Roundtable: How Old Should a Doctor Be?

On January 6, 2018, Dr Haider Javed Warraich published an op-ed in the New York Times titled “For Doctors, Age May Be More Than a Number.”  In this responsive roundtable, writers Anna Fenton-Hathaway (English literature), Jordan Babando (sociology), and Benjamin Gagnon Chainey (French literature) consider the possibilities and provocations of thinking about how a doctor’s age informs their medical practice.

Decline Ideology: What We Talk about When We Talk about Age

Anna Fenton-Hathaway

Decline is a metaphor as hard to contain as dye. Once it has tinged our expectations of the future (sensations, rewards, status, power, voice) with peril, it tends to stain our experiences, our views of others, our explanatory systems, and then our retrospective judgments.

—Margaret Morganroth Gullette, Aged by Culture

Dr. Haider Javed Warraich, 29, opens his recent New York Times op-ed with the question he hears “all the time” during his work as a doctor: “Can I ask how old you are?” We are to understand that this question is posed skeptically, by patients who would prefer to see a “silver-haired doctor” at the bedside. The whole of medical training, built as it is on the “young learning from the old,” serves to reinforce this prejudice against the young. Such prejudices are keeping health care in a harmful holding pattern, Warraich argues, and so he calls for older doctors to share more power with younger ones or step aside. According to him, “Young doctors are ready to make health care both more innovative and patient-centric,” but this revolutionary spirit is being met with resistance: “are the senior doctors they work with, and the patients they take care of, ready for them?”

This narrative should be familiar to all of us. It goes like this: We are being held back from progress due to our misplaced trust in experience—experience that very likely explains why we’re in this mess to begin with. You may recognize this trope from contemporary American political rhetoric, where institutional knowledge and competence are portrayed as inimical to change, or from media rehashes of Generation X’s complaints against the Baby Boomer generation (a conflict so useful that it has survived the swapping-out of its actors; its current version pits the Millennials against everybody else). Admittedly, Warraich supports his version of this trope with studies by “researchers at Harvard” and a 2005 meta-analysis indicating “an inverse relationship between the number of years that a physician has been in practice and the quality of care that the physician provides” (Choudhry et al.). But the mechanism that would explain such findings, as well as much of Warraich’s overall argument, relies on something besides data: namely, our implicit assent that decline is the natural order of things. Wherever there are gaps in the evidence or leaps in logic, the reader is expected to fill them in with what age studies critic Margaret Morganroth Gullette calls decline ideology.

Gullette coined the phrase “decline ideology” to describe two phenomena: our broader cultural apprehension that “aging” equals loss or failure; and the forces prompting us to understand this equation as both an essential truth and a biological fact. Her Aged by Culture (2004) is a brilliant field guide to the various species of cultural messages shaping our perceptions of age and aging, many of which read decline into what might otherwise be seen as neutral change.

Approaching Warraich’s op-ed from a critical age studies perspective means, for one, exposing where the piece interprets the negative effects of a specific, individual process as symptoms of aging-in-general (Jordan Babando does this when he analyzes the effects of compassion fatigue and burnout on some, but not all, experienced physicians). An age studies perspective also seeks to provide a check on certain unacknowledged assumptions, such as the belief that systemic change derives from a conflict between the young and the old rather than from the efforts of intergenerational coalitions. When people doing the same job understand themselves as distinct groups in competition for resources or power, somebody is benefiting from the conflict—but it’s usually not one of those groups. Rather than granting Warraich’s arbitrary and disempowering division between young and old, then, Benjamin Gagnon Chainey challenges him to think more expansively about the “rapport between one’s age and the ages of others.”

* * *

“There are 19- and 20-year-olds I work with who will blow your mind,” a friend tells Warraich as they collaborate on a machine-learning model for predicting in-patient mortality. These “mind-blowing” workers attract the most enthusiastic praise depicted in the piece, and it is implied but not stated that they are programmers. Elsewhere, Warraich claims that medical training “is far too long given that the average age of physicians completing is the early to mid-30s.” Oddly, although he links to an article that discusses the financial burden of medical school and downward pressure on physician salaries (as well as burnout due to increasing administrative tasks), he offers neither of those reasons for the “given” here. Does starting a career in one’s mid-30s seem to Warraich so universally galling that it needs no further explanation—a sign of deferred adulthood, perhaps, or of not pulling one’s weight? A more plausible answer emerges when we juxtapose the 29-year-old Warraich to those inspiring figures ten years younger, and follow the signs from Warraich’s dissatisfaction with medicine to an industry he finds more open to youthful disruption: the tech industry.

