Welcome everyone. Welcome to the session called the Sunset Boulevard of Critical Care, the Aging ICU Practitioner. I suggested this session because as I'm getting older, I've been thinking about the end of my career. What are my options? There are a lot of different issues and what I tried to do today was to ask our speakers to talk about some of these issues. All of our speakers today are well known to all of you in the field of critical care medicine. They've been exquisitely involved with the Society of Critical Care Medicine. They're national and international speakers and many of you have heard them several times. We have four speakers today. Dr. Anthony Gerlach is a professor of pharmacy at Ohio State Medical Center. He's a SCCM council member as I am and he will be talking about the day after tomorrow. That's for those of you who are under the age of 50, making plans for the future in terms of retirement. The second speaker is well known to all of you. This is Dr. Christopher Farmer, who is the chief of critical care at the Mayo Clinic in Arizona. He was also, as you know, the past president of SCCM. Dr. Farmer will be talking to us about the pursuit of happiness. What are your options? You hit that 50 mark or that 60 mark. What are the options available to you in terms of retirement or semi-retirement? The third speaker is Dr. Donald Chalfin. He is a clinical expert for Siemens Healthcare. He was also a practicing clinician for many years. He has an adjunct faculty appointment at Thomas Jefferson in Philadelphia. Dr. Chalfin will talk about something very close to his heart, practicing medicine and critical care as an intensivist with a chronic disease. I think for those of us who have gone through COVID, as I have myself, and now have some residual issues, this is an important issue. Those who have acute illnesses, as well as chronic diseases. Dr. Chalfin had a liver transplant, I think about two, three years ago. What did that do to his life? What did that do to his practice and his family? I think it's a fascinating topic. We have to accept the fact as we get older, we do have chronic comorbidities. So I think this will be a very interesting session. Last but not least is someone well known to all of you, Dr. Michael DeVita. Michael DeVita and I have been friends for years. He was at the University of Pittsburgh for many years and left and went to Harlem Medical Center where he is the director of critical care medicine in New York and is a professor at Columbia University. Mike DeVita is an ethicist, he's a palliative care specialist, and he will talk to us about the ethics of mandated retirement. This, as some of you may have heard, is becoming a more popular issue. Is it ethical? Should we be subjected to cognitive testing? I find that very interesting and I hope you do as well. I did want to include a session on gender inequality, or at least the differences between men and women in terms of retirement. We clearly know that there are differences in terms of pay, development as professionals, editorial ships, et cetera. Is there a difference in retirement? Unfortunately, just for lack of time, we couldn't include this session. I hope you all enjoyed this session. As I said, this was something near and dear to my heart. As all of us are aging, these are things that we unfortunately or fortunately need to think about and need to act upon sooner rather than later. You don't want to be at that age of 60 or 65 or 70 and not to have explored your options. I welcome you to this session, the Sunset Boulevard of Critical Care Medicine, and hope you all enjoy it. Thank you. I hope to see you again in person one day at the SCCM Congress. Well, hello, everyone. My name is Tony Gerlach and I'm a critical care pharmacist at The Ohio State University. I would like to thank everyone for joining me today on my talk the day after tomorrow, Making Plans for the Under 50 Practitioner. Just a couple of disclosures. Really, I have no real or potential conflicts of interest, but I wanted to say I am 47 years old, so I'm a little under 50. I've been at my current job for over 20 years. When I first started and was getting ready for this talk, I was thinking of my career path and my career journey. If I would have thought of where I started or when I started back 20 plus years ago where I was today, I would have never have thought I would be where I am. Looking over my career, it really is a long and winding path. You have many turns and many forks in the road, and how do you maneuver through them? Looking back in my early years, the first seven or so, I got my bachelor's of pharmacy and then moved on and got my doctorate of pharmacy and decided I needed postgraduate training. My first goal was to complete a residency, which I did in cardiology. At that time, I moved into surgical critical care. Really, those first few years, my main goal was establishing my clinical practice. I had a huge amount of learning curve or going up a hill because both critical care and surgery were a little bit new to me. Luckily, I had some great mentors to help me along and help me down that path, including Kerry Pickworth, Debbie Goff, Joe Dasta, and Chuck Cook. It was during this time, especially with Joe and Chuck, that I focused on conducting some research with my first project being Nuance A-Fit. In addition, I really did like teaching. Part of my early goal was lecturing at the College of Pharmacy and then developing a surgical ICU rotation for pharmacy students and pharmacy residents. Then, Kerry and Debbie encouraged me to become adjunct to faculty at the College of Pharmacy. Anyone who's ever seen an e-mail from me knows that my writing skills are not always the best. I really did want to improve those early on. Just like the Marilyn Monroe movie, The Seven-Year Inch, I think when you start practicing, especially as a clinical pharmacist where you're rounding every day with the ICU service, that the seven-year inch is real. After seven or ten years, where are you going to go and how are you going to promote professional growth? I think if there is no professional growth, that leads to a lot of dissatisfaction in your job and increases burnout. I've seen that a lot with my colleagues. It was during this time that I really did meet with my mentors to really see what should I focus on and how should I help with professional growth. My good friend, Debbie Goff, said research is your gift to the world. Luckily, I decided to focus a lot on research at that time. At the time, since we were one of the few places using Dexmedetomidine, I focused a lot of that research on the safe use of Dexmedetomidine. That really happened organically. After that time, that seven-year inch, my career path through the next seven years really focused more on developing that research and really developing to our clinical practice. During this time, as we were growing, I realized that I had to learn to say no and give up some things, or I was just not going to get anything done. I was able to help grow with my colleagues and give more support to other areas, including the burn service and neurocritical care. It was also that time that I was able to read, find my teaching activities. I went up and was