The Retired Consultant Redux – A Conversation With Two Internists

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.

The Retired Consultant

 

I happened across this old post on approaching retirement today and reread it. Of course, I am biased but it holds up well.  It contains information about psychiatrists retiring that you will not see anywhere else – including why we are happy.  I currently spend much of my day doing the usual chores, exercising, and writing.  I have several writing projects going and am near completing one that is unique.

I don’t get out much and I like it that way. I am an introvert and have been subjected to the usual jokes about introversion.  The pandemic was a factor but not the only one.  I just got back from working out in a gym that has Cybex machines.  After that I went to Target to pick up a supply of blueberries and frozen burritos.   

On the way out – I stopped to get a mocha and 2 biscottis.  The barista was young and we talked about the closing time of the coffee shop relative to the store. I associated to what I was doing at that age.  I was a janitor in a dormitory. It was a thankless job.  Luckily with increasing college experience I was able to move on to more technical work as a lab and research assistant.  I wondered if she would reflect on her work as a barista when she got to be my age and I sincerely hoped she would get to my age and beyond.  I thought about writing a poem about that brief encounter, probably because I had just read two Emily Dickinson poems and have a history of writing free verse in the style of ee cummings.

On the drive home, public radio was playing election coverage from South Carolina.  It was the GOP primary and I shut it off. I always have public radio in the background – but listening to this is just too much.  I drove, drank my mocha and crunched on my biscotti in silence. I had some thoughts about biscotti.  A competitor has a much harder biscotti.  It is so hard the almonds are cut sharply with the slices.  The biscotti I was eating was not as hard but still had an almond and vanilla crunchy taste.

I started thinking about a paper I was writing. Even though it was about rhetoric, it seemed quite exciting.  I have not encountered any papers like it.  I thought about where it should be submitted and how I should modify the introduction. One of the most insightful and informative books I have read lately was about rhetoric. It tied together so many things.  The author was gracious enough to respond to two of my emails.  I need to incorporate more of his concepts into the paper – but his book is encyclopedic.

I thought about some advice I had given lately.  Even though I am retired and people know it – they still call me.  I tell them that technically I am not treating them or directly giving them medical advice because we do not have a physician patient relationship, I don’t have a working office setting or records, and I don’t have malpractice coverage.  They understand that and it doesn’t deter them.  I am licensed and recently contacted the Board of Medical Practice about continuing medical education (CME) credit reporting this summer. The pandemic created a lot of confusion about deferred CME reporting.  I need to report 75 credits and I currently have 74 with a 6 CME credit conference in March. I wonder how long I will keep that up in retirement.

On the home stretch, I think about the advice I have given people over the years.  The qualified advice on the system over the past 2 years tells me how bad things have gotten.  Parents calling me about their adult children who are not doing well.  Adult children calling me about parents who are not doing well.  The occasional email directly from a person who is dissatisfied with treatment. Many calls about what happens in emergency situations.  Many calls about what specific diagnoses, imaging findings, and labs really mean.  Was the emergency department trying to talk me out of being admitted? Why wasn’t I treated with anything?  It just seems like I sat there a long time, nothing happened, and they sent me home.  Are these side effects that I am getting from this medication and what can be done about it?  Are there any resources out there that can help me? I don’t seem to be getting any help?

I try to help people negotiate available systems and help them prioritize what should happen first.  There is a general reluctance to call their clinic or doctor and report that there are potential side effects. Overall, there is a lack of help for people with psychiatric disorders. I know that is not strictly true and that there are many large systems of psychiatric care nearby – but even when people get in - there is difficulty getting what they need. I shock them with basic information about when to call their doctor and what might be helpful to discuss.  I never second guess their doctor.  I am focused on how to help them get the answers they need.  It is not at all like practicing psychiatry.  The most valuable product of that work is a patient who feels understood at the end of the session. None of the people calling me feel understood at even a superficial level.

Just a few years ago, I was an insider working in an intense hospital environment. I was generally feeling the stress all day long. I had the physical manifestations of that stress that were measurable – but I pushed through every day and made it home to unwind.  In some cases I could not unwind and ended up calling my nursing staff at 2AM to make sure that things were going OK.  I think about that right after thinking that I should still be working – just based on all these systems problems that people are telling me about.

I come to the realization that I can’t do it anymore. Cognitively and technically it is certainly not a problem. I have no doubts that my diagnostic and treatment skills are still there. Physically it is an interesting story.  I just lifted plenty of weights and will lift more tomorrow.  My aerobic capacity is very good. I have posted some of my chronic health problems here on this blog to illustrate diagnostic, pathophysiology, and treatment concepts. So generally my health is pretty good.  That can always turn on a dime.  I can’t work anymore because of the stress response.  The mental and emotional demands of work become physical demands and that creates significant problems. Doctors reading this in those environments know what I am talking about and I wish them the best because I know nobody is trying to alleviate any of that pressure.  Nobody is trying to help them.

I finish off my mocha and biscotti as I am pulling into the driveway. It is 7PM and dark out here in Minnesota.  I had over 30 years of pulling in my driveway in the dark after work and still feeling tense and in some cases jumpy about what happened that day.  Things are different now.  I can decide how much pressure I am under and when I can unwind. I wish I could do more for all these people who need help – but I can’t. 

It is time to finally take care of myself.

