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If you’re reading this post on the gapyearaftersixty.wordpress.com site, you are in the wrong place. This blog has moved to http://GapYearAfterSixty.com. Please visit us there for the latest updates on our year of reinvention and to subscribe to our blog via email.  – Debbie Weil and Sam Harrington

 

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A fellow retiring physician: what are the odds?

BarbieIt was one in a million. Debbie and I were furling the sail on my son-in-law’s 22-foot sailboat after a short sunset cruise in Stonington harbor. The fishermen were in for the day. The wind was dying down. The water was calm.

We were exulting in a flawless trip. The outboard worked as designed. The knots held. No halyards snarled. We took the mooring in a single try. As sailors we are not adventurous. We take pride in the small victories over the wind and waves. We do not heel.

I noticed a sharp-looking Avon skiff approach with a pair of well-dressed travelers. Matching aviator sunglasses, clean fleece tops and pressed blue jeans. Not locals, yet most summer folk are gone and there is only the occasional yacht passing through.

I was wearing my full AARP; a Tilley hat, Cocoon sunglasses and Keen boat shoes. I looked like a pervert. Debbie was also dressed for the elements and, therefore, unrecognizable but her female presence legitimized my appearance enough to allow a stranger to approach. The female of the couple called out, “Which is the town dock? Please.”

I responded, “Barbie…..? Barbie!!”

It was Barbara. Barbie was my college classmate as well as an occasional college roommate of Debbie’s. We had not seen her for years. My instant recognition was based on her voice, her movement and her silhouette. It was not based on a true visual identification.

We reconnoitered on shore and after sharing a brief overview of our recent past we learned that she and her husband, both physicians, had retired and had been living on their 44-foot sailboat for 15 months. Their travels to and from the Caribbean made our sailing excursions seem small but the shared excitement of the moment overwhelmed this self-deflating perception.

Stunned at Barbie’s retirement

Barbie expressed no surprise at my Gap Year announcement. She seemed completely understanding. I, however, was stunned that she had retired. She was the most energetic and committed physician that I can conjure up. She had an academic/research/clinical career as a hematologist and during past meetings was bubbling about her students, her fellows and her patients.

Although her retirement decision was clearly multifactorial I did pick up on comments that resonated with me. “I just got tired of documenting every 15-minute patient interaction for their insurance companies,” she said, off handedly. I could sympathize with that.

She also noted that her career was not going to become more rewarding. I know she had established a great reputation, she had contributed to the literature in her field, she had saved patients and she had done lots of good.

What I heard her telling me was that the rewarding aspects of her distinguished career were being squeezed out by the unrewarding requirements of more documentation, more metrics to observe, less face-to-face time with patients and less appreciation as measured by salary or patient gratitude.

Finally we also shared the philosophical perspective that many physicians, and others, acquire as we observe the deterioration of our patients, friends and family. Disease and disability come to us all. We do not know when it will arrive or what form it will take but it happens with more frequency as we age. If we want to take advantage of our health to do something other than practice medicine we have to make our own calculation and seize the moment.

Great physicians are looking elsewhere for satisfaction

I suppose it seemed like a “One in a million, Doc” moment [Ed note: obscure Seinfeld reference – Debbie] when Barbie’s boat neared ours, but that is not the point of this blog folly.

What I am trying to say is that medicine has changed so much during my generation that the personal sense of pride, accomplishment, appreciation, service, humanity, communication, human interaction and compassion has been so diminished by the institutionalization and dehumanization of metrics, technology, documentation and production pressures that many great physicians look elsewhere for satisfaction. .

If one of my peers had asked me: “What are the chances Barbie will take early retirement?” I would have replied, “One in a million.”

Addendum: gone is the intoxicating pleasure of being in charge

The next generation of physicians was born computer literate and is unaware of the difficulties of the transition from paper to EMR (Electronic Medical Records). They are also unfamiliar with the practice of medicine with fewer third-party overseers, regulators, and a wall of technology between patient and physician. They are members of teams of providers and are not likely to know the intoxicating pleasure of being completely in charge.

