Douglas R. Bacon, M.D., Editor

When the Time Comes

etiring with grace — this simple act is perhaps the most difficult accomplishment of many careers. A glance at the world of professional sports gives many examples of athletes who should have left their field of glory long before they did. The image of Muhammad Ali slumped against the ropes — no longer the brilliant, swift jabber of days gone by, but a tired old man being knocked around by someone with far fewer physical gifts — is a hard memory to erase. How depressing it was to see Wayne Gretzky working as a second-line center, no longer able to control the movement of players on the ice and losing his “magical” touch around the net. Michael Jordan, the man who seemed to defy gravity, coming out of the front office and the bench as a substitute player, clashed directly with his great years as the dominant guard in the National Basketball Association.

Sports aside, what about anesthesiologists and other physicians when the time comes to retire? How do we know when it is time to stop caring for patients, cease teaching and perhaps cut out ties with organized anesthesiology? How should senior anesthesiologists deal with the conflicting feelings that they still have a contribution to make but no longer feel comfortable with the rigors of practice? When does the line of experience cross with the feeling of youth and vigor?

History may hold some clues as to the proper way to act. One of the great mysteries in academic anesthesiology is why Ralph Milton Waters, M.D., chair of anesthesiology at the University of Wisconsin, Madison, and credited by many to be the founder of the first academic department in our specialty, literally walked away from what was one of the strongest departments in the country in 1949 and settled among the orange groves in central Florida? Why did he seldom attend any anesthesiology meetings despite volumes of invitations? Why have his residents and almost two generations of anesthesiology historians attempted to canonize him?

Lundy’s Legacy
Another mystery concerns John Silas Lundy, M.D. By most accounts, Dr. Lundy was a nasty, miserable lover of ETOH. He could be caustic and cause acute embarrassment for those around him. He spent 35 years at the Mayo Clinic, most of it as chair of the department, from which he helped to develop the American Board of Anesthesiology and the 90-day courses for the armed forces in World War II. He was an individual used to being in charge and controlling the project’s destiny, be it the Anaesthetists’ Travel Club or any of the myriad organizations with which he was involved. His textbook has largely been forgotten, much like the man. Why is he marginalized by the same writers of history who laud Dr. Waters?

Remembering McMechan
Small, crippled by rheumatoid arthritis and unable to practice his chosen specialty, Francis Hoeffer McMechan, M.D., devoted his life to creating an infrastructure for anesthesiology, first in the United States, then North America and finally the world. He is remembered in Australia and Europe as a founder and creator of specialty societies. Today he is largely forgotten, this man who defined the specialty between 1910 and 1930. Current Researches in Anesthesia and Analgesia, the first journal devoted to anesthesiology and currently published as Anesthesia & Analgesia, and the creation of the International Anesthesia Research Society have become his lasting legacy. Why is he so obscure as a figure in anesthesiology history?

Aging occurs at different rates. Some physicians practicing into their 70s have much to offer patients, residents and junior colleagues. Some others in their late 50s or early 60s are clearly in over their heads. During my residency in the mid-1980s, when pulse oximetry and end-tidal carbon dioxide monitoring were introduced into everyday anesthesiology, several of the very senior attendings retired, not wishing to learn or cope with these new monitors. As the computer has become ubiquitous throughout the operating room, from documenting the preoperative assessment to the termination of care in the recovery room, I have witnessed senior colleagues becoming increasingly frustrated with these machines. Rather than enjoy the wealth of patient information now quickly accessible, they long for the simple paper and pen of “the good old days.” Yet it has been noted that hand-created anesthesia records have severe limitations in legibility and, occasionally, accuracy. Like the discussion that occurred over postintubation hypertension when automated blood pressure reading was introduced, the accuracy of the computer-generated chart may cause some anesthesiologists to change their practice. Dr. Waters may well have felt that he was slowly falling behind, and the time came to leave the stage without regret, still at the top of his “game.”

Outside the clinical setting, decisions involving committee work can be less stressful as no lives are at stake. Physicians wishing to stay active in their specialty after retirement from clinical actively will often continue their commitments to the professional organization. While experience and a willingness to work are important, often segments of a project become mired in years of friendship that do not allow new perspectives and new people to come to the fore. Dr. McMechan was like that. Surrounded by a cadre of people who firmly shared his beliefs, he remained convinced that the American Medical Association (AMA) would and should have nothing to do with physician anesthesiology so long as AMA tacitly recognized the practice of nurse anesthesia. AMA was well aware of this hostility, especially after the overture for a board in the early 1930s was rebuffed. The original incorporation of the American Board of Anesthesiology as a sub-board of the American Board of Surgery was a direct result of Dr. McMechan’s attitude. ASA, I am convinced, would never have formed and become a national entity if Dr. McMechan had been able to put aside his AMA prejudices. His failure of vision as a leader has led directly to his obscurity, even among anesthesiology historians.

At the recent Board of Directors meeting, term limits for ASA members serving on the reference committees were passed by secret ballot. This important first step allows for more active participation of the members in the Society. The limits passed are long enough so that experience, the collective memory of the institution, is not lost, yet fresh perspectives are continually added to the mix. Dr. Lundy was always trying to control who did what and for how long. In running the AMA Section on Anesthesiology for 14 years, Dr. Lundy was of the opinion that he had to establish a strong program, and thus he remained at the helm. I would argue that any strong program will outlive its initial leader or, by definition, it is not a strong program.

For a society devoted to professionalism, such as ASA, there is a difficult balancing act between career-long experience and youthful enthusiasm. The Society clearly rewards those with a lifetime of achievement, e.g., the Distinguished Service Award and the Award for Excellence in Research. For those just beginning their careers, ASA offers recognition through the Presidential Scholar Award. While no specific award has been created for those of us in mid-career, leadership roles as junior officers, committee chairs and the like allow us to accept responsibility while gaining wisdom in the affairs of organized medicine. While our roles vary as much as our ages, the importance of commitment to the Society and a willingness to participate in the hopes of leaving anesthesiology better than the way we found it remains a constant.

Organized medicine aside, ASA is working alongside the appropriate outside agencies to ensure that appropriate educational venues exist to keep current. The ASA Annual Meeting, a five-day experience in continuing medical education, demands tremendous effort on the part of both volunteers and paid staff. Read the excellent piece by Vice-President for Scientific Affairs Charles W. Otto, M.D., on page 3 about all the activities our Society supports to ensure ample continuing medical education for all members. While we stress politics often, there is an equal if not greater effort by the Society that is placed on educational activities. Lack of ASA-sponsored educational material is not an excuse for lack of knowledge.

Keeping Fresh
To be a professional means to know when the experience/knowledge dialectic is in balance and when it is not. One way to begin to ensure competence is to continue to take the recertification examinations offered by the American Board of Anesthesiology. The maintenance of certification in anesthesiology program, while seeming painful, helps to organize and focus continuing medical education and helps with the process of lifelong learning. When it is no longer possible to “keep up,” the time comes to exit the stage gracefully, being remembered as a strong clinician. To fail to take continuing medical education seriously, and perhaps continuing to formally demonstrate qualifications through the mechanisms that exist, is the beginning of deterioration of our specialty. Likewise serving ASA without the ability to look beyond personal internal prejudices does no one any good. For those who cannot recognize their limitations, telling someone it is time to leave is exceedingly difficult, yet it remains our duty. Our patients and Society demand the highest professional standards from us; we must act professionally and responsibly.

— D.R.B.

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