The Joy and Meaning of Medicine

Chapter 10


THE JOY AND MEANING OF MEDICINE


Scenario


“It’s amazing—I think I’m busier now that I’m retired than I was when I was working at the hospital. Look at all the preparation we’ve done for the Well-Being Advisory Board meeting next week! It all looks great. Thanks so much, Ellen.”


Dr. Louise Newton smiled across the table in appreciation for all the hard work her colleague, Ellen Jackson, had completed. Louise looked around the well-furnished office. It was designed in a mixture of grays and blues, and the walls were adorned with matching steel-gray-framed pictures of several exotic tourist spots, including views of the Golden Gate and Brooklyn Bridges. Others showed various clinics and hospitals where members of the Hills Medical Society worked. A new, modern computer console sat atop a circular work desk in the center of the room that was surrounded by matching chairs.


Louise was looking forward to the meeting next week and thought all the preparations were in place. She stood up from her chair, took a deep breath, and stretched. A slim, conservatively dressed woman with short, sandy hair, today she wore a brown suit and matching silk scarf and her usual thin, gold-rimmed glasses. She looked the picture of fitness and health; acquaintances were often surprised to learn she was a retired pediatrician because she looked closer to 50 years old than to 60. She kept fit with regular hiking and played golf with a handicap of 15 that she knew she could improve if she could find time to play more than once per week. She could not see her handicap improving soon, however, because her life was so full with her volunteering and community activities. When she occasionally reflected on her professional life, she genuinely could not understand how she had had time to work as a full-time physician in the past. She knew she had made the right decision when she had finally retired from clinical work 3 years previously, after working part-time for a few years before.


Ellen Jackson, who had now been CEO1 of the Society for nearly a decade, knew Louise well. She had worked with her on committees for years, but it was only during the past year, while Louise had been serving as president, that they had become friends. They had a mutual passion for working on behalf of the medical group that represented more than 6,000 physicians in the western region of the United States.


“I’m so pleased with the advisory group on physician well-being that we’ve put together and how enthusiastic everyone has been about this project,” Ellen said. “I know that will be a longstanding legacy of yours, Louise. After all, you have driven this topic while you’ve been president, and you’re such a great example of how physicians should look after themselves, their colleagues, and their community. I just wish you’d be more willing to tell your own story to inspire others.”


Ellen knew she was taking a bit of a risk asking Louise again about this, because they had talked about it several times, and each time Louise had been adamant about preserving her privacy. However, she felt strongly that Louise was such a good example of resilience and overcoming adversity that her colleagues could learn so much from her.


“I know you want me to do that, and I know why. I really do want to help my colleagues as much as possible, and I’ve been thinking a lot about your request, Ellen. I wonder if it would be possible to talk about myself on a podcast, perhaps with a series of preplanned areas of discussion and the assurance that I can cut any sections I don’t feel comfortable about? We didn’t discuss that as an approach for telling my story, but I think a podcast might be okay with me if we do it carefully and find a sensitive interviewer. I was impressed by the example podcast you played for me last week; it was like hearing a friend’s life story in my living room.”


Louise looked at Ellen, who smiled back. Ellen was pleased by her friend’s gradual change of mind, but she was not at all surprised. Ellen had a comprehensive program on well-being planned for the Society and knew that Louise was the right person to be the medical leader and example for other physicians. She thought about the first time she had sat down with Louise to discuss her idea for a physician well-being program that would be available to—and, she hoped, would involve—most of the physicians in her region, whether they belonged to the Society or not. She knew, as did almost all of the regional physicians, about Louise’s tragic background. Louise’s husband, who had been a prominent obstetrician, and both of her teenage daughters had been killed by a methamphetamine-intoxicated hit-and-run driver 15 years previously. Louise had been badly injured but had recovered from her crushed pelvis and broken legs, although her psychological injuries were much more severe. Ellen knew Louise still had regular nightmares and continued to see a local psychiatrist who specialized in treating physicians and who, Ellen had discovered, was helping a surprising number of the medical society members. She had recruited him for her advisory board early on.