 

George Dawson, MD, DFAPA

Supplementary:

@dahlle on Twitter read this post and posted the NASA Task Load Index - a workload measure that has been validated across a number of settings.  Just looking at the scales - it is easy to see how physicians can max out almost every scale except for the physical demands (at least for non-surgeons).  With enough stress - heart rate and blood pressure increase just like you are running.  

It is also an illustration of how things can get rapidly complicated when there are people actively standing in your way and other people demanding that you do more.  Work setting is critical here as well as adaptation to work.  I have talked with hospitalists who told me their cognitive performance dropped off steeply on day 6 (of 7).  On the other hand I have talked to physicians who were used to seeing 30 patients for a minute or two at a time in an afternoon who were not stressed at all. 

At least one study has established a dose response relationship between physician task load using this scale and burnout:

Harry E, Sinsky C, Dyrbye LN, Makowski MS, Trockel M, Tutty M, Carlasare LE, West CP, Shanafelt TD. Physician Task Load and the Risk of Burnout Among US Physicians in a National Survey. Jt Comm J Qual Patient Saf. 2021 Feb;47(2):76-85. doi: 10.1016/j.jcjq.2020.09.011. 

Graphics Credit:

Biscotti is via Wikimedia Commons.  https://commons.wikimedia.org/wiki/File:Biscotti_1.jpg

Mokkie, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons

Yes - I am Retired and here is why....

 

Yes – I am Retired

Last January I posed the question  ”Are there any good jobs left for psychiatrists?”  Eleven months later – I have the answer and the answer is NO.  For the past 11 months I have been looking and have seen at least a hundred jobs descriptions forwarded to me by various people. I have also interviewed and negotiated a couple of times only to get a contract that was completely unworkable.  I am not an attorney but I don’t think you have to be when you see a contract suggesting that you are going to indemnify and hold harmless a large corporation for any problems that might arise during the course of your employment. I did incorporate that experience into a CME lecture I gave in November about telepsychiatry and encouraged legal consultation with contracts.

The job postings that I considered were remarkable for the obvious amount of leverage they would create for employers and some of those employers had clearly never worked with psychiatrists in the past.   What do I mean by leverage?  Leverage is bullet points in the job description. When I started out back in 1986 – job descriptions were straightforward.  I can still recall the first interview I had at a community mental health center where I was eventually hired as medical director. They asked me about my treatment philosophy in psychiatry and my exposure to community mental health.  They asked me if I would be comfortable supervising the community support staff and psychotherapists. I asked them about the medical resources in the area, where I could do physical examinations if necessary and where I could get laboratory testing done.  All of the stuff psychiatrists are trained to do.

Current job postings list a number of bullet points that seem irrelevant to the job of a psychiatrist. Things like customer and stakeholder focus, change management, systems thinking, courage, commitment, emotional resilience, training (prescribing appropriate medications, documentation, collaborating with therapists, considerable annual HR rules), and so on.  The term “stakeholder” is cringeworthy. For 36 years I have treated people who had the toughest psychiatric and medical problems. All of that treatment was based on establishing a relationship with the person.  In many cases that involved foreign language interpreters, deaf/hearing-impaired/ASL interpreters, and various attorneys, advocates, ombudsmen, case-managers, and social workers. Family involvement is often critical.  If there are any stakeholders besides me and the patient – those would be the stakeholders. But in the business world – the stakeholders are other businesses and bureaucrats. They also include middle managers in any business that hires me. I may go in to work one day and find a team of bureaucrats angry with the way I am doing things – not from a quality-of-care perspective but from a business perspective.  They may decide to make my life a living hell until I do what they want me to do. All of the irrelevant bullet points also come in handy at the annual review. A supervisor may solicit anonymous opinions about whether or not I am fulfilling the requirements of corporate citizenship irrespective of my work as a psychiatrist.  That is all corporate leverage.  It has happened too many times and I am done with it. As far as I can tell that eliminates me from the pool of psychiatrists eligible for employed positions.

I have considered private practice options and gotten a lot of advice about it. The problems at this stage are considerable due to the up-front investment and the issue of tail coverage or malpractice insurance coverage necessary when I eventually stop working. Establishing a reliable documentation and medical records system as well as the necessary network security and insuring that is also a wild card. Private practice seems like an option if I hit the lottery but not before.  It does lead me to give out the advice that starting all of these essentials for private practice earlier in a medical career is probably a good idea.  As an example, I have talked with psychiatrists younger than me who have carried their own malpractice policies independent of their employer's policy. That is something I never considered, but today see it as a great idea.   

I did a CME presentation in November and I think that went relatively well. I could do more – but doubt that will ever develop into anything sustainable. This blog will keep me going in the foreseeable future. I like reading about psychiatry, medicine, neuroscience, and basic science.  I have an interest in staying current as well as knowing where the research is headed. One of the reasons I started this blog was because I had a significant number of psychiatrists approach me and ask what I was reading and how I kept up on recent research.  This blog has enabled me to reach psychiatrists around the world and correspond with many on relevant issues. I have never capitalized this blog in order to avoid any appearance of financial conflict of interest. So, like most retirees I will be living on Social Security income and retirement savings.

