Health 2022;22(1):988). Our responses when patients share worries about ageism and/or racism may greatly strengthen or harm our trustworthiness. Yet there is little information available to help us navigate these uncomfortable—albeit valid—expressions of patient mistrust during clinical encounters. 

Background

Ageism and racism are influenced by societal tendencies to judge the value of individuals’ lives (Farrell TW et al, J Am Geriatr Soc 2022;70(12):3366–3377). These observations are not confined to the social realm—they are fundamentally true in health care, too (Lundebjerg NE and Medina-Walpole AM, J Am Geriatr Soc 2021;69(4):892–895). American medicine is partly built upon ideas about who deserves to live and how equally they should be treated. Both ideas were promoted by the American eugenics movement (Sfera A, Front Psychiatry 2013;4:101). Eugenics means “well born,” and the eugenics movement aimed to improve the population by limiting the reproductive rights of people deemed “unfit” to live by those in power (Micklos D and Carlson E, Nat Rev Genet 2000;1(2):153–158). 

Steps to address ageism and racism in clinical practice

How can clinicians counteract these harmful legacies in real-time clinical practice? Here are some tips to help clinicians build patient trust.

1. Create a safe space for patients to share their experiences of health ­injustice

Despite feeling uneasy, you ask Mr. Jones and Mrs. Baker to share more about their concerns. You learn that Mr. Jones’ son was restrained for agitation in your hospital’s psychiatric ED last year during a manic episode. You also learn that Mrs. Baker’s mother received ECT decades ago with resultant severe cognitive ­impairment.

2. Resist the urge to find “objective” reasons to dismiss patients’ expressions of health injustice

For Mr. Jones, you recognize that your first temptation is to defend your colleagues by finding valid reasons they restrained his son—for example, you wonder whether his son’s mania could have threatened staff safety. For Mrs. Baker, your first instinct is to explain how ECT has advanced since her mother’s era. You identify these automatic assumptions so you can lean into your patients’ concerns instead of pushing back.

3. Understand history and disparities literature to validate your patients’ concerns

Ageism and anti-Black racism in American medicine have been documented through various historical and contemporary practices. Evidence highlights ongoing disparities:

• Use of restraints: Research indicates that Black patients are more likely to be subjected to restraints compared to their White counterparts. This disparity suggests potential biases in clinical decision making (Eswaran V et al, JAMA Intern Med 2023;183(11):1229–1237).
• ECT: Studies have found that Black patients are less likely to receive ECT, often due to misdiagnoses. This underutilization points to systemic issues within psychiatric care (Parker CB et al, Psychiatr Serv 2021;72(6):684–690; Parker CB et al, Am J Geriatr Psychiatry 2020;28(11):1129–1132).
• Ageism in medicine: American medicine and society often hold negative attitudes toward older adults, which can adversely affect their psychological well-being. These attitudes may contribute to disparities in the care and support older adults receive (Kang H and Kim H, Gerontol Geriatr Med 2022;8:23337214221087023).

You can honor Mr. Jones’ trauma by acknowledging that racism is real: 

“It’s painful for me to hear about your son’s treatment, so I know for you it must be an incredibly painful subject. I can understand why you would doubt my suggestion about ECT. I want to offer you a better experience. Please hold me accountable to that.”

To Mrs. Baker, first acknowledge how difficult it must have been to watch her mother struggle with her mental health:

“It must have been incredibly hard to watch your mom go through those experiences. You’re right—ECT from decades ago could be problematic. I’d be happy to discuss how modern ECT has improved many of those problems, if you’d like.”

You can then add:

“Policies and practices that can harm older patients are common but sometimes hard to spot by someone who isn’t living the harm. Can you please tell me more about your concerns of age discrimination with your boss?”

4. Think of discrimination not as a binary (“ageist/not ageist” or “racist/not racist”), but as a spectrum of behavior 

This offers more freedom to reflect upon the problematic attitudes or behaviors of fellow clinicians and acquaintances. 

You learn that the last three employees to be fired by Mrs. Baker’s boss were all near retirement age. You better understand her perspective that her boss may be operating in an ageist manner. You tell her, “Thank you for trusting me enough to share your concerns. I can see how those three people getting fired makes you suspect age discrimination.” 

5. Use these conversations to build trustworthinessas a clinician and express that you will do your best to fight inequity alongside your patients

Validating Mrs. Baker’s concerns earns the opportunity to help. You offer, “Perhaps I can assist our social work team to advocate with your boss.” Mrs. Baker then consents to voluntary hospitalization for ECT for her depression. 

Mr. Jones does not consent to ECT. Nonetheless, he tells you, “You’re one of the first clinicians to ever really listen that this system isn’t as perfect as you think. Messed-up things happen, so I respect that you can talk about racism without telling me I’m wrong. I still don’t want ECT, but what else can we do?”

Carlat Verdict 

Ageism and racism are becoming more prevalent as America’s population ages and diversifies. Clinicians can build trust by using history and disparities literature to validate patients’ concerns of health injustice.