How old do you have to be to provide good health care?

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?

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8 comments

  1. This is such an interesting issue. I freely admit to being “ageist” when it comes to medical practitioners. While I’ll take whatever I can get during an emergency, I’m much more selective when looking for a primary care provider (or obstetric provider, etc). I want someone far enough out of residency to have a wealth of experience, but not so far into their career to be on the downhill side of their skill level. After all, if a physician is too old, they may not be familiar with the latest techniques and research. They may not keep up on their reading. They may have a well established patient base, and feel free to sit back on their laurels rather than continuing to strive for excellence in their field. Basically, I want someone exactly where you are: in the middle of that slow incline.

    The age issue, in my book, is one about which we can’t make absolute statements, but we can certainly make generalizations. It’s not fair to say that NO 22-year-old could be a good health provider, but it’s certainly fair to say that it would be the exceedingly rare early 20-something who would have what it takes. Consequently, if I were picking a provider with whom I was previously unfamiliar and for whom I did not have recommendations, I would not pick a 22-year-old. The situation would be quite different if said 20-something came with glowing reviews both from their (older) medical field peers and from patients, though I would still proceed with caution.

    In the end, it’s a funny issue. We’re blatantly and appropriately ageist when it comes to, say, university professors; very few students would pay good tuition money to have a 22-year-old lecture to them and grade them. Gravitas comes with age, up to a point. Why is it ok to be ageist in academia, but not in medicine? Sure, a 22-year-old can hold my hand as well as a 45-year-old, but I have (untrained) friends who can perform that same service. With a health care provider, what I REALLY need is someone with the skills that come with experience, and experience comes with age.

  2. It’s a certain realism that comes with age. There are some “youngsters” that are immensely mature for their age – but they are the exception and their actions speak for themselves. Unfortunately, there is no emotional competency entrance exam for medical school or midwifery training – instead they are left to Rate Your MD – and will either soar or sink accordingly.

    Medicine is a business about people – and knowing that means you know the difference between ‘good medicine’ – (technically competent) and ‘great medicine’. It’s good to know there are great providers in the system – even those who look much younger than they are.

    1. I largely agree with Mrs. W’s comment, and agree that a professional — once out in practice — will soar or sink according to their ability. However, while I realize I’m taking off on a tangent with this reply, I do want to point out that ratings websites aren’t necessarily reliable. I understand the theoretical utility of professional rating websites (“Rate Your MD” etc), but feel they often fail tremendously in practice. If you think about it, only exceptionally good or poor experiences will (generally) lead the average individual to take time out of a busy day to rate a medical professional online. As such, when you look at ratings on those sites, you’re not seeing a reflection of the “average” experience with that professional.

      Further, a terrible rating might be more of a reflection on the rater than on the medical professional. For instance, perhaps the rater expected the physician to do exactly what the rater (unreasonably) requested, and the physician did not feel that was the appropriate medical course of action [ex: patient is having a headache, demands physician do a CAT scan, physician refuses on the grounds that there is no medical justification]. Perhaps the rater got mad when the physician (appropriately) discussed a health issue with the patient [ex: patient is diabetic and refuses to modulate diet, insists on more medication. Physician continues to medicate, but also insists (appropriately) that diet and exercise are paramount to controlling the condition]. Perhaps the rater was denied medication that the physician did not feel was appropriate [ex: patient presents with a cold, demands antibiotics (which are of no utility in a viral infection), and physician refuses. Alternately, patient presents with long-term inappropriate use of narcotic pain medication, physician refuses to refill prescription, and instead offers a taper plan and/or rehabilitation].

      In this day and age of self-diagnosing (often incorrectly) on the Interwebs, patients often show up at the doctor’s office and treat the provider more like a fast-food worker (“I’d like this, this, and this”) than as a trained medical professional…and patients get mad when the provider won’t “do as they’re told.”

      1. Kirsten –
        I agree and that speaks more to the need to actually conduct formal patient surveys to get feedback from the average. Imagine if those lacking the people skills could be identified and coached – or similarly those lacking the technical skills (note patient surveys are good at picking up ‘people’ problems, less good at ‘technical’ problems). But that being said, people talk, and when somebody asks on some miscellaneous web-board whose a good ‘x’, often times the same name will come up. Similarly, when asking about who to avoid, often times the same ‘x’ will come up.

        There’s a gap in the information that the system has on what is provided and while not perfect Rate Your MD and other message boards do somewhat fill that gap. I agree wholeheartedly that it is flawed and needs to be improved though.

  3. VeritasLiberat · · Reply

    Doctors should be older than me. Because when I walk into a doctor’s office and the doctor looks fifteen years younger than me, I feel really really old. 🙂

    1. That will work for you…for a while….what about when you really are really really old? At some point, you’re going to want a doctor younger than you…or at least one that can see.

  4. I am old now (a grandma) who has been a nurse for 26 years, but I graduated from my RN program at 20 and got a job in a Peds ICU caring for trauma cases and cardiac surgery babies. I could legally shoot up peoples children with morphine and could not drink a beer at the local bar.

    I have many times reflected on what I brought (and didnt bring) to the bedside being so young. At that time in my life, not only did I not have any children, as I was born the last on both sides of my family, I didnt even KNOW any children.

    There were times when I was a robotron – I cared for critically ill children with no emotional reaction at all…they were sick, I took care of them. There were probably times when that is what needed to happen – a PICU is so full of emotionally wrenching things, a few robotrons probably help the place function. I hope that during the times that my immaturity left a lapse, I hope my peers stepped in.

    These 26 years changed me dramatically, I now care for loss situations where emotional support is pivotal. I am perhaps a study in growing, evolving and doing the best you can for whatever state of life you find yourself in.

    perinatalbereavement.com

    1. I think there are a lot of beautiful stories to be heard from healthcare providers…thanks for sharing yours!

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