I don’t anticipate many existential issues in retirement apart from the typical death anxiety from time to time.  One of my goals has been to live as long as possible, and based on my family history I have lived this long just by avoiding cigarette smoking, exercising, and getting timely medical care.  My diet has gradually transformed to a relatively healthy one.  Being married to an extrovert means that I am never socially isolated.  Retirement has resulted in a massive amount of freedom to finally do what I want.  For decades I was constantly working or worried about work – initially the patients but eventually the bureaucrats and patients. I also worked too long and found that I was living somewhat of an alternate existence. I did not know what it was like to go to a shopping mall in the afternoon – I was working. All of those daytime everyday activities were available to me during vacations where most of my time was spent recovering.  The freedom to go to a mall or Target or even to a local coffee shop for a mocha anytime I want to is something I really have not experienced since the first two years of medical school.  I plan on using it to the max as the pandemic clears.

Freedom also means much more time.  I have about 4,000 books in my library and a steady stream of incoming subscriptions of medicine and science journals. Not all of those books were meant to be read cover-to-cover, but I want to make sure that I read those that were meant to be read that way.  At some point I will probably reread Zen and the Art of Motorcycle Maintenance for a final time. That book is a mysterious connection to my past as well as one of my all-time favorites.

More time for exercise will be a challenge. I decided to adopt a treadmill strategy for workouts so that when a cardiologist orders another stress test I will be ready. So far that strategy has worked well.  My only limitation is joint pain and back pain.  I think a lot about the day that pain might not go away and necessitate surgical intervention. This is my hopeful exercise routine going into retirement (I have actually bumped the 6 MET treadmill routine to 8 METS).  The cycling section is currently on hold after doing about 71 sessions due to a medical problem.

I plan to push this as far as possible, but the writing is on the wall based on 4 decades of high levels of activity. The decision about surgery will depend on how things are going at the time as well as the quality of consultation. The insight I have developed here is that maintaining high levels of activity as you age is more than determination. It is a matter of back and joint preservation and what can be done to restore it, as well as what other medical problems exist.

The final existential issue in retirement is the one that many people seem to fear and that is meaningfulness.  I can recall running early retirement groups as part of residency training that were based on that theory, but it was never evident to me that was really the issue. I certainly have not found any physicians who found retirement to be a problem.  I have a number of goals in place that involve writing.  A senior psychopharmacologist sent me an email and suggested that I cover mechanisms of action of biological treatments in psychiatry. I will certainly try to maintain the position of being an advocate and defender of the profession for the basic reason that nobody else seems to be willing to do it.  I explain how this has evolved and happened in the past few decades and the previous post on this blog captures some of my thinking on this topic. Several papers are in the works on the diagnostic method in psychiatry, rhetoric used against psychiatry, and sleep transitions.  I am also in the process of outlining a book on diagnostic and treatment methods in psychiatry.  My goal with the book is too keep it as short as possible and not to get into all of the trivia seen in typical textbooks. The target audience will be trained, early career psychiatrists, and like most old people – I hope to pass on some wisdom that will prevent common mistakes.

Along with the meaningfulness, a few words about ageism are required here.  I have encountered it in blatant forms in the past 5-10 years from psychiatrists. It bothers me only in that these psychiatrists seemed to be unaware of their attitude and I have the position that psychiatrists need to be aware of their biases. To some degree it is expected of physicians in their 30 and 40s.  Medical training encourages competitiveness and it takes a while to develop a collegial attitude. Is that transition is the same in psychiatry as in other specialties? There are several reasons why it might be lagging. First and foremost is the constant barrage of negative and inappropriate criticism the field is under compounded by the lack of response by any leaders in the field or professional organizations. That atmosphere encourages people to come forward and say: “I am not like the rest of the psychiatrists who you are criticizing. Your criticism does not apply to me and here is why?”  That is an attitude I was explicitly critical of when I started to write this blog but probably did not articulate that well. I did say that my experience with psychiatrist-colleagues is that they are thoughtful, professional, and very competent with few exceptions. I don’t accept the unique psychiatrist defense against inappropriate criticism even though many authors of these articles come off that way. If the competitiveness and the unique psychiatrist defense is in the background, does it make ageist biases more likely?  I think that it does.  I have experienced the comments and the smirks from people who should have known better – even not counting the obvious gaslighting comments here on my blog. Psychiatrists should know better.  

Another factor are special interest groups like the managed care industry and recertification boards. The managed care industry has emphasized at times that younger physicians are more "managed care savvy" (as if that is a good thing) and the need to train residents with that same goal in mind. The implicit suggestion is that older physicians who generally do not like managed care are less "savvy".  Medical boards, after rolling out years of questionable recertification processes and data to suggest that older physicians may know less than younger recertified physicians have apparently come around to the position that a lifelong continuing medical education approach is now acceptable for board recertification.  That was where all of this started. In the meantime there has been about 20 years of rhetoric suggesting that older physicians, especially those who were grandfathered in to lifelong certification were self-serving and had less knowledge than the people being run through the recertification mill. In reality, there was not a single older physician who did not believe that lifelong education rather than an arbitrary recertification examination was a superior process. Managed care and the recertification boards were essentially splitting physicians based on age and facilitating ageist biases. 

The meaningfulness dimension also includes collaborating with others. I am currently working with a friend of mind on postmodernism.  He happens to be an expert in all things postmodern and I am running my theory about postmodern rhetoric by him.  I hope to collaborate with other researchers on theory and even experimental design and analysis for a number of problems in psychiatry. I also like making basic graphics and would consider collaborating on that. I don’t need any reimbursement for the right projects – authorship credit will do.