Ellen pushed her thick, blonde hair back, using her glasses as a headband. She decided it was time to relax. Ellen took pride in looking her best and keeping fit. At 5’8” tall, she was able to stand out well in her new pink linen blouse, classic navy suit, and 3-inch heels. Her simple gold wedding band was a reminder of her long, successful marriage that was perfect in all respects except for the lack of children, something she always shrugged off in polite conversation. She turned to Louise.


“Well, I have to say I’m pleased by your change of mind, Louise. I should probably show you the draft agenda for next week’s meeting. I want to go over it with you.” Smiling, she passed Louise the sheet of paper. “There, look at item one. The creation of more regular podcasts featuring members discussing their own view of well-being in medicine. I’ve been hoping for a while that you would be the interviewer for the first few, but now I’m wondering if you would be prepared to be the first person interviewed. Is that a possibility?”


“How do you do it, Ellen? I think you’ve had all this planned. I can’t believe how good you are at getting people to do what you want!” Louise exclaimed, not sure whether to be flattered or embarrassed. She certainly wasn’t angry, although she could see how effectively Ellen had manipulated her to get what she wanted. “I knew I should never have become friends with you. You know me too well, I suspect, and knew that I’d eventually agree to do what you wanted. Oh well, you win.”


Ellen laughed. “Okay, so maybe I outmaneuvered you, but I also know that you will only allow yourself to be manipulated if you want to be. Anyway, let’s face it: Even if you tell only half of your story, I think you will help a great number of your colleagues.” She slowed down her talk and looked seriously at Louise. “I know you won’t want to talk about the crash and losing Bruce and the girls. I’m not suggesting that. What I do think would be helpful is discussing your whole approach to practicing medicine—your outside activities, especially volunteering, and your concept of giving, and how all that ultimately led to your retirement from clinical practice. I leave it to you to decide how much you want to share about your background. To me, your approach to your life is what will help our local physicians. After all, you’re a classic Baby Boomer, just like a third of our members, and you’ve shown others the way to transition out of practice. You wouldn’t believe how many are having difficulty doing that and come to us for advice. They want to know about so many issues—taking up new interests, financial management, finding colleagues with interests in common whom they can get to know, working part-time, or volunteering. They need help making their lives feel more interesting and meaningful.”


Louise nodded. “I know physicians need to learn about retiring and how to transition out of clinical practice, but I didn’t realize you thought I had done this so well. Thank you for that; I really appreciate what you said. What is it that you think I can teach others? I’m always so afraid that if I speak publicly about anything personal that I will be expected to talk about the crash, and I prefer not to do that. I’ve spent enough time working through it in private, and those memories and feelings I prefer to keep to myself.”


“I know that only too well, Louise,” Ellen answered empathetically. “Let’s just have you talk about the past 10 years of your life. Do you know what struck me first about you when we started to get to know each other a few years ago?”


“No. That I was single? That I was looking to do things with the Society? That everyone used to look at me sympathetically but never said anything about my losses? Embarrassed and not sure how to speak to me?”


“Maybe a bit of all of those. You’re right. It never ceases to amaze me how difficult many doctors find it to be open with you. How they sometimes, even now, treat you with kid gloves because they all know what you’ve been through. It surprises me that as doctors they don’t have the communication skills with a colleague to show empathy but at the same time to be respectful of your privacy. I think that’s one of the things you can teach them, if you want, although it’s not what I’d planned: how to approach a colleague in distress respectfully and tactfully.”


“I think not,” Louise replied. “I also think I should keep away from substances and driving, which is just as much a problem for some doctors, especially with alcohol, as it is for the general population. I’m still too angry about that and wouldn’t trust myself on that topic. So what do you think I’ve done well, Ellen? And please do tell me what it was you noticed about me early on. We seem to have gotten off that track.”


