Do We Mistreat the Elderly in America?
Ira Byock, MD was the Director of Palliative Medicine at Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire and is currently Professor of Anesthesiology and Community & Family Medicine at Dartmouth Medical School.
Dr. Byock has authored numerous articles on the ethics and practice of hospice, palliative and end-of-life care. His first book, Dying Well, (1997) has become a standard in the field. His most recent book, The Four Things That Matter Most, (2004) is used as a counseling tool widely by palliative care and hospice programs, as well as within pastoral care.
Dr. Byock has been a consistent advocate for the voice and rights of dying patients and their families. He has been the recipient of the National Hospice Organization’s Person of the Year (1995), the National Coalition of Cancer Survivorship’s Natalie Davis Spingarn Writers Award (2000), the American College of CHEST Physicians Roger Bone Memorial Lecture Award (2003) and the Outstanding Colleague Award (2008) of the National Association of Catholic Chaplains.
Question: Do we mistreat the elderly?
Ira Byock: Yeah, I think contemporary America deeply mistreats the elderly in so many ways, I think ageism is alive and well in the United States in our culture. I think the way we fund and staff nursing homes is an absolute national disgrace, it’s a abomination. And if it was really known and understood, we wouldn’t be able to live with ourselves, I think this becomes a political issue very quickly, because we all tolerate this, we are all – we are all complicit in the neglect frankly the engendered acculturated neglect that occurs not only for the elderly but for anybody who is physically dependent, physically seriously disabled, or seriously ill and dying. It’s as if they remind us of our mortality, and so we don’t want them around.
I think to a large extend frankly, our nursing homes today function as warehouses that actually have a cultural function, though it’s an embarrassing one of segregating people who are ill infirm demented or just playing frail and elderly, keeping them out of our sight. We hire entry level workers, we often don’t pay those workers a living wage, there are far too few of them to take care of the people who live there. And yet these are our grandparents and our parents and our brothers and sisters, some places there are children. And it is so not okay, that really if – many people could see what I have seen and know what I know about nursing homes, you would think that we would be out in the streets demanding better care to start with better staffing of the nursing home and better support for the people who work in them.
Ira Byock: Well, I think people who work in nursing homes are truly heroes in America today, and I want to distinguish the systemic neglect of nursing homes and the systemic lack of support for nursing homes from the people who work within them, they are some of the most committed people I know, but nursing homes are understaffed, every study that’s ever been done has shown that they are woefully understaffed, in some studies even governmental studies, they show that 90% of nursing homes are understaffed and many, many residents of nursing homes are seriously malnourished, starving, not because they can't eat, or don’t want to eat, but because they need help in eating, and there is simply not enough aids to help the residents of nursing homes eat at meal time. In some studies it’s a ratio of 15 people who need help in eating at meal times for each one aid to help them eat.
This is a national disgrace, and unless or until we can staff our nursing homes at levels that are at least at a safe and prudent level, I would say we can’t build another highway, we can’t fix another pothole in the highways we have, we can't make another even high-minded adventure overseas in our military or anything. We have to take care of our grandparents and our parents, but we are not at this point. And I don’t understand and I have been part of efforts in New Hampshire to bring this to the attention of presidential primary candidates, we have huge support from the citizen tree [phonetic] of New Hampshire to make these issues a priority, please visit: reclaimtheend.org, remarkable citizen initiative that I was part of, but we haven't done it yet, and noticed it’s not a top tier issue in the presidential campaign, but it is endemic issue.
And it gets even worse, I would say that we have a crisis that surrounds the way we care for people, and the way people spend the last chapter of the lives and the way they die today. But unless we act, these will be good old days. We will look back on the way we cared for people today, we will look back at today’s nursing homes, and they will in retrospect look like luxury hotels. We boomers may well yet live to see real human ware houses from the inside.
Question: How do we fix it?
Ira Byock: Well, the irony here is that, these are all correctable problems. This is not rocket science clinically or, from a health systems perspective, and it’s really not even that expensive to do this well. When 20% of Americans are dying in ICUs, when 50% of Americans are dying in hospitals, what we spend is much on the last part of last year of life as we spend on in the rest of healthcare for any given individual, at least to their adulthood. We can care well for people through the end of life, we have to stop avoiding death as if it were optional and begin to actually look at what a package of services and living situation, patients with their families need to live a full and healthy life.
