The Yale Journal for Humanities in Medicine |
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Retirement: A Debate
Herbert J. Kaufmann
nek.hjk@verizon.net
and
Howard Spiro
howard.spiro@yale.edu
with a reaction by
James Scheuer
scheuer@aecom.yu.edu
******
Introduction
Retirement gets a lot of notice these days, and as a physician wrestling against it, I thought our readers might benefit from the following, in part from recent issues of Yale Medicine, courtesy of its wise editor Michael Fitzsousa.
-- Howard Spiro
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Why
I Retired
Hebert J. Kaufmann, M.D.
“My
second fixed idea is the uselessness of men over the
age of sixty.”
William Osler, The Fixed Period, 1905
Osler spoke those words in his last address at Johns Hopkins before he left to become Regius Professor at Oxford. He then went on to cite Trollope’s novel The Fixed Period in which an idea is advanced that men were to retire at 60, spend a year in contemplation and then be chloroformed. The jesting tone of his remarks was missed by the newspapers of the time and he was taken seriously. A great brouhaha ensued which caused Dr. Osler both considerable distress and some amusement.
To read Osler today is to experience some of the best aspects of Victorian humane and medical thought. Much of that thought is not outmoded.
I retired in 2000. When I told people what I planned, they asked why. I was 67, apparently fit, enjoyed an interesting practice and my mind seemed not to be failing. Of course, there were and are lots of good reasons to leave practice: HMO intrusiveness, decreasing reimbursements, loss of collegiality in medical communities and suchlike. But these matters were not really at the root of my decision.
When they get to a certain age, doctors should retire. As they age, they become increasingly irrelevant to their medical communities. The generational difference that slowly develops makes communication less cordial. True, we all belong to the same fraternity but the handshake changes. Doctors usually confer and refer among an age cohort roughly ten or 15 years to either side of their own ages. The tone of a medical community is usually set by the doctors in their 40’s and early 50’s. I practiced in one community for over 30 years. What I saw was that doctors who stood at the pinnacle of the profession when I arrived slowly became “Dr. Who?”. Usually they did not know that their knowledge was slipping. They probably did not know it because their loyal patients continued to love them. It was sad to see. I did not want it to happen to me. I could see it would have happened. There are many doctors in our area and some in my group who are younger than my children. Many of them could not bring themselves to call me by my first name.
I gradually lost the intense desire to know everything in my field, and even if I had kept the desire, it would have been impossible to do so. In order to use new knowledge one must have a schema, a sort of intellectual hat rack, on which to hang new concepts. I do not have an up-to-date intellectual schema to incorporate what I understand of genetics and molecular biology. Even many of the titles, much less the contents, of articles in my specialty journals were incomprehensible to me. It is in these new fields that basic knowledge is growing and clinicians should have a grasp of their specialty’s basic science. And, basic science aside, so far as clinical information goes, in my field, gastroenterology, much of it seemed to me to be recycled knowledge arrived at by newer methods. It may have come with better statistics or larger patient populations or with MRIs and endosonography instead of barium and fiberoptics, but it did not help an experienced physician take better care of his patients. At major meetings, I increasingly found myself choosing between papers I had no background to understand or symposia that told me little, as I watched hordes of young men and women bustle past.
Medicine is a unique activity. It offers the opportunity simultaneously to engage in intellectual problem solving, humane ministering and, in some areas, technical expertise. I retired after 34 years of practice and 45 years after entering medical school: really, more than a generation ago. It has been a time of tremendous, awesome, unforeseen developments in medicine and I had a wonderfully satisfying career.
I think what Osler had in mind when he gave The Fixed Period address was the relationship of physicians to their colleagues and to new knowledge. Doctors should not be chloroformed but they should retire.
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It's Never Too Late to Work: An Open Letter to Herbert Kaufmann
Howard Spiro, M.D.
Dear Herbert,
I read your recent essay, delighted at your eloquence if pained at your
conclusion that doctors should retire, but grateful -- at near 80 -- that you
left unspecified the age for desuetude. Somewhat solipsistically, you condoned
your own retirement by pointing out that aging doctors grow out of touch with
junior colleagues who prefer their own peer group anyway, that older
practitioners no longer understand the science in medical journals, and that
-- in your words they grow irrelevant as far as their colleagues are
concerned.. But you mostly slight the loyal
patients, as you called them. They too have aged and many
would not have been unhappy to rely on an old doctor like you who looks at
the world from their same perspective , a helpful coeval who can aid
in their medical decisions and minister in a way to their very human problems.