In tech, the idea that a teenager or 20-year-old is the best source of creativity has become a sort of truism. The idea that older professionals are less adaptable, less savvy, and slower than their younger counterparts, meanwhile, has become a largely unchallenged “fact.” This decline narrative is frequently applied to Silicon Valley’s employees, but it applies to its wares as well. From personnel to iPads, obsolescence seems to arrive more and more quickly, a troubling phenomenon Gullette calls “speed-up.” Quietly aligning himself with tech through repeated references to innovation, Warraich indicates he would welcome a shift toward that industry’s problem-solving techniques (predictive analytics among them) and values (innovation, newness, youth). Yet he does not say how such techniques and values would stem increasing administrative obligations, address patients’ unequal access to care, or eliminate other factors that keep physicians from being fully “patient-centric” today.

When Warraich provides startling data about the apparent effects of aging on physicians, he does so largely without comment, leaving even a convinced reader a little unsure how to proceed. One study he cites, for instance, looked at hospitalists from four age categories—less than 40, 40-49, 50-59, and 60 and above—and calculated the mortality rate for over 700,000 admissions (of Medicare patients 65 years old or more) treated by those physicians. The authors concluded that, “Within the same hospital, patients treated by older physicians had higher mortality than patients cared for by younger physicians, except those physicians treating high volumes of patients” (Tsugawa et al.). They found that readmissions did not vary with physician age.

In accounting for the lower mortality rates, Warraich remarks that “younger doctors are more likely to adopt innovative practices” but also that their “inexperience . . . allows them to be free of malignant relics from the past. Having not trained in an era steeped in medical paternalism, younger physicians are more likely to place the patient on the pedestal rather than themselves.” Setting aside the slippage between a general lack of experience and the lack of a specific experience, at least the term “malignant relics” lays bare a potential reason behind the success of the young (or the failure of the old): they were trained in a different era. Yet if bygone values are somehow to blame for 50-year-old doctors’ poorer performance than that of the 40-year-olds, what does the volume of patients have to do with it? Put another way, if a basic inclination to self-importance is the problem here, why does that effect recede when the focus is on readmissions rather than mortality, or when patient volume is high?

While Warraich’s discussion of the study above uses generation-based reasoning, the meta-analysis he cites suggests that diminished performance is a life-course effect—something that will happen to everyone, regardless of training or status or orientation. This is not just the narrative of decline, it is its frank assertion. I did not sift through the list of references consulted for the meta-analysis. Even if we grant its validity, though, we are left with the questions “why?” and “what next?” If the “inverse relationship” is attributable to aging-in-general, Warraich may be lashing himself and his early-career peers to a trajectory they may soon find less affirming. And if it is specific to a single age cohort, a result of exposure to medical paternalism, won’t the problem reach its natural end-point when the physicians in question retire?

For those remaining in the profession, of course, the idea that there’s “a consistent, positive relationship between [physicians’] lack of experience and better quality of clinical care” poses a strange challenge: How does one pursue a lack of experience, or positively accumulate it?

* * *

As a kind of academic activism, Gullette’s brand of age studies is meant both to uncover decline ideology and to resist it. “Speed-up at any age, the dominance of decline narrative, early nostalgia, age apprehensiveness, slicing life into mutually hostile stages—these are crimes against the life course,” she writes (36).

My attempts to police these crimes here, however, have led me to a disarming, and to my mind positive, realization: Warraich’s right. Patients do take age into account when they imagine the doctor they want. What’s unique is that the ideal is not that of youth or beauty, or even necessarily that of “cutting-edge” technique. Conversations I’ve had about an “ideal” physician’s qualities have instead highlighted things like judgment, restraint, knowing when not to intervene, and even, for some, the peculiar comforts of an “old-school” approach. Taken together, these qualities can be understood as a form of Aristotle’s phronesis: that flexible, practical reasoning in the face of uncertainty that Kathryn Montgomery has argued is precisely how doctors think (4-5).