That doesn’t mean we have to implant electrical defibrillators in every body. It doesn’t mean that we necessarily have to provide 4th, 5th and 6 layer chemotherapy to every body, but it does mean that we have to staff our nursing home, so that our parents and grandparents have somebody to answer the bell if I need to get up and go to the bathroom or are wet, have somebody to help them eat. It does mean that families at home can get somebody to help them teach them how to care for, perhaps an elderly frail spouse maybe with memory loss or pain from osteoporosis. Those sorts of things we can do. We do have to engage more than just the paid healthcare system though. It has to be caring for people through the end of life. It has to be part of our families and communities. So this responsibility is really shared, I believe in the communities of our towns but also of our neighborhoods, of our buildings, the communities of our faith communities of our service groups, those sorts of things. This ought to be just part of what we do for one another, and not sort of somehow segregated and isolated.
Question: Should people take care of their parents at home?
Ira Byock: Well, to the extend possible, absolutely, people – one of the great commonalities of the human condition is that the large majority of people would rather be at home during the last part of life, not everybody. But into the 75 to 80% of people say, yeah I want to be at home, or in the home of my family or friends, I don’t want to be in some institution. And so yes, now it’s hard these days because people have to work, many couples have two jobs or three jobs between them just to make ends meet, to pay health care insurance and the like.
So we have to make provisions through insurance and through policy to make that possible, but I don’t think we will ever completely avoid the burden that caring for one another represents. I don’t want to somehow give the impression that some change in policy or insurance is going to just make this easy. It will never be easy but it doesn’t have to be nearly as hard it is today.
Question: Which culture treats its elderly well?
Ira Byock: I am not traveled that much, I think the United Kingdom does a good deal better than we do. I think Canada that are partners to the north does it somewhat better than we do. For one thing in America many times people I meet in healthcare for are worried about leaving their families with financial burdens. They want to get this over more quickly, because I don’t want to leave my family with bills to pay and go through all of our family life savings.
That’s an American source of suffering, you don’t hear that from patients in Canada. They still worry about lots of things, pain and suffering and being a burden to their family in other ways, but this notion that we are going to go through all of our wealth and in fact leave our family with debts, boy that’s a big theme that I here from patients today, and it is an American source of suffering.
Recorded on: March 21, 2008
Do we mistreat the elderly?
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Northwell Health is using insights from website traffic to forecast COVID-19 hospitalizations two weeks in the future.
- The machine-learning algorithm works by analyzing the online behavior of visitors to the Northwell Health website and comparing that data to future COVID-19 hospitalizations.
- The tool, which uses anonymized data, has so far predicted hospitalizations with an accuracy rate of 80 percent.
- Machine-learning tools are helping health-care professionals worldwide better constrain and treat COVID-19.
The value of forecasting<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yNTA0Njk2OC9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTYyMzM2NDQzOH0.rid9regiDaKczCCKBsu7wrHkNQ64Vz_XcOEZIzAhzgM/img.jpg?width=980" id="2bb93" class="rm-shortcode" data-rm-shortcode-id="31345afbdf2bd408fd3e9f31520c445a" data-rm-shortcode-name="rebelmouse-image" data-width="1546" data-height="1056" />
Northwell emergency departments use the dashboard to monitor in real time.