able to get promoted to associate professor at the College of Pharmacy. During that time, I also was inducted as a fellow of the American College of Critical Care Medicine. Like always, you'll see improving writing skills. Now, not all of this was good. At that time, I was also passed up for residency program director, but I am a firm believer, as you get out, that when a door closes, a window opens, and you just really have to look hard enough. Sometimes your path is a little bit different than what you imagine. It was during this time that, although I was passed up for residency program director, I was actually asked and I accepted to be a non-physician faculty member of the Surgical ICU Fellowship Program. Me and my teaching activities went just beyond pharmacy and went more interprofessional with the physicians. During this time, I also developed more research and continued to hone in my clinical practice, which was good. At this time, I worked with my colleagues who were developing advanced practice for professional ICU Fellowship Program and worked to help with education for them. As well, as I went down the path and I got some leadership opportunities in professional organizations, including the Society of Critical Care Medicine. Now, along with these activities, especially my research, it actually helped promote some of my interests outside the world of critical care. Really, that was traveling the world. I was able to go to South Africa as a visiting professor, and that's where I was able to go on safari and see giraffes and wild, as well as some of my research went to some European conferences and was able to go on to Europe for the first time, which also stroked my interest in traveling and getting outside of America. Now, that leads us to where am I today? I think even before the COVID pandemic hit, as I kept saying, the more I know, the less I know. That is a quote from Socrates. Really, the last two years, I've garnered that. There's a lot that we know, but there's a lot that we don't know. I also think, as it sounds, really everything goes back to the basics. In these times that it's a time of transition, it's always good to think about what the basics are and to go back to that. What is next for me? I feel that right now in my current job and where I am, especially looking forward to the next 10 to 12 years as I'm hitting the twilight of my career, is I'm at this crossword. Where do I go from here? What road do I go down? Also, do they all converge and go back together? I don't know. Only time will tell. How do I and how am I assessing what is next? I think one of the things, especially 2020, has really taught us is we really do need to learn how to embrace change. Especially as you grow up and the next generation comes down, I think one of our great guests, besides research to them, is really mentoring them and thinking about what can we do better? What skills do I need to learn? In the last couple years, I've really focused a lot on antibiotic resistance, especially how it relates to critically ill patients, but with the upcoming area of metabolomics, it's something that I need to really focus on. Those are some of the things clinically that I'm working on. I think this is a good time to really think about what makes you happy. I've done a lot and I've been lucky. I've had a great career, but what really makes me happy at work? After coming and thinking about it, I think teaching and mentoring others is really what joy I give to other people and help elevate the practice of critical care and pharmacy throughout the world. At that time, I think it's really hard for some of us to learn how to say no. Learn how to say no and really look at what you're doing. Recently, I've come to realize that I do a lot, but not everything has my same goals and learning how to say no and getting out of some of your responsibilities. I think too, at this point in my time, is really setting boundaries between work and professional time. Recently, I just saw a a tread on Twitter about how to promote work and life balance. I think one of the things that I've been trying to do recently is not really be so connected to work. When I'm off, especially the weekends or vacations, don't check work email and specifically don't have work email set to your phone and getting notifications that work is there. Now, I think it's always good to look where you are, but how to grow. I think one of the things I've also realized is every once in a while, you have to do something that scares you because that's a great way that it helps you grow both personally and professionally. I think once in a while, if something excites you, but it's scary at the same time, it means you probably should do it. Conclusions with my talk is really thinking about where your goals are. They need to align both professionally and personally. You really need to take time outside of work because it's going to help mitigate these burnout. At the same time, I'm also a firm believer of celebrating all these milestones that are happening. You should also determine what you're passionate about and also determine what changes you can influence. Even though you might be passionate about something, but you can't influence those changes at the hospital or at work or whatever, it's just going to put undue stress on you. Really, I think this is a good time to think about discussing with your mentors and those ahead of you. How did you get through this and what can you do to help advance your career? Now, thank you very much for taking your time to me today and have a great day. Hello, everyone. Thank you for coming to this talk today. Several months ago, Marie Baldessari approached me and said, hey, we're going to have this session at the 50th Congress for the FCCM and we're going to talk about sunsets. We're going to talk about retirement. We're going to talk about walking away from clinical practice. Now, I've done that at the end of 2018. So she said, would you like to participate in this? Sure. I said that would be great. So she contacted me and asked me to develop some slides around the topic of the pursuit of happiness. What are the options for retirement from clinical practice? So a couple of points to be made before I move on to the next slide. First of all, we all know this. Happiness is not something you pursue. Happiness is who we are. So you're not going to find it from the things that you do. You've got to find it from within yourself. And the second thing is retirement itself. Is it really retirement and what is that all about? Let's talk some about these things. Okay. So first, disclosures. Here they are. Well, I want to make a couple of points with this one too. I'm going to talk you through what I'm doing using this disclosure slide. So at the end of 2018, I had the opportunity to retire from Mayo Clinic with emeritus status. So I took it. I was 62 years old and thought to myself, this would be a good time to cash out and I don't have to stop. But now I've got the wherewithal to go out and do some things that are very different from what I've done before and use different parts of my brain and do some other kinds of work. So that sounded really good to me. Secondly, working in the ICU, that