You and I are longtime friends, you were once my student, and so I hope you will
let me repeat why I continue working , and why I believe you have chosen
wrongly. A mid-1930 liberal, I was raised in that more generous era when
obligations to the community arose from the sense that we Americans were all in
the same boat , or as John Donne put it. "No man is an island, entire of
itself." On my retirement from Yale at 75, I was eager to work for
the poor, or disadvantaged as the postmodern world has it, but the authorities
in my clinical department were less than enthusiastic at the prospect of my
hanging around after 44 years. Luckily enough, I joined the
gastrointestinal group at 40 Temple St, a few blocks from where Marian and I
live and a five-minute stroll to the Medical School. Working there
happily since 1999 , I find two days a week for six hours just enough ,
for more would be tiring and might turn me more cantankerous than ever.
I see all sorts and conditions of patients, some adolescents and more adults ,
many my age or older. I feel great kinship with the elderly and I
shape my advice to them rather differently from the way I did at a callow
50. I am far less likely than before to urge optional surgery for many chronic
conditions, ever since several friends over 70 recovered from operation
far less alert and competent than they had been before. Such
post-operative deficits are not always obvious, but the family will tell you
that Grandpa has lost his sense of humor or that Grandma no longer has her usual
verve and enthusiasm. When people ask me what I lost after my cardiac bypass, I
reply -- optimistically I hope -- that I lost my impatience. But maybe
it's those beta-blockers I take.
Those who come to see us old doctors get time and attention. We can act as
mediators between what the CAT scans and MRI show and what the patient feels.
We know the truth of the aphorism that the eye is for accuracy but
the ear is for truth. We have the time to listen and I enjoy the
talkativeness that once would have annoyed me in my rush to get everything done.
We no longer fear death nor are we greedy for more days on the earth, like many
of our aged patients who, given the chance to comment, seem to agree.
Also, we have learned that time and " nature" -- the
Creator if you will -- heal many wounds, for we have practiced long enough
to be aware how many problems get better on their own. We are wary of the
urge to be " proactive," so universal among our younger colleagues.
"Prevention" flies on every banner and even 80-year-olds cannot
escape pills to lower cholesterol or tame the prostate Cardiologists
straighten every bend and twist in the coronary vessels even when their patients
have no pain, busy as the gastroenterologist plucking polyps from octogenarian
colons.
You worried that to practice at the top of the profession requires keeping
up-to-date on science and you were disconsolate at your growing failure to find
intellectual delight in modern science, but you did not seem to remember that
the care of patients is just that, care not always cure. I failed you as a
teacher if you imagine that most of the people who come to see me require
that I trace the twists and turns of amino acids. It may be
fun to read the science of our medical journals, but little of that is required
to care for patients in office or clinic Indeed, I doubt that in
daily practice even the wisest clinicians use the organic chemistry or physics
from college , or the molecular biology of medical school.
I wish that you had continued to see patients one way or another. For there is
the matter of payback, our duty or obligation to continue working at least
part-time, not in the same earnest frenzy as before. There are
nowhere near enough physicians and we who are spared can make a
contribution by working part-time in office or clinic to let someone
else bear the heavier burdens of the hospital . We should enlist some of
the 70-year-old physicians spending their days on the golf course back into
practice some hours or days a week, they and their patients might be the
better for it.
You may have ignored too much the personal side of medicine and medical care.
Only now, after a lifetime of experience are you able to share the viewpoint of
the elderly . You may have missed a wonderful chance to contribute, not as
a brash technician but as a contemplative old physician. We need elderly
doctors in our intensive care units , not taking care of patients and not, one
hopes , lying in a bed , but as knowledgeable patient advocates
wandering around the unit asking questions about what is being done and why, and
to what purpose. The intensive care unit might even be a place for
elderly doctors to talk to the families of the patients being taking care of by
younger experts.
There is much good also to be said for the viewpoint of the old, who have had
experience and now have the leisure for contemplation. To be sure, it is
frustrating to recall clever schemes that failed in the past and all too
often to face blank stares in the condescension of the young, ignored by
being yes- yessed to death .. Yet you still have much to offer, to
yourself and to your patients, and to your colleagues. It takes staying
power, iron pants, and stamina and a willingness, no an eagerness, to
accept a changed role. People may think that you are irrelevant, but as
long as you are convinced that you are not, you have something to say to
them..
