Intended for healthcare professionals

Feature Essay

No country for old men: on mentoring in medicine, by David Loxterkamp

BMJ 2017; 359 doi: (Published 18 December 2017) Cite this as: BMJ 2017;359:j5756
  1. David Loxterkamp, family physician
  1. Seaport Community Health Center, 53 Schoodic Drive, Belfast, ME 04915, USA
  1. dloxterkamp{at}

For medicine to retain its ethical foundation and dedication to service, people at the end of their careers must pass the torch to those at the beginning, writes David Loxterkamp

When I entered family practice in the 1980s my concept of “the work of medicine” was exactly like my father’s. The science of medicine had advanced well beyond sulfa, penicillin, and the Salk vaccine, but I too worked generally alone, on intuition and the fumes of exhaustion, and for my patients’ gratitude and the community’s respect. We felt as though we could handle almost all problems that came our way, and we accepted them as our own.

Then came the electronic medical record; patient centered care; population health; hospital consolidation; physician employment; expanding roles for nurses, physician assistants, and pharmacists; healthcare teams; the social determinants of health; robotic surgery; and genomic medicine. Our work has gotten better—and easier—but it would be completely unrecognizable to my father’s generation. And it’s quickly drifting beyond my reach.

Medicine is no country for old men.

The retirement cliff

No Country for Old Men,1 a 2007 neo-western written and directed by the Coen brothers, tells the tale of a rancher who stumbles across a botched drug deal and $2m in cash. He runs with the money, but he’s not fast enough to escape a hired gunman, a bounty hunter, and an aging sheriff who trails them in a wake of violence. The film won instant critical acclaim, including Academy Awards for best picture, best director, and best supporting actor.

Audiences were riveted by the plot, action, and cinematography, but what really grounds the film is its quiet narration by the sheriff, Ed Tom Bell (Tommy Lee Jones). Bell is contemplating retirement, not out of fear for his life but because he can no longer comprehend …

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