While I did hear a few stories like Warraich’s, in which patients or family members initially worried that the doctor appearing at the bedside seemed too young or inexperienced, they said that a quick reframe did the trick: rather than evaluate the physician’s competence on the basis of experience, they decided to think of it in terms of recency of training. To me, that evaluative flexibility is a positive sign. It means that decline is not yet our default logic when we contemplate a physician’s age—but also that we are not asking the impossible of experienced physicians. (Even phronesis is subject to setbacks, and can be stymied by a singular case.)

It’s an indication of our own collective wisdom that we haven’t locked ourselves into a single narrative or age-based ideology on this subject. Let’s not start now.

Thanks to Tod Chambers, Bryan Morrison, and Dan Gleason for talking through these ideas with me, and to Arden Hegele for her encouragement and exceptional editing.


White Coat, Dark Ego: The Fragility of a Young Doctor

Jordan Babando

Wisdom is not a product of schooling but of the lifelong attempt to acquire it.

—Albert Einstein, The Human Side

In “For Doctors, Age May Be More Than A Number,”  Dr. Haider Warraich provides a brief personal reflection about the challenges of being taken seriously as a young doctor, while also criticizing older physicians for being neither as cutting edge nor as successful in treating patients as their younger counterparts. Dr. Warraich does not necessarily proclaim “out with the old and in with the new,” but he does insist that older and more experienced physicians perform more poorly than young ones—and that the data backs up his assertion. What the article misses, however, are the hardships and trauma that seasoned physicians have encountered throughout their careers—hardships that can transform them unrecognizably from the individuals they once were when they first entered the profession. In fact, rather than indicting medicine’s ageist cultural expectations of physicians, the article reveals more about this young doctor’s struggle to find his place in the profession. Dr. Warraich’s primary complaints—of not being taken seriously and promoted quickly because of his youth and inexperience—are rooted in what I call Doogie Howser Problem.

The Doogie Howser Problem: The Challenges of the Young and Inexperienced

From 1989 to 1993, the American Broadcasting Company (ABC) aired a television series called “Doogie Howser, M.D.” The series follows a fictional 14-year-old prodigy with photographic memory who becomes America’s youngest licensed physician. As he struggles with the daily trials of being a teenager, Howser must also constantly grapple with being taken seriously as a young and inexperienced medical doctor. This is a recurring problem for Howser, as he has to prove himself to his patients, their families, and the other medical staff who are older and more experienced. This, in my view, relates to the problem Dr. Warraich describes (albeit in a highly exaggerated form)—hence the Doogie Howser Problem.

In one scene, a patient questions Howser’s ability to treat him properly and calls him “a kid.” Howser responds, “True, but I’m also a genius. If you have a problem with that I can get you someone who’s older but not as smart as me.” What Howser is missing here is the same problem that the op-ed has overlooked. Howser forgets that being a genius, scoring among the top percentile, or even being able to remember everything that he was taught in medical school, do not translate into being the best physician in diagnosing and treating every patient. Indeed, one research study showed how hospital units with more experienced staff had fewer medical errors, while units with more highly educated staff did not perform any better (Blegen et al., 2001). Failing to recognize the benefits of experience neglects the practical know-how of those who have experienced situations outside of medical school training—a very rich potential source of knowledge that young physicians should tap into through engagement with their older colleagues.

Narcissism, Fragile Egos and Measurements of Success

One of the challenges for young physicians that Dr. Warraich’s article raises is the problem of evaluation and peer comparison once the doctor has entered the workforce. The rigor of medical school acceptance means that students are almost universally high academic achievers, accustomed to “being the best, to being treated as if they are gifted” (Sinclair, 2014). While in medical school, students continue to strive for top performance and work hard to achieve high grades in their board licensing exams. But once they leave school, the new doctors lack, often for the first time in their intellectual lives, the structure of a formal grading system, which they had earlier used to measure their own success and to compare themselves with their peers. In the workforce, promotions come rarely, and senior positions are occupied by older, more experienced doctors.