The transition from the minimal documentation of the generation before me to the EMR has been quite a struggle. I remember consulting on a terminally ill patient, with constipation versus partial bowel obstruction, 30 years ago.

Doctors don’t get paid for “The last chapter”

The primary care physician spent a long time with the patient and family counseling them on the decline and the expectations they should have for the last few days of her life. I joined in for a bit of edification. His final note for the day read, “The last chapter.”

Woefully inadequate for this day and age, and documenting nothing except his palliative care orders, this physician could not be reimbursed for anything now. Yet he did his duty then; I saw him do it.

I also remember the handwriting police. I was one of them and also the occasional offender. I never understood how some doctors took pride in their illegible notes that could lead to medical errors.

The EMR will solve the documentation issues of “date and time.” It will replace the frustration of multiple signatures with the frustration of multiple log-ins. It will allow the creation of notes that satisfy the regulators and payers and it will do it with reams of information created by pre-population, cut and paste, and endless templates. It will not make the care of patients better.

Summer is over: what comes next?

Fog_flickrIt is Sunday, September 1st. It is early morning. The lobstermen are not fishing. The summer people have left. The fog is thick. The air is heavy. It is hours before the local church bells ring. The locally-ground 44 North Sumatra coffee is dripping. The quietude is total.

The pleasures of not commuting

It is the first day of the second quarter of my Gap Year. I have summered in Maine. I have not traveled to and from DC attempting to steal a weekend here or a fortnight there. I have not suffered the indignities of the TSA or the vagaries of East Coast weather and associated flight delays.

Rather, I have basked in my time here. I have not tried to cram a sail or a motorboat cruise or a golf game or a bike ride into limited available hours. I have let the time roll over me and the activities happen. It has been blissful and now it is quiet.

Admittedly, the days have blurred together. This is in part the result of better-than-average weather so that good stretches are not defined by bad stretches. It’s also because there is danger in the luxury of time. The best times are not separated and highlighted by downtime. The special activities segue from one to another and in doing so lose a bit of what makes them special.

I have felt that. I have not felt the stress of travel. I have enjoyed myself being self-indulgent. I have started some new projects. I am ready for more commitment.

End of summer signals absence

But this morning it is quiet. The roads are empty. The exercise walkers are absent. Only the locals are about. I expect to see Doug, my neighbor, and his rescue dog, Rosie, cut across my yard and then the yard of the Catholic church adjacent to our house. It is a shortcut from his house to the road. The shortcut predates our arrival here in Stonington. It is understood that the shortcut belongs to the locals.

The challenges of the next quarter of GYA60 loom. We must start our French studies before leaving for Paris in November. I must resume my short book project. [Ed. note: Sam hasn’t shared it with me. I’m looking forward to seeing what he has written. – Debbie]

Making new plans

We must cement our travel plans to Europe to benefit from early booking. We must deal with fewer options for entertainment along with fewer friends, family and recreational activities. We must embrace the bigger spaces between diversions. We must include time for household maintenance, more home cooking, more self-improvement, more meditation and more exercise.  We must organize our time better.

We must cope with being alone, together. I am ready to try this. [Good to hear. Me too. – Debbie]

Will quiet mean lonely?

It is so quiet now. Is it just the physical absence of people? Is it loneliness setting in after one day? Is it because so many people who treasure this place during the summer do not want to try to make a life here during the winter? Do I feel down because they are rejecting what I want?

Obviously, the practicalities of a life elsewhere draw them back, just as Debbie and I returned to Washington for three decades to work and to educate our children. The reason I am seriously pondering a move to a small town on the coast of Maine is because I have fewer, if any, obligations to pull me elsewhere.

What is the draw of our old neighborhood?