There are so many other things that physicians over 70 can still do. My
friends Kay and Robert Zufall opened a free clinic for Hispanics in Dover NJ 10
years or more ago in a volunteer enterprise that still gives other aging doctors
the chance to work a few hours a day and to talk with old friends. Osler may
have been joking, but he was dead wrong in any case. Surely you remember
that Harvard Medical School did not admit women as students until mid-1940s
under the mistaken expectation that they would abandon medicine for pregnancy,
but look at all the women doctors around us now.
Given your health and intellectual agility, you had another 15 years or more
ahead of you. You should not now so eagerly abandon what it took so long
to learn , nor should any of us be abashed to continue working, or to confess
that work defines us and that we enjoy being useful.
God bless. Your friend and quondam teacher,
Howard Spiro
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A Response to Howard Spiro's Open Letter
Herbert J. Kaufmann, M.D.
Dear Howard,
That you should respond to my essay with a letter half again as long as that to which you responded, brings to mind, was it G.B. Shaw’s, coda to a letter when he wrote, “Forgive me for writing a long letter but I did not have time to write a short one”. My response to you will be shorter.
My two main reasons are relevance to my medical community and lack of an adequate intellectual schema in which to incorporate new knowledge.
I was bothered by the impending irrelevance that I had seen afflict older physicians. Friends of mine, particularly doctors and attorneys with whom I have discussed this, concur in the recognition. Does being troubled by that prospect reveal inadequate ego strength or simply an accurate perception of reality? Choose one!
The problems of understanding and incorporating new knowledge and it’s effect on how I wanted to practice are linked to your statements about continuing to practice in a changed capacity and the wisdom that comes to some with age. All the kindness and wisdom in the world that a practicing doctor offers are not, in my opinion, worth much if not backed by up-to-date knowledge. I suspect that the doctors who practice part time in clinics after retiring are not offering first rate medicine.
You take me to task for not being a “mid 1930’s liberal”. I plead guilty. The implication that somehow it was immoral to retire and deprive the world of my (supposed) talents is a bit harder to take. Perhaps I should have spelled out my thoughts more clearly. I thought for me to continue practice and encounter the loss of respect of my colleagues – and one’s colleagues know you better than you know – and be unable to use new information properly would have been to practice under false pretenses.
Do I think everyone should retire at a specific age? Of course not. With rare exceptions, however, there comes a time when older physicians should make way for younger ones. I chose what I chose. I make no apologies. I loved medicine but do not miss it. I am very happy in my current state.
Your long-time friend and student,
Herbert
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A Reaction to Hebert Kaufmann's Remarks
James Scheuer, M.D.
scheuer@aecom.yu.edu
Dear Herbert:
I write to you as a friend from childhood, and also as one who knows of your fine medical career.
I have enjoyed the interchange between you and Howard Spiro in The Yale Journal for Humanities in Medicine.
Howard will not remember, but for the record, I graduated from Yale Medical School in 1956, so Herbert I should be even more obsolete than you. I have not retired, although I have slowed down. My career has included being a cardiac investigator, cardiac educator, consultant cardiologist, program director of an internal medicine residency program and chairman of a department of medicine. After 12 years in the latter post, I stepped down voluntarily in 1999 and took a sabbatical in a myocardial cell biology laboratory in England. I then returned to Albert Einstein and Montefiore and am still full time, although not working the ridiculously long hours I kept during my career through June of 1999. In the ensuing years I have done some laboratory research and have a small consultation practice, make teaching rounds in our coronary care units and on the consult service, and I am currently director of the cardiology fellowship training program.
A few comments on some of your statements.
1. “…usually they did not know their knowledge was slipping.” Was their knowledge slipping or just failing to grow with the times? If it is the latter, I believe that with some CME activities on clinical topics, that Howard has it right. They could continue to be wise and useful physicians, but they should diminish their loads and apply more thought per patient (not bad advice for most physicians in busy practices).
2. “…should have a grasp of their specialty’s basic science.” True if you are teaching, but is it necessary to everyday practice of office gastroenterology? I believe Howard’s remarks on this issue are relevant here.
