Dear Dr. Horton #6: Twilight

Welcome to this week's edition of Dear Dr. Horton. Send the anonymous questions that keep you up at night to a real former Dean of Medical Student Affairs, Dr. Jillian Horton, and get the perspective you need with no fear of judgment. Submit your questions anonymously through this form, and if your question is appropriate for the column, expect an answer within a few weeks!

Dear Dr. Horton,

I am a recently retired physician, and your blog seems like a great idea to me. Support and acceptance are needed at all stages of our careers.

Burnout is a reality in our profession, as is ageism. Because of ageism, it is often difficult to balance limitations with outside expectations and many physicians simply choose to retire. My hope is that will change — our profession will see, acknowledge, and embrace the value of our aging colleagues — but that is simply not true now. How can the profession both assist the transition and get maximum value from its most experienced colleagues?

Signed,

Twilight

Dear Twilight,

I like your question, but I don’t think anyone under the age of forty is going to listen if I write about retirement. So I’m going to pose a different question related to your point about ageism. What is the value of age and experience in medicine, relative to the boundless energy and raw talent of youth?

This is where I’m glad that I started my life as a classically trained musician. In music, there’s the concept of masterclass. Every serious musician knows that in a masterclass, the maestro doesn’t necessarily have to demonstrate more technical proficiency than those who come to play and learn. The maestro may no longer be in his or her physical prime, and some of these students may be prodigies — but they still need the maestro. So what if Horowitz dropped a few notes by the time he was in his seventies? Only a fool would say he had nothing to teach them.

Even though I knew this from musical life, it took me a while to see it in medicine. You are right that medicine is rife with ageism. When I was an intern, I suffered from a diagnosable case of imposter syndrome, but was also coinfected with hubris. This wasn’t really a paradox; hubris was an illness of the group, not the individual. Whenever my peers and I had a very elderly attending on service, we rolled our eyes and gritted our teeth. They slowed us down. These docs were nothing like the hotshot, celebrated seniors in the years ahead of me — residents who made putting in central lines look as easy as sticking a straw in a juice box. These late-career attendings didn’t seem up on the most current guidelines, and they weren’t much use in a code. Sometimes we would chuckle about how the old guy, nice though he was, might be ready to attend in the retirement home... and while he was at it, he could pick out his own room.

One case gave me insight into the many ways in which this thinking was arrogant and just plain wrong.

Mr. A. was a man in the prime of his life. He had a successful career, a loving wife, and doting, accomplished children. He also had an aggressive cancer, and he presented with painless jaundice and ascites. Before we could even establish the primary, he was actively dying.

His family’s grief and bewilderment were raw. They had no time to adjust to anything. One day, at the end of a difficult week, after we had agreed that we would not subject him to futile interventions in the ICU but before we had formally discussed palliative care, his wife ran out to the nursing station, screaming that she thought he might have stopped breathing.

I hurried into the room. Mr. A.’s lifeless, yellow body lay still, his eyes open.

“Do something!” his wife sobbed, then yelled at me. “Can’t we do something?”

He didn’t need a central line; this wasn’t a code, and there were no guidelines I could quote. I stood there, useless to this woman in the very worst moment of her life, struggling to manage my own visceral reaction to the sight of her dead husband.

But somehow, behind us, my attending had materialized in the room. “I’m so sorry, dear,” he said, and he folded her in an enormous hug. Mrs. A. sobbed into his white coat for a good five minutes while I alternated between stupidly staring at the floor and making sure Mr. A. was really dead.

Afterwards, my attending offered the same comfort to Mr. A.’s two children, and later, to me over coffee and a talk he knew I needed. We spoke about what it felt like to watch somebody like Mr. A. succumb to an overwhelming, disfiguring disease. He helped me navigate complex feelings of revulsion, failure, and grief by offering kindness, presence, and wisdom… qualities I had been too immature and inexperienced to appreciate.

I learned several important lessons that day. The first was that young people have no idea what they don’t know, which is what makes ignorance so dangerous when we are young. I was too junior to have a clue that my attending wasn’t fussing about Mr. A.’s rising creatinine or bilirubin because he knew that Mr. A. was going to die. Instead, he was focusing on building a relationship with the family. But because he wasn’t doing what my peers and I were doing, I made a fundamental attribution error. I thought he was less capable than us because he was old. I didn’t know what I didn’t know. And what I didn’t know was how much he knew about practicing medicine in contrast to my peers and I, who had never really practiced it at all.

