The Older Psychiatrist in an Era of "Unprecedented Change"

January 22, 2013

Mental rigidity can occur at any age, while wisdom and experience are hard-won--over time.

[Editor’s note-Please see “Planck's Law of Generations,” by S. Nassir Ghaemi, MD, MPH.]

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

I realize that I cannot simply wax philosophic and expect to be accorded any credibility-the young psychiatrists of today have taught me this, as well as several dozen trial attorneys. I could cite for you, at length, evidence that supports why and how older physicians add significant value to the profession. I could go on long-windedly about how they may be less narcissistic and have greater wisdom.8 How they tend to have a greater capacity for emotional regulation and are better at ignoring irrelevant stimuli.9,10 Apropos of their role as workhorses, I could discuss how they are more resistant to the cognitive effects of sleep deprivation, restriction, and fragmentation.11 Finally, I might finish up with an exploration of how they tend to have lower psychological distress and burnout, which they attribute to lessons learned over their years of training and practice.12 Yes, I could go that sterile, evidenced-based route, but then I would miss the opportunity to discuss two things I find infinitely more interesting: Our fetishization of change and 1970s science fiction movies.

The fetishization of change and Logan’s Run

By the time most persons have neared or passed the half-century mark, they will have witnessed a fascinating, if not sanctimonious, expression of the eternal recurrence-each new generation “imagines that they face an unprecedented period of perpetual . . . transformation.”3We are in an age of unprecedented change! It is an era of such exceptional modernization and acceleration that any attachment to the past condemns us to an embarrassingly antediluvian failure to reach a glorious future. The path to progress lies before us-clear out all traditional and thus antiquated dead wood, for the superior ambition of modernization “demands that society break with the old ideas that are holding it back.”3

It is not until one has lived enough life, and witnessed enough repetitions, that the perpetual restating of the proclamation of unprecedented change eventually leads one to consider “just how novel is the latest version of the ‘new age’”?3 On finally recognizing this phenomenon, one begins to see how “the ceaseless repetition of the proposition that the past is irrelevant serves to desensitize people from understanding the legacy of human development on their lives.”3 The ceaseless change takes on a life of its own and becomes “an omnipotent, autonomous force that subjects human beings to its will.”3 Yet we all eventually bow down to the imagined ultimate supremacy of novelty, innovation, and upgrades. This has been referred to as the fetishization of change, which distances society from its past and undermines “the foundation on which a forward-looking intellectual life can be constructed.”3

The turning of our collective backs on the past brings to mind the classic 1970s sci-fi movie (and novel) Logan’s Run.13 If you are a “psychiatrist under a certain age,” you may not have heard of this movie. Not to worry-it is about due to be remade with Hollywood’s latest 20-something stars. The movie takes place in a dystopic, ageist future in which everyone who reaches age 30 must submit to an unquestioning, voluntary death. This is signaled when a colored crystal in one’s palm turns a certain color. Before that, life is a carefree stroll through the pleasures of youth.

The protagonist, Logan, is a policeman of sorts (called a Sandman) whose job it is to track down and kill citizens who “run” from society’s lethal demand. Then one day Logan becomes a runner himself. I’ll not spoil it for you, but will tell you that one of the premises is that society cannot sustain a culture without wisdom, experience, and tradition. I do realize this is a hard message to swallow in an age when youth is so highly prized that it is practically stolen from the souls of our children.

Conclusions

Dr Ghaemi wisely notes “there are always exceptions” to the problem of generations, and he gives several honorable examples of his own. By way of my own experiences, hard-won and patiently discovered, I cannot escape the notion that the exceptions we speak of are worthy of careful, thoughtful concentration, which coincidentally happens to be “an art of slow acquisition.”2 Osler might agree with me that a student of medicine may become “mind blind” at any age. Therefore, what we are left with, once we exclude biological and constitutional factors beyond our control is our capacity to remain lifelong students and adapt to change without rejecting our hard-won historical knowledge. To do so sentences us, paradoxically, to the opposite of true progress-a fate no different from that of Sisyphus: we are condemned to ceaselessly re­invent the wheel, never building on the sweat and toil of efforts past.