3. “…it did not help an experienced physician take better care of his patients.” At least in Cardiology, I believe new clinical information does help us provide better care. For example the use of statins, ACE Inhibitors, beta adrenergic blocking agents markedly improve the care of patients with coronary disease and congestive heart failure. I know there are similar clinical advances in gastroenterology, and I would wager that you maintained your currency on those that you needed for patient care. Keeping up on this kind of information is not difficult; we are bombarded with it in journals, talks and on the internet. It does require interest of the recipient and if that interest is not there, I agree the individual should retire. I have been able to keep up moderately well with the molecular aspects of cardiology and with the advances in clinical cardiology. This is made possible by working in an academic division where we have frequent conferences on all aspects of cardiology. I get tremendous satisfaction from the accomplishments of my younger colleagues, many of whom have been my students. I am not as up to date in some of the highly specialized activities of clinical electrophysiology and interventional cardiology as the younger faculty members, but I am not embarrassed to admit this publicly and ask their assistance. On the other hand they ask me for my perceived “wisdom” on some of their most difficult cases, and in a few of these I believe I have even helped.
4. Your emphasis on “care of his patients”. Do the young physicians really provide better care than you did? I doubt it, but if one feels inadequate in any one case why not admit that to the patient and refer him to a colleague who, in that particular situation is more qualified? The patient will value your honesty.
5. Irrelevancy and willingness to accept a lesser position. The perception of irrelevancy may be yours, but it is not irrelevancy if one is willing to change his role yet continue to make a contribution. I can tell you that stepping down from the chairmanship of a very large department, and becoming one of the troops was not all bad. If one can accept his new and lesser role he can achieve new relevancy and new gratification. Howard, a world famous leader in gastroenterology seems to have been able to do this with some comfort. I believe a change in one’s professional role can bring renewal throughout a career.
I think a key issue in redesigning one’s professional life as he ages is to slow down, be more thoughtful about each patient and each activity, not feel the pressure to produce, whether it be numbers of patients, practice collections, publishing of papers or winning grants. The diminished pressure allows for more personal and professional quality time.
How can I justify continuing in my current role? Am I just deluding myself? I believe I have a significantly broader viewpoint to bring to the field than most of our younger faculty members who are highly focused and subspecialized. I have a much deeper understanding of the physiologic basis of cardiac function. This is useful in our training program and lends a perspective that would not otherwise exist. When those of us with this background retire, the world of cardiology will go on, but something will be lost.
Your 34 years of practice, I am sure, brought exceptional skill and wisdom both to your colleagues in practice and your patients, and that cannot easily be replaced. I also feel that certain considerations you mention for leaving practice are realistic, some from which I have been shielded in the privileged environment in which I work. As you have pointed out to me, being in an academic environment at this late stage of a career provides more protection than having to meet the demands of a private practice, where you occupy costly space and have less flexible schedules, all of which require maximal economic and professional productivity.
It is true that some physicians remain in professional life too long, and many of us (perhaps myself included) may deceive ourselves about our continued worth. However, I do observe colleagues in private practice here who still, in their seventies do an admirable job with their patients and teaching. They continue their GME activities and keep quite up to date. Others, much younger may have never kept up and may never have been the care giver that you were and could be at your age.
Osler’s comments of course were made at a time when the world was quite different. Even in our lifetime we have seen many more of us “elderly” remain “young” into their seventies. As you yourself note, one size does not fit all. Hopefully, most of us will recognize when we have outlived our usefulness. Unfortunately some will not. For the latter, our profession should develop systems that deal with those who remain in practice too long. Others, perhaps like yourself, will decide that they have reached a point of diminishing personal rewards and even professional worth, and for them retirement is right.
I am not aware of any good research into factors in physician retirement which relate to the kind of feelings you express. A brief survey of Pub Med and Google uncovered a few articles on the effect of HMO’s and the structure of medicine on retirement trends. The IOM website is silent on this subject. One would think that the IOM should be interested in this topic. Perhaps it is time for such a study, one which could also evaluate some of the questions surrounding the adequacy of care provided by aging physicians who do not retire.
Herbert, today I am happily quite busy, so do not have the time to write more concisely. I do want to thank Howard and you for stimulating me to reexamine my own situation, and again consider, how long I should continue.
Most cordially yours,
Jim
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Published: January 25, 2004 and August 19, 2004