One Morning in Maine: Why I don’t miss practicing medicine

One_Morning_in_MaineIf the world were merely seductive, that would be easy. If it were merely challenging, that would be no problem. But I arise in the morning torn between a desire to improve the world, and a desire to enjoy the world. This makes it hard to plan the day.

– E. B. White

This is one of the variations on a famous quote by the author. It is commonly referenced here on the coast of Maine, presumably because E. B. White lived nearby and, more importantly, because the mornings in Maine are so inspirational. [Ed note: E. B. White lived in North Brooklin, ME for the last few decades of his life.]

Yesterday, while riding my bike for exercise, I stopped to chat with a neighbor. He is a retired judge and occasional golf partner. He expressed surprise at my “Gap Year” plan and my retirement from private practice.

He assumed that my personal identity and professional identity were inextricably entwined, as were those of his brother-in-law, a family practitioner. He asked me if I missed my practice.

I did not skip a beat. “Not a bit,” I replied.

My Gap Year is to define a new relationship to time, space and family

He opined that I was likely to become bored, as he did after his forced retirement. He now does some part-time administrative judging. I pointed out that is what the Gap Year is all about. It is to allow me to define a new relationship to time, space and family. I will find something useful to do but it will be something other than private practice.

On reflection, I do miss my patients and I do miss my hand-picked group of colleagues, particularly my partner, who practiced with the sense of devotion and care that I did. I do miss my former office staff.

But the sense of relief that I am no longer trying to function in the most sophisticated, complicated, and yet dysfunctional healthcare system in the world is indescribable and far outweighs my sense of loss.

Enjoying vs. improving the world

For forty years I tried to “improve the world.”

The last ten years included my work as a trustee trying to nurture the hospital to which I had devoted my career. I am surprised at how easily I can let it go and more surprised at the anger I harbor toward the doctors who game the system, the administrators who perpetuate the system and the organizations that abuse the system.

When Lord Melbourne advised a young MP, to “try to do no good, and then you won’t get into any scrapes,” he did not mean to say “do bad things.” He meant that the willful act of doing good was likely to lead to unintended and unpleasant consequences.

For a year I will enjoy the world.

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Following in my footsteps, but in a new era of medicine

Sam_Amanda_ElizaI am indescribably proud of my two daughters who are both embarking on careers as M.D.’s.

Why, you might ask, am I leaving the practice of medicine just as they are starting?

It is an easy rationalization. My era is over.

Yet the medical profession remains the career with the most promise of honor, achievement, and excitement.

How can I describe my era?

I looked on it as an era of great promise. The advent of anesthesia, radiology, and antibiotics among others, each lead to a leap forward in progress. When I put on my intern’s white jacket and left for my first morning at Grady Memorial Hospital, I thought I would synthesize that knowledge into the most effective delivery system ever.

However, after forty years of training and practice I see the opposite. The promise I hoped for has not come to pass. I have seen the expense of medicine rise at an astronomical rate, while the benefit has plateaued.

I have seen a population over-diagnosed and over-treated at fantastic cost and yet life expectancy has improved by only a few years. I have seen, and I have participated in, vast screening programs that have found precancerous conditions and early cancers; yet the absolute number of cancer deaths has been minimally reduced.

Many studies say that the majority of the reduction in cancer deaths can be attributed to the reduction in smoking and not our prevention programs.

Of course there have been great strides during the past forty years. A notable one is the advent of minimally invasive surgery. I like to think that by embracing endoscopy in the early ‘80s I foresaw this. The treatment of bleeding ulcers and the removal of GI neoplasms with scopes was the original definition of “minimally invasive” and eventually replaced surgery for these problems.

Still, despite $2.7 trillion in expense, the U.S. health care system ranks 37th in developed countries according to the WHO. After forty years of trying to make a difference, I have changed from the scared but optimistic intern into an ex-practitioner who asks himself: “Why would I even want to be the best gastroenterologist in such a second-rate system?”

Sam_Timothy_May2013I have seen medications, technologies, screenings, and treatments layered upon patients with an exponential rise in the cost curve and barely a hint of change in the benefit curve. We are living in a crisis. This era must end.

My daughters are joining the profession of medicine during a great transition. Private practice is over. The next era is about teamwork and managing complexity. They will step in and become part of the solution.

grandpa_docOur family has a long tradition to uphold and my children (including my son, a lawyer) know it. The first cataract extraction in the U.S. was performed by their great great great great grandfather, a cofounder of Boston Eye and Ear. Since then there has been a physician in every generation.

My daughters are the seventh and eighth physicians in seven generations and I am pleased to note that my mother made her contribution as a nurse.

I am so proud of them all.

Stepping into the void after 31 years

iStock_the_Void_000006635563XSmallI have stepped into the void.

After 31 years in private practice, I have graduated.

I have finished my charts at the hospital, changed my status from Active Staff to Honorary Staff, turned in my office parking pass and key card, and carried home the detritus of my career in three cardboard boxes.

Self-unemployed.

It turns out that closing a practice is harder than opening one. The response of so many patients has been most gratifying. For the past month people have been lining up to say goodbye.

The lines have not been long enough to brag about, but it is touching just the same. Many have signed up for a farewell colonoscopy.

Technically one has to change the corporation, amend one’s partnership agreement, arrange for new health insurance, end the malpractice insurance, and in our case terminate the pension plan.

But now it is time to reboot.

Because we have been so busy, our Gap Year plans have suffered from a lack of imagination to date. It turns out that the first six months will be spent doing what we frequently do but for much longer and unencumbered by patient care.

Tomorrow I am going to visit my 92-year-old father for a week. Usually I am there for 48 hours.

Then, after a month of transition we will spend four months on the coast of Maine. I usually spend two to three weeks with some harried long weekends intermixed.

Five weeks of November and December will be spent in Paris. Though we have been many times we are always in and out in seven days.

After that nothing is planned and I hope to come up with something exotic. Time will tell.

It turns out that I have to negotiate with my wife. If this were a real gap year I would be negotiating with my parents.

Which is worse?

When will the Void hit?

Many of my patients say they are so happy to have retired. Others say they went mad and returned to work.

Because I have had a happy and satisfying career; because I plan to do something constructive after my gap year; and because I had a natural break in my career path and life trajectory that made this gap possible, I am optimistic that the Void will be brief.

Here’s hoping.

Onward.

Editor’s note: Sam has had a distinguished career as a physician. Deets here. – DW

P.S. I think Sam will let me be his editor. We’ll find out…