Why do people want to live in DC’s upscale Georgetown? Why is it so crowded? Why does it seem exciting? Is it because of the quaint architecture and brick sidewalks? Is it because of the faint smell of history? No, not really. It is because of desire.

It is exciting because it is crowded. It is crowded because people want to see and be seen. Those who can afford to, want to live there so that they can feel rewarded by the sense of superiority associated with living in a place that others desire. Radix malorum cupiditas est.

[Ed. note: I’m leaving the Latin in because Sam will protest if I take it out. But I don’t think “feeling superior” is the reason I love Georgetown. It has many charms. – Debbie]

For me, I have been there and done that. I expect the only thing I will miss in Georgetown is my local tavern with its “heavy pour” and its clubby bar clientele. [Ed. note: And a few special friends – Debbie] I do not know for sure whether I can leave all this behind. I have to try it. I have to try life with less desire and less external stimulation.

[Ed. intrusion: and I want to try a life where there is less stimulation to “buy.” So far, I spend much less money in Stonington. More about money later. – Debbie]

We are embracing serendipity

One Gap Year lesson I have stumbled on is to embrace serendipity. We have not over-planned or over-scheduled, we have only roughed out blocks of time and ideas. We had the luxury of three months of self-indulgence to start with. During that time much has occurred by serendipity.

I met a state politician with whom I might work on health care policy and reform. Socially, we met a resident of Paris who manages a professional language school and who will connect us with the right tutors and guides. We met a friend of a friend who has a non-profit educational program in Uganda and who will sign us up to work there next winter. We also met a friend of a friend who has traveled to Madagascar and will help with reliable contacts to plan a trip.

All this simply by talking and chatting and letting our contacts extend themselves. People really want to help people change, grow, shed the commonplace and divest themselves of their former routine.

Share your dream and people will help. Serendipity happens.

Next week we return to DC for some business meetings, doctors’ appointments, housekeeping chores and some catching up. The trip will test our resolve to return to Stonington for a quieter life. I hope I will remain true to my new refrain, “Away happens.”

Right now the only sound is the drip of fog from the trees.

[Ed. note: “away happens” means the undesirable necessity of leaving Stonington and Deer Isle for mainland resources such as healthcare. – Debbie]

Photo credit: Design Development (Flickr) Aerial view of the Deer Island Thorofare.

On steering away from shore

Chart_MatinicusThe end of summer is approaching. Technically we have until September 22nd before the Autumnal Equinox. Practically speaking, on the coast of Maine summer ends in the middle of Labor Day weekend.

The town is quiet. Eighty percent of the summer jerks [Ed. note: aka “people” but I let it go. – Debbie] are gone. By Sunday another ten percent will depart. By Monday five more percent will depart and only the extended summer folk will be left. I am trying to become one of them.

Stonington’s Main Street has been packed for the last six weeks. Parking on both sides of the road has narrowed it to a single lane in many places. Tourists, treating it like a pedestrian mall, have further snarled traffic. The restaurants have been crowded for breakfast, lunch and dinner. Now there is room to spare and traffic flows smoothly.

The weather is cooler. The days are shorter. Autumn is in the air.

Trying out loneliness

I feel lonely. I want to try loneliness.

I have had the six summer weeks of my dreams including weeks of perfect weather, boating, sailing, island hopping, golf, birding and planning. Never before have I had so much of Maine. The previous pattern was one week here, two weeks there and fighting weekend plane traffic. It has been no more spectacular than before, and some memories have already been lost as the days blend together, but the absence of travel hassle has been wonderful.

Now we get serious, however, as we look into the future of beautiful autumn weeks with far fewer people to share them. This was part of the Gap Year plan; to test a quiet time; to step into another void.

Matinicus Island: 22 miles offshore

Matinicus-Island-600x314This week we cruised to Matinicus Island. It is described as a “godforsaken rock” by many. Indeed, it is a small community of lobstermen, their families and minimal support services, twenty-two miles off the mainland.