The medical profession offers a rude awakening from the ongoing external validation that some medical students have become accustomed to. Lifelong learning for physicians is extremely important for proper patient care; however, apart from requiring doctors to complete continuing medical education hours every year to maintain their licenses, the profession lacks tools for evaluating ongoing learning (Hojat et al., 2006). Furthermore, physicians can go years without ever hearing statements of positive reinforcement or praise (Sinclair, 2014). Without assessment programs or verbal rewards, physicians are left to seek a sense of success in workplace promotions, one of very few viable methods to measure their accomplishment relative to others—and with fewer promotional positions available due to changing demographics in the profession, this is admittedly a frustrating state of affairs for success-driven young physicians. Still, a physician’s focus on maintaining their ego through external rewards can lead to negative consequences, both for patient care and for the physician’s own development.

A sense of self-esteem and confidence is important to the doctor’s practice. According to Banja (2005) there are even healthy “medical narcissists” who work hard to be the best, while maintaining their self-esteem. But overdependence on external feedback causes some physicians to rely on negative behaviors to protect themselves when things go wrong (Alexander et al., 2010: Banja, 2005). Some individuals might not ask others for help, especially from their perceived competitors. They might also have trouble admitting failure, and may exaggerate their medical abilities (Alexander et al., 2010). When their capabilities are questioned and their confidence is damaged, they tend to retaliate or become defensive rather than accepting their shortcomings (Banja, 2005). Crucially, all of this can contribute to a lower quality of patient care.

Dr. Warraich’s op-ed suggests that an intergenerational conflict between older and younger physicians is the principal cause of the junior doctor’s sense of professional malaise. But might it be also that young doctors, with their lifelong training in an environment focused on external accreditation, are too dependent on institutional rewards to support their self-esteem? In this light, the article’s critique of older experienced physicians—those who occupy the coveted senior roles—seems a self-defensive deflection from the emotional challenges of being a junior doctor who has lost their external support system. “Silver-haired” physicians should not be portrayed as some sort of healthcare risk, while making their age and experience the scapegoat. If this article’s focus were truly on the caregiving limitations of older physicians, it would have instead opened a discussion of the underlying causes and potential solutions for shortfalls in their patient care.

Death, Compassion Fatigue, and Burnout

Because Warraich’s piece does not explain why a more experienced physician might provide worse care, I’d like to speculate briefly about potential causes. One typical charge against older physicians is that the quality of their practice is diminished by compassion fatigue and burnout, which result respectively from interactions with patients, and from the stresses that come from the everyday work environment (Gallagher, 2013). Many physicians suffer from both compassion fatigue and burnout, which have been recognized as occupational hazards (Boudreau et al., 2006). Encountering death is a particular challenge of the profession, and has been found to impact every physician in some way (Gallagher, 2013). It must be difficult for physicians to witness the death of a patient to whom they are close. I doubt it gets easier as such experiences recur.

Doctors do feel sad and they grieve for their patients. Ofri (2013) finds that over time they can either recognize and address that sadness, or store it away for later. What physicians cannot do is keep it out, since grief and sadness always find a way in. Ofri further notes that physicians who are unable to deal with sadness and grief properly begin to suffer from mental health problems that negatively impact their own lives—and those of their patients. Burnout and compassion fatigue, for example, can lead to physicians becoming depressed or detached from their jobs: they can develop poorer concentration and decision making, experience increases in errors, and maintain a lower quality of patient care overall (Gallagher, 2013). Some physicians who have spent years in their field will no longer resemble the selves they once were when they first entered medical practice, just as a new soldier is changed by years of service and the traumatic events that come with it.

It’s relevant to note that compassion fatigue and burnout are less likely to occur in physicians who have high self-esteem, personal control, and optimism (Alarcon et al., 2009). External factors are also influential, of course: workplace stress, work-life balance, and workplace relationships might also negatively impact the care a physician provides.