Credit: Northwell Health<p>One unique benefit of forecasting COVID-19 hospitalizations is that it allows health systems to better prepare, manage and allocate resources. For example, if the tool forecasted a surge in COVID-19 hospitalizations in two weeks, Northwell Health could begin:</p><ul><li>Making space for an influx of patients</li><li>Moving personal protective equipment to where it's most needed</li><li>Strategically allocating staff during the predicted surge</li><li>Increasing the number of tests offered to asymptomatic patients</li></ul><p>The health-care field is increasingly using machine learning. It's already helping doctors develop <a href="https://care.diabetesjournals.org/content/early/2020/06/09/dc19-1870" target="_blank">personalized care plans for diabetes patients</a>, improving cancer screening techniques, and enabling mental health professionals to better predict which patients are at <a href="https://healthitanalytics.com/news/ehr-data-fuels-accurate-predictive-analytics-for-suicide-risk" target="_blank" rel="noopener noreferrer">elevated risk of suicide</a>, to name a few applications.</p><p>Health systems around the world have already begun exploring how <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7315944/" target="_blank" rel="noopener noreferrer">machine learning can help battle the pandemic</a>, including better COVID-19 screening, diagnosis, contact tracing, and drug and vaccine development.</p><p>Cruzen said these kinds of tools represent a shift in how health systems can tackle a wide variety of problems.</p><p>"Health care has always used the past to predict the future, but not in this mathematical way," Cruzen said. "I think [Northwell Health's new predictive tool] really is a great first example of how we should be attacking a lot of things as we go forward."</p>
Making machine-learning tools openly accessible<p>Northwell Health has made its predictive tool <a href="https://github.com/northwell-health/covid-web-data-predictor" target="_blank">available for free</a> to any health system that wishes to utilize it.</p><p>"COVID is everybody's problem, and I think developing tools that can be used to help others is sort of why people go into health care," Dr. Cruzen said. "It was really consistent with our mission."</p><p>Open collaboration is something the world's governments and health systems should be striving for during the pandemic, said Michael Dowling, Northwell Health's president and CEO.</p><p>"Whenever you develop anything and somebody else gets it, they improve it and they continue to make it better," Dowling said. "As a country, we lack data. I believe very, very strongly that we should have been and should be now working with other countries, including China, including the European Union, including England and others to figure out how to develop a health surveillance system so you can anticipate way in advance when these things are going to occur."</p><p>In all, Northwell Health has treated more than 112,000 COVID patients. During the pandemic, Dowling said he's seen an outpouring of goodwill, collaboration, and sacrifice from the community and the tens of thousands of staff who work across Northwell.</p><p>"COVID has changed our perspective on everything—and not just those of us in health care, because it has disrupted everybody's life," Dowling said. "It has demonstrated the value of community, how we help one another."</p>
A new study proposes mysterious axions may be found in X-rays coming from a cluster of neutron stars.
Are Axions Dark Matter?<span style="display:block;position:relative;padding-top:56.25%;" class="rm-shortcode" data-rm-shortcode-id="5e35ce24a5b17102bfce5ae6aecc7c14"><iframe type="lazy-iframe" data-runner-src="https://www.youtube.com/embed/e7yXqF32Yvw?rel=0" width="100%" height="auto" frameborder="0" scrolling="no" style="position:absolute;top:0;left:0;width:100%;height:100%;"></iframe></span>
New research suggests you can't fake your emotional state to improve your work life — you have to feel it.
What is deep acting?<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yNTQ1NDk2OS9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTYxNTY5MzA0Nn0._s7aP25Es1CInq51pbzGrUj3GtOIRWBHZxCBFnbyXY8/img.jpg?width=1245&coordinates=333%2C-1%2C333%2C-1&height=700" id="ddf09" class="rm-shortcode" data-rm-shortcode-id="9dc42c4d6a8e372ad7b72907b46ecd3f" data-rm-shortcode-name="rebelmouse-image" data-width="1245" data-height="700" />
Arlie Russell Hochschild (pictured) laid out the concept of emotional labor in her 1983 book, "The Managed Heart."
Credit: Wikimedia Commons<p>Deep and surface acting are the principal components of emotional labor, a buzz phrase you have likely seen flitting about the Twittersphere. Today, "<a href="https://www.bbc.co.uk/bbcthree/article/5ea9f140-f722-4214-bb57-8b84f9418a7e" target="_blank">emotional labor</a>" has been adopted by groups as diverse as family counselors, academic feminists, and corporate CEOs, and each has redefined it with a patented spin. But while the phrase has splintered into a smorgasbord of pop-psychological arguments, its initial usage was more specific.