In retirement I run into colleagues who are interested in
the process and how it is going. I was greeted with a “How is my favorite
retired psychiatrist” yesterday. It originated from a highly qualified
subspecialist who was immersed in hospital work when I first met him. We talked
briefly about his changing roles over the years going from hospital based acute
care practice, to an outpatient specialty practice, to his current role of tertiary
consultant seeing the most difficult problems in his field. I told him that was
the role I miss the most – seeing the most difficult to diagnose and treat
cases and being the one to figure out what to do.
It is not an easy life – especially if you are as neurotic
as me. It involves constant research and
revision of approaches. It involves close follow up. It involves sleepless nights and
anxiety. It involves balancing
innovation against not wanting to make a mistake. Sometimes it involves convincing other people
to go along with you when they may be reluctant. It also involves tolerating
the suffocating routine of excessive documentation and jumping through unnecessary administrative hoops as well as the occasional overt harassment. But in the end – you end up
being a physician that both your patients and colleagues can count on and that’s
something.
We discussed the nature of treating these populations. He
told me he likened his practice to neurology because of the reputation that the
level of esoteric diagnoses are not matched by esoteric treatments and often there
is not much that you can do. I never understood this degree of pessimism. I have been confronted with people who told
me their last doctor told them: “Look there is nothing more I can do for you.” And we were able to make some progress.
Finally – we discussed the 2 year milestone and how many people
leave retirement and have to go back into active practice at that point. He made the observation that this seems to
happen across professions where possible – and it seemed to depend on attitudes
to retirement and whether you had anything to do. He did not think retirement would be a
problem. I estimated he had about another
8-10 years of practice left. I had my usual thoughts about all of the people I knew who never made it to retirement. I also thought about retirement from physically taxing work and the problems that involves - not the least of which is adjusting caloric intake to prevent excessive weight gain.
The second conversation was more technical. It was an
opinion about gabapentin. The patient in
question was taking it long term for back pain and had a history of back
surgeries. More recently she was on diuretics and other medications for atrial
fibrillation and congestive heart failure. She was seeing several specialists
and they were dutifully getting all of the correct labs but nobody seemed to
notice the gradual increase in creatinine to 1.7 and 2.4. That correlated clinically with increasing
somnolence, ataxia, and falls. After
reading the package insert on gabapentin he called me to discuss a dosage
adjustment with renal insufficiency.
I recalled a healthy young man I was treating who became acutely
confused and ataxic after he was started on simvastatin by a consultant. In
psychiatry, this scenario raises suspicions of intoxicants even in a hospital setting.
But given the circumstances I decided to also look for a cause of delirium. The acute labs showed that he had acute renal
failure as an idiosyncratic reaction to the statin and he was transferred to
medicine to treat the problem. The acute
renal failure led to the accumulation of gabapentin and the delirium and
ataxia.
As we discussed the cases, the internist pointed out the
difficulty with today’s fragmented medical care. All of the medication were ordered and the
labs were done – but nobody seemed to be paying any attention to how the
patient was doing. It reminded him of a quote from one of his mentors George Magnin, MD
who used to say to his Medicine residents: “What are you going to do until the doctor
gets here?”
That quote struck me as genius both as a motivating factor
and the immediate reality of the situation. When you are confronted with a patient who is
having a problem – you need to be able to do something about it. That doesn’t
mean that you will always know what to do – and if you don’t you at least need
to know how to triage the problem so that the patient gets the correct care. We try to increase the likelihood that will
happen by specialization, subspecialization, and settings to match the
illnesses with the specialists, but those matches are far from perfect.
I had this experience to illustrate. I got a call from an emergency medicine
physician who was seeing a patient I was treating for bipolar disorder. I knew
him and his family very well from years of treatment. The ED doc wanted me to hospitalize
him for acute mania but his wife who was with him said he was not manic and she
did not want him admitted to a psychiatric unit. After a brief description of his symptoms I
said: “Put him on the phone so I can talk with him.” Within 30 seconds I could tell he had a
fluent aphasia with paraphasic speech errors. When
the ED doc came back on I told him that this was not mania – but most likely an
acute stroke syndrome and he was hospitalized on Neurology where the stroke diagnosis was confirmed.
“What are you going to do until the doctor gets here?” – means
that doctor. The one who can diagnose
and treat your problem. That is the one
that matters. In this era of health
apps, checklists, self-diagnosis, electronic health records, telemedicine, and so-called artificial
intelligence that is still all that matters.
Being that person is hard to attain and hard to walk away
from.
George Dawson, MD, DFAPA
Image credit: Wikimedia Commons per their CC licensing the details of which are available by clicking on the graphic.
Additional: The identities of the physicians were anonymized in this post. I doubt that any physician benefits from being associated with me or this blog.
A psychiatry resident who is finishing up a consult-liaison fellowship and I met by zoom because he wanted to talk to someone about consult psychiatry. It was because I was the only faculty member who had any length of time doing the job until I retired 4 years ago. Some things never change. It brought back memories. Despite regular workouts, I'm realizing I need to add another exercise: push-aways from the dinner table.
ReplyDeleteEither that or go back to the hospital and do your stair routine...
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