“It was your approach to giving and volunteering, how you were so genuine and active about it and seemed to really enjoy the work. I remember you telling me that you’d discovered you looked forward to the 2 half-days of volunteering you were doing at the time more than you enjoyed your clinical practice, but you never told me why that was. Can you remember your first volunteer jobs? I think one was at the women’s shelter and one was at the local primary school. Is that correct?”


Louise smiled; those were happy memories. “Yes, you’re right. Those were my first two volunteer roles. You know, I did both of them for several years, and I still go back to the school to do some basic biology seminars with the sixth graders before they leave for middle school.”


“What did you do there? Why did you enjoy it so much?”


“Well, not surprisingly, the roles were very different, but they both involved direct contact with children, so I thought I could use my pediatric skills but not have the administrative restrictions of medical practice. At the shelter, I was referred a lot of children. Many of them had been through awful traumas, some not unlike my own, really. What I liked was being able to spend lots of time with them without being limited by a schedule. I’ve always liked talking to children. I learned a lot about play therapy from one of the social workers there. It was fascinating watching the children paint, draw, and play while they talked about their worries, their fun, their families, and their fears. I’d never really taken the time to do that with children before; I’d always left it to the social workers and child psychiatrists. I suddenly found a whole new area of work that I loved, and I think I actually did help quite a few of the children. I especially liked the younger ones, below the age of 6, because they were so open about everything. Some of them asked a lot about me too, and I gradually found I could tell them about some of my losses, which in retrospect was helpful. Once I even ended up painting pictures of my own children in response to the inquisition of a particularly sweet 5-year-old whose older siblings had been murdered. I thought of trying to retrain and take a fellowship in child psychiatry, but it hit me that one of the main reasons I really enjoyed this work was because I was less restricted by professional boundaries. I loved being able to just spend time with the children. It was freeing for me and made me think about the way I was practicing clinically. The answer seemed to be to change my clinical practice style rather than try to get a new qualification, so that’s what I did.”


“How fascinating. What did that involve?” said Ellen.


“Well, it made me turn my practice into one where I could give more time when a patient required it. I completely changed my business model and got away from the restrictions and stress of billing codes. I was a bit ahead of my time, but I developed a pediatric concierge practice. I wasn’t so worried about the financial side because Bruce had been well insured, but it worked out well; I told all of my patients’ families that I would be charging a monthly retainer for my services and joined up with an adult concierge practice so that we could help cover each other. I ended up being able to see my patients as much as was necessary and found my work so much more satisfying. I was in control of my practice and no longer involved with the insurance companies. I loved it, and so did my patients. My concierge practice allowed me take on a reasonable panel size, and I could decide who needed 10 versus 45 minutes. Most pediatric appointments don’t require 30-plus minutes, but when that was needed, I could manage it. The parents and the kids liked it, and so did I. I never had problems getting referrals, and the practice was the best of all worlds for me and the families I worked with. I was less stressed and was enjoying medicine and my life in general.”


“Well done! But what about the school volunteering? It seems that you’ve continued that all these years,” said Ellen.


“That’s true, but now I teach a 10-week course once per year on human anatomy and physiology, really preparing the sixth graders for what they will start learning about puberty and their bodies in middle school. In the past, I’d worked mainly with children in the first and second grades, helping in the classroom, not really trying to use my medical skills. I wasn’t there as a physician. Yet I really wasn’t completely divorced from it, especially with the children who had ADHD2 or autism who often had behavioral problems. I was really a teacher’s aide one afternoon per week for several years, and I specialized in teaching them art. I studied up and became an art docent for 5- and 6-year-olds. It was fascinating for me. I was given a large container of prints each week to share with the children, and they became so engaged! They liked being shown famous paintings and being encouraged to tell everyone, including me, what they thought about the art in front of them. Then we would bring out the art supplies, and I would encourage them to draw or paint as they wished—no rules. I enjoyed seeing how they expressed themselves in art class and watching them develop over the course of a year.


