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Simone's OncOpinion: Physicians at Their Peak

Simone, Joseph V. MD

doi: 10.1097/01.COT.0000392699.58144.6e

I don't know much about Olympic swimmers or professional quarterbacks, but by my unscientific observation, I would guess that a top notch swimmer probably peaks in competitive ability at about 20 years of age, give or take four years or so. I would also guess that a competitive professional quarterback probably peaks at about 30 years of age, give or take four years or so.

By that I mean that they will not consistently perform substantially better after reaching that peak. Subsequently, they will perform at about the same level for a while and some time later, slowly or rapidly, progressively get worse. They may still perform satisfactorily, but not at their historically best level. There are exceptions, but the variations are most likely to be when the decline occurs, not if it will occur. A decline is inevitable.

I have often wondered when physicians reach their peak of skill as a doctor. To be clear, I am speaking of physicians as practicing doctors who provide ongoing care for patients on a consistent basis. Of course, this is not easy to measure (maybe impossible) so my attempts to tease this out cannot be a straight line because we have no quantitative comparatives, such as swimmers' race times and gold medals or quarterbacks' touchdowns and interceptions, to use as a gauge.

This is basically a personal reflection of my five-decade span as a physician and as one who has observed, trained, worked with, and judged many physicians. My focus is on physicians as practitioners of the art and science of medicine face-to-face with patients, not as a chair of medicine, leader of a practice group, laboratory scientist, or any other related professional activities that physicians may enter.

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What Is Meant by ‘Peak’?

The first challenge in this exercise is what is meant by peak? Peak of what? Surgical or other technical skills, diagnostic skills, compassion, knowledge? Wrestling with these questions led to my approaching the issue from a slanted angle rather than head on.

When I view the evolution of physicians' abilities, I believe there are at least three overlapping phases. The first is experience. This is the basis for all the rest. The next is intellectual insight, which combines experience and knowledge acquired from experience and indirectly from publications, meetings, grand rounds, colleagues, and students.

The third stage is humility, knowing the boundaries of one's ability and the common sense to act accordingly. Humility implies that one is open to becoming wise, to acquiring wisdom. This is the opposite of the know-it-all.

Each of these three qualities can be, and usually are, expanded over time and each reaches a peak, often independent of the other two. For example, an experienced and knowledgeable surgeon with long experience and excellent technical skills may remain infantile when it comes to humility and tends to inflate the accolades he receives to justify acting beyond his experience, knowledge, and skills. I can think of examples for radiation and medical oncologists as well.

If a physician lacks one of the three pillars described above—experience, intellectual curiosity with knowledge, and humility—it would be impossible to reach a high level of medical practice. The peak of one's ability would not be “competitive” and it would be difficult to imagine such a practice being even satisfactory.

The degree to which one raises his/her skill level in all three of these qualities will collectively determine the peak of skillful medical practice.

For this purpose, one may encompass all these qualities into a single “measure” (really an attribute) of peak ability and skill: wisdom. Experience, intellectual curiosity, knowledge, sensitivity to patients and their needs, and a measured balance of good judgment and humility contribute to what we might call “medical wisdom,” which includes the application of all three qualities.

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‘The Road to Wisdom’

Let's digress for a bit about “wisdom.” First, here is a short poem:

The Road to Wisdom

The road to wisdom? Well, it's plain

And simple to express:


and err

and err again,

but less

and less

and less.

Piet Hein (Danish poet)

This reinforces the idea that wisdom comes from experience, learning, and the ability to accept that one has erred (or observed another who erred) and change one's practice, the latter being a sign of medical wisdom.

So back to the initial question: When do physicians reach their peak? It may vary a bit by specialty, but my guess is that most physicians are at their best and have reached their balanced peak in their 40s, but as late as their mid-50s. They may reach their peak of technical skill, knowledge base, or intellectual curiosity earlier, but wisdom is like a fine red wine—it takes longer to develop.

I have known physicians who remained at or near that peak in all three qualities well into their 60s, but more often there is a decline in stamina or enthusiasm, or distraction with other duties that causes slippage; slippage in one area may be mitigated if the pillar of wisdom stays strong and a humble mind stays open.

Of course, some of this speculation is autobiographical. In my own case, I thought I was the best pediatric hematologist-oncologist on earth in my 30s, a clear lack of humility.

I believe I reached my peak as a physician in my early 40s and remained close to that level until about a decade later. I accrued administrative responsibility by then and eventually started to lose track of antibiotic doses and much of my imaging skill due to lack of use. The fellows and nurse practitioners knew more about many details than I did.

When I left St. Jude for Memorial Sloan-Kettering in my mid-50, I realized that I could not and should not assume primary responsibility for patients because of this decline and because I was undertaking a full-time administrative job and would not be readily available to patients and families. Interestingly, I found I could still think about and discuss clinical problems clearly (as in rounds and conferences) and retained what I believe was good judgment for quite a while; technical day-to-day bedside knowledge declined first and analytic wisdom faded last.



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Humbling to Realize...

It is humbling to realize that, in my view, despite all my training and experience and study, I was at my very best as a physician for only a decade or so. I like to think I was pretty good before and after that period, but who can say? Certainly not I.

Humility is the only one of the three pillars that I believed has continued to grow in my case. A review like this is one reason why.

© 2010 Lippincott Williams & Wilkins, Inc.
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