It was the first time that I personally steered my boat away from shore and to an invisible point out in the ocean. I was alone with Debbie. We looked toward the horizon. Nothing was there. [Were we looking at empty ocean all the way across the Atlantic? – Debbie] We had every advantage of modern nautical instruments that allowed us to “see” over the horizon so we knew, intellectually, the island was there.

Pointing to the unknown

Debbie and I have traveled beyond the horizon many times with others at the helm. But emotionally and metaphorically, this was a special moment. We were steering our own little boat into the unknown. The next morning, making our way back through pea soup fog it took no extra strength to sail home on instruments alone. We had already taken the big step of sailing away.

Of course, hundreds of thousands of people set sail over the horizon everyday, mostly for work, sometimes for pleasure. I will do so again, someday. It may seem like just another day to them. I suspect they remember their first turn off shore.

The total engagement of coastwise piloting

All of my personal boating has been coastwise piloting. This is the term for making one’s way from place to place around the shoreline. In Maine the coast is particularly unforgiving with granite ledges, spirited seas, tidal changes and ephemeral, often violent, weather. It takes the use of every sense (and supplementary technology: radar, plotter, depth sounder, radio) to do it safely.

It can totally engage, and in my case, satisfy the intellect. I had a random thought while returning by boat from dinner on another island last week. Monitoring the horizon, the compass, the radar and the seas I was completely “connected” in a way that social networking can’t replicate.

Today I toured the Sunbeam. She is a 75- foot vessel operated by the Maine Sea Coast Mission that supplies medical, spiritual, economic and youth development programs to the Maine island communities, including Matinicus. The captain and crewmembers were a pleasure to meet. I am jealous of the never-ending wonder of the ever-changing coast that they get to enjoy.

Looking for new safe harbors

As I poke my nose into health care issues both large and small around the Coast of Maine I am looking for a place to resume my life’s work. As I turn away from my former routine, indeed, as I turn from former shores and safe harbors, I am looking for new challenges and new safe havens.

I have just learned that I will never sail solo around the world. [When we were scanning the horizon for Matinicus, I believe I said I didn’t think we were destined to sail around the world together. – Debbie]

The challenge of coastwise piloting in a boat, or in life, suits me fine.

Poetry, place and a quiet summer evening

OHA_boatsREAD THIS POST on our new blog.

If you asked me how many poetry readings I’ve attended in Washington DC over the past three decades, I would be hard pressed to come up with a handful. Surely, you say, DC has so much going on there must be poetry readings and live performances every night of the week. But that is precisely the point.

When you live in a big city there is too much going on. It is overwhelming. Our response (and I’m ashamed to admit this) has been to ignore much of DC’s cultural activity except for the occasional play or concert. It was easier to stay home rather than fight the traffic in the evenings.

In Stonington, Maine, it is different. Life is slower. Some things are closer, while many conveniences are much further away. We step out of our cottage and walk about seven minutes down the quiet main street to the Opera House, the locus of cultural activity on Deer Isle. Despite its name, the century-old Opera House (first built in 1893) is a multi-purpose venue, hosting live theatre, dance, music, movies and, at one point, roller skating. (Full disclosure: I am a member of the Opera House board.)

Last night was an evening of poetry. Two Maine poets read their own work and then a handful of local residents read a selection of poems, prefacing each one with brief commentary on “Why I chose this poem.” The theme was “home” and “place.”

Stonington_Aug2013It was a lovely and intensely meaningful evening. Sam and I have been coming to Deer Isle and to our family island for 40 years. And for the past seven summers we’ve come to our house in Stonington. So in some ways, this is “home” in the deep sense of the word, as much as, or more so, than Washington DC.

Let me offer you a few snippets of the poems and tell you a bit about the readers. Poet and author Deborah Cummins was curator of the event. On stage, she began the evening by quoting Irish poet Eavan Boland:

“There is the place that happens,
and the place that happens to you.”
– Eavan Boland

You may have to think about that for a minute. I did. The “happens to you” part makes perfect sense if you’ve been captivated by the starkness and beauty of the Maine seascape, as we have.

