Abstract
This article is the third of a trilogy of papers that have explored the effects of age and experience on psychiatric practice. It focuses on the effects of life experiences on attitudes towards personal ageing and the ways in which such attitudes may impact on professional practice and retirement decisions.
Changes and experiences associated with ageing can be grouped into three categories: maturational or ageing changes; changes caused by a particular person's life experiences (history); and cohort or generational effects which are a function of a particular age group's intersection with history [1]. This article focuses on the effects of personal life experiences associated with the characteristics of age, gender, perceived health and occupation. It explores whether differences between practising psychiatrists on the variables influence their attitudes (whether, overall they feel positive or negative) towards their self-ageing.
There is considerable discussion in the literature in regard to whether attitudes towards personal ageing impact on professional behaviour towards older patients and the appropriateness of care and treatment. Writers claim that attitudes have a profound effect [2]; however, research to date has focused on attitudes towards the generic concept of ‘older people’, with little attention given to how a person feels about his or her own ageing. It has been argued that attitudes are predominantly negative, affect quality of life and service provision and are related to the quantity and quality of contact [3–5].
It would seem that frequent contact with physically and mentally ill older people can result in negative attitudes towards ageing, particularly in less well-educated health professionals. It is not known whether psychiatrists who work primarily with the elderly hold negative attitudes towards personal ageing.
The Reactions to Ageing Questionnaire [6] is an Australian instrument designed with the specific purpose of measuring attitudes towards personal ageing. The study reported in this article was conducted in order to assess whether life experiences associated with important demographic variables influence how a psychiatrist feels about ageing and the impact of such attitudes on psychiatric practice.
There were two main aims of this study: first, to explore whether there is a relationship between gender, age and perceptions of personal health on psychiatrist's reactions to personal ageing; second, to determine whether psychiatrists' reactions to personal ageing are associated with field and location of practice, approach to clinical practice, retirement planning and post-retirement activities. We hypothesised that older psychiatrists would have more positive attitudes to personal ageing than younger psychiatrists and that psychiatrists' attitudes towards personal ageing would influence the style of clinical practice, retirement planning and post-retirement activities.
Method
The selection of subjects and design of the study are detailed in the first paper of this trilogy [7]. Briefly, a postal survey was undertaken of all RANZCP Fellows aged 40 years and under; every second Fellow by alphabetical listing aged 41–54 years; and all Fellows aged 55 years and over who were resident in Australia and New Zealand.
The survey questionnaire contained items pertaining to age; sex; ethnicity; professional qualifications; length, location and type of clinical practice; and hours of work. Fellows in ‘active’ practice were asked to comment upon the benefits and drawbacks of their current age and experience on their current clinical practice and the types of cases they would be confident about seeing or would be reluctant to take on.
The battery also contained the Reactions to Ageing Questionnaire (RAQ) which was developed and validated in Australia by the Community Disability and Ageing Program at the University of Sydney [6]. This instrument measures attitudes towards personal ageing in terms of an individual's expectations of what s/he will be like as an older person. The RAQ consists of 27 statements of reactions to ageing. The items were validated using a sample of 531 practising health professionals and members of the general population [6]. Higher scores on the RAQ are consistent with positive attitudes towards personal ageing.
Student's t-test was used to assess whether there was any difference in RAQ score between male and females and whether there were any differences in this score based on field and location of practice, anticipated reasons for retirement and anticipated post-retirement professional activities. Multiple regression was used to explore the relationship between age and attitudes towards personal ageing. Analysis of variance (ANOVA) was used to explore the effect of health on attitudes towards personal ageing. Open-ended responses (the benefits and drawbacks of age and experience on psychiatric practice and effect of age and experience on case selection) were categorised into broad groupings post hoc by consensus between two of the investigators (SW and BD). All analyses were two-tailed and alpha was set at 0.05 except where multiple comparisons necessitated adjustment using the Bonferroni correction. All data were analysed using SPSS for Windows Version 8.0 (SPSS Inc., Chicago, IL, USA).
Results
Sample description
The overall survey had a response rate of 57.9%, with 628 practising psychiatrists from Australia and New Zealand returning completed questionnaires through a mail response. Of these psychiatrists, 529 completed the Reactions to Ageing Questionnaire, or had 10% or less of items missing. (In the case of missing responses, substitution with the mean was used.)