“I learned a lot about art, and art history, and I used to love hearing how the children interpreted famous paintings. You should’ve seen their fascination with Mona Lisa’s eyes and how they seemed to move and follow people around. They made up the most fantastic explanatory stories for this. One creative boy suggested she might have been a zombie on The Walking Dead. What an influence TV has!”


“But you’ve been going there for more than 12 years by now, I suspect. How did your role change?” said Ellen.


“It’s sad to say, but ultimately it changed because of the school’s funding situation and their need for a biology teacher. I was available and free, and the principal approached me to take up part of this role. So about 3 years ago I changed from art docent to biology teacher. I enjoy what I do, but it’s a bit more formal, and I’m not sure I’ll continue for too long. I feel I had a better relationship with the children when I could communicate with them through the paint box.”


“Tell me what you’ve been doing since you gave up your clinical practice. How was it, making that change?”


“Giving up my practice was the big decision. I had been working 3–4 days per week for a number of years and doing the volunteering and playing some golf the rest of the time. Remember, I was still recovering from losing Bruce and the girls, so I didn’t want lots of extra pressure, and I was suddenly a single woman at a time when I’d been expecting a meaningful retirement with my family. I think at one level I was still overwhelmed with my losses, or at least that’s what my psychiatrist thought. I was clinging to my clinical practice to provide some structure in my life, as though it were a life raft. For me, the problem was letting go of that life raft and the security of clinical practice. I think that’s what a lot of physicians find after practicing for 30 years or more. It can be pretty scary to suddenly stop. What do you do instead? I was lucky because I was financially secure and had a good financial advisor, so I didn’t need to worry about that.”


Ellen nodded. “It’s amazing how many physicians are bad money managers and don’t plan ahead for their retirement. For intelligent people, it’s really very odd. Perhaps they’re just used to assuming that if they continue to work hard everything will work out okay. What I see at the Society is that every time we put on a financial planning seminar we’re inundated, and not only with the young doctors. A surprising number of your more mature colleagues attend.”


“You’re right. That’s something I will always be grateful to Bruce for. He was very organized, and he left me financially secure after he died.” Louise suddenly looked away from Ellen, feeling emotional and distressed. “I don’t know why that suddenly hit me, but I guess this grief process just goes on a long time. I’m sorry if I’m embarrassing you.”


“Don’t worry. It’s good to see you show some emotion sometimes, Louise. You are one of those women whom everyone finds rather intimidating because of your amazing capacity to overcome difficulties and to show resilience in the face of whatever life throws at you. I know you’re good at acting positively even when you’re feeling down,” Ellen replied sympathetically.


Louise wiped her eyes with a tissue and gathered herself. “Where was I? The decision to retire, that’s right. Well, I had three main reasons. First and most importantly, I thought that after 34 years as a pediatrician, I had done my bit. My passion for my children and their families was less than it used to be, and I deserved a break. I started looking around for other things to do and was enjoying my volunteering more than working as a physician, where much of the work, even in a concierge practice, was pretty simple. Second, Bruce and I had always talked about retiring at around 60 years old so we could travel and work on our ‘bucket list,’ and when I discovered that the average physician worked until they were 68 years old, I knew that wasn’t for me and that I would finish earlier. I wanted to see if I could enjoy myself again after losing my family. It really hit me when I realized that I would never be a grandmother because both of my daughters had died—that my losses and grief would continue, even vicariously, going forward. I knew that Bruce would have wanted me to give myself some time.” Louise paused and looked out the window, deep in thought. She was remembering Bruce, the love of her life, and still missed him deeply.


“What was the third reason? It sounds like you already had two strong motives,” Ellen said, trying to bring her friend out of her reverie.


“I did, but the tipping point came one day when I was here for a committee meeting. I don’t think I’ve ever told you this. Do you remember Abbie Parsons, that sweet, young internal medicine physician who was quite an active member here for several years?”


“Yes, I do; she was very friendly but quiet. She moved away from here about 3 years ago, I think. I was always surprised at her move because she seemed so keen to get to know everyone. I had coffee with her several times right at this table.”



