Aging, uncertainty, and independence: how doctors and patients manage growing old in primary care

There are two basic assumptions about medical care that both patients and physicians subscribe to upon entering the exam room: 1) that a medical recommendation can be made, and 2) that patients can comply with the recommendations. But in some instances, this is not the case; previous research shows, for example, that adhering to normal guidelines for older patients can actually diminish their quality of care. In this dissertation, I explore what doctors do when the assumptions that drive medical care no longer apply by focusing on one setting where this issue is especially relevant – primary care for older adults. For older patients (defined here as adults aged 65 or older), the absence of these assumptions is linked to negative understandings of old age. Clinicians can feel that treating older patients is futile because often their health problems cannot be cured, leaving providers uncertain about the best clinical course of action and whether the chosen treatment might cause more health problems than it alleviates. Thus, older patients and their doctors must grapple with a few core issues each time they meet: the entanglement of medical and non-medical problems, uncertainty about how to address complex health issues, and whether older patients are independent and reliable enough to carry out the recommended course of action. Using a combination of ethnographic and conversation analytic methods, this dissertation demonstrates how the process of aging – and the problems that are associated with it – are confronted and managed collaboratively in primary care interactions. Chapter 2 begins this examination of aging in interaction by discussing how the stigmatized label of being old is talked about. This chapter shows that although the label of old age is stigmatized, it can be mobilized as an interactional tool that facilitates discussions about uncertainty. Chapter 3 explores how patients demonstrate independence and personal responsibility for their health through strategic question design. Chapter 4 examines instances in which patients’ ability to manage their health may be irrelevant because the doctor has no treatment to offer, and that in these situations, doctors can provide empathy