The sample consisted of 383 males (72.4%) and 146 females (27.6%). Ages ranged between 31 and 83, with a mean age of 50.3 years (SD = 12.2). Additional demographic characteristics are contained in Table 1. There were nine fields of psychiatric practice, and respondents nominated three fields in order of time spent in them. Based on the selection of three fields of practice, 398 (75.2%) worked in general psychiatry, 221 (42.8%) in psychotherapy, 111 (21%) in family, child and adolescent, 99 (18.7) in community psychiatry, 86 (16.2%) in consultation-liaison, 83 (15.7%) in administration, 72 (13.6%) in forensic, 65 in psychogeriatrics (12.3%), and 45 (8.5%) in research. Percentages add up to more than 100% as most respondents indicated they practised in more than one specialty.
Demographic variables and Reactions to Ageing Questionnaire (RAQ) score
Table 1 contains mean scores on the Reactions to Ageing Questionnaire (RAQ) for each sample group based on age, gender and health. Lower scores indicate a more negative attitude towards self-ageing. Results indicate that age, gender and self-rated health had significant relationships with RAQ scores. Age was treated as a continuous variable in multiple regression, but is displayed in Table 1 by the age groupings used for sample selection (see Method). Younger practitioners had a more negative attitude than older psychiatrists (adjusted r2 = 0.01, p = 0.02), although the relationship was not particularly strong, with age explaining only a minor proportion of the variability in RAQ scores. A similar relationship between age and RAQ score was reported in Gething [6]. Men had a more positive attitude towards self-ageing than women (t = 2.38, df=527, p = 0.02). Health was found to have a significant main effect on reactions to ageing, with respondents who self-reported their health as good or excellent having a more positive reaction than did those who rated their health as fair (F = 5.41, df=2, 522, p<0.05). In summary, the older psychiatrist, males and those who report good health express more positive attitudes about their personal ageing.
Location of practice and Reactions to Ageing Questionnaire (RAQ) score
Anticipated retirement and Reactions to Ageing Questionnaire (RAQ)
Next we explored the relationships between field and location of clinical practice on attitudes towards personal ageing. There were no significant differences in RAQ score between the different fields of psychiatric practice. Participants who worked in psy-chogeriatrics reported the highest RAQ score (110.4) while those who worked in forensic psychiatry reported the lowest (102.6). However, there were no significant differences between these groups (t = 2.42, df = 527, p < 0.05, NS after Bonferroni). There were significant differences in RAQ scores based on location of practice, with psychiatrists who worked in universities reporting a significantly lower RAQ score than psychiatrists who did not work in universities (see Table 2).
The relationship between attitudes towards personal ageing and retirement planning and post-retirement activities was examined. More negative attitudes towards personal ageing were expressed by respondents who said they would retire due to deteriorating health. Results are shown in Table 3. Anticipated post-retirement professional activities were not found to be associated with attitudes towards self-ageing.
The effects of reactions to personal ageing upon (i) the benefits and drawbacks of age and experience on psychiatric practice, and (ii) the effect of age on case selection were also explored. These categories are described in greater detail in the other papers in this trilogy, and are as follows.
Benefits of age/experience on psychiatric practice
The benefits include: being better able to communicate with patients of own age/life stage; wider, more balanced life perspective; increased credibility and respect from patients and peers; age of no benefit; increased confidence and competence; more respectful and tolerant of patients; more enthusiastic, optimistic.
Drawbacks of age/experience on psychiatric practice
The drawbacks are: age irrelevant; fatigue, lack of energy, motivation; negative patient attitudes, concerns about psychiatrist's age; less able to cope with work demands; difficulty keeping up to date with knowledge, new perspectives; impaired memory or mental capacity of psychiatrist; impaired physical health of psychiatrist; lack of credibility and respect from patients and peers; less enthusiastic and more pessimistic, cautious with patients.
Cases interested in taking on due to age/experience
These include: none, age irrelevant; older patients; younger patients; mood disorders; marital, family cases; depends on gender of patient; stress and anxiety.
Cases reluctant to take on due to age/experience
These include: none, age irrelevant; younger patients; personality disorders; long-term, chronic patients; violent/dangerous or acting out patients; medicolegal cases.
Although younger age was reported earlier as being associated with more negative attitudes towards ageing (see Table 1), there were no significant relationships between the benefits and drawbacks of age and experience on psychiatric practice and RAQ score, or between case selection and RAQ score.
Discussion
Considerable research indicates that younger people hold relatively negative attitudes and beliefs about older people and that these result in reluctance to specialise in aged care [8–10]. Findings of the present study are consistent with the earlier literature and indicate that younger psychiatrists hold more negative views than their older colleagues. This has important implications for professional education, particularly in the light of claims that many conditions go untreated because professionals falsely assume they are an inevitable part of ageing [5].