According to Heraclitus, change is the only constant in life. Yet embracing this maxim blindly runs the risk of “pedagogical chaos,”3 in terms of ensuring that future generations of psychiatrists have a solid foundation on which to develop and improve the profession in a meaningful way. The concept of lifelong learning is directed at precisely this dilemma of ceaseless change. Thus, the challenge becomes this: how long can one maintain lifelong learning, whilst also remembering the lessons of history? Mental rigidity can occur at any age, while wisdom and experience are hard-won-over time. Or as Osler2 put it: “The way of life that I preach is a habit to be acquired gradually by long and steady repetition.”

We desperately need competent psychiatrists of all ages-young, middle-aged, and old-to fill our waning ranks and relieve the suffering of patients who need us. As long as one accepts the role of eternal student, always learning, always questioning, mentally flexible, the age of the psychiatrist seems irrelevant. How do the young and old compare in their approach to knowledge? They don’t. They complement each other.

A postscript: My beloved Firebird broke down completely about 5 months after I bought it. Years later, I asked my father how he could have allowed me to buy such an obvious lemon. He told me that he knew he could not have convinced me otherwise, and that it was a lesson I had to learn for myself.

There is one transcending level. . . . This person is aware of the endlessness of entering deeply into a certain Way and never thinks of himself as having finished. He truly knows his own insufficiencies. . . . Throughout your life advance daily, becoming more skillful than yesterday, more skillful than today. This is never-ending.1

References:

References

1. Tsunetomo Y. Hagakure: The Book of the Samurai. Wilson WS, trans. Boston: Shambhala Publications, Inc; 2002.

2. Osler W. A Way of Life and Other Selected Writings of Sir William Osler. New York: Dover Publications, Inc; 1951.

3. Furedi F, Kimball R, Tallis R. Re-reading C.P. Snow and his elusive search for authority. In: Whelan R, ed. From Two Cultures to No Culture: C. P. Snow’s ‘Two Cultures’ Lecture Fifty Years On. Trowbridge, Wiltshire: The Cromwell Press Group Ltd; 2009.

4. Draper B, Winfield S, Luscombe G. The older psychiatrist and retirement. Int J Geriatr Psychiatry. 1997;12:233-239.

5. Draper B, Luscombe G, Winfield S. The Senior Psychiatrist Survey II: experience and psychiatric practice. Aust N Z J Psychiatry. 1999;33:709-716.

6. Aleccia J. No relief: shortage keeps older docs on the job. 2009. http://www.msnbc.msn.com/id/31507763/ns/health-health_care/t/no-relief-shortage-keeps-older-docs-job/#.UJQkoYUZzJw. Accessed December 17, 2012.

7. Glenn B. Younger physicians dislike Obamacare, pessimistic on future of U.S. healthcare. April 12, 2012. http://medcitynews.com/2012/04/younger-physicians-dislike-obamacare-pessimistic-on-future-of-u-s-healthcare/#ixzz2B65RXMH2. Accessed December 17, 2012.

8. Twenge JM, Campbell WK. The Narcissism Epidemic: Living in the Age of Entitlement. New York: Free Press; 2009.

9. Kaszniak AW, Menchola M. Behavioral neuroscience of emotion in aging. Curr Top Behav Neurosci. 2012;10:51-66.

10. Mather M. The emotion paradox in the aging brain. Ann N Y Acad Sci. 2012;1251:33-49.

11. Harand C, Bertran F, Doidy F, et al. How aging affects sleep-dependent memory consolidation? Front Neurol. 2012;3:8.

12. Peisah C, Latif E, Wilhelm K, Williams B. Secrets to psychological success: why older doctors might have lower psychological distress and burnout than younger doctors. Aging Ment Health. 2009;13:300-307.

13.Logan’s Run (1976). http://www.imdb.com/title/tt0074812. Accessed December 17, 2012.