The Older Psychiatrist in an Era of "Unprecedented Change"

Confucius was not the only man to become unperplexed after reaching the age of forty. Upon reaching the age of forty, both wise and foolish have gone through an appropriate amount of experience and will no longer be perplexed.

—Yamamoto Tsunetomo, Hagakure: The Book of the Samurai¹

One trial after another, one failure after another, has given him power . . . while change is the law. . . . Mankind, it has been said, is always advancing, man is always the same.

—William Osler, A Way of Life²

After reading Dr Ghaemi’s well-written treatise on how the young and the old compare in their approaches to knowledge, I experienced the following intrusive recollection:

On turning 16, I had saved enough money to buy a used car. I had a choice—a conservative, reliable sedan, or a souped-up Firebird with a stereo system that was more dependable than the engine. I sat impatiently at a stop sign in my Firebird while an elderly man with a walker struggled across the street in front of me. Eager to hear the excessively loud engine under my command, I muttered under my breath: “Come on old man. . . .” My middle-aged father, sitting in the passenger seat next to me, calmly said, “Take it easy. You’ll be old one day too.”

Let us set aside any speculations about my unconscious wishes to run over my father. I would beg your indulgence and trust—this has been well attended to over the years. Instead, I offer this scenario as an example of how age and experience engenders wisdom and farsightedness. I begin with this allegory because I wish to make the point that assimilating the new scientific knowledge with our historic legacy is critical to ensuring that we “possess the intellectual resources with which to engage the problems of the future.”³ This necessarily requires the insight and understanding that typically come with age. To turn our backs on this is a symbolic “rejection of the authority of the past”—which is inevitable and necessary, but done unwisely or prematurely, risks the loss of “important dimensions of historical experience.”³

I commend Dr Ghaemi for broaching this sensitive but important subject. I’ll not contest that there are differences between older and younger physicians. Nor will I deny the magnificent innovative spirit that emerges from bright young minds. However, since I am not convinced that there is a true “problem” of generations, I have a few things to say about medicine and psychiatry as “a way,” and a shared effort between young and old.

A physician’s skill and commitment to lifelong learning varies with the individual, and minds may become inflexible at any age. Although the appearance of the paralysis may differ with age, the final common denominator is immobility. In my experience, the young can become just as fixed on unhelpful notions as the aged. Dr Ghaemi notes that “the problem of generations” is that “new ideas tend to grow” only after the young are no longer indoctrinated with the obsolete ideas of their elders. There are certainly examples of this throughout history. However, there are also examples of younger generations repeating the mistakes of history on their own, or otherwise reinventing the wheel, because of a lack of having learned from the masters.

Our Australian and New Zealand colleagues have been studying age and the psychiatrist for a while now. They surveyed many hundreds of psychiatrists, both young and old, and found that most older psychiatrists gradually retire by reducing work hours and developing new interests.⁴ But here is where it gets interesting—the overwhelming majority of younger and less experienced psychiatrists believed that senior psychiatrists have wisdom to offer them.⁵ The wisdom was primarily conveyed via mentorship and supervision. Incidentally, the younger psychiatrists reported being more reluctant to take on psychotherapy cases. Perhaps some more mentoring and reassurance from older psychiatrists is in order? The truth of the matter is that we are facing a future that promises a serious psychiatrist shortage. At a time when older psychiatrists are considered the “workhorses” who maintain longer hours, do we not imperil the profession by discounting them?⁶ Will the younger psychiatrists be able to shoulder the burden alone? I would have my doubts about this, at a time when they acknowledge the value of mentorship and admit they are pessimistic about the future of health care.⁷