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Why the Geriatric Geriatrician Is (Almost) Immortal

2013; Elsevier BV; Volume: 14; Issue: 4 Linguagem: Inglês

10.1016/j.carage.2013.03.017

2377-066X

Jerald Winakur,

Aging and Gerontology Research

First, a disclosure. I graduated from medical school in 1973 and have practiced internal and geriatric medicine for 36 years. I have never applied for nor received a grant for scientific research. I am not on a board of directors that offers recompense and have no ties to Wall Street, K Street, or Big Pharma. I took the Hippocratic Oath at my convocation and still remember the gist of it. As of this date, I am enrolled in Medicare, and I hope to collect Social Security a year from now. Despite all of the above, this essay is about aging physicians, not sanctimony. In another context, I could discuss the mistakes I have made in both my professional and personal life. But I would need much more space than this column allots. No, I have no reason for sanctimony. I am grateful for what I have: the love of my family, the gratitude of a moderate cadre of patients, the respect of a small circle of dedicated colleagues, and my opportunity to influence a few medical students each year. As a geriatric geriatrician, I am truly blessed. In defense of my medical mistakes, at the time they occurred I believed with all my heart and soul that what I was doing for my patient was the right thing to do. I say this also without sanctimony. The bad things that occurred – the complications, the poor outcomes – happened in the normal course of events in an everyday, garden-variety practice by one who always tried his best at his chosen profession. In this, I am just like the vast majority of my doctor colleagues out in the world, practicing what we do day in and day out. Still, over the span of a long career, somehow it is the mistakes that stand out. The times things go well fade into the background of all that is expected in a professional lifetime, all that we inevitably expect to go according to plan. The mistakes, therefore, are stark. They stand as unyielding as stone markers. But how many of these are related to the age of the medical practitioner? Now is a time of accountability. Commercial airline pilots must retire at age 65 and FBI agents at 57, according to a good article on this topic by Sandra Boodman in the Dec. 10 Washington Post. “Doctors are not immune to the effects of aging,” geriatrician Dr. William Norcross – age 64 – told Ms. Boodman. He directs the Physician Assessment and Clinical Education program at the University of California, San Diego. It is one of a growing number of programs that perform intensive competency evaluations of doctors. Hospitals around the country are making such physical and cognitive screening mandatory for doctors to maintain staff privileges. At the University of Virginia, such screening begins at age 70, and at Stanford it's age 75, according to the article. Norcross told Ms. Boodman that he believes that there are 8,000 doctors in the United States practicing with full-blown dementia. One-third of us who work into our nether years don't even have a personal physician who ought to be screening us for hearing loss, visual impairment, declining motor skills, and early cognitive impairment, he said. In a 2009 article in Clinical Orthopaedics and Related Research, orthopedist Dr. Ralph Blasier wrote that “essentially every treatment technique taught 25 years ago has been abandoned and replaced” (Clin Orthop Relat Res. 2009;467[2]:402–411). Much of this criticism of older doctors smacks of ageism, and not everyone agrees with the idea of mandatory age-related deficit screening. My 70-year-old surgical colleague keeps trying to retire from the surgical group he founded, but his younger associates won't let him. He is the only one who can bail them out when their minimally invasive techniques get them into trouble and they need someone with the depth and breadth of surgical experience that they never had in their training programs. As a geriatric geriatrician, I can look back over my 40 years in medicine and reflect on my proceduralist colleagues and their obsolescing technical skills. And I am sympathetic (even though we geriatricians are in a subspecialty that pays us less to see an 80-year-old woman to evaluate the “spell” that she just had than our ear, nose, and throat colleague gets for cleaning the wax out of her ears). All of us – doctors and other humans – have aging brains. Half of us will have some degree of dementia, recognized or not, by the time we are 85. But among our physician colleagues, the technical skill set we geriatricians develop over a lifetime ages well. (Note that I make a distinction between technical and knowledge skill sets.) Here is all I've ever needed in my examination rooms: a blood pressure cuff, an otoscope, an ophthalmoscope, tongue blades, a reflex hammer, two tuning forks, the stethoscope around my neck, and a cheap wristwatch with a second hand. Most importantly, I need a quiet, private space with a comfortable chair for my patient, another for a family member, and one for me – along with the time to sit in it and the patience to listen. Not much technical obsolescence happening here. Those of us who practice the “cognitive” specialties of medicine may work for many years before we hit our stride in judgment and compassion – qualities that are essential to our effectiveness as physicians but ones that cannot be honed by technical and algorithmic approaches to patient care. Who measures us on “quality scales” such as these? Witness Dr. Ephraim Englemann, the 102-year-old rheumatologist at the University of California, San Francisco, and director of the Rosalind Russell Medical Research Center for Arthritis. “I'm very much opposed to retirement,” he told Ms. Boodman. Nevertheless, he tells his colleagues should they notice he is slipping: “Let me know and I'll get the hell out of here.” Kudos to a centenarian who recognizes that a time may come when he just might have to call it a day. But not just yet.