Conclusion: Medicine Cannot be a Selfish Endeavor

Although Dr. Warraich’s article promotes a movement of patient-centered care spearheaded by young doctors, the piece undermines its own assertion with its critique of senior physicians and the patients who prefer their care. Shouldn’t “innovative and patient-centered care” involve trying to accommodate a patient’s request and taking their needs, concerns, and preferences into consideration? While the author makes several good points—that learning should be a two-way street between physicians both young and old, and that an open and non-condescending dialogue for the sharing of knowledge is beneficial for both physicians and their patients—the piece would benefit from an honest and open discussion both of why the patients of older physicians might receive inferior care, and of the institutional and professional norms that undermine a junior doctor’s confidence. Rather than attacking senior doctors, Dr. Warraich might instead focus his energies on changing negative cultural perceptions of young and less experienced physicians through a continuous demonstration of positive and empathetic patient care. This tactic would prove much more beneficial than writing defensively about concerns about inexperience, especially in ways that wrongfully bolster the competencies of younger, less experienced physicians at the expense of those of older, more experienced ones.

The Challenges of Professionalism for Today’sand Yesterday’sMedical Youth

Benjamin Gagnon Chainey

Every generation, no matter how paltry its character, thinks itself much wiser

than the one immediately preceding it, let alone those that are more remote.

It is just the same with the different periods in a man’s life;

and yet often, in the one case no less than in the other, it is a mistaken opinion.[1]

—Arthur Schopenhauer, The Ages of Life

Dr. Haider Warraich’s op-ed opens with the question all health professionals are asked as they begin their career, whether as physicians or nurses, physical therapists, occupational therapists, or psychologists—“Can I ask how old you are?”[2] The writer is concerned with the matter of age in medical practice: he criticizes older generations of doctors, while praising the “innovative and patient-centered” character of younger doctors and medical school candidates.

This desire of up-and-coming medical staff to put forward their expertise, even though they lack the experience that comes with time, is both understandable and admirable. But the op-ed piece neglects a number of important philosophical considerations about the complexity of the “ages of life,” to pastiche the title of an essay by German philosopher Arthur Schopenhauer. It may appear ironic for a young doctor to resent being asked their age by a radio host, as if it did not or should not matter in (the perception of) their identity— although it is precisely the first question, along with that of gender, that they ask of their own patients.

In the middle of the 19th century, the “century of scientists” that would push medicine definitively into its modern path, Schopenhauer wrote, “Our whole life long it is the present, and the present alone, that we actually possess” (Ages of Life). Taking Warraich’s op-ed piece as an invitation to debate, I would like to complicate the article’s familiar portrait of  technologically-savvy and innovative youth in opposition to outdated older people. My thinking could be summarized in a more nuanced title: “Not Only for Doctors, Age Should Always Be More Than a Number.”

Between experience and expertise: professionalism

From the outset, the self-styled young doctor states: “In many professions, a premium is placed on experience, with age often a surrogate for expertise—but probably no profession places more primacy on age than medicine.” Although we should prioritize neither one, Dr. Warraich’s assertion calls for a definition of the difference between expertise, founded on the mastery of ideas, and experience, based on a more “intuitive knowledge” of the world, as Schopenhauer explains:

But ideas furnish no information as to the real and essential nature of objects, which, as the foundation and true content of all knowledge, can be reached only by the process called intuition. This is a kind of knowledge which can in no wise be instilled into us from without; we must arrive at it by and for ourselves.

It is this epistemological consideration that Dr. Warraich questions, perhaps unknowingly, when he invokes the better quality of healthcare provided by younger caregivers:

A paper published last year by researchers at Harvard showed something very striking — patients being taken care of by younger doctors were less likely to die. […] The majority of research shows a consistent, positive relationship between lack of experience and better quality of clinical care.

Dr. Warraich is perfectly right to point out this paradoxical aspect of patient care. However, it would be interesting to view it in light of the professional aspect of medical education —something his article does not explicitly address. A group of Dutch researchers investigating medical training highlights professionalism as a core competency of medical practice, but one that is harder to evaluate objectively.[3]

Paradoxical relations to the medical hierarchy and history

Dr. Warraich’s op-ed piece is not opposed to the importance of professionalism. The author places innovation and quality of care at the center of his practice. The piece does, however, raise questions about the relationship between young doctors and the old guard of the medical institution. Schopenhauer noted pessimistically, “it becomes a habit for today to look down with contempt upon yesterday,” and Dr.  Warraich similarly glorifies medical youth when he states: “Their inexperience also allows them to be free of malignant relics from the past. Having not trained in an era steeped in medical paternalism, younger physicians are more likely to place the patient on the pedestal rather than themselves.”

