A photo of Arthur Lazarus, MD, MBA

Reviews | I may be old school, but I’m not outdated

I was not content to retire at 65 like many of my contemporaries, some who left medicine even earlier. Still, I couldn’t resist the buyout package my employer offered me when I reached my golden age. The problem I encountered was not that I was suddenly retired; it was rather that I had not retreated into anything.

Unemployed, I thought long and hard about my next move. My only prerequisites were that whatever new job I took on had to be portable so that I could travel and visit my grandchildren who were scattered from the east coast to Hawaii with a stop in between . My “recall career” was to be virtual and not involve direct patient care, not even via telehealth. I found it in the form of a Collaborating Physician – a Physician who oversees Advanced Practice Providers (APPs: Nurse Practitioners or Physician Assistants) because their state regulations require it.

The responsibilities of collaborating physicians vary from state to state and generally involve reviewing records at a minimum. I guess reviewing the graphs of APPs is considered a good indicator to assess their quality. However, I do insist that in addition to reviewing records, I speak directly with PPAs and discuss their patients – similar to conducting “curbside consultations”. They are quick and easy and give me a much better idea of ​​the supplier’s qualifications and expertise.

“Oh, Dr. Lazarus, you’re so old school,” I was told.

What does it mean to be “old school”? A baby boomer? Educated before the era of computers and PowerPoint? Did you take classes in person rather than virtually? Handwritten notes mapped before the advent of electronic medical records? Looked at patients rather than computer screens? Have you listened to their stories? Probably all of the above – and more.

Suneel Dhand, MD, an internal medicine physician and health and lifestyle coach, described seven core traits of old-school physicians: attentive, unhurried, thoughtful, clinically astute, personally connected, independent, and technologically unleashed. I believe that old school values ​​still appeal to modern medicine; patients and families seem to want these qualities in physicians. In addition, strong doctor-patient relationships promote better outcomes.

I’m proud to be an old school doctor, even though the term “old school” has a negative connotation. Thomas Cohn, MD, is a physiatrist and pain specialist who touts old-school benefits on his website. He notes that in many cases, old-fashioned medicine gives him time to do a detailed history and physical exam and correlate signs and symptoms without the need for extensive laboratory and imaging studies.

Dhand says, “The old-school doctor has the diagnosis in his head right after talking and examining his patient.” This explains why I insist on personally supervising APPs – I’m more interested in how they treat their patients than how they treat their cases. Since about half of the total text of the medical record is duplicated from previously written patient text, reviewing the records is a waste of time. The duplication also makes me doubt the veracity of the information contained in the medical file.

The essence of my interactions with APPs is to ensure that they have captured the primary complaint, taken a full history (± physical exam for psych patients), including family and social history, and performed a thorough examination systems and mental status examination. I want to know more about diagnosis, differential diagnosis, treatment plan and response to treatment. You know, old school.

Paul Simon said, “Every generation puts a hero on the pop charts.” I find it more telling that each generation seems to regard the previous one as “old school”. The classic textbook The real doctor: the modern “old school doctor” was written for young doctors by medical scholar Wingate M. Johnson, MD. The manual contained “the wisdom of the world”, according to a review of the book in JAMA. Here’s a revelation: The book was published in 1936, when Johnson was around 50 years old. The “young doctors” were probably half his age. Old-fashioned medicine has been around for a long time, still marked by generational gaps.

During medical school, some of my classmates ridiculed a senior attending physician who they considered old school. He wore a bow tie, mumbled and groped the halls of the hospital, and always seemed to be in a hurry. The incumbent ran a busy outpatient internal medicine practice, made house calls and circled around his inpatients. Medical students thought of him as a dinosaur.

But the participants also taught us and conducted research, thus fulfilling the tripartite academic mission. “Where does he find the time and energy to do all this? asked the students. When Dhand met an old-school doctor, he asked a more incisive question: “How did we get to the point where a genuine, caring doctor became the odd one out?”

I think I know the answer.

The incumbent has remained steadfast towards his patients. They loved him and stuck with him for decades. Attendance was versatile and efficient. Contrary to the stereotype of the old school doctor who has dropped his knowledge and lost his clinical skills, this participation has been brilliant. In fact, he was the director of our continuing education department.

I assumed medical students feared they wouldn’t measure up to assistants once they became practitioners themselves, so they felt compelled to belittle him. They poked fun at him, joking that each of his entries in the chart read the same – ‘as above, see below’ – in reference to the patient’s heavy reliance on staff of the house for the overall management of his patients. Rather than seeing the participant as a role model, he was reviled and marginalized for his seemingly old-fashioned ways. Yet nothing in his thinking was out of step with the times.

The use of pejorative terms like “old school” has its origins in ageism. The labeling of an “old school” physician compensates for interns’ insecurities and feelings of inadequacy. It’s a riff from an old theme so eloquently explained in The house of God — the desire for connection thwarted by ageist (and other) assumptions that separate people. Sharing memes poking fun at older people only deepens divisions.

While visiting my daughter (the one who lives “in between”), I told the story of a loved one who got lost while driving to the supermarket. When I tried to give this person the right directions after the accident, she got mad at me. “You are mansplaining,” said my daughter. To his surprise, I immediately knew what the term meant and replied, “I may be old school, but I’m not old fashioned.

Arthur Lazarus, MD, MBA, is a member of the Physician Leadership Journal editorial board and adjunct professor of psychiatry at the Lewis Katz School of Medicine at Temple University in Philadelphia.

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