was getting pretty hard for me, particularly the night shifts, multiple of those per month and so forth. And so it was time for me to step away from the bedside. So I did that. And I made this company called Trajectory Group. And you look at my website and it's got a lot of we, but we is really me. And I'm out there by myself and some others are starting to join me. And I work with various different entities to help. This isn't a commercial, but just showing you what I'm doing. The first one that I'm working with and the ones that are here are paid. There's some others that I'm doing that are not paid, is Reese Architecture Firm. This is a for-profit commercial architecture firm. And I was put on their board of directors. And in that capacity, I'm their healthcare representative. I get to sit with current and former CEOs from all kinds of different industries that touch architecture. And for me, it's like going to class and being paid an honorarium. These are really smart, motivated, insightful people. And it's been an incredible opportunity to learn. And I'm enjoying it very much. The next is the company you see there, Arch Healthcare. This is a chronic condition management. It's a startup company. And so I'm working with them as their chief medical officer. And in that capacity, I'm helping them to develop some things that will resonate with clinicians, that will make their life better, and help the patients in the process. Particularly, this relates to diabetic limb disease. And it's a very expensive proposition. How do we make that better? And how do we do that in a way that entices clinicians to participate in it and makes better for the patient, better for them, and for the clinicians? And so I'm doing that and working with them. Lots of fun. I'm working with an e-care organization that provides the whole spectrum of telehealth services from pharmacies and drug stores all the way to ICUs and all points in between. And I am working with them as an advisor and a consultant on a variety of different projects. The main one is the NETSEN project, the National Emergency Telecritical Care Network. The SCCM is a partner in the development of this program, as is the federal government with TATRIC and ASPR. And I'm leading one of the teams, the one from Avera e-care. And we're developing a portable platform that uses tablets and phones and laptops. So the tagline for this is EICU from anywhere to anywhere in what we're doing. It's been a tremendous amount of fun doing this and very, very gratifying and satisfying. I'm working with a health care system in Vietnam. Multiple hospitals. They have seven going to 12 hospitals. They're not-for-profit. And I'm working as a consultant with them, helping them to build programs, telehealth, rapid response teams, education programs. And this is not just critical care. Through internal medicine, the emergency departments, other parts of the hospital. So this has been very gratifying as well for me to do that. The challenge for me over the last year in 2020, like everyone else, no travel. And trying to drive culture change and change management with Zoom and other calls is really a challenge. And then finally, I'm working with another startup company that is critical care focused in the IT world. Okay. No data slides here. So where did I start with deciding what I wanted to do? And I think we should all think about this when you make this transition. And that, at its crux, is what is relevance? How do you define relevant? Well, here's the dictionary definition for that. And I looked at it, and I think when people look at their self-gratification and other things, a lot of it has to do in a workplace, professionally, with feeling like you're relevant and you're making a difference with that. So that was very important to me. One important note, though, is that relevance may or may not have to do with impact. They're similar in what they do, but they're not necessarily related to each other. You can do things that are highly relevant that may not change the system that are very gratifying and so forth for what you do. So disconnecting these two things together, you can seek both, but realize that you don't necessarily do one without the other. Or you can, excuse me. The next step for me in defining relevance is right here, answering these questions. They seem simple. Who am I? Why am I here? And what is fulfillment? But you can get into this very quickly and realize these are not so simple. They're actually very deep questions that have a lot to them with what's happening. So I went through these questions first in trying to define what I would do and how I would do it, and what I wanted to accomplish and achieve with that in defining relevance. All of us come from this place. Here's where we are, and you see light speed and blurred, and other things with that. Critical care, long hours, high intensity, unwavering commitment to team, constant task saturation, constant crisis management, lots of moral distress, lots of burnout. You look at all of this, and someone from the outside says, wow, that's really hard. And yet, almost every one of us look right back and respond and say, well, yeah, but let me tell you, this is a highly fulfilling career. I feel like I made a big difference in a lot of people's lives. And if I had it to do over again, I'd do critical care again. Many and most of us say that. Here's another point that I realized. Stress is an addiction. We all like to talk about stress and compare it. It's almost a woe is me for where stress is, and how tired you are, and sleep deprived, and exhausted, and I this, and I that, and all the things that go with it. But really, stress is addictive. I took several different quotes, and I crunched them all together, and this is what I came up with. Stress is the spice of life. The complete absence of stress is death. And so when you, quote, retire, what about that? It's not good to just go out in your life and create stress, especially for those around you now, and particularly outside the workplace. But having cognizance and awareness of this is very important. So here we are now. No more ICU, no more of the constant task saturation. Are you on a pier fishing, looking at azure waters? Are you catching up on sleep and not setting an alarm? Are you outside hiking, or playing golf, and looking at beautiful vistas? More time with family, back in the hospital in a different capacity, teaching, missionary work? Or are you just hanging out, saying, I'm not sure where all this is going to go? It's all because of this. 100 miles an hour to zero miles an hour, rapid deceleration. That can be injurious. So what are you going to do about that? How does that work? Well, you might go through this phase, and that's not necessarily good. How do you know if this is too much? Well, if you're with friends, and somebody brings up food, and you start referencing something you saw on the food network, you're probably watching too much of that. And it may be time to broaden your horizons a little bit. And then there's this. In critical care, death is our near constant companion. And we learn to coexist with that for our patients, and for ourselves, too, because we have to also cope with