The most significant aspect of meaningfulness for many physicians is realizing how your profession has impacted your family. For too many years, physicians are emotionally involved with strangers often to the point of exhaustion. That process takes its toll on the people who you are supposed to be the most emotionally involved with and that is your spouse and your family. The increased freedom of retirement allows for a fuller realization of that emotional involvement and reflecting on what has happened over the decades of work.

That is my current retirement process. I will post any changes here on the blog.  I hope there will be a noticeable improvement in the quality of writing here on the blog.  I know there is information contained here that can’t be found anywhere else and I am satisfied with that accomplishment as well adhering to the general goals that I started out with.  If anyone reading this has any suggestions for topics that I should be covering feel free to post it in the comments section below or send me an email.

George Dawson, MD, DFAPA

Supplementary 1:

With no good jobs being available for psychiatrists what are the options?  Unless you can identify a funding source and open up a free clinic there really aren't many.  People in my situation can simply retire and I think that many are.  In fact, one of my medical school colleagues told me that all it took was the pandemic on top of the current administrative headaches to make that decision. I am sure that somewhere somebody can find a niche and avoid some of the administrative headaches.  Learning what it takes for private practice at an early age seems like a possibility but the administrative costs are shockingly high.  I recall an internist telling me that for his 2 physician practice they required 3 full time office staff just to handle the billing and coding requirements for hundreds of insurance companies. In my 3 psychiatrist outpatient clinic we needed 1 fulltime staff person to handle phone calls and prescription refills and could have used  nurse just to handle the prior authorization calls. The business world has conveniently set things up so that the barrier to private practice is high and it is easier to settle for one of their problematic jobs.  I am not sure there is much that can be done to reverse this.

Supplementary 2:

To paraphrase an old automotive commercial: "Quality is no longer job one!"  I was a quality and utilization reviewer for psychiatric hospitalizations in both Minnesota and Wisconsin in the 1980s and 1990s.  We had stringent criteria for reviewing records and making these decisions. As the federal government invented the managed care industry and turned control over to them including all of the reviewing - quality dropped off the radar. Now what consumers see are media polls of "Top 100" hospitals and curiously most of the hospitals that you drive by seem to have made that list.   The same administrative processes that have removed physicians from the decisions about program design and how patients are seen in a clinic have also removed them from monitoring quality and designing quality improvement programs.  I know because I have been in the meetings where administrators presented their ideas about quality.  They were clearly less knowledgeable about healthcare than Toyota is about producing cars.  At least Toyota listens to the people making the cars. 

Supplementary 3:

I have always dreamed about working. It is always inside a massive hospital that is staffed like you would expect a university hospital to be staffed – teams of specialists and their residents and medical students. None of the buildings look familiar – they are all brain fabricated and in technicolor. The people in those dreams all look, sound, and move realistically. The predominate mood in the dream is anxiety.  Some of it is the real anxiety of everyday medical practice – did I miss anything and have I remembered everything? It is the anxiety that you experience when you are under pressure and on the edge of being overwhelmed. It is the kind of anxiety that leads to physical symptoms like accelerated heart rate, palpitations, muscle tension, and restlessness. Last night (01/08/2022) I dreamed I was in another large medical center.  In this case I was on both a Renal Medicine team and an Internal Medicine team.  I could sense that I was a resident and paying attention to multiple deadlines and schedules.  In real life no resident would do rotations on both of those services at once.  There is just too much work and it would never happen. I was looking at labs and notes on Renal patients and figuring out what I needed to do – but then realized I needed to be on Medicine rounds and started to get increasingly panicked.  I recall thinking that this was an impossible position and asking myself how that came about.  I woke up with a fast heart rate and feeling anxious but immediately realizing it was just another working dream. Various interpretations of that dream are possible ranging from the affective tone of the dream (work anxiety) to possibly wishing I was still at work.  I have definitely experienced elements of both. In medical school Renal Medicine was one of my favorite rotations and I was one of a few people who rotated through Renal, Infectious Disease, Cardiology, and Endocrinology in addition to the required Medicine and Surgery rotations. There was very little that I did not like about medical school or training. On the other hand it was extremely stressful and I was never able to lose that stress and anxiety in 35 years of practice. If anything, the way I practiced tended to increase the stress and anxiety. So here it is almost a year since seeing my last patient and medicine is still very much on my mind.  With any luck it will get to the point that I can stop working in my dreams.

Photo Credit:  Eduardo Colon, MD

 

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.

Are There Any Good Jobs Left for Psychiatrists?

I quit my job last Thursday night at about 9:30 PM.  My term of employment was officially over at the close of business today – Tuesday January 19, 2021.  It happened during an exchange of fairly terse emails with my immediate supervisors. Those emails occurred in the context of a flurry of daytime emails that were critical and could easily be interpreted as making me look as bad as possible.  I have no plans to disclose the nature of these conflicts or the content of those emails.  

I know from experience that responding to the content of these messages at face value and ignoring the meaning is a mistake that you can never recover from. It is also a mistake because it assumes that the people representing corporations have a genuine interest in you as a human being.  People – no matter how good they are – are always expendable to the modern corporation and there is no better example than healthcare companies. I also believe that because several of my previous supervisors said it directly to my face.