An example of such ageist attitudes was demonstrated by one 36-year-old female who wrote:
I do not believe in treating old people if demented or sick–I think euthanasia is a great idea. I have no intention of getting to that point, I would gladly suicide first.
The promotion of positive views about age, and education about the prevention and treatment of age-related conditions, should form an integral part of psychiatric training which may be best obtained during a rotation in old-age psychiatry [11].
We found that negative attitudes towards ageing (‘ageism’) declined over the lifespan, with older psychiatrists showing more positive attitudes about personal ageing than do younger psychiatrists. It has been postulated that the ageing process may be particularly difficult for doctors because it forces changes in self-perceptions that have been at the core of the doctor's identity [12]. However, it would seem that as psychiatrists directly encounter the life circumstances associated with ageing, myths and stereotypes are challenged which, if personal health is maintained, are not supported by personal experience. As one 54-year-old male commented:
I'm a bit surprised to find myself coming up with so many positives. I think it is somewhat liberating not to feel so driven by the ambitions of youth or torn by some of the conflicts of earlier stages.
And a 77-year-old male provided the following aphorism:
Old age is a bad habit which those, fully occupied, have no time to acquire.
In contrast, perceptions of poor personal health were associated with negative attitudes about ageing. As one 62-year-old noted:
I do not see my age as really being of any importance in work or private life. I think health is a much more important factor.
Alterations in cognitive and physical capacity force doctors to confront their own limitations and the potential that their needs may conflict with those of their patients [12]. It would seem that in these circumstances negative attitudes towards ageing may be a proxy for attitudes about personal health. Several of the respondents were quite insightful about the way health may affect their practice, with a 63-year-old male commenting:
My only real concern is about a possible failure of my health that interrupted a therapy where the patient had entered the dependent stage too intensely to easily recover.
The finding that women held more negative attitudes about their ageing is interesting, although the factors that underlie the formation of such differences are not clear. Personal appearance may be an issue. Martha Kirkpatrick [13, p. 141], a female psychoanalyst, wryly commented: ‘While one would not care to be seen only as a sex object, the alternative for older women is to be invisible, not a seen object at all’. This viewpoint was echoed by a 64-year-old female:
I attempt to disguise (my age) as much as possible– hair tinting, etc.–as I believe more credence and feeling occurs for my patients.
Another possibility is that role conflict involving the care of ageing parents and grandchildren may contribute to negative attitudes. As a 63-year-old stated:
Unwilling to be involved with College due to pressures of personal life–caring for grandchildren. It has always been the same, being female and having a family role makes you too busy.
And a 64-year-old wrote:
I wonder if other older female psychiatrists have had heavy responsibilities related to aged parents–one hears so much about motherhood interfering with careers but nothing about the other end of the spectrum.
Few aspects of psychiatric practice covered in this survey were found to be significantly associated with attitudes towards personal ageing. This is encouraging as it suggests that any negative personal attitudes about ageing that psychiatrists might possess are having little impact on such practice. Considerable debate has occurred in the literature about the effects of area of professional practice on attitudes towards ageing [14,15]. The present study suggests that field of psychiatric practice had no impact on attitudes towards personal ageing, although it is heartening that psychiatrists who work with the elderly tended to have more positive attitudes. Gething reported that people with higher levels of accurate knowledge about older people also reported more positive attitudes about their own ageing [6]. The present study lends support to that finding that positive attitudes towards ageing are associated with greater levels of knowledge about older people. The finding that psychiatrists who include universities among their locations of practice areas hold more negative attitudes cannot be explained by the present study. It may be that the rapidly changing nature of work in universities is producing uncertainty and negativism about the future. However, this argument is speculative and the topic warrants further exploration.
Conclusion
The project indicates that age, gender, health and location of psychiatric practice influence a person's attitudes towards personal ageing. The relationship between these factors is complex and the role of factors such as gender and area of employment warrant further exploration. As Kendig [16, p.104] has argued: ‘There is no greater challenge for health professionals than responding to older people and population ageing’.
Footnotes
Acknowledgements
We thank the RANZCP for their cooperation in administering this survey and College Fellows who assisted by participating in the project. Appreciation is also expressed to the Nursing Research Centre for Adaptation in Health and Illness at the University of Sydney that provided administrative support for the aspect of the project reported in this paper, and the School of Community Medicine, University of New South Wales for financial support.