This remark could easily be turned on its head: “Their inexperience also keeps them apart from beneficial relics from the past,” which again Dr. Warraich does not oppose. He pleads for an intergenerational cooperation in the medical body: “As a young doctor, I constantly look to my mentors for guidance. Yet, at the same time, I also believe that experienced physicians need to look to younger doctors to bring a fresh perspective to health care’s most vexing questions.” In itself highly legitimate, Warraich’s plea for the acknowledgement of younger doctors’ input takes on a paradoxical overtone when this input is not limited to technology, but also to end of life care, and the medical-scientific understanding of old age and death:

Nowhere is this truer than at the end of life. Research shows that younger doctors are more likely to discuss important but difficult issues with critically ill patients such as prognosis, preferences for life-sustaining treatments, hospice and the place where patients may want to die.

It does appear as a contradictory statement that youth should know more about the suffering of old age and the apprehension of death than old age itself. This paradox is even more salient when compared to Schopenhauer’s words: “The cheerfulness and vivacity of youth are partly due to the fact that, when we are ascending the hill of life, death is not visible: it lies down at the bottom of the other side.” All of this raises the question: how could youth better apprehend and cure the sufferings of old age if it does not see them, feel them, or experience them directly? Could distance to death in fact help better look at it? Or could it be that, not suffering themselves, younger people could be more efficient in treating the ills of old age?

Who sees and fears death?

For there is indeed danger in the belief that one is best positioned to apprehend and forestall death. It implies knowing what it means to suffer, to get old, and to die. Beyond any medical and scientific discourse—and, I should now add, beyond any technological innovation—I ask Dr. Warraich’s and his fellow young doctors: how do you think your relationship to technological innovation and to evidence-based approaches, but also to suffering, to old age, to death, will evolve and transform as you too grow older?

I salute Dr. Warraich’s demands for the contribution of younger health professionals to better care practices and the bidirectional nature of the pedagogical relationship, as when he notes:

To move forward, recognition is needed not just for the traditional model of learning in medicine — the young learning from the old — but also for the fact that there is much that more experienced physicians can learn from young doctors. Mentorship is a two-way street, with the most successful academics also being the greatest champions of their trainees.

However, I also ask the same medical youth not to remain insensitive to the philosophical implications of such demands, and to keep in mind Schopenhauer’s stressing of an epistemic vacillation: “But the most curious fact is that it is also only towards the close of life than a man really recognizes and understands his own true self,—the aims and objects he has followed in life, more especially the kind of relation in which he has stood to other people and to the world.” To this consideration, Schopenhauer adds a warning for all apprentices to meditate upon, whether young in age, in expertise, or in experience:

In a young man, it is a bad sign, as well from an intellectual as from a moral point of view, if he is precocious in understanding the ways of the world, and in adapting himself to its pursuits; if he at once knows how to deal with men, and enters upon life, as it were, fully prepared. It argues a vulgar nature. On the other hand, to be surprised and astonished at the way people act, and to be clumsy and cross-grained in having to do with them, indicates a character of the nobler sort.

What is important, then, may not be so much one’s age, but rather the rapport between one’s own age and the ages of others. And this, too, Dr. Warraich seems to integrate with humility and optimism in his op-ed piece. As he begins his thirties, he makes a judicious attempt to turn the lacunae of his inexperience into motivation, and his expertise into experience:

Over time, I have begun to see my lack of experience as a strength. Feeling like I have more to learn forces me to keep my eyes and ears open as I hope to learn from all those around me — from the seasoned clinicians who have seen medicine evolve from a cottage industry to an industrialized behemoth, from the patients who share their lives with us and, finally, from the medical students, interns and residents who are even younger than I am.