</p><p>First coined by sociologist Arlie Russell Hochschild in her 1983 book, "<a href="https://www.ucpress.edu/book/9780520272941/the-managed-heart" target="_blank">The Managed Heart</a>," emotional labor describes the work we do to regulate our emotions on the job. Hochschild's go-to example is the flight attendant, who is tasked with being "nicer than natural" to enhance the customer experience. While at work, flight attendants are expected to smile and be exceedingly helpful even if they are wrestling with personal issues, the passengers are rude, and that one kid just upchucked down the center aisle. Hochschild's counterpart to the flight attendant is the bill collector, who must instead be "nastier than natural."</p><p>Such personas may serve an organization's mission or commercial interests, but if they cause emotional dissonance, they can potentially lead to high emotional costs for the employee—bringing us back to deep and surface acting.</p><p>Deep acting is the process by which people modify their emotions to match their expected role. Deep actors still encounter the negative emotions, but they devise ways to <a href="http://www.selfinjury.bctr.cornell.edu/perch/resources/what-is-emotion-regulationsinfo-brief.pdf" target="_blank">regulate those emotions</a> and return to the desired state. Flight attendants may modify their internal state by talking through harsh emotions (say, with a coworker), focusing on life's benefits (next stop Paris!), physically expressing their desired emotion (smiling and deep breaths), or recontextualizing an inauspicious situation (not the kid's fault he got sick).</p><p>Conversely, surface acting occurs when employees display ersatz emotions to match those expected by their role. These actors are the waiters who smile despite being crushed by the stress of a dinner rush. They are the CEOs who wear a confident swagger despite feelings of inauthenticity. And they are the bouncers who must maintain a steely edge despite humming show tunes in their heart of hearts.</p><p>As we'll see in the research, surface acting can degrade our mental well-being. This deterioration can be especially true of people who must contend with negative emotions or situations inside while displaying an elated mood outside. Hochschild argues such emotional labor can lead to exhaustion and self-estrangement—that is, surface actors erect a bulwark against anger, fear, and stress, but that disconnect estranges them from the emotions that allow them to connect with others and live fulfilling lives.</p>
Don't fake it till you make it<p>Most studies on emotional labor have focused on customer service for the obvious reason that such jobs prescribe emotional states—service with a smile or, if you're in the bouncing business, a scowl. But <a href="https://eller.arizona.edu/people/allison-s-gabriel" target="_blank">Allison Gabriel</a>, associate professor of management and organizations at the University of Arizona's Eller College of Management, wanted to explore how employees used emotional labor strategies in their intra-office interactions and which strategies proved most beneficial.</p><p>"What we wanted to know is whether people choose to engage in emotion regulation when interacting with their co-workers, why they choose to regulate their emotions if there is no formal rule requiring them to do so, and what benefits, if any, they get out of this effort," Gabriel said in <a href="https://www.sciencedaily.com/releases/2020/01/200117162703.htm" target="_blank">a press release</a>.</p><p>Across three studies, she and her colleagues surveyed more than 2,500 full-time employees on their emotional regulation with coworkers. The survey asked participants to agree or disagree with statements such as "I try to experience the emotions that I show to my coworkers" or "I fake a good mood when interacting with my coworkers." Other statements gauged the outcomes of such strategies—for example, "I feel emotionally drained at work." Participants were drawn from industries as varied as education, engineering, and financial services.</p><p>The results, <a href="https://psycnet.apa.org/doiLanding?doi=10.1037%2Fapl0000473" target="_blank" rel="noopener noreferrer">published in the Journal of Applied Psychology</a>, revealed four different emotional strategies. "Deep actors" engaged in high levels of deep acting; "low actors" leaned more heavily on surface acting. Meanwhile, "non-actors" engaged in negligible amounts of emotional labor, while "regulators" switched between both. The survey also revealed two drivers for such strategies: prosocial and impression management motives. The former aimed to cultivate positive relationships, the latter to present a positive front.</p><p>The researchers found deep actors were driven by prosocial motives and enjoyed advantages from their strategy of choice. These actors reported lower levels of fatigue, fewer feelings of inauthenticity, improved coworker trust, and advanced progress toward career goals. </p><p>As Gabriel told <a href="https://www.psypost.org/2021/01/new-psychology-research-suggests-deep-acting-can-reduce-fatigue-and-improve-your-work-life-59081" target="_blank" rel="noopener noreferrer">PsyPost in an interview</a>: "So, it's a win-win-win in terms of feeling good, performing well, and having positive coworker interactions."</p><p>Non-actors did not report the emotional exhaustion of their low-actor peers, but they also didn't enjoy the social gains of the deep actors. Finally, the regulators showed that the flip-flopping between surface and deep acting drained emotional reserves and strained office relationships.</p><p>"I think the 'fake it until you make it' idea suggests a survival tactic at work," Gabriel noted. "Maybe plastering on a smile to simply get out of an interaction is easier in the short run, but long term, it will undermine efforts to improve your health and the relationships you have at work. </p><p>"It all boils down to, 'Let's be nice to each other.' Not only will people feel better, but people's performance and social relationships can also improve."</p>