Then came Maine poet Dawn Potter. I was not familiar with her work. She was mesmerizing. Her poems are muscular and sturdy, rhythmic and clear and so very evocative of small town life. She lives in Harmony, ME where, of course, things are not always harmonious.

She read First Game, about attending a basketball game at her son’s elementary school. The players are awful she explained in advance. They are too short, clumsy and overmatched. The games are painful to watch. Of course, the devoted parents go anyway.

The poem evokes the moment when, the team losing badly, the crowd shifts in their seats.

Excerpt:

“… and in that instant an alarm, a buffalo instinct, ripples among the parents: an obstinate, unspoken urge to circle their hapless calves.– Dawn Potter.

You can find First Game and other recent poems by Dawn Potter in her anthology, How the Crimes Happened.

Local means heightened intimacy

What was most notable about last night’s poetry reading was the intimacy of the event. As Sam pointed out, reading to a group of people you know, that you’ll run into at the grocery store and on the street, “ups the ante of the emotional exposure” (his words).

Ben_BarrowsThat was particularly true for Ben Barrows, son of the well-known publisher of the local Penobscot Bay newspapers. After a decade working on economic development and crisis response in far flung places (from Antarctica to Azerbaijan), he returned to Stonington recently to take up the position of general manager of his family’s business.

He told us how hard the decision was to return home to live in the place he grew up. Then, after describing a month spent inside a U.N. installation in Afghanistan, his fear of drowning and of being so far from the ocean, he read Inland by Edna St. Vincent Millay, Maine’s Pulitzer Prize-winning poet.

Excerpt:

“… Far from the sea-board, far from the sound
Of water sucking the hollow ledges,
Tons of water striking the shore,—
What do they long for, as I long for
One salt smell of the sea once more?
– Edna St. Vincent Millay

Other readers included the town manager; the lead reporter for the local paper, a seventh-generation islander (retired businesswoman and politician), and a former math professor who now volunteers at the high school. All year-rounders (as opposed to summer people)they were surprisingly funny and eloquent. And a reminder that everyone in a small community wears multiple hats.

My favorite poems, both by Maine poets, weren’t dense or difficult. But they captured perfectly daily life in a remote place on the coast of Maine:

Why I Have a Crush on You, UPS Man by Alice N. Persons

Excerpt:

” …you bring me all the things I order
are never in a bad mood
always have a jaunty wave as you drive away
look good in your brown shorts
we have an ideal uncomplicated relationship
you’re like a cute boyfriend with great legs
who always brings the perfect present… “
Alice N. Persons

I admit I do have a bit of a crush on our UPS man. He brings dog biscuits for our daughter’s dog, either because he’s nice or because he’s afraid of dogs.

And finally, Starting the Subaru at Five Below by Stuart Kestenbaum, poet and director of the nearby and famous Haystack Mountain School of Crafts.

Excerpt:

” …Finger tips numb, nose
hair frozen, I pump the accelerator
and turn the key. The battery cranks,
the engine gives 2 or 3 low groans and
starts. My God it starts… “
Stuart Kestenbaum

If we make it year-round in Stonington (not a foregone conclusion at this point), I expect we may have trouble starting our car in the middle of the winter. And maybe Sam or I will be asked to be a reader at next year’s poetry event.

PHOTO CREDITS: top, Opera House Arts; middle, Debbie Weil via iPhone; bottom, Opera House Arts

Bombast, swagger and lobster boats

lobster_boats_racingIt’s 0530h. West Penobscot Bay is throbbing with the sound of diesel motors, thousands of horsepower under the decks of hundreds of lobster boats. The sun has been up for twenty minutes. By now, many of the lobstermen have been hauling traps for two hours.