the death, and the pain, and the devastation that's around us with our patients. And we suffer right along with them. You have to, and that's very difficult. But now you're past that, and there's more time to think about your own mortality. And all lives lead to death. So how do we balance that, and continue to lead a full life, and recognize where all of this ends up, and continue to be in a happy place, if we can go back to the happiness part? So for me, in defining all of this, I said, I'm going to transition. I'm not retiring. And in fact, when people would come up and say, hey, I hear you retired from Mayo. And I was quick to blurt out to them, no, no, no, no, no. I didn't retire. Don't use the R word with me. I transitioned. I'm doing other things at this point. Well, why do we do that? Why did I do that? And what does that mean? Is it my insecurities? Am I not able to deal with this? What would I do differently? And in fact, one of the errors that I think I made is, as I retired from Mayo, I rolled right over into the consulting, because a lot of that stuff had already been put in place for me. And so there was not even an extra breath. I went one day from one job, the next day to the other. For each of us, with introspection, and sometimes, unfortunately, even with self-absorption, we spend our entire lives becoming experts about ourselves. That doesn't have to be a bad thing. It can be a good thing. In fact, it can help us think through where we go next and what we want to do. So as you do this, here's my advice, based on what I've done right, but more importantly, what I've done wrong. In defining your relevance, don't be in a hurry when you leave clinical practice to do the next thing. If you've got to coast or spend some of the money that you've saved, that's OK. But take some time first. Draw a map. Where are you going? How are you going to get there? And if you don't know where you're going, any road will take you there. But I would also call out, as you see here, that map rhymes with nap. I never did the naps while I was working. Naps were a sign of weakness, or so I thought. But now, I've become a subject matter expert in naps. And a power nap is a really good thing. And I wish I would have figured that out sooner. What might come next after that, and why? What is important, and why? And where do all of these things fit together? Calibrate your contributions. And this gets back to the impact thing. Is that important? And how do you contribute? Is it something that everybody knows about that you can Google and find it? Or is it helping your grandson do their homework and learn about a concept? Or is it both? What are those things, and what do they mean for you? So carefully define relevance, and where that. Okay, so let's talk about relevance. Here's my map. I made this map with all these circles. I used copy-paste. It was just easier to do that. So the circles are all the same size. But really, they're not the same size. So what does all of this mean? Well, let's start with family. I think all of us would say the family circle is much, much bigger than the other circles. But it's important to consider what we say and what we've actually done. Our lives in critical care have also been our family. And how do we merge all of these things together? And importantly, how do we make sure that we're really doing what we say and making our family be the biggest circle? For the rest of these, this is me. Entrepreneurism, I had an itch. I wanted to scratch it. I've described that to you, what I'm doing. May not be what you would do, but it's been fun for me, and I've enjoyed it a lot. And I believe I'm making a difference, and I am doing something different. I'm helping others to build things. I built things during my career, programs and projects and so forth. But now others are doing that, and I have the satisfaction of assisting and coaching and watching them do that. And finally, less regrets. I don't think there is such a thing as no regrets, but we try to have less regrets. This is the end of my talk, and I'll end with this slide. And this is for Marie. Here's your sunset. Here's a road that takes you where you wanna go, and all the things that go with that. So lots to think about here. And I thank each of you very much, and I wish you well with your own journeys. Good day, everybody. First of all, I am Donald Chalfin. A little bit about myself. I'm an intensivist. I am on the faculty of the Jefferson School of Population Health of Thomas Jefferson University. And I'm currently working as a clinical expert for Siemens Healthineers, working on COVID research, developing predictive models. First of all, I'm very happy to be here, and I'd like to thank the SCCM. I'd also like to special thanks to Marie Baldiselli. I will speak in about, again, in the context of this section, I will be speaking about what's it like on the other side of the stethoscope with the intensivist as a patient, and also speaking about a chronic disease, if you will, living and practicing with a chronic disease. And my lecture is gonna be, I will be providing a personal story. But first I wanna give just a few disclaimers. As I said, I am a current employee for Siemens Healthineers, but this lecture contains no references to any product or material from Siemens. The views expressed here are completely on my own and reflect my own experiences. I'll also like to say, as I said before, it's wonderful to be part of this program, but in general, it's wonderful to be part of any program, and hence my personal story. Okay, I'd like to start out by just giving a few aspects as I was thinking about this lecture, thinking about physician health and illness. And first of all, I think it's important to understand that as I was developing this lecture, when I did a literature search, as I do for any lecture, there's a significant literature on substance abuse and the impaired physician, even using the search terms illness, chronic illness, physician afflictions, and so forth. There's also significant literature on recommendations and also recommendations for the aging physician. And this includes credentialing and licensure from various professional organizations, from the AMA, and also from various states and credentialing bodies. There is significantly little literature, minimal literature on the chronically ill physician, and for that matter, the acutely ill physician, which I found very curious. Now, I think it's important, and judging from my experience, that there are certainly practice and practical considerations and limitations. And there are issues related not only to the physician's safety, but to the patient's safety. And this includes the ability to safely perform procedures, the stamina, and one's ability to tolerate the workload, and also the burden that one might place on someone's coworkers, and going along with that, cognitive and intellectual repairment. It's a personal issue, it's a practical issue, and it's a patient safety and performance issue. There, along with that, there are certainly legal, liability, and ethical issues, and I think there are also patient expectations and what are our own practitioner expectations. But before I get into this, I'd like to go