I was very clear in my email that the reason I was quitting was a decision that happened that day.  It is good to maintain clear boundaries when it comes to these decisions.  Sometimes there is a lot of emotion involved and when that happens a lot of charged rhetoric.  By the time 9:30 PM rolled around – I was very cool.  I had been in a heightened emotional state all day.  That tends to happen when people say things about me that are not true and try to make it seem like I am personality disordered.  By heightened emotional state I generally mean a hyperadrenergic state. Anxiety, stress, tachycardia rather than anger.  That distressed state resolved as soon as I realized the situation with the administrators was hopeless and all I had to do was quit.  As soon as that occurred, I was able to relax and fall asleep like nothing had happened.  A complete cessation of the emails was also helpful.

That decision in the last paragraph was very important to me.  As the son of a railroad engineer, I was socialized to be very wary of any special interest (whether it was a company or a union) that could affect your work or personal freedom. Being very clear on what you want to experience was all part of that socialization and at times it was fairly stark. There is a long learning curve.  I did not really become an expert at it until I walked away from a previous job 12 years ago. I thought I was going to work at that job my entire career and retire – much like my Dad viewed his railroad job.

I recall my father showing me the front of his Brotherhood of Locomotive Firemen and Engineers trade paper and angrily making the following statement: 

“Do you see this big house?  That is where the President of the Union Lives!  Do you think he cares about what happens to us?”  (Fairly certain my Dad would have probably used much more colorful language  but I don’t want to embellish).

Of course not, Dad.  I heard a radio program several years ago about first-generation white-collar workers from blue collar families.  According to the speaker, they were much less likely to integrate their business lives into their social lives.  The example given was that they would not invite their boss over for dinner.  But nobody stated the reason – and that is basic working-class distrust of management.  Second-generation white-collar workers may also have a much higher tolerance for bullshit than blue collar folks. In my family of origin, bullshit was not a humorous or value free word.  It was generally a pejorative.  

There is also the way you exist in the work place.  Some people need the social aspect at work for many reasons including reassurance that they are in good standing.  A lot of us like to keep our heads down, do the work, and not comment on all of the social behavior in the workplace.  We don’t want to hear about other peoples’ problems – not because we don’t care about our fellow man but because we were raised to mind your own business.  I am in the latter category and find that it works very well.  People I work with over time know they will be treated fairly and they know that I am very loyal to them.  That may be another reason why I react so strongly when people make things up about me.

The boundaries are significantly less clear in a white collar setting, especially with institutional rules and training on what constitutes civility. Unless you are fired precipitously and escorted out by security there are the superficial niceties – even if you are dying the death of a thousand cuts.  “Oh you’re leaving? We are sorry to see you go! Let’s have some cake in the break room! Don’t be a stranger!”  All the while stories are being spun about what happened to either make it seem like you were basically a jerk or you were never there in the first place. At a previous job I endured months of gaslighting and abuse.  At one point I asked my primary care doc for a prescription for a beta blocker just to control my heart rate and blood pressure from the stress. I joke about taking them like M&Ms, but at the time it was no joke.  That was not going to happen again.

When I think about the range of normal and pathological workplace dynamics I always come back to the work of the late Peter Drucker.  He was described as the world’s greatest management thinker.  One of his key concepts is the knowledge worker.  In other words, employees who were trained in a profession – in many cases an independent professional. Drucker pointed out that these employees need to be managed differently by virtue of the fact that they know more about the business than their boss does.  Further that they are not managed for widget production as productivity.  In the current healthcare environment, the most highly trained employees are physicians. They are treated like production workers and clerical workers rather than knowledge workers and in many cases replaced en masse by other workers who can do some of what they do.  As an example, I recently did a search through my health care system looking for a primary care internist in the event that my current internist retires.  The search pulled up 50 practitioners and only 2 were physicians.  The way health care systems deal with knowledge workers is to either get rid of them or ration them.  All part of the unending death spiral of low-quality care in America.

One of the big human-interest stories of the pandemic is that medical school applications are apparently way up.  The reason given is the presence of Anthony Fauci, MD in the news.  In all of these clips, only a tiny fraction of Dr. Fauci’s expertise and body of work is visible but his demeanor and consistent references to science make him easy to identify with. He is a physician that others want to emulate.  The problem for all of these prospective medical students is that there are very few places any more where a physician can practice at the top of what they were trained to do.  There are practically no physician environments that maintain an academic focus that was common in every setting that I trained at in the 1980s.

Apart from the workplace politics and all of the completely unnecessary stress it produces my immediate consideration is finding a new job.  I do not need to work. I could simply retire.  When I was working a burnout inpatient job – I fantasized about retiring early just to escape the place.  Since then, I have concluded that I am still at the top of my game and have an excellent skillset to offer people with significant psychiatric problems.  These services are clearly needed. In addition, I have a unique approach to psychiatry that I think needs to be out there to counter the low-quality checklist approach that has very little to do with psychiatry.  The problem is finding the ideal environment to utilize that skill set.  The figure below gives an example of the practice environments that I have worked in and whether my skill set was utilized or marginalized.

 

Drawing on that experience whether I get another job at this point or retire depends on the following factors:

1:  Malpractice coverage: I could easily set up a private practice in the era of telepsychiatry but any psychiatrist planning to retire at some point needs tail coverage.  That is malpractice insurance through the statute of limitations for malpractice in the state you practice in.  In Minnesota that is three years and would costs tens of thousands of dollars.  That’s right - three years paying out a good deal of money on the hypothetical that you might be sued during that time – whether you have previously been sued or not.

