It’s never to late to work: An open letter to Herbert Kaufmann

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-1930s 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 operations 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 and 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 the 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, though 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, N.J., 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. 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