Perspective
The Graying of a Physician
Aging means recognizing limits. Why do physicians have such a hard time knowing when to let go of their practice?
By Charles R. Meyer, M.D.
In Alpharetta, Georgia, north of Atlanta, pediatrician Leila Daughtry-Denmark* had an office in a small frame house where on Monday, Tuesday, Wednesday, and Friday she saw only walk-in patients. On Thursdays, she volunteered at a free clinic. Dr. Denmark examined and treated children and dispensed medical wisdom to parents about the dangers of cow’s milk for infants and secondhand cigarette smoke for all children. With its tattered, antique furniture, rotary-dial phone, and absence of nurses or receptionists, Dr. Denmark’s office was a bit unusual. But that’s because Dr. Denmark was no ordinary pediatrician. She was the first intern at Atlanta’s Egleston Hospital for Children. She was the third woman to graduate from the Medical College of Georgia, graduating in 1928. And when she retired in 2001, she was 103 years old.
Who would take their child to a 103-year-old pediatrician? Would they worry about the doctor forgetting to check the heart sounds or prescribing the wrong antibiotic? According to one article on Dr. Denmark, “Her unique style inspires confidence, children are instinctively drawn to her, and her diagnoses are very much on target.” Yet I do wonder. Medicine makes harsh demands on the minds and bodies of its practitioners. Aging inevitably wears on those same minds and bodies. What does medicine do to physicians’ aging? What does aging do to physicians’ medicine? How well do they retire, and do they retire early enough? Are older doctors better equipped than younger ones? And why did Dr. Denmark want to practice medicine for 70 years?
When I finished my medical training and joined a six-man group of internists in Minneapolis, I was 29 and the youngest member by 10 years. I thought I knew a lot. I had just passed the internal medicine board exams, infamous for flunking 40 percent of examinees. I could name 15 causes for most symptoms and five treatments for most diseases. I was primed to stamp out illness, and I had vowed that I wasn’t going to turn into an L.M.D., a pejorative nickname used in many training programs for the local M.D. who has sent mismanaged, near-dead patients to the training program’s referral hospital and who obviously couldn’t have read a medical textbook in 15 years or he wouldn’t have mishandled his poor patient so egregiously. I felt the primal fear implanted in doctors during training that being wrong was sinful and the way to avoid being wrong was to know everything, or almost everything. Armed with my quiver of medical facts, I was ready to show my new partners, their patients, and the medical community how medicine should be practiced. I thought I had all three necessary criteria: knowledge, experience, and wisdom. Actually, I was light on the first two and lacked the last.
I joined my medical group so the senior partner could retire. Dale C. was 65. With salt-and-pepper, wavy hair, a confident air, and a smooth backswing, Dale was a society doctor. For 25 years, he had worked hard to build a practice and a prosperous patient network. He proudly proclaimed that he had been a member of the local country club for 30 years. Now that he was entering what he playfully called “the male climacteric,” he was ready to slow down. Except that he couldn’t. He did take three- or four-week vacations, but as soon as he returned home, he would add office hours. His faithful following would wait months to see Dr. C.
Ten years after I joined the group, Dale was still practicing. He was doing a reasonable job, partly because he had given up taking care of hospitalized patients and mainly did routine office visits. Yet, he had his occasional lapses. Many times he walked out of the office forgetting that he hadn’t finished with his last patient. Covering for the “senior” partner, I would go into the exam room, mumble something about Dr. C. “being called away,” and finish the visit. His comments about people’s names or medical terminology got vaguer. He wasn’t dangerous, but he definitely had lost his edge.
This was happening during the final years of Ronald Reagan’s second term, which he finished at the age of 77. I found myself asking, How can Reagan daily manage the country at 77 and few physicians ever practice effectively past 70? What’s the difference between doing the job of President of the United States and practicing medicine? Presidents have a lot of help, and no major decisions are made by one person alone in a room. Given the orchestration behind every presidential appearance, mistakes are practiced out. For a professional actor like Reagan, even in the beginning stages of Alzheimer’s, each public appearance was one more stage with one more script that he could do in his sleep with half his brain. Doctoring, however, is an individual job.
For surgeons, only they are doing the cutting. If they make a mistake, everybody in the operating room knows it. When they should hang up the scalpel may be obvious to many before it’s obvious to the scalpel wielder. Physician and writer Richard Selzer expressed it poetically in Letters to a Young Doctor: “An old surgeon who has lost his touch is like an old lion whose claws have become blunted, but not the desire to use them. Knowing when to quit and retire from the consuming passion of your life is instinctive. It takes courage to do it. But do it you must. No consideration of money, power, fame, or fear of boredom may give you the slightest pause in laying down your scalpel when the first flagging of energy, bravery, or confidence appears.”
For internists, the signs are less obvious—the overlooked abnormal potassium, the unconscious decision not to check the heart during this visit. Some are oversights of knowledge; many are flaws in attitude, a sense that I’ve done this hundreds of times and I can tell whether it’s worth checking without actually checking. The compulsivity that is selected for by medical school admission standards and reinforced during medical training dulls with the years, and when corners are cut, things can get missed.