I have an appointment to take the gasman to the island to fix the stove’s thermostat. [Ed note: it is wildly out of whack, resulting in charred brownies and other disasters. – Debbie] He better bring the right fittings; it’s a long way back to his truck on the mainland. He is taciturn and a man of few words even when pushed into conversation.

Self-absorbed bombastic bloviators

Occasionally I will meet a self-absorbed, bombastic bloviater (SABB) here in Maine. You know the kind of person. It’s usually a guy, very confident and always very opinionated. They control every conversation and always have the last word. If you meet such a person in Maine, they are usually from “away.” Because they are from away they are usually on vacation and if they can afford to be here on vacation they are usually “successful.”

Such behavior is more common in the big cities which, in my experience, means New York or DC. How it leads to success is what I do not understand. Bombast leads to lack of communication and poor communication leads to failure. Yet, SABBs survive.

Defining the SABB syndrome

Let me further define this SABB syndrome. I do not mean an ignoramus. I do not mean someone who is simply verbose and pompous. I mean a person who dominates a conversation, finds themselves on the wrong side of the facts and then is unable to accept that. Finally, by the end of the exchange, they are still trying to convince me they are right; i.e. that black is white. Or, they may use a technicality to change their position while never acknowledging that they were wrong.

They not only survive, they thrive in the world of business and politics. There is an old expression, “Close only counts in horse shoes and hand grenades.” But it must be good enough in a lot of business dealings to make money. “Close” does not count in medicine. In medicine you have to get it right.

SABBs in the operating room

Of course bombastic bluffers do exist in medical practice. They are frequently marginalized, but not always. If I was asked to see a patient by a newly-acquainted physician and I found the doctor overbearing, I would finish my consult and treatment plan and that would be the last elective consult I accepted from them.

More importantly, the SABB personality is frequently associated with or confused with the surgical personality. “Frequently wrong but never in doubt” is an old saw applied to surgeons. In fact, surgeons may never be in doubt but a good surgeon is well trained and rarely wrong. They have to make hundreds of intraoperative decisions that both the patient and the physician must live with forever.

When the SABB-like personality appears in the operating room or on the wards it plays out as a physician dressing down a subordinate physician or a nurse. This used to be considered a part of the natural order of things in a hospital. “The doctor is always right.” Things have to be done their way. But as patient safety studies gained traction in the ‘80s and ‘90s it became apparent that these abusive physicians were, in fact, responsible for treatment errors and because of their poor communication skills were associated with a disproportionate percentage of the malpractice cases.

The euphemism applied to this  kind of behavior is “disruptive physician” and it is equally represented among male and female physicians. Medical staff leaders monitor such behavior at the peer review level and correct it or rescind privileges. The less obvious cases are hard to define and lead to lots of friction among the medical staff. Because of the important association of this disruptive behavior with medical mistakes, it must be eliminated.

Why is SABB behavior tolerated?

Does this happen in the corporate boardroom? I do not know personally but I am confident that it does. The threshold for culling someone from the organization, however, would be quite different. If they produce, if they make money, if they are “successful.” I suspect more SABB behavior is tolerated.

I wonder if health care systems should not require personality profiles before hiring physicians. It is easier to withhold a position than to withdraw it. Most of these disruptive physicians can be identified in advance. Some malpractice insurance companies have started this practice and do not offer policies to the SABB physician.

I am no longer in practice. My peer review responsibilities are shrinking. I have never been corporate. Now I only experience SABB behavior at social events where it is irritating but inconsequential. Maybe that is why I let it get under my skin.

Or maybe I wish I had a little more chutzpa myself, more self-confidence untempered by decades of behavior moderated for a professional medical setting. I admit that achieving a bit more self-expression is a Gap Year goal. Leaving the World Domination Summit I did affect a bit of a swagger.

Or maybe I wish I were out on a lobster boat where the organizational chart consists of one captain and one crewmember.

*Image credit: Guy Biechele / Flickr