into the personal side of what brings me to this lecture. And I show a photo here of my son and I, and we both look very happy. But there might be some who might know me, and you might know that, see, that I look a little bit different. I'm not just having a good tan. This is severe jaundice as a result of NASH, which progressed to, with me, I developed, I'll show a timeline. But I developed NASH, which morphed into decompensated cirrhosis, which subsequently morphed into hepatocellular carcinoma. And I had to stop working as a result of that, okay? This is a picture after I recovered, taken about a year ago, doing one of my favorite things. This is sea kayaking, and it happens to be in the South Island of New Zealand, which I was able to do right before our travel restrictions. But about two years prior to that, a year and a half prior, this is a photo of me, and I think it's a few instances. This is right after I had a liver transplant. My son's watching over me. Thankfully, I was extubated about two to five minutes after this photo. And those who look at this photo might note that, hey, there's something unusual. There's a guy with a swan inside him. I found that quite curious afterwards. But basically, to say what happened, I developed NASH, which is non-alcoholic steatohepatitis. My liver was good. This is just a general photo of a healthy liver. My liver essentially morphed into, I could show some of the pathology, but essentially was really something like this. And a little about my timeline, this all started, probably started before, but I noticed in about November, from November to March of 2017 to 18, I was becoming more lethargic. And I had developed a significant tan despite the fact that I was nowhere near the sun. I was diagnosed with NASH and cirrhosis. I had a high MELD score of 24. Between March and June of 2018, I had multiple tests. Those hundreds of lab tests, a lot of imaging, two liver biopsies, including one that was suboptimal. I had a right heart cath and a left heart cath. Fast forward two months afterwards, after diagnosis, I was diagnosed with hepatocellular carcinoma and my disease worsened. I was developed, I had hospitalized for two weeks, with sepsis, secondary to Legionella pneumonia, not fun. And subsequently, so important to know my issues that I was denied a transplant initially. I subsequently had to scramble, my wife and I. I ended up going across the country to the Ochsner Clinic. I was listed for transplant on July 18th. And two days later, two, three days later, I was transplanted with a DCD donor. And just a little bit forward on that, just the rest of my timeline, I pretty much just illustrate this, that it took me almost a year and a half, longer than a year and a half, two years to recover with a significant, I had two rejection episodes and I had a lot of other pathology as a result. And it was a prolonged recovery and it took me a while before I could work. And I even started working clinically, but I had to stop because of COVID and I'm at a higher risk due to my underlying immunosuppression from my transplant medications. Now, I'd like to think about my life after, this is me before, you noticed the T-shirt, it was very appropriate, I think. And afterwards, I think a significant part is, I'd look to look at some of the benefits, is a significant weight loss. This is me at the Taylor about close to a year after transplant. I don't recommend that approach to weight loss, but you like to look for the good in everything. So let me give you just a few thoughts. Why do I feel particularly fortunate? I got a liver within two to three days of being listed. Most people wait much longer, many in fact die waiting for transplant. We have excellent, we had, and we have excellent healthcare and too many Americans are under or uninsured. And certainly with transplants and with everything else, a lack of proper insurance equals, is access denied or denied, access delayed rather. I'm a physician, my wife's a physician. We had the wherewithal to advocate for ourselves. Many people don't have that ability. The other aspect is, I was able to take the time to recover and convalesce, took about two years and I still feel some residual fatigue and still have to monitor myself very closely too. I had the ability, I had the family support, I had other support. Many people, too many people don't. And I think that's a real issue to address. Forgive me for just thinking about the social implications of it, but it's important. Lastly, I realized that I needed to appoint an interim CEO of everything that's me. This happened to be my wife. And I think one of the first things if I can think about and one of the main lessons is that as my condition worsened it became evidence what I could and what I should not do. And I think that's something that's unique for us as physicians. And this is a book by Harvey Mandel and Howard Spiro. As I mentioned before, there's limited literature. This was published in 1987. But I think one of the key aspects, what it points out to is as a doc, when you're ill, the setting doesn't change, but all of a sudden, as I said in my title, we're on the other side of the stethoscope. And when a doc is sick, you'll note that this is 1987 literature. So please excuse the pronoun exclusive. Exclusive, is this a, exclusive. Well, my speech actually was not impaired, but every now and then. When a doctor is sick enough to be admitted to the hospital, he can no longer write orders. Orders are written about him, removing him from control of his own situation. Now, one thing it's interesting from the literature is that recently the Lancet had an editorial focusing on when the doctor is sick too. And I thought it was a very pointed editorial that listed a few key thoughts. And I think one thing we have to face as docs is that when we're sick, unhappy, we tend to feel that I treat illness, I don't get sick myself. We're deniers. We're notoriously bad at seeking health ourselves. And I'm a prime example of that. But I'd like to think that I realized I could not put patients first. And I think I had people around me to inform me about that. And I think that's a key aspect of being ill is that in having a long-term illness is that it's not only your aspect, but putting the patient first, suppressing your ego, if you will. I also recommend that people read the excellent book, which by the way was featured at the SCCM last year by Dr. Rana Audish, who's an intensivist in Michigan, who wrote about her experience with severe sepsis and subsequently acute liver failure. And she describes the phrase physician-patient hybrid in that we aren't trained to see patients, we are trained to see pathology. Also, this sort of goes against the edict or the aphorism from William Osler, who said a physician who treats himself has a fall for a patient. However, when you become sick, I think it's important to realize that we're not gonna check our brain and our intellect and our experience at the door. And what she says is that she felt she had to be vigilant over her care because she knew what would happen if she left the watchtower. The other thing I think it's important to realize is everyone has expectations for the trajectory of her