“Well, she had another side, and she confided in me about it one day. She told me she had severe bipolar disorder and a tendency to self-medicate when she was sick. She apparently had almost lost her license on several occasions when she was manic. Fortunately, she had enough insight not to practice when she was unwell, but the medical board still became involved after a hospital reported her for stealing tranquilizers, and they were reviewing her fitness to practice. At her request I tried to help her and keep her practicing, but she decided it was all too difficult, and when she became depressed about 3 years ago, rather than fight the medical board, she just gave in and voluntarily gave up her medical license. She resisted treatment and always refused to go to a physician health program. It was awful, because she used me as her main shoulder to cry on. Her husband was hopeless; he was a nice guy but had no insight. A building contractor, he was quite successful and was supportive of her when she was first ill, but he just didn’t understand the professional requirements needed to continue practicing. He eventually left her, taking their two young children with him when she was hospitalized on one occasion. In the end, she literally took flight. She left the area and returned to the East Coast to live with her parents. They had always been her main support when she was younger, and she reverted to them in this crisis. I kept in touch for a while, but for the past year she hasn’t been taking my calls or responding to my e-mails, so I really don’t know what’s happening with her. I hope she isn’t in big trouble. It always used to worry me that she might attempt suicide, but I haven’t heard anything, and I think her parents would contact me if something like that happened.”


“I’m so sorry. I had no idea. That’s tragic. It must’ve been kept very quiet, because I heard nothing about all this,” said Ellen.


“I guess that’s because, as you know, there’s this ‘cone of silence’ about impaired doctors,” said Louise. “Anyway Abbie had a big impact on me and made me think that I could really do something worthwhile with my medical knowledge and experience that was not centered on pediatrics. So that was my tipping point, the reason I finally decided to retire. I wanted to contribute to the health of my colleagues, and that’s why I’ve become so much more involved in the Society and in trying to get our ‘Joy and Meaning in Medicine’ program going. For me, this is a new passion, and something I can do on a volunteer basis, that is even more meaningful than my previous clinical career. So Abbie was good for me; she made my decision to retire much easier. She gave me a reason to look at alternative useful ways to enjoy myself and to do good, which is so much more rewarding than I could ever have expected.”



“How fascinating!” Ellen smiled broadly at Louise. “See, I told you that you would be great on our podcast. Wait ‘til our members hear how you got interested in physician well-being and how rewarding it is.”


“Okay, okay, I give in! I’ll coordinate a time to record it with your assistant—as long as I’m primarily able to promote the ‘Joy and Meaning in Medicine’ program. And of course I won’t mention any specifics that would identify Abbie.”


One month later, Louise recorded her interview for the podcast.


“Let me tell you what we have planned for the program that we’re calling ‘Joy and Meaning in Medicine,’” said Louise. She smiled at her interviewer, a family medicine physician who was becoming somewhat of a local celebrity through his own social media involvement promoting the importance of preventive medicine. “We have several components, all of which overlap, and that we hope will reduce the amount of burnout and distress common in many physicians.”


“This sounds really important, Dr. Newton. Like many physicians, I suffered burnout in a past job, but now, having changed my work to focus much more on prevention and a community approach to medicine, I believe I have left that behind. Am I an example of the sort of doctors you are trying to help?” Dr. Anthony Read moved his face to the side of his condenser microphone to catch Louise’s eye fully, making it clear that he was serious about his personal question.


“You know, Dr. Read, I had no idea you’d experienced burnout, but given that the problem is so common, it’s not surprising. So yes, you are an example of a colleague we’d like to assist and involve. I’d like to pick up your comments about a community approach to medicine, because that’s exactly what we’re planning for this program. As you know, most burnout is caused by organizational and systemic stress. It’s not usually the fault of physicians, who are mostly very resilient people. Recent research shows that medical students, at entry to medical school, are actually more resilient than nonmedical postgrads, but 10 years later are twice as burned out as their professional nonmedical equivalents in the population. So we’re taking a series of approaches aimed at changing the organization and culture of the local medical system as well as putting in place programs to help doctors rediscover their resilience skills.”