As Dr. C. showed, retirement is an emotional trial for physicians. They give up the adulation, spoken or unspoken, of their patients. They give up the power of making decisions based on knowledge acquired with headache and sweat that do make a difference, sometimes paltry, sometimes cataclysmic, in people’s lives. To decide to do it is difficult; to be told you have to do it is devastating.
Stories about aging physicians are whispered sotto voce in the doctors’ lounge—the orthopedic surgeon whose partners quietly but not so politely elbowed him out of practice after the botched operations became a pattern rather than an event; the octogenarian family physician who virtually went from closing his office doors into the Alzheimer’s unit of a local nursing home; the 85-year-old general practitioner who could barely limp from the hospital to the parking lot and who, after he hit a pedestrian, had his driver’s license taken away while he still had a medical license. Why do these physicians keep practicing when they must know subconsciously if not consciously that they are slipping? Mostly, because they don’t know anything else. They have devoted a lifetime to acquiring and using their medical skills. Many have but a few outside interests. And even the passionate golfer can find the game wearisome if played seven days a week.
Aging in medicine, or any profession, means recognizing limits. An internist who has practiced for 18 years and who had to take two years off for chemical dependency treatment told me he’s learned that he “can’t take care of the whole world or solve everybody’s problems.” It’s a perspective lacking in new practitioners fresh from training in which they are drilled to take care of the “whole patient” and be “the complete doctor.” Setting limits on what they will and can do may be something the next generation of doctors has learned sooner and better than my generation. Most of the doctors emerging from residency who we have interviewed to join our group want clearly defined limits on the hours they will devote to the practice and militantly guard their nonmedical lives. Whether their generation will age better in the practice of medicine is yet to be seen.
I have become a student, a spectator, and a victim of aging. I know the physiology; I know the pathology. As patients come back year after year, I study the changes: Matt is fuller around the middle, Fran is walking with a cane, Art can’t come up with the name of his brother. I watched my five original partners age, then retire or die. I feel myself changing from what I was as a cocky new internist, striding into town. I’ve noticed some physical changes—the “ache of the day,” the split-level glasses, and, yes, the graying temples. But the mental changes are most important and, perhaps, the most controllable. I’ve learned that the number of years is less important than what genetics and environment have dealt to each person and what a person’s attitude deals back to age. Age doesn’t have to ossify people or doctors. It’s a matter of looking for the pearls beneath dross of the day, the zest culled from humanity.
It’s finding the story behind the medical history. I saw a new 94-year-old patient who had had two previous coronary bypass operations, but the piece of her past that made her memorable was the fact that, until two months before our first visit, she had lived in a cabin at 4,000 feet in the Sierra Nevadas with her closest neighbor five miles away and mountain lions in her front yard. One more coronary bypass survivor can be dull and add dust to your brain; a 94-year-old who contends with mountain lions adds zest to your life.
I realize now that what seemed old to me about my partners, and what feels old to me about me at the end of a bad day, is thinking that all those people I saw were just patients with pat diagnoses that were either solvable with easy answers or unsolvable because they were difficult people or medical science didn’t have the answers.
Am I a better doctor at age 58 than I was at 29? I think so. Although I certainly don’t know as many medical facts and likely would struggle with the internal medicine board exam, I do know disease in people better. As one of my current partners put it when I asked him what was different for him after 15 years of practice, “I can walk into an exam room and spot a really sick patient almost instantaneously.” I can pick up nuances in patients’ stories that would have whisked right by me in the first years of practice. I can sift more intelligently, knowing which chest pain to pursue and which to let be. With the years, knowledge may fade but instincts sharpen.
Canadian writer Robertson Davies fingered the real problem when he wrote this about his aging colleagues: “What ails most of them, and what has ailed them all their lives, is that they lack curiosity. They have never engaged themselves strongly in anything. The waters of life have washed over them without anything soaking in. They are not interesting when old because they were never interesting when young. … Curiosity … is the great preservative and the supreme emollient.” Your hair can be gray or gone, but true aging is losing interest.
I’m not sure what kept Leila Daughtry-Denmark opening up the door to her Georgia clinic every morning. At 103, she’d earned her place on the front porch rocker. Maybe, like other doctors who have trouble hanging it up, she didn’t know what else to do. Maybe, even 73 years after she got her M.D., she liked the prestige and adulation. But I guess that maybe she had more than a little of what T.S. Eliot was getting at when he said, “old men [and old women] ought to be explorers.” MM
Charles Meyer, M.D., is editor-in-chief of Minnesota Medicine.
*Leila Alice Daughtry-Denmark, M.D. (born February 1, 1898, in Georgia), was considered the oldest practicing pediatrician in the world when she retired at age 103 in May 2001. She began her private practice in pediatrics in Atlanta in 1931. In 1932, whooping cough swept through the community, prompting her to begin studying the disease. Over the next six years, she published her research in the Journal of the American Medical Association and, with Eli Lilly and researchers at Emory University, developed a successful vaccine. She was among the first doctors to object to cigarette smoking around children and drug use among pregnant women. She feels that drinking cow’s milk is harmful and that children (and adults) should eat fruit instead of drinking juices, and drink only water. She resides in Alpharetta, Georgia.