Retirement By Default or Transitional Year?

 

As noted in a previous post, I stopped working on January 19, 2021. That is one month and two days ago. Since then I have been exercising on a daily basis, reading, outlining papers, and preparing posts for this blog. I have also been actively looking for positions in adult psychiatry or addiction psychiatry. The positions that have come up have all been fairly standard managed-care positions. In other words I would be using the standard electronic health record in Minnesota and I would have productivity expectations based on relative value units or RVUs.  Casual readers of this blog know that I have worked under those systems and would not do it again.

The second option is private practice. I greatly appreciate recommendations from a number of colleagues including some that were highly specific. There is no doubt at all that if I was just completing my residency and know what I know today about the practice environment that I would go into private practice. That option at this point is more complicated. I realize that a clinic infrastructure and all that entails is not really necessary now that everyone is doing telemedicine and telepsychiatry. On the other hand, I am very aware of the necessary medical basis of psychiatry and know that the farther you practice away from medical settings - the less likely you are to be able to attend to medical problems and medical monitoring. I also base this opinion on seeing three presentations by a physician I would consider to be the top telepsychiatry practitioner in this state if not the country. In all those presentations he emphasized the need for clinical monitoring on the receiving end. That would typically include vital signs, lab testing, arranging the necessary medical testing and referrals to medical practitioners. He also made it a policy to drive out to meet all of the individual patients at least once a year in the 5 county area that he covered. That would preclude me from setting up a telepsychiatry practice focused on seeing people in their homes.

I have a lot of concern about the boundary issue that occurs with telepsychiatry outside of clinical settings. I would have no difficulty assuring confidentiality on my end from my home office. I would be very concerned about confidentiality on the other end if I was seeing someone in their home. There is also the question of medical records and how they would be handled whether my private practice was established for two years or another 10 or 15 years.

After this month off, and the above considerations the practical question is whether or not I am on the glide path to retirement. A significant part of my time has been used to complete all the necessary Social Security and Medicare paperwork. A lot of that paperwork has been redundant and poorly thought out. I have been planning for retirement for at least 30 years and strongly considered it 10 years ago, but nothing prepared me for the rules, forms, and surveys from federal agencies. As just one example, I was not aware of the fact that Medicare Part B (and in some cases by default Part D) premiums were indexed against earned income from the previous year. A related problem is that no two people give you the same answers to questions about Medicare or Social Security. After two months, I think the paperwork is all finally complete.

I anticipate that retirement will be a relatively easy process for me. My life is structured around exercise, academics, and art. I have more than enough to keep me interested. During a recent conversation with a retired biochemist who is a good friend of mine - he pointed out that those are the things that keep him going.  I agree with that philosophy. That does not mean that I will be conflict free. When you have been talking with people for decades for most of the day in a very specific way and you are good at it -  there will always be the nagging question about how many more people you could have helped. That is also the time during my day when I am the calmest and most focused. Sitting alone in my library is certainly relaxing but there are times when it has the opposite effect on my focus. I have too many things to focus on and very few of them are as important as talking to a patient. 

The social aspect of work will be another more subtle loss. I am fortunate enough to have worked with excellent colleagues that I actively dialogue with and expect that to continue. But there are colleagues from other disciplines where that kind of work-related dialogue will just disappear. A lot of people seem to focus on whether or not they will maintain their relevance when retired. My work has always led me to the conclusion that the only people I was relevant to in the workplace were the patients I was treating. I don’t consider myself to be an opinion leader in the field. I am regularly consulted and expect that will fade away over time if I am not actively practicing.  Ageism is prevalent and younger generations will generally consider older practitioners to be less relevant - even if they may know a lot less than the older person.

The most significant aspect of psychiatry that I will miss is research. I was very fortunate to be involved in a research project with the Mayo Clinic over the past three years. That research team, their conceptual depth, intelligence, technical expertise and productivity was absolutely stunning compared with research efforts I have been affiliated with in the past. That is a significant loss both in terms of the knowledge I was acquiring but also because I expect this research team to have the best shot at determining relevant biomarkers for psychiatric  disorders and associated personalized medicine approaches for these disorders. My personal past research included both plant tissue culture (somatic embryogenesis of Douglas Fir (Pseudotsuga menziesii) and Loblolly Pine (Pinus taeda), and clinical drug trials of antidepressants, antipsychotics, anxiolytics, and pharmacotherapy of Alzheimer’s disease as well as neuroendocrinology studies of depression. I also studied quantitative EEG of psychiatric disorders and more specifically the effect of Alzheimer’s disease on quantitative EEG.  I am still interested in research work and that includes bench type research if those positions are available. I am also available for literature research, editing, and writing papers. My friend the biochemist has continued to do that in retirement and I plan to try it with or without collaborators.

That is my current status - not retired and actively looking for work. But the work can’t be just any job and after carefully considering - it won’t be private practice. My current job requirements are fairly high relative to other employed psychiatrists but not in the salary sense. I have very specific practice environment requirements in mind and the tradeoff is that I know as much neuropsychiatry and medical psychiatry as anyone and practiced it in high acuity environments. I am hopeful that the right job will materialize, and at this point will give it up to one more year.

Either way I will still be plugging away at this blog.

 

George Dawson, MD, DFAPA

Supplemental 1:

I thought I would add this thought after the fact.  My guess is that there are a significant number of psychiatrists in my current transitional phase.  The pandemic has highlighted a couple of issues that apply.  The first is the widespread use of telemedicine and telepsychiatry - specifically its successful implementation. The second is the levels of distress experienced by front line caregivers from various professions.  Apart from the usual avenues of assistance there have been informal programs set up to assist these workers and refer them to appropriate resources. I can think of no better use of my abilities than to assist in this area, but exactly how to assist is the problem.  All of the documentation, hardware, software, medical resource availability, and malpractice issues that I described in the main post still apply.  No single person has enough resources to provide this service unless they set up a private practice.

With the advent of telemedicine, it is possible to have a centralized administration that can provide all of the necessary services and coordination to get psychiatric services out to the people who need them.  I think it would be relatively easy to find psychiatrists to staff that service.  A uniform administrative structure could be used similar to other government-civilian service organizations like the Peace Corps.  At the humanistic level it would serve the dual purpose of providing services and matching that with a resource in search of a home and that is skilled psychiatrists. 

Supplemental 2:

I was reminded today of the success that I have had treating patients with conversion disorders, fibromyalgia, and seronegative (also known as "chronic") Lyme disease.  That reminder was a reference to how to approach people with chronic post  COVID-19 symptoms. I would be very interested in clinical trials or direct clinical service is any setting that specialized in seeing this patient population. Brain fog has become a term of interest as well as a pejorative term with the politcalization of the SARS-CoV-2 pandemic.  I have discussed that symptom with hundreds of patients and again would welcome a clinical setting or research setting where I could do more.  To me this has been a significant problem in primary care clinics that has been unaddressed by most of psychiatry and neurology.  

Graphics credit:  Aircraft on final approach image was downloaded from Shutterstock per their standard user agreement.  It symbolizes a glide path the retirement.