“That sounds great. Before we get on to why you became involved in setting up this program, perhaps you could summarize what it involves? I really like the emphasis on changing the culture of medicine. I know I’ve secretly always felt a bit ashamed that became burned out. It sounds like one of the first approaches might be education for all of us about not blaming ourselves, about not blaming the doctor. Is that the case?”



“You know, it certainly is,” responded Louise. “I’m pleased to hear you say that. Setting up this program has really made me think about our lives as physicians. I imagine you’re similar to me. I remember how, when I started medical school, I felt like I was on top of the world and could conquer any problem. I went to medical school to spend time with patients, to cure them, certainly not to spend several hours each day filling in forms and sitting at a computer. I was positive, resilient, and used to working hard and playing hard. I thought every problem, no matter how difficult, could be solved if I just put my mind to it.”


“That’s right. I can well remember the thrill of starting medical school. I had the most enthusiastic classmates. Is that something you’re hoping to recapture with this program?”


“Most certainly. That’s why we’ve called it ‘Joy and Meaning in Medicine,’ because we know that’s how physicians start their careers, and I personally believe that it’s possible to recapture that essence. But we need to work at it, because so many forces in health care fight against us. For example, I have never met a doctor who said he or she went to medical school to be able to spend massive amounts of time documenting notes in the EMR!3


“Well, that is certainly true,” said a thoughtful Dr. Read. “Let’s get back to what you are doing, though?”


“Well, we have activities both for individuals and for groups of physicians. One example is our series of evening seminars and socials that starts shortly. It will include everything from painting, writing, and food and wine appreciation to financial management, volunteering, public speaking, and leadership skills. These will not be your typical lecture-style evenings; for instance, we’re combining public speaking and wine appreciation by inviting a speaker from Toastmasters to co-present with a sommelier from one of our best restaurants. We intend these evenings to be very interactive and hope that they will engage our members in a positive way so that they not only learn things of use and interest to them but also, just as importantly, network and get to know their colleagues. We’re going to hold these evenings at all sorts of different places—restaurants, art galleries, wineries—almost anywhere that is not medical. In fact, that networking issue is something we think is super important, especially for those doctors who work for different health systems and would not normally get to know each other. So we’re also setting up some monthly ‘at home’ events for physicians who live in differing geographical areas where they can get to know each other better and gain more individual support. We’re even paying for psychologists to go to each of these meetings to facilitate the groups as they get going.”


“That sounds excellent—networking and fun. I like the sound of the painting and writing evenings and will check them out. But what else do you have?”


“Naturally, we’ve set up a website where everything is listed, and that has a well-being blog and provides access to what I hope will become a regular series of podcasts, just like this one we’re doing now. We’re fortunate that so many of our physicians have such interesting backgrounds. It isn’t really hard to find people to interview who have fascinating stories. You’d be surprised by how many doctors like the idea of doing exactly what you’re doing now, being guest podcast interviewers. Our next podcast features Dr. Nigel Hawley, who, before he went to medical school and trained as a cardiac surgeon, was not only in the Marines as a special services soldier but also completed a master’s degree in philosophy. Now, in the latter stages of his career, as he starts to wind down his operating room time, he has become the chief wellness officer for his health system. So we’ll have lots to discuss with him. Setting up these podcasts has been a great exercise in finding out just how diverse are the interests and backgrounds of many of our local physicians.”


Louise stopped for a moment. She was keen to pause and change direction. She looked across the interview table above the bulbous microphones toward Dr. Read, who, like her, was wearing large high-fidelity earphones. “Of course, we’re doing a lot more than just education and networking. We’re also offering serious services for those physicians who want to take them up, including an anonymous self-assessment survey on our website that allows individuals to self-stratify themselves on the basis of their degrees of risk of depression, substance use disorder, and suicidality. We employ a psychologist to review all the results, and she engages with the respondents whose survey results show them at high risk to offer help if they are prepared to break their anonymity, either seeing them herself or arranging for their referral to other mental health professionals. We’re finding this to be a great way of getting over our doctors’ traditional reticence to engage in care themselves.”