2:  Practice environment:  The graphic below shows how badly the practice environment has deteriorated with the invention of managed care, pharmacy benefit managers, and an expensive labor-intensive electronic health record (EHR).  That means I have a choice again between setting up my own office, hiring staff, buying and setting up and EHR or going to work for a managed care company who has all of this but expects me to become a template monkey and fill out 20-30 patient visit templates per day.  I use the term template monkey out of respect for one of my colleagues who is a proceduralist and told me at lunch one day that is what she had become.  She presented it as a joke, but it is a fairly depressing self-observation from one of the most highly trained MDs in the profession and the hours it takes her to complete arbitrary forms that have nothing to do with quality medical care.

While I am at it my inpatient and outpatient workflow is 30 minutes per patient follow up and 60-90 minutes for initial evaluations with some time in between for documentation and coordination of care.  That coordination of care typically involves acquiring and reviewing records and speaking to the patient’s treating physicians.  I also need to be able to dictate all of the notes rather than type them in to a template. I have yet to see dictation software work seamlessly enough, but I have seen transcription companies with industrialized versions do excellent job for a very low price. I need help from clerical resources, I don’t need to become a clerical worker.  

3:  Availability of necessary equipment, tests, and specialists:  For 22 years I worked in a very collegial environment that was full of medical and surgical consultants. I knew all of them and they knew me.  There was mutual respect and plenty of information exchange.  We consulted informally at lunch.  If I had a patient with complex problems – I would just do the evaluation, order all of the tests, make a diagnosis and then call a consultant if necessary.  I have not been in that environment for a while and I am not used to leaving things hanging and depending that people will follow my advice and see a cardiologist.  In fact, I know that people rarely follow through.  Anyone who suggests that you can just kick the can down the road, doesn’t really understand the practice of medicine or psychiatry.  In order to offer treatment, I need to determine that the patient does not have serious underlying illness and that I am not making any pre-existing conditions worse.   So, I need a medically intensive environment.  I thought I could do without it but that was a big mistake.

Apart from my current situation, this is a problem across the entire country.  Medically trained psychiatrists and neuropsychiatrists are unable to find suitable practice environments.  Managed care companies are quick to offer appointments with any prescriber for anxiety and depression or even more complicated problems. This is a system wide problem even though there is no organized system of mental health care in the country.  If I get lucky and find the resources I need – the system will be lucky – at least in the geographic area where I can serve patients.  It is a basic fact that the necessary practice environment for most medically intensive psychiatrists has become a fantasy in the United States.  That fantasy could easily be remedied by a national work force supplying psychiatrists with what they need and paying them as employees.

If I am not fortunate enough to find the right practice environment – I will be enjoying retirement and to me a lot of that will still be studying psychiatry, medicine, and science.  It is what I do and I enjoy doing it.

Old patterns of behavior die hard – at least for me.

George Dawson, MD, DFAPA

Supplementary 1:

My official last day was the close of business on Tuesday January 19 and that is why this is being posted later that same day.

 Supplementary 2:

I do wish my fellow former employees the very best (including the administrators) and hope that everything goes well for them.  After I announced my resignation, I received at least 50 very positive emails telling me that they liked working with me and wishing me well in the future.  In many cases they were extremely complimentary. We all worked together to help people solve very difficult problems in a highly constrained environment. We were typically successful to some degree. For all of the compliments all that I can say is thank you and:

“The light that shines on me – shines on you”.

 

 

 

A Positive Story for Christmas

I ran across the story posted by Minnesota Public Radio about a psychiatrist retiring in northern Minnesota. The past 30 years or so Dr. Hardwig was the only psychiatrist in International Falls Minnesota. For people not familiar with Minnesota geography I included a map of the state at the top of this post.  It is a town of about 6400 people right on the Canadian border.  It is ranked as the 133^rd largest city in Minnesota. The closest Metro area would be Duluth with a population of about 85,000 people.  International Falls is 163 miles from Duluth and 296 miles from Minneapolis.  As noted in the article, this is a tough place to practice psychiatry. There are few resources and no easily accessible psychiatric beds.

Dr.  Hardwig practiced exclusively in this environment until his recent retirement. In the article we learn that his schedule was always full. He was always willing to fit people into his schedule based on need. He provided a valuable service to this patient’s and primary care physicians in the area. He successfully developed a way to interact with his patients in the community and maintain clear boundaries. He treated the entire spectrum of psychiatric disorders out of necessity. There were no specialists for him to refer to at least in the practical sense. When you advise people that they have to travel 100 or 200 or 300 miles to see a specialist they are willing to do it once or twice but not for the rest of their life.

Full disclosure on my part, I know Dr. Hardwig professionally. He was one of my predecessors as president of the Minnesota Psychiatric Society.  That means over the three years of that professional cycle, he commuted to the Twin Cities and developed agendas, ran meetings, met with MPS members, and conducted all of the other duties of those offices. He was a thoughtful president with a unique perspective also conducted one of our more unique scientific meetings. He also belonged to a discussion group about medicine and psychiatry in that group he talked about his ideas for recruiting psychiatrists into rural areas. That idea was one of the main points of the MPR article.  The shortage of mental health professionals in general and psychiatrists in particular was emphasized. 

This shortage is nothing new. When I started out as a psychiatrist back in the late 1980s, I was assigned to a physician shortage area in northern Wisconsin. I was the only psychiatrist in a county of about 50,000 people for a period of three years. During that time I was the medical director of a community mental health center and for one year commuted to a town 65 miles away to keep their small inpatient psychiatric unit open. They had a deal with the federal government and would lose significant funding if that unit closed down.