recovery. And I agree with her wholeheartedly. In that, I think everyone has expectations which are guided, or for that matter, biased by hope. And that she never ventured from being a patient very far that first year. And I think that only happens, me now, two and a half years post-transplant, from back to health, but still having to watch myself, having to get screening tests and certainly get frequent lab tests, although far less frequently in the past, is that to never venture far from being a patient that first year. I think the longer, the more remote you are from going to a hospital or a doctor or a rehab facility for a few, for some time, the more remote you become as a patient, the more you're able to separate yourself and put things in the rear view mirror. Now, that depends. That certainly may not be the case with a persistent chronic illness, but I think that's an important issue. Just a few more points. The physician-patient hybrid, if I can expand upon it. When you're a doc who's sick, it's the best thing that there is, it's also the worst, and both coexist. I think the concept of presenteeism is very key in that just as you don't want people to go to work if they have the flu, or these days, if you're recovering from COVID, it's harmful to you, your coworkers, and especially for the patients. As a physician-patient hybrid, you're scared just like patients are, but your fear is quite different from others in many ways. We know too much, we have expectations. I also would say, avoid the VIP syndrome, okay? We can reduce errors, we can also increase them. At least that's my experience. I'd also like to say that when you're a physician who is ill, or a physician-patient hybrid, you may be less, you're unlucky, but you're less unlucky than other patients. I say that as a note of reassurance. I also wanna say that, and I found this, that we ask, and this is what Dr. Audish states, is that we may ask for data, because this is what we're based upon. We're connected to the literature viscerally, but what we really want is nonsense. Reassurance, forgive me for that. What we really want is reassurance. And I'd also like to add, going back to what I said before, the aphorism of Dr. Be the patient is nonsense. Speak up early and often, don't check your brain at the door, but then again, don't assume control of your care. All right, just a few other thoughts. Become the CEO of you, but allow someone to step in as your CEO when you can execute the plan, and it's probably gonna occur earlier than you think. Remember, loss of independence is emotionally and physically debilitating. It's frequently ignored, and everyone is scared. It manifests in overt and subtle ways, and I would ferv that if I can take lessons of being a doc again, it's made me more conscious of this being a patient. When you're ill, it's okay not to answer the cell phone. It's okay to turn off the TV, and it's important to remember that pain and weakness and boredom could be direct suck. Be proactive, and do your best to mitigate, and seek help for that. This will take time. Remember to be respectful and thank others. When you forget this, which you will often, apologize. And I can't emphasize this enough, which is to practice overt presenteeism. Err on the side of caution of not resuming work too early for both your patients and your co-workers' sake. And it's also our duty to recognize limitations due to illness and impairment. It's one similar duty to recognize and report impairment of others. And lastly, I'd like to just draw upon Rabbi Halal's maxim, if I am not for myself, who will be for me? And this is not just a call to arms to be selfish about things, but it's just to recognize that as good as your doctors, your nurses, all caregivers are, it's best for you to stay informed. You're your own best advocate. In other words, know your condition, and know the system well, and be prepared to seek help. Now, I can go on and speak for this for quite a long time. But I think it's important to realize how having a chronic illness and an acute presentation has really informed me. I think it's important to recognize, I think it's important to recognize our limitations, our responsibilities, and what we can do and what we cannot do. And if people would like some more information, feel free to contact me on Twitter or via my email. It's been a pleasure. I hope this has been informative. Thank you very much. Hello. I'm Michael DeVita. I'm Director of Palliative Care Services at Harlem Hospital and an intensivist at the hospital. And I've been invited to speak to you about mandatory retirement and mandatory testing, and whether it is legal, and whether it is ethical. I want to start off by talking a little bit about the clinical data. And the impact. First off, we're all getting older. So even if this isn't an issue for you now, it will be someday. Some 150,000 physicians in the United States are over 65 and are in active practice, which is about 15% of the entire physician workforce. So we're not talking about a small number of individuals here. In fact, many of those, 11% of the entire workforce is over the age of 70. Now, associated with age are declines in cognitive performance. I think we are all aware that perhaps we're not quite as sharp as we were years ago. And this is a process that is normal and continues over an entire lifetime. In addition, I'd like to make the point that psychometric test scores have not been shown as yet to be associated with patient safety or physician fitness to practice medicine. And yet, there are a number of organizations that are making it an important part of either credentialing or privileging. The top five you can see are healthcare institutions, which are requiring either testing or screening or retirement at the age of 70. And this has largely been mimicked after other professions, which are high risk and include the potential loss of lives, such as airline pilots, FBI agents, et cetera. Yale, in 2016, required cognitive testing and vision testing for all practitioners over the age of 70, and every two years after that. And they were basically trying to protect patients as much as possible. And they were mimicking these other professionals that I just mentioned. They did this for all clinicians, irrespective of whether there were any clinical concerns. And in fact, no clinical concerns were raised amongst any of the people who were tested in their first study, which was reported earlier this year in JAMA. They looked at 141 clinicians aged 69 to 82, none of whom had had performance issues. And a little over half completed the testing and had no issues. Twenty-four percent had minor abnormalities, and they were able to complete the credentialing process, but they had to be retested in two years. And the remainder had either minor or severe abnormalities that required that they either voluntarily or from a mandatory perspective reduce their work and in fact were not credentialed. Not surprisingly, in February of this year, Yale was sued by the EEOC, the Equal Employment Opportunity Commission, for age discrimination. And they alleged that federal laws were violated in their clinician reappointment process. What they stated was based on the ADEA, which