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 the crimes and criminals he now encounters. The Wild West that he, his father, and grandfather—all lawmen—once reined in has inexorably changed.

The title of the movie (and the original book by Cormac McCarthy) is taken from the opening line of a William Butler Yeats poem, Sailing to Byzantium.2 The critic Richard Gilmore has described the movie as a lament, not only for those who are alienated from the country of the young but “for the way the young neglect the wisdom of the past” and for the reality that “old things are out of alignment, that balance and harmony are gone from the land and from the people.”

This kind of dislocation now faces a whole cohort of physicians: the baby boomers. In 1949, at the peak of the post-war population explosion, the birth rate in the United States—as in Canada, Australia, New Zealand, and many European countries—hit a 30 year high. Now the boomers are moving through their seventh decade of life.

The problem is not (just) that we are so many but that we have an actuarial life expectancy of another 20 years. Many of us will work professionally for some of that time: indeed, a quarter of practicing physicians are over 65.3 And, with a predicted shortfall of 52 000 primary care physicians by 2025, our services are needed.4 But studies also show that older doctors experience a cognitive decline of over 20% from ages 40 to 75.3 What is the profession to do?

For those who must leave medicine, retirement is no easy cliff to negotiate. Many people jump: it’s their reward for a distinguished career or an escape from bureaucratic hell. Some have no other clothes to wear outside a scrub suit or white coat, so they brace themselves at the precipice. Others meander down an uneven slope, increasingly out of step with the pace, expertise, and aspirations of their younger colleagues.

I’m one of those—or all of them. Like everyone else, I want to feel needed. I may think 20% slower, but I still have something to offer: something traditionally called mentoring.

Institutional memory

Older doctors possess a treasure trove of institutional memory, even if we need to look up what was once on the tip of our tongue. We know what solutions have failed in the past; what things run in cycles; what kinds of promises are easy to believe but hard to keep.

We know that “the truth wears off,”5 as promising treatments fail the tests of time and replicative research. We know that people are invested in what they believe, either because it’s easier than changing their mind or because reputations and portfolios depend on it. And we’re cautious about new ideas that raise patients’ hopes more than their chances of survival.

We know how to talk to patients and, more importantly, when to listen. We know that they value eye contact, a firm handshake, honest talk and mutual respect, a sense of companionship if not friendship, and our familiarity with their business, their hobbies, their shtick. We also know a little about ourselves and how our mental state, an underlying bias, or assumptions can influence a decision.

We know a thing or two because we’ve seen a thing or two. (Farmers Insurance advertisement)

The need for support

We now have time to advise our younger colleagues and other members of a less experienced healthcare team. Young physicians experience things that profoundly move them but that also shake their self confidence: the miracle and fragility of new life; the death and decline of people we love; suffering without cause; or suffering where we’re in some way culpable. At times, they’ll be thoroughly confused and immobilized by fear and doubt. Where they expected answers, they’ll find silence or conjecture. When they speak with authority, they’ll too often hear the ice of certainty cracking beneath them.

We must support our young learners; buffer, even rescue, them from their cognitive peril. They will make mistakes and are entitled to learn from them. In fact, mistakes are the most powerful learning tool we possess. But mistakes are a double edged sword. Those of us who have felt the guilt or shame of a clinical error must prevent it from injuring twice.

We can’t let instant access to data seduce us into believing that medicine is (only) a predictable science. While we are entitled to our personal time, we must learn when to share it with the most vulnerable people under our care. Though guidelines, checklists, and templates can improve office efficiency, they deprive us of the power of stories to reveal and convince. Older doctors bear witness to how much is lost through these kinds of transactions, and how little is gained.

A reciprocal process

This is my plea: we need each other—those of us who are entering the profession and those who have one foot out of the door. Medicine is a long and labored haul. It exposes our weaknesses and vulnerabilities as effortlessly as it does the strengths of our tradition. Mentoring may be the best remedy we possess: a reciprocal process meant for young and old, confused and strident, beleaguered and hopeful, rested and weary—because we’re all of these things at unexpected moments and because, in our hubris, we’re more suited to offering help than requesting it.

The poet-physician William Carlos Williams summed it up: “When you say you want suggestions, I can only come up with my shame, as I remember it, and its sources; and I can only say: let’s have some heart-to-heart stories to tell each other, the folks who teach medicine and the folks who are learning it.”6

Mentoring requires us to be there, on site, with a readiness for engagement. But that’s not all that young doctors need. They need reasonable schedules, some slack in their day, and more time with family, friends, and patients. In moments of crisis they’ll need a therapist or lawyer. And mentoring isn’t the only honorable thing an older doctor can do: communities are desperate for organizational leadership, public service, and volunteers at every level.

The light of wisdom

No Country for Old Men opens with a soliloquy from Sheriff Bell as the camera pans across the windswept plains of Terrell County, Texas.7 “The crime you see now, it’s hard to even take its measure,” says Bell. “It’s not that I’m afraid of it. I always knew you had to be willing to die to even do this job. But I don’t want to push my chips forward and go out and meet something I don’t understand. A man would have to put his soul at hazard. He’d have to say, ‘OK, I’ll be part of this world.’”

Well, we are still a part of it. There are things about it we still understand. And, for many long years, we’ve borne its torch. Before the flame flickers out, let’s leave our younger colleagues with the warmth of our companionship, the burn of idealism, and the light of whatever wisdom we have yet to convey.


  • Competing interests: The author has read and understood BMJ’s policy on declaration of interests and has no relevant interests to declare.

  • Provenance and peer review: not commissioned; not externally peer reviewed.


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