One of the early lessons I learned was that I was no longer practicing medicine in a large multi-specialty clinic with unlimited resources.  It is quite a shock to go from an academic psychiatry department with about 60 full-time staff and 24 residents to be the only psychiatrist in town. Professional isolation has been the term used to characterize that situation and also explain why psychiatrists don’t want to wander too far from Metropolitan areas. The atmosphere has improved to some degree with the advent of a functional Internet. While I was in that position, they were trying to get me a telepsychiatry connection through a local hotel satellite television. In the end the cost was exorbitant at about $20K/year and we never tried it.  Today telepsychiatry is routine in the same area and has been used for a decade by the local VA clinic.

The workload was fairly intense at times because our clinic handled all of the crisis calls from the county and I was backup for any nurse, case manager, or psychologist who was doing crisis intervention in the community or in some cases the county jail. There was no cross coverage for vacations or professional conferences.  I was on call 24/7 wherever I was across the country.  On any given night I could find myself seeing somebody in jail, at home, in the small general medical and surgical hospital in town, or any of several nursing homes. But even more pressing was the fact that I was a lightning rod for those people with mental illness and a propensity for violence. All these factors led me to return to a large multi-specialty group at the end of my three-year tenure.

When it comes to figuring out what it takes to be the only psychiatrist in town, treat all possible problems, and do that for decades - I don’t have the answers.  Dr. Hardwig clearly does and by all accounts he did a great job. In my postings of the MPR article in various places around the Internet, I had another psychiatrist question my use of the word “great”. I don’t really see any other way to describe it. What else can you say about the psychiatrist or any physician who practices intensely with minimal support and resources and gets the job done?

There are all kinds of reasons why physicians are critical of one another. There is the competitiveness of youth and the need to secure a position. Most physicians notice that slips away by midcareer and a more important function is teaching and mentoring rather than competing against everyone in the field. Psychiatry is at a disadvantage relative to other medical specialties. The media spin on psychiatry is decidedly negative as I noted in several recent posts. I don’t know if that just gets uncritically accepted or internalized especially by psychiatrists who are criticizing the rest of us. Even though this MPR story was positive it mixed Dr. Hardwig’s career accomplishments with the specter of psychiatrist shortages in rural America. I understand their point, but in terms of motivation focusing on this accomplishment would have potentially done more to motivate people to practice in that environment.  The accomplishments of Dr. Hardwig are certainly inspirational.

I have nothing but the best wishes for Dr. Hardwig in his retirement. Even though there are tens of thousands of psychiatrists to go to work every day and get the job done, his job was probably more demanding with no cross coverage for call or vacations. They have been trying to recruit a replacement ever since he announced he was going to retire and have no success so far. 

I hope they do succeed in finding a psychiatrist as unique as the one who just retired.

George Dawson, MD, DFAPA


References:

Alisa Roth. In International Falls, the last psychiatrist for 100 miles just retired. December 20, 2019. Link.


Graphics Credit:

User: Wikid77 (from National Atlas of the United States) [Public domain]: File URL: https://upload.wikimedia.org/wikipedia/commons/e/ed/Map_of_Minnesota_NA.jpg

Closing In On Retirement

A happy retirement dream:  I am walking along the edge of a canyon that I have walked many times before.  In physical reality this canyon does not exist.  There is a large herd of buffalo stampeding through the canyon and making a lot of noise.  On the opposing ridge there are 5 or 6 wolves trailing the herd.  I see a family to my right and step into their yard to warn them about the wolves.  The father reassures me that everything is under control and there is nothing to worry about.  He has three small children playing behind him.  He introduces me to a friend who I recognize from college and who has not aged well.  I am sure that I remember his name but don't say it just in case I am mistaken.  I realize that I am late and need to take a test, but it is a long way back to town.  I think about asking my brother to pick me up and take me there - but I am already 15 minutes late.....


Closing in on retirement is not what I expected.  I can remember sitting in 8th grade English class and wondering what it would be like to live to the old age of 40.  Now that I am well past that and surprisingly healthy what is the best way to transition?  Many people who retire these days are in a similar position. Chronic illnesses are better managed and most people anticipate a phase of active retirement, before moving on to less activity.  One of the critical questions is how to make that transition as a professional.  Besides feeling fairly healthy and fit, I also feel like I am at the top of my game as a psychiatrist.  At a time when most psychiatrists are over the age of 55, should I try for a more gradual transition from patient care and teaching?  Or should I just walk away?  A lot of people seem to think that they have the answer.  They have observed my work habits that included too many hours and too few compromises and have concluded "You will never retire!"  The psychiatric colleague who I have known the longest has concluded that about herself.  She thinks that she will end up being  carted away some day from the job that she has worked for decades.  I know I could not do that because I walked away from that setting 6 years ago - burned out and fully intending to call it quits.  When you work a job for 22 years, it is easy to lose sight of the fact that there are many more reasonable jobs out there.  Some of us just hunker down in longevity mode and don't see it until a crisis hits.