You'll be glad ya' decided to smile<span style="display:block;position:relative;padding-top:56.25%;" class="rm-shortcode" data-rm-shortcode-id="88a0a6a8d1c1abfcf7b1aca8e71247c6"><iframe type="lazy-iframe" data-runner-src="https://www.youtube.com/embed/QOSgpq9EGSw?rel=0" width="100%" height="auto" frameborder="0" scrolling="no" style="position:absolute;top:0;left:0;width:100%;height:100%;"></iframe></span><p>But as with any research that relies on self-reported data, there are confounders here to untangle. Even during anonymous studies, participants may select socially acceptable answers over honest ones. They may further interpret their goal progress and coworker interactions more favorably than is accurate. And certain work conditions may not produce the same effects, such as toxic work environments or those that require employees to project negative emotions.</p><p>There also remains the question of the causal mechanism. If surface acting—or switching between surface and deep acting—is more mentally taxing than genuinely feeling an emotion, then what physiological process causes this fatigue? <a href="https://www.frontiersin.org/articles/10.3389/fnhum.2019.00151/full" target="_blank">One study published in the <em>Frontiers in Human Neuroscience</em></a><em> </em>measured hemoglobin density in participants' brains using an fNIRS while they expressed emotions facially. The researchers found no significant difference in energy consumed in the prefrontal cortex by those asked to deep act or surface act (though, this study too is limited by a lack of real-life task).<br></p><p>With that said, Gabriel's studies reinforce much of the current research on emotional labor. <a href="https://journals.sagepub.com/doi/abs/10.1177/2041386611417746" target="_blank">A 2011 meta-analysis</a> found that "discordant emotional labor states" (read: surface acting) were associated with harmful effects on well-being and performance. The analysis found no such consequences for deep acting. <a href="https://doi.apa.org/doiLanding?doi=10.1037%2Fa0022876" target="_blank" rel="noopener noreferrer">Another meta-analysis</a> found an association between surface acting and impaired well-being, job attitudes, and performance outcomes. Conversely, deep acting was associated with improved emotional performance.</p><p>So, although there's still much to learn on the emotional labor front, it seems Van Dyke's advice to a Leigh was half correct. We should put on a happy face, but it will <a href="https://bigthink.com/design-for-good/everything-you-should-know-about-happiness-in-one-infographic" target="_self">only help if we can feel it</a>.</p>
"You dream about these kinds of moments when you're a kid," said lead paleontologist David Schmidt.
- The triceratops skull was first discovered in 2019, but was excavated over the summer of 2020.
- It was discovered in the South Dakota Badlands, an area where the Triceratops roamed some 66 million years ago.
- Studying dinosaurs helps scientists better understand the evolution of all life on Earth.
Credit: David Schmidt / Westminster College<p style="margin-left: 20px;">"We had to be really careful," Schmidt told St. Louis Public Radio. "We couldn't disturb anything at all, because at that point, it was under law enforcement investigation. They were telling us, 'Don't even make footprints,' and I was thinking, 'How are we supposed to do that?'"</p><p>Another difficulty was the mammoth size of the skull: about 7 feet long and more than 3,000 pounds. (For context, the largest triceratops skull ever unearthed was about <a href="https://www.tandfonline.com/doi/abs/10.1080/02724634.2010.483632" target="_blank">8.2 feet long</a>.) The skull of Schmidt's dinosaur was likely a <em>Triceratops prorsus, </em>one of two species of triceratops that roamed what's now North America about 66 million years ago.</p>
Credit: David Schmidt / Westminster College<p>The triceratops was an herbivore, but it was also a favorite meal of the T<em>yrannosaurus rex</em>. That probably explains why the Dakotas contain many scattered triceratops bone fragments, and, less commonly, complete bones and skulls. In summer 2019, for example, a separate team on a dig in North Dakota made <a href="https://www.nytimes.com/2019/07/26/science/triceratops-skull-65-million-years-old.html" target="_blank">headlines</a> after unearthing a complete triceratops skull that measured five feet in length.</p><p>Michael Kjelland, a biology professor who participated in that excavation, said digging up the dinosaur was like completing a "multi-piece, 3-D jigsaw puzzle" that required "engineering that rivaled SpaceX," he jokingly told the <a href="https://www.nytimes.com/2019/07/26/science/triceratops-skull-65-million-years-old.html" target="_blank">New York Times</a>.</p>
Morrison Formation in Colorado
James St. John via Flickr
|Credit: Nobu Tamura/Wikimedia Commons|
Archaeologists discover a cave painting of a wild pig that is now the world's oldest dated work of representational art.
- Archaeologists find a cave painting of a wild pig that is at least 45,500 years old.
- The painting is the earliest known work of representational art.
- The discovery was made in a remote valley on the Indonesian island of Sulawesi.