“That’s fascinating. I’ve heard of such self-assessment tools being used in other health systems occasionally as a way of engaging high-risk physicians in care,” said Dr. Read. “What else have you been doing?”


“Well, we’ve been following up on a regional burnout survey that we undertook a few months ago that showed that up to 40% of our physicians had some symptoms of burnout. I’m proud to say that we’ve managed to get grant funding for up to six coaching sessions each for a large number of our members who are interested. We have several accredited life coaches working for us, all of whom are expert in burnout and similar stresses, and we already have more than 20 physicians signed up for the sessions via our website. Of course, if they want more than six sessions, they can arrange that themselves, in which case they pay for the extra sessions. We hope that this coaching will be sufficient for most of our members, but we know that some have more significant problems such as depression and substance abuse. Of course, we also know physicians have an increased risk of suicide, so what we have done for those doctors is arrange a process whereby they can be referred urgently to psychiatrists in our community who have volunteered to see colleagues and to fast track any referrals from our program.”


Dr. Read, who’d been listening intently throughout and letting his excellent interviewee have her head, decided it was time to intervene and present some ideas of his own. He thought the conversation was important and had just come to the conclusion that he felt safe enough to reveal some of his more deeply hidden secrets.


“Dr. Newton, all that you’re doing is so important. It seems to me that you’ve set up a substantial range of coaching and counseling services that are specifically designed for physicians. And that’s on top of all the education and networking opportunities you’re offering your members! I wish all this had been available 20 years ago when I first came here. I’ve never spoken about this in public before, but I am one of the people who could have really benefited from this program. I seriously contemplated suicide after my first marriage broke up and my now ex-wife took my children away. I was lucky and had some very supportive friends who made sure I was well looked after and treated, so I did fine in the end, but this program is such a great way to reduce the stigma of psychiatric disorders. That shame and stigma kept me from initially getting help, and since then I can think of at least two colleagues whom I believe died from suicide, although one died in a single-vehicle accident and the coroner did not determine it to be intentional. It’s great that these sorts of services are being made available. I just hope they get used. Congratulations on setting up this program. What a great role for a regional medical society to play.”


Commentary


Two major themes of importance are discussed in this scenario. The first is retirement and how physicians can transition into this role in a way that not only allows them to contribute meaningfully to society, if they so choose, but also to take up the role as a respected elder within the medical and broader community. One approach to retirement involves volunteering and taking alternative roles that enable physicians to use their skills and experience to benefit their communities, just as Louise did. The second theme is the need for comprehensive programs that encourage the continued well-being and health of communities of physicians, like the one Ellen and Louise were developing in the regional medical society. The programs described in this scenario are based on those developed and run by the Sierra Sacramento Valley Medical Society (SSVMS; www.ssvms.org), which is a national leader in this field. The SSVMS has developed a truly innovative role and set of programs for its physician community and their families that could be copied and continuously enhanced by other medical societies nationally.


So what do we know about physicians and retirement? Overall, surprisingly little has been written on this topic, and almost no formal studies exist, so the first conclusion has to be that this is yet another area for physician well-being that merits considerable research. It is actually quite difficult to determine the precise age of retirement of many physicians. Is it retirement from full-time practice? From part-time practice? From paid or unpaid practice? From teaching and research, as opposed to clinical work? However, quite a lot of interesting information, usually anecdotal, has been written in blogs and presented in podcasts that provides valuable insights.


