The Yale Journal for Humanities in Medicine

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: August 19, 2004