I put some preliminary communications out there.  I concluded a couple of years ago that the most rewarding and efficient use of my time would be teaching - preferably psychiatric residents.  Residency programs are much different today than when I was a resident.  Business management has basically corrupted them.  Today it is virtually impossible to be teaching clinical faculty anywhere and not have the same productivity expectations as psychiatrists in private practice.  In other words there is the expectation that you can see large numbers of patients and continue be an innovative and creative teacher.  Your salary is "justified" by the amount of billing that is generated.  That has never really worked for me.  I just attached one of my old storage devices to my current network this afternoon.  Sitting there on that drive was a series of 10 PowerPoints on psychopharmacology from 2008.  They were all 2 hour lectures and I came up with them from scratch after meeting with the residency director of a program I was affiliated with.  The residents that year had requested that I teach the psychopharmacology lectures.  I had peripheral involvement with the program until that point - largely due to the administrative restrictions.  She thought it was really important for me to do it and I agreed that I would, but it was a significant time penalty for me.  There was no productivity credit for preparing and delivering the lectures and no additional reimbursement.  It was all done on my own time after taking care of all of the clinical work, billing and documentation.  All done late at night and on the weekends - free gratis.  Despite that, I was confident that I did a good job and the residents appreciated the work.

The point I am at in psychiatry, I am confident that I can teach nearly anything and do a good job of it.  I am not confident at all that I want to transition into retirement seeing 75 - 100 very ill polypharmacy patients and teaching residents how to tweak that polypharmacy.  You really don't need an experienced and knowledgeable psychiatrist to do that.  I know that this is not really psychiatry, but somebody's business model of how to generate revenue and not consider all of the information that merits consideration.  I can't sit by and look at people who have never had a manic episode being misdiagnosed with bipolar disorder, or the endless people with chronic stress in their lives expecting that medication will somehow change that, or the high functioning person with "ADHD" who really wants a prescription for a stimulant so they are not at a competitive disadvantage in college or professional school.  Beyond that - I can't bite my tongue and listen to how they are seeing a therapist who is a "sounding board" and endlessly rehashing either their childhood or what happened last week and how that is supposed to be productive psychotherapy.  I can tell them what they need to do to get better and if necessary do the therapy myself.  And then there are the people with non-epileptic seizures, psychogenic mutism, chronic Lyme's disease, chronic pain, chronic daily headaches, reflex sympathetic dystrophy/complex regional pain syndrome and endless somatic permutations that need psychiatric care but walk in saying they don't: "I am here because my doctor thinks this is all in my head".  There are the people with delirium, dementia, movement disorders, and abnormal MRI scans.  I can see all of those people until my dying day, but it does not make an impact unless what I know can be amplified through current residents.

Before business managers ran medicine there was the kind of room I need at the current stage of life.  Senior staff in those days were the people the house staff and attendings consulted.  The absolute best teaching team that I ever worked on was a Nephrology team at Froedtert Hospital in Milwaukee.  It was my last rotation in medical school.  I recall finishing rounds at 10:30PM on the night before graduation and walking across the county hospital grounds to my apartment like it was yesterday.  That team was staffed by two senior Nephrologists in their late 60s.  The remaining team members included a Nephrology Fellow, two internal medicine residents, an intern and me.  There was no myth that these senior staff somehow knew less or were less relevant.  It was quite the opposite.  We rounded twice a day until all of the consults and hospitalized patients were covered and the senior staff were the primary discussants.  That myth is alive and well today, largely as a means to disenfranchise the tested clinical methods in medicine and make future generations of physicians dependent on organizations run by business managers rather than colleagues.  Organizations that have promoted the idea that tests and arbitrary and unvalidated performance metrics are more important than spending enough time with patients and enough time discussing clinical scenarios with a broad range of physicians including the most experienced colleagues.  It is no coincidence that the myth thrives in non-academic hospital environments staffed by generalists working impossible shifts.  Knowledge and academics seems at its leanest point in the past 50 years.  

At this point I am resigned to do what I can.  I have offered my services but there are a significant number of reasons why none of that may come to pass.  The hardest thing about retirement for me comes down to three issues.  First, there are not nearly enough people to take my place.  Psychiatry is possibly the best example of how a field can be decimated by political and business influences even in the midst an obvious shortage of services.  Throughout my entire career there has been a shortage of psychiatrists and nobody has done a thing about it.  Second, the very inefficient transfer of knowledge.  I was personally taken out of the teaching loop for a long time by business practices that made it impossible for me to teach.  What I know is not written down in texts and if I don't pass it along - it dies with me.  That is counter to the evolution of how knowledge is passed from one generation to the next.  Only American politics and business practices can stop evolution in its tracks.  Finally, being an active part of a person's treatment and recovery from mental illness is important to me.  In every case that involves an internal process on the part of the psychiatrist.  In retrospect, I have attributed it to having great teachers and colleagues, a great memory, a particular personality characteristic, scholarship, or just being compulsive.

Despite what the measurement based people say, the validation of that process is totally subjective.  At the end of the day or years/decades later - it is a person saying that you made a difference in their life and knowing that happened because you gave them the best medical advice that you could at the time.  For me personally, it has also meant seeing people who have the most severe problems.

I won't miss any of the productivity based work any more than if I walked off any assembly line.




George Dawson, MD,  DFAPA




Addendum: 

I realized in the last couple of years that this blog factors into the transition as well.  People have always asked me how I know something when I quote research or suggest a particular treatment or method of analysis.  I think that part of what I am doing here on these pages is illustrating how I know something.  Hopefully fellow psychiatrists, but especially medical students and residents will find it useful.


Attribution:

The graphic at the top of this post was downloaded from Shutterstock on July 4, 2016.