What we do know is that the median age of retirement from clinical activities by primary care physicians is 65 years (Petterson et al. 2016). The retirement age from clinical activities varies by specialty, and several studies have shown variations ranging from about 64.5 years for obstetrician-gynecologists up to 66.5 years for cardiologists. Women tend to retire 1 year earlier than men, but many physicians continue to be active in other professional, nonclinical activities after retirement, and the median age of retirement from all professional activities is typically about 1 year later, at 66 years, although this is likely younger than in the past, as the American Academy of Family Physicians has reported that the average age of physician retirement was 70 in 1980 (The Physicians Foundation 2016). This is in comparison with the average age of retirement of the non-physician workforce of 63 years. Data are lacking as to how many physicians work part-time prior to retirement.


But why do physicians eventually decide to retire, and why later than other professionals? An interesting blog by Wall Street Physician (2018) examined this and described a series of financially oriented reasons, which I have adapted as follows:




  1. Age. Many individuals simply pick a preferred age and retire at that time, even if they have not reached their financial goals. They decide to have a less stressful lifestyle on the basis that time is a nonrenewable resource.



  2. Net worth. Many physicians have a target financial retirement number in mind and retire when they have reached it.



  3. Ability/Health. Medicine is a difficult profession and is constantly changing, as described throughout this book. It is hard to keep up with the latest literature and new drugs, treatments, and technologies. This leads many physicians to retire before they lose their abilities or the capacity to keep current. The EMR is one reason that substantial numbers of physicians have retired over the past decade. Other physicians retire because of impaired health, and it is fairly uncommon, for instance, to find surgeons operating full time beyond the age of 63.


Wall Street Physician gives the following advice: “Don’t be like the professional athlete when it comes to retirement…. The goal is to do it on your own terms. Athletes are notorious for staying in the game for too long… even though their skills have noticeably declined.” The author concluded that financial independence gives physicians the option to retire on their own terms, so one message for all physicians is to ensure they obtain good financial advice from experts as early in their career as possible, ideally starting in medical school, so that they can control their own retirement decisions, just as Louise did in the scenario (Wall Street Physician 2018). Many physicians find it genuinely hard to retire simply because medicine is such a meaningful, all-enveloping occupation that they do not wish to give up the role. This has been well described by Mokotoff (2018), who, in an insightful blog titled “Why Doctors Don’t Like to Retire,” wrote the following:



I believe there are multiple reasons. For many physicians, medicine is the only employment they have had in their adult life. Despite drops in salaries and autonomy, they still enjoy above-average wealth and income and may fear loss of this post-retirement ….  Some have few hobbies and fear boredom. That is a reasonable concern. Most of us are used to being respected by the public and inwardly fear that loss as well …. [T]he act of retirement brings into hard focus that this is indeed the “last stage” of one’s life. Although we deal with the death and dying of our patients daily, when it is “our” death and dying, well, that is a different matter. The hassles of corporate and industrialized medicine will continue to affect physician retirement rates. However, for many of those in the profession, the idea of life without medicine is just too scary to contemplate.



When physicians finally do retire, either completely or partially, most live a rewarding and interesting life, just as Louise did in the scenario. Fawcett (2018) recently described some discoveries he made during his first year of retirement:





  • I don’t miss medicine ….  I think tapering off my practice, while I started a new writing, speaking, blogging, consulting business, played a big part in allowing me to let go of this major part of my life ….



  • Vacationing feels different now. When I was working as a surgeon, I needed vacation time to get away and unwind. Now I live a much more relaxed life, and I don’t need to get away to unwind. Now when I travel, it is for a different purpose, to explore the world. I changed my perspective from unwinding to exploring, and that is a whole different feeling. I also write while on vacation…. It is almost like a reversal now. When I’m home, I’m on vacation, and then I go away on vacation to get some work done ….



  • I’m never going to catch up. I did have some big hopes for catching up on a lot of things that were getting put off. The state of caught up doesn’t exist ….



  • My life is very good now and much more relaxed. I’m glad I pulled the trigger on repurposing, as I feel I have a new mission in life and am enjoying its pursuit. Letting go of the old life was easier than I thought.

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Mar 29, 2020 | Posted by in PSYCHIATRY | Comments Off on The Joy and Meaning of Medicine

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