is the Federal Age Discrimination and Employment Act, which prohibits the arbitrary use of age in decisions that impact employment status of individuals. And this has been upheld by a number of court cases that have been done. So there's both case law and legislation that supports this. Unanswered is whether screening mechanisms can be applied to a particular age group. That is something that is yet to be decided, but it is very likely to be considered to be discriminatory as well. And so the bottom line from the ADEA standpoint is laws don't support age-triggered screening. And there are disability court cases that do support case-specific individualized assessment. So if you have a concern about somebody, it is perfectly reasonable to test them. But if there are no concerns, it is unreasonable to take a particular class of individuals and test those people. Now medical staff is a little bit complicated. Many physicians are not actually employed. So the ADEA, which is an employment legislation, does not apply. Yale is both an employer but also a privileger. And so for the clinicians who are employed, there is an ADEA claim. For the physicians who are not employed, it is not clear that this type of activity is impacted by the ADEA at all. State licensure boards, on the other hand, don't have any particular requirements in this regard. They have the authority and responsibility to license, discipline, and ensure competency. And if state licensing boards wanted to include cognitive testing as part of ensuring competency, this certainly would be upheld by the law, by courts. I think it's interesting that the American Board of Medical Specialties does not discriminate on the base of age. If you pass the board exam, you're board certified. It's saying that you have the knowledge capability to be practicing medicine. And that is a little different from the testing that has been done that Yale and other organizations have been requiring. Now, what is tested in neuropsychological screening? This is a listing of the types of tests that are being done in terms of the domain and the test description. And you can see that these are all fairly important, but they are not central to what it is to being a physician. And so you can reasonably raise the concern that testing this may not apply to whether you could be a good doctor or not. This is a study by Koronek, where he looked at clinicians who had had quality concerns. Those physicians were cognitively tested. And he had age-matched controls and cognitively tested those. And the important part in this slide is that there is a huge amount of overlap between those that had medical, clinical issues and those that did not. Meaning that the screening test is probably not a good indicator of whether somebody is going to have quality problems. And I think this is because the cognitive skills are not the only important characteristics to be a good doctor. There are technical skills, your ability to use your hands. And there are team skills. And these may be equally or more important than cognitive function for safety. Also, none of these studies have considered board certification status in the quality of care that was delivered. An often cited paper by Sugawa in 2017 looked at hundreds of thousands of Medicare admissions and tens of thousands of hospitalist physicians and looked at the impact of age on their mortality rate. And you can see that the mortality rate for those under 40 who had about five years of experience was 10.8%. And that went up to an absolute mortality rate of 12.1%. And this was corrected for the age of the patients. So there is a measurable difference. Is this an important difference? I think is up for debate. But I think an important finding that was not highlighted well in this study is that amongst high volume physicians, age had no factor in mortality. Those that were elderly, high volume physicians had exactly the same mortality as young high volume physicians. And it may be that age is simply a marker for the volume of patients you are carrying. Surgical skills have been tested. In this study by Stolberg, he looked at 17 surgeons who videotaped a laparoscopic colectomy. It was then evaluated by 10 peers and two national experts on a one to five scale. And then they looked at the complication rate that those clinicians had had over the preceding two years, from 2014 to 2016. And you can see in box A in the top left hand side that skill level was proportional to safety. So the higher the skill level, high is five, had the lowest complication rate. And this could be unpacked in unplanned readmissions, unplanned reoperations, death and serious morbidity, all of these, all of those, there was a significant difference. So skills testing is probably better than cognitive performance testing. I'd like to make the point that clinical performance, which is really the bottom line that we're trying to act on here, can result from a number of issues that have nothing to do really with cognition that may be related to social and medical issues. For example, addictions, marital and financial problems, psychiatric disorders, and endocrinopathies, cancers, and such, they all can impact clinical performance. And so we have to be careful about choosing age and cognitive testing as something that matters for clinical performance when it seems that it does not, and ignoring other issues that may be more important to how well we do. So my recommendations is I think all physicians reasonably should be investigated to see if there is poor performance, and those that are identified to have poor performance, those should be carefully evaluated to see whether it is a cognitive defect or some other factors may be involved, and then to remediate those if possible and if not, removed from clinical duty. This seems to be a fairer process to me. We all have cognitive gaps. These are known as our blind spots, of course. And one of the nice things in today's world is we do have references at our hands. We can phone a friend, we can Google and do other things with our smartphone to help fill gaps that we might have in memory or breadth of knowledge. Repetition and mnemonics enhance memory of specific items, so for subspecialists and super specialists, they may actually be a bit more immune to cognitive defects because there is such a huge rehearsal factor. Cognition is not skills, and clinical performance is skills. That's the bottom line, and we have to realize that cognition by itself does not impact. I think communication and empathy are equally important as cognitive capabilities in terms of being a good physician. So ethically speaking, to wrap up, there is a duty to ensure high-quality care through both assessment and remediation, and this is, ethically speaking, fidelity to our patients and to our profession. I think it is unethical and potentially illegal to arbitrarily choose any group for assessments. It is unfair because we are using the unit of measurement should be the individual and not the class of person and the class, and this is a justice issue. It is ethical to evaluate all individuals provided there is a valid measurement instrument for that specific purpose, and it is ethical to evaluate selected