In the end, young Dr. Warraich’s invitation is the symptom of a need, a necessity within the medical body to reflect on its evolution, its past and its future, and the inevitable tensions it faces: intersubjective ones, but also epistemic, temporal, and cultural ones. In that sense, Dr. Warraich’s team would gain from joining forces with a medical humanities team, to find ways of cooperating that would be not only more efficient, but also more profoundly humane concerning the best care to provide to suffering, aging, and dying bodies. Such a collaboration holds exciting promise, especially if Dr. Warraich is correct when he reports the words of a young colleague about upcoming generations of physicians: “‘There are 19- and 20-year-olds I work with who will blow your mind,’ he told me.” The challenge of such cooperation would be all the more exhilarating if we take up the words of Schopenhauer, who predicted in the “century of scientists”:

Youth is the time for amassing the material for a knowledge of the world that shall be distinctive and peculiar, — for an original view of life, in other words, the legacy that a man of genius leaves to his fellow-men; it is, however, only in later years that he becomes master of his material. Accordingly, it will be found that, as a rule, a great writer gives his best work to the world when he is about fifty years of age. But though the tree of knowledge must reach its full height before it can bear fruit, the roots of it lie in youth.


Anna Fenton-Hathaway

Choudhry, Niteesh K., Robert H. Fletcher, and Stephen B. Soumerai. “Systematic Review: The Relationship between Clinical Experience and Quality of Health Care.” Annals of Internal Medicine 142, no. 4 (Feb. 15, 2005): 260-73.

Gullette, Margaret Morganroth. Aged by Culture. Chicago: University of Chicago Press, 2004.

Tsugawa, Yusuke, Joseph P. Newhouse, John D. MacArthur, Alan M. Zaslavsky, Daniel M. Blumenthal, Anupam B. Jena, and Ruth L Newhouse. “Physician Age and Outcomes in Elderly Patients in Hospital in the US: Observational Study.” BMJ 2017; 357: j1797. doi:10.1136/bmj.j1797.

Montgomery, Kathryn. How Doctors Think: Clinical Judgment and the Practice of Medicine. New York: Oxford University Press, 2005.

Jordan Babando

Alarcon, G., Eschleman, K. and Bowling, N. (2009). Relationship between personality variables and burnout: A meta-analysis. Work and Stress, 23(3): 244-263

Alexander, C., Humensky, J., Guerrero, C., Park, H. and Loewenstein, G. (2010). Brief report: Physician narscissim, ego threats, and confidence in the face of uncertainty. Journal of Applied Social Psychology, 40(4): 947-955

Banja, J. (2005). Medical Errors and Medical Narcissism. Sudbury, MA: Jones and Bartlett Publishers.

Blegen, M., Vaughn, T. and Goode, C. (2001). Nurse experience and education: Effect on quality of care. Journal of Nursing Administration, 31(1): 33-39

Boudreau, R., Grieco, R., Cahoon, S., Robertson, R. and Wedel, R. (2006). The pandemic from within: Two surveys of physician burnout in Canada. Canadian Journal of Community Mental Health, 25(2): 71-88

Einstein, A. (1979). The human side: New glimpses from his archives. Princeton, UK: Princeton University Press.

Gallagher, R. (2013). Compassion fatigue. Canadian Family Physician, 59(3): 265-268

Hojat, M., Veloski, J., Nasca, T., Erdmann, J. and Gonnella, J. (2006). Assessing physicians’ orientation toward lifelong learning. Journal of General Internal Medicine, 21(9): 931-936

Ofri, D. (2013). What doctors feel: How emotions affect the practice of medicine. Boston, MA: Beacon Press.

Sinclair, K. (2014, July 15). Think medical school is for you? You’re probably wrong. The Globe and Mail. Retrieved from

Warraich, H. (2018, January 6). For doctors, age may be more than a number. New York Times. Retrieved from

Benjamin Gagnon Chainey

[1] Arthur Schopenhauer. (1851) 2004. The Ages of Life. Counsels and Maxims from the Essays of Arthur Schopenhauer (T. Bailey Saunders, trans.). Project Gutenberg. All citations from Schopenhauer are taken from this edition.

[2] Haider Javed Warraich. (6 January 2018). Opinion | For Doctors, Age May Be More Than a Number. The New York Times. Available at All citations from Warraich are taken from this piece.

[3] Mak-van der Vossen, M., van Mook, W., van der Burgt, S., Kors, J., Ket, J. C. F., Croiset, G., & Kusurkar, R. (2017). Descriptors for unprofessional behaviours of medical students: a systematic review and categorisation. BMC Medical Education, 17(1), 164.

Header image from Doogie Howser, MD.

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