The second lesson I learned that day was that when we’re young and can’t distinguish between the forest and the trees, we sometimes set fire to the forest. My arrogant, condescending attitude towards this attending almost deprived me of what he had to teach. That’s one more thing I learned that day: we can always act with more humility.

Twilight, you and I both know that no cohort is perfect. Some senior attendings have attitudes and practices that are dated and offensive, just as some students are abusive and unprofessional. Those people are in every demographic in every profession, and no person or group deserves to be smeared because of the conduct or characteristics of a select few. So let’s not focus disproportionately on those bad apples. Let’s focus on deepening the connection between the history and future, maximizing opportunities for mentorship programs and fostering intergenerational community in medicine.

The senior attending in this story never taught me to do procedures, or discussed pharmacokinetics in detail, or gave me detailed notes on my examination of the third cranial nerve. But he gave me a masterclass on what it means to be a healer. He taught me presence, compassion, and humility. He showed me what it looks like when you bring yourself to the bedside, every day. He was Horowitz fudging a couple of notes. My team and I had been stuck on those notes, too immature to understand that this was a masterclass.

I think that’s what ageism in medicine can cost us. We get dazzled with our own cleverness, as if hitting all the right notes is the only thing we can measure. Meanwhile, we don’t even recognize that what we’re making is music. Or see that it is art.

Yours,

Dr. Horton

 


Note: This is a true story, although the case described occurred approximately 20 years ago. Pertinent details have been changed so that the patient’s family cannot self-identify.

Dr. Jillian Horton is a graduate of McMaster Medical School and completed her residency and fellowship in general internal medicine at the University of Toronto in 2004. She was the Associate Dean of Undergraduate Student Affairs at the University of Manitoba from 2014–2018 and now directs programs in wellness and medical humanities at the Max Rady College of Medicine. She has won awards for mentorship, professionalism, and teaching at the undergraduate level. She is also a mother, musician, and writer. As an Associate Dean, she cared so much about undergraduate students because she never forgot what it felt like to be one of them.

2 thoughts on “Dear Dr. Horton #6: Twilight

  1. Twilight

    Dear Dr. Horton:

    I hesitated before composing this response as it seems somewhat like a conflict-of-interest posting on a letter I sent. However, after reflection I reasoned that it was important to acknowledge the wisdom in your reply and to try to clarify my intent. Part of my intent is reflected perfectly in your response. Wisdom is earned over time and our older colleagues have value that sometimes is not easily appreciated in our busy lives. The original intent of my submission was to ask my younger colleagues to start thinking about how they can influence meaningful change in our culture so that by the time they are ready to think about retiring they can maximize their value and balance that with their preferences and needs. Some of your readers will be formal leaders – educators, administrators, regulators, researchers, politicians. Most of your followers will lead in other ways – chiefly by providing valuable service to the public – our common goal and most important objective. Some will be part of a team in a hospital setting. Most will be part of a team outside that setting for the majority of their contribution. Each setting has its challenges when I think about what changes might foster longer careers and encourage our aging colleagues to continue to contribute and extend their best-before-date. Someday this will be you. Because cultural change is glacial I feel it is important to encourage our younger colleagues to start reflecting what changes would be productive so that the culture is ready for them when they transition themselves. Any ideas I put forward seem irrelevant as I am retired.

    Sincerely
    Twilight

    Reply
  2. Anonymous

    If I may disagree with you, Twilight, I think you underestimate your younger colleagues’ interest and appreciation for your thoughts and ideas (is this perhaps internalized ageism?). I also think that the challenge of balancing medical culture’s expectations with personal needs and values is certainly not unique to those “transitioning” out of practice.

    I am just “transitioning” into practice, and I often feel that it is impossible to meet medical culture’s expectations (generally re: amount of time spent working and scope of practice) with my own desire to have some sort of life outside of medicine. I often hear comments that new physicians simply do not have the work ethic of their elders. I find this demoralizing when I already feel like I have zero work life balance at this stage in my career.

    Fortunately for me, I have senior colleagues at all stages in their careers in my office, and many of them have reached out at various times to encourage me at this point in my career. When a colleague, who has been in practice almost longer than you have been alive, takes the time to tell you about their early career and offer non-condescending encouragement, management advice, ideas and wisdom, it is a precious gift. I deeply value your hard-earned wisdom.

    I’m not sure I have the answer to the question, but I think listening and valuing the perspectives and ideas of everyone at every stage of their careers is an essential place to start, and I think we can all relate whether or not we are on the brink of retiring or starting out ourselves.

    Reply

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