Several times a week, I have patients ask me how old I am. I know I look younger than the age stated on my driver’s licence. When I wear a surgical cap my paltry handful of grey hairs are not visible. I have some wrinkles, but not many. My stock response to this question, is “certainly older than I look, I use a lot of sunscreen.” That usually deflects the inquiry and allows me to feel good about providing the patient and their family with a reminder to engage in preventative skin care. I then go on, in my most professional manner, to assess the patient’s risk and readiness for anesthesia, lay out the options and help them make an informed decision.
I suspect they ask this question because it would probably be more reassuring during the stressful time around surgery to be introduced to an older (and seemingly wiser and more experienced) anesthesiologist. An older, kind man with some laugh lines and an easy demeanor is probably what my patients picture when they think of “doctor,” if they picture anything at all. Certainly not a young woman.
I don’t blame them, and I’m not insulted. I know I’m inexperienced. Don’t get me wrong, I’m well-trained and a competent provider and I do a good job. Maybe a great job. But I feel green. I haven’t been practicing independently long enough to have seen all the things that my colleagues who are cresting towards retirement have seen. I don’t have a large well of personal experience to draw on when faced with a difficult case. I do however, have self-awareness and I am not at all shy about asking for help or a second opinion.
We were shown a graph in residency training that charted “competence” over time. The line shot up at the beginning of training…then there was a sort of slow incline that continued until about 10 years into independent practice. Then a slow decline to retirement. I’m on that slow incline, having not yet reached my peak.
That’s all well and good…but the other half of the picture for any provider aside from “knowledge” and “technical skills” consists of communication skills, empathy and emotional maturity. Where is the curve for that?
The path to becoming a specialist physician in Canada consists of a minimum of three years of post-secondary study followed by four years of medical school (three if you go to the University of Calgary) and then two (family medicine) to four (internal medicine) to five (most specialties) to six (some surgical specialties) years of residency training. Some do another year or two of fellowship (sub-specialty) training. To be a doctor in Canada is then a minimum of eight years of training after graduation from high school. I’ve had 13 years. Those 13 years were filled with experiences that forced a lot of internal growth. It was brutal. I had to see people die. I had to see people grieve. I had to see joy. I had to see disappointment. I had to see hope. I had to see resignation. I had to learn to see the subtext in a multitude of situations. I had to learn to read people to see when there was an unspoken subtext. I had to learn how to draw that out into the open so that we could face it together.
I had to grow up. 13 years might sound like a ridiculously long time but I don’t see how it could have been any shorter and have given me the experiences I needed to be able to interact with patients the way I can right now.
There are so many paradoxes in training for health care professionals right now. We are short of providers so churn them through training quickly. We need to move from time-based training to competency-based training. We need more young students. We need more mature students.
I think we need to give students more time, during supervised clinical encounters, to develop communication and empathy skills and have those experiences that will allow them to “grow up.” We try to teach this early in medical school but I think these skills come later. It is very stressful looking after patients when you haven’t yet developed a firm grasp on the required medical knowledge and technical skills. So stressful that students have a very hard time simultaneously developing and expressing empathy and a humanistic approach. To me, that’s just a completely understandable way of prioritizing tasks…first figure out what to do…then figure out how to do it. The problem is, if you graduate too soon, you’re able to do the first half, but not the second.
And I think that’s what happened with a midwife I met this week. This isn’t to pick on midwifery. In Canada I’ve had the pleasure of working with many excellent midwives and many very young and immature medical students and nurses. This individual just happened to be a midwife. A young one. Young in age and young in manner. She was a “millennial.” I was called because her client wanted an epidural and when I entered the room, the young woman in labour was shaking and not coping well. I spent about 30 minutes in the room placing the epidural and then hanging around to make sure it was well established and that there were no side effects. I passed the time by chatting to her and her family members about her labour and the baby.
The midwife didn’t really help her client through the epidural process…or through any of the contractions preceding it. She had a conversation with another midwife who came into the room about a staff meeting that had been scheduled for the next week and spent time entering it into her smart phone. She spent a lot of time entering information into the electronic chart. She did her job. She just didn’t do all of it. In thirty minutes I didn’t see any empathy or concern for the labouring mother or any behaviour that wasn’t directly related to operational tasks like hooking up monitors or charting.
It seemed unprofessional to me. And shocking. My middle-aged male obstetrician showed more care and interest in me as a person than this midwife showed towards her client. I was upset by it…and then I went home and thought about it some more. Although she seemed disinterested, I was only there for 30 minutes. The patient had been in labour for a good 14 hours by that point. Maybe she was sleep deprived. Maybe she didn’t feel confident enough in front of another (older, seems strange to think of myself that way but there it is) health care provider to be her usual self. Maybe she was great and I just didn’t get to see it. Or maybe she was too young.
Midwifery training is only 4 years (full-time) and the only pre-req is high school which means you can be a fully qualified midwife at 22.
Perhaps the reality is different. I had an acquaintance that tried for two years to be accepted to a midwifery program before chosing to go to a nursing program instead of continuing to apply. Competition for training spaces seems to be fierce. Maybe you need to have a degree or two under your belt plus a few years of volunteering in the third world to be accepted. Maybe not.
But I would argue that for most, 22 is far too young to have that degree of responsibility and care. Way too young except for maybe an exceptional individual with exceptional maturity. I just don’t see how the average person could cram enough experiences and relationships into 22 short years to be an effective health care provider.
Am I ageist? Probably. What do you think? Can you be too young to provide good health care or does it not matter if you have the ability to make it through training? And…how can I help the students I come into contact with (medical students and residents) to develop these “soft” skills?