individuals based on their individual performance. Once again, thank you very much. Thank you for attending this session. I have to tell you, and I was delighted to hear from one of the Congress co-chairs that this was one of the most widely attended sessions, which means that there are a few of us out there who are interested in what happens in our careers as we age. We have some time for questions, and I want to thank all of our speakers. Unfortunately, Dr. Farmer could not be here today because of family issues, but certainly the rest of the speakers are here, and once again, thank you all. Mike, I'd like to ask you the first question. So you mentioned, you know, cognitive skills and a decreasing skill set, team skills, procedural skills, so how does one test all of that? I mean, what is the best way, or should we not be tested? You know, I don't think we've figured this out really well. We haven't figured this out, whether we're talking about age or, as Don mentioned, other diseases or even addictions and so on. I think we have to start off with better measurement of quality, and once you've identified that there's a quality issue, then it becomes pretty easy to then focus on, all right, so what's underlying it, and is this person competent or not, and how do we remediate it? All right. Tony and Don, a question for you that came up in the chat room. So how does one prepare? I mean, how do you know, Don, if you should go into industry? And Tony, how do you know what your next step should be? Should you stay in clinical practice? Should you do something else? I think that's the question that many of us ask ourselves. I mean, I feel I'm at the pinnacle of my career, but I'm not exactly sure what to do next. Should I just stay in Florida and, you know, stay in the sun and fun? Where do I go? Well, first of all, I guess, this is Don, if I can take this first. I think given the snow back East Marie, I think Florida, at least temporarily, sounds like a good option. But, you know, let me just put my spin on it. And I think part of this is independent of disease. And I'll go to something that Chris said, which is I think my belief, and especially the nature of critical care, I think life is too short to have one career. And I think all the careers that we have in the field should be complementary. I will say that now that I'm back to work, unfortunately, I can't do direct patient care until I complete my vaccines. And that's due to the fact that being a transplant patient, I'm on multiple anti-rejection medications. Thankfully, it's going down. But, you know, that puts me at an enhanced risk for COVID. And I don't think I do myself, my colleagues, or my patients any good. But even when I went to industry a few years back, and even went into industry, I was also seeing patients, and I'm still continuing to teach. And I do plan on going back to see patients quite soon. So I think it's a matter, and again, going back to what Chris said, is finding the appropriate balance. I think there's a very important role for success, succession planning. And something I'd also like to state that I think, you know, I felt a little funny given the lecture now, being that, and you referred to yourself, so many people have been afflicted with COVID. And far too many people relate to BNL and the sequelae of BNL, than we would have expected pre-pandemic. But life has changed in general about that. I think there's something to be said for, you know, career planning and being proactive about it. I think, you know, and I realize, too, that doing nights and doing the weekends, you know, I think it's helpful to realize that it gets harder to bounce back. And there's no such thing as an easy night. And I find that the older you get. And I have to be very honest with myself. I'm back to health, but also my stamina is still a little bit less. And I think you have to be fair and honest with yourself. I think one advantage of being a physician, and I think one advantage of being a critical care physician, is there are so many other opportunities. And lastly, I think it's okay, and I think it's correct to say, it's time to do something different. It's time to order your priorities around. I think we have to get away from the approach that these, you know, you have to stick with it. And it's a sign of weakness if you don't. We have to recognize our weaknesses that we may have. Apologies for going on so long. Oh, no, thank you. Tony, your words from someone younger. I think you have to add a certain period of time. And for me, it's always been when a door closes, finding what that window opens, as I said in my talk, and I think for me too, is when I start not caring and not having empathy for my patients, that there's a problem. And then it's always going back, what gives me joy? What's changed so much? And I think, you know, as you get new opportunities, and I would say I'm lucky I work in a big medical center where they started advanced practice provider fellowship program, that actually teaching those and that teaching that I can give to people is really what gives me joy. And what can I do to focus my career to do what gives me the most joy? And realizing things that don't give me joy that I see as busy work, it's time to give up. I recently just gave up being on the IRB, and I'm very happy about that decision because I just didn't have enough time. And as you go out with there, and you know, I started burn service here, but realized I didn't have the time to dedicate to it. And although there's always going to be a little bit of me that's sad that I'm not the burn pharmacist, I gave it to other people and mentored them to make it much better, and more importantly, it helps patient care. So I think you need to look at it. And I know a lot of people have gone into industry or have changed their careers, and that's totally fine what you want to do and what works in your lifestyle. And I think what we tend to do now with phones and everything is have all work on you here, and you have to take a break. I try not to answer emails on my days off or when I'm not at work anymore, and it's made for a much happier Tony. I think your point is so well taken. I think, you know, we have to be somewhat self-serving. We have to look at what gives us joy in our life, whether it's working in industry or working with patients, and when we no longer feel that joy of going into work every day, then we have to think about other options. But I think the whole, one of the points of this session was for you all to think about your options ahead of time. Come up with a 10-year plan or the five-year plan or the one-year plan, and hopefully we've given you a few tips on how to do that today. Once again, I sincerely have to thank all of you, including Dr. Farmer. I hope you've enjoyed this session. I certainly have, and we'll see you all next time. Thank you.

aging ICU practitioner

retirement planning

options for retirement

practicing medicine with chronic disease

ethics of mandatory retirement

professional growth

pursuit of happiness in retirement

options for practitioners over 50 or 60

living and practicing with chronic disease

recognizing limitations

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