A Reason to Retire?
List of authors.- Neil Berman, M.B., B.Ch.
Article
“Why are you retiring, Lennie? You’re only 64.”
I was in my 40s, part of a busy cardiology practice in a community hospital just outside Boston. Lennie was an old-time internist, an avuncular solo practitioner beloved by the community. His recordkeeping was meager, but his instincts were huge. When Lennie referred someone to see me and I couldn’t diagnose the problem, I looked again. Invariably, there was something going on that Lennie had sensed and I had missed.
Lennie’s decision to retire puzzled me. I knew he’d had some medical issues, but he was still running a busy solo practice. At the time, his answer puzzled me even more.
“My patients’ illnesses are starting to get to me,” he said.
I didn’t really appreciate what he meant, but his answer stayed with me. Having just retired myself at 71, I now understand exactly what he meant. Part of my professional effectiveness depends on maintaining a certain distance from my patients. I must be able to concentrate on the situation evolving before me: the symptoms, the signs, the lab tests, all the hard data that will inform the therapeutic decisions ahead. I can’t afford to be distracted by the “soft” data: the sadness of someone being struck suddenly by sickness, or sometimes the relentlessness of the condition. Some conditions are eminently predictable, but others are just sheer bad luck. Many are degenerative, and their frequency increases with age.
As a young physician, I was able to compartmentalize illness: it was something that happened to my patients, not to me. I could understand their illnesses, but I never saw myself in their place. I would try to alleviate their suffering, but my primary task was to diagnose and treat their condition. Patients were almost a different species from me: they developed different conditions, and we had different problems.
There was a certain egalitarianism to this approach: all patients were treated equally, no matter how sad their plight. I’d been taught to avoid identifying too much with my patients, for both our sakes. My patients wanted a cool head to be responsible for their treatment, not someone who was as scared and overwhelmed as they were; and I needed the distance from their suffering to be able to face the same situation with the next patient. Empathizing was not considered “professional,” but I think the real reason for avoiding it was that it undermined our defenses against the disappointment of failing in our mission to cure disease.
Objectivity helped me cope with the stress of dealing with my patients’ life-threatening and life-changing situations. It enabled me to see my work in a more intellectual and less emotional light. Did I make the right diagnosis? Did I choose the best treatment? Did I explain the condition to the patient and the family well enough? Rather than: How does he cope with not being independent anymore? How does her family survive without a breadwinner anymore? How does he feel knowing he has just a few months to live?
But as I grew older, this distinction became harder to maintain. The typical description in my chart of a “70-year-old elderly gentleman” could suddenly be me. My patients and their problems became more difficult to compartmentalize as separate from me. I started to feel the “extra-medical” aspects of their illnesses much more acutely than I had when I was younger — the unfairness of disease, the inevitability of age and the breakdown of the body. Now there was an extra dimension to treating my patients: each of them was a reminder of where I could be going. I identified with them on a new level, feeling each progression of their illness in a personal way that I hadn’t before.
During the Covid pandemic, rates of physician burnout increased dramatically. Many factors contributed to the stresses causing burnout, including long working hours, increasing administrative burden, and rising caseloads, all of which worsened during Covid. But Covid also carried the additional personal risk of infection, potentially leading to serious illness or even death. The patient lying in front of me was not only someone who could have been me, but now also someone who presented a distinct danger of infecting me and causing me to develop the very illness I was treating. The shelter of objectivity was never less evident than during the pandemic, producing a situation not unlike what I was experiencing.
Over the course of my career in clinical cardiology, the part of the job that brought me the most satisfaction was my interactions with my patients. Sure, I loved the challenge of constructing a coherent narrative from a series of disparate clues and then working out how to test the validity of that narrative. I loved the feeling of being “knowledgeable,” albeit about a very small section of the human condition, and being asked to weigh in when a problem arose in that section. But what really sustained me throughout my career were the relationships I built with my patients. We had a contract whereby I would listen to them, examine them, direct the appropriate testing, explain their condition, and suggest the best options for their treatment. It was a professional relationship. I was taught that as little as possible of my personal story should be shared with my patients. The purpose of our interactions was to address patients’ problems, not my own, so I knew much more about their lives than they knew about mine.
About 6 months before I retired, I wrote a letter to my patients explaining that I was going to retire and telling them somewhat personally what being their doctor meant to me. My subsequent visits were more personal, took longer, and were more emotionally laden than previous visits, but they were also more satisfying and helped me see my career from a slightly different perspective.
Our relationships with our patients are complicated. On the one hand, the lack of time, the number of patients, and the administrative burden associated with caring for patients all interfere with our relationships with them and contribute to job dissatisfaction and burnout. On the other hand, when those relationships become more personal and more intense, our work may also become more stressful because holes have been poked in our armor of objectivity.
As I grew older and more susceptible to the conditions I had spent my professional life combating, that armor became increasingly porous, ironically permitting more fulfilling relationships with my patients but also causing increased stress and perhaps leading to earlier retirement. Should I have developed more personal relationships with my patients all along, or would that have made me less effective professionally and more stressed personally? I really don’t know the answer to that question.
I often think of Lennie’s answer to my question about his retirement some 25 years ago. As usual, Lennie was spot-on — it just took me a while to understand why.
Funding and Disclosures
Author Affiliations
Supplementary Material
PHYSICIAN JOBS
OCTOBER 11, 2023
More Perspective
PERSPECTIVE OCT 12PERSPECTIVE OCT 12A Reason to Retire?
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A Reason to Retire?
List of authors.- Neil Berman, M.B., B.Ch.
Article
“Why are you retiring, Lennie? You’re only 64.”
I was in my 40s, part of a busy cardiology practice in a community hospital just outside Boston. Lennie was an old-time internist, an avuncular solo practitioner beloved by the community. His recordkeeping was meager, but his instincts were huge. When Lennie referred someone to see me and I couldn’t diagnose the problem, I looked again. Invariably, there was something going on that Lennie had sensed and I had missed.
Lennie’s decision to retire puzzled me. I knew he’d had some medical issues, but he was still running a busy solo practice. At the time, his answer puzzled me even more.
“My patients’ illnesses are starting to get to me,” he said.
I didn’t really appreciate what he meant, but his answer stayed with me. Having just retired myself at 71, I now understand exactly what he meant. Part of my professional effectiveness depends on maintaining a certain distance from my patients. I must be able to concentrate on the situation evolving before me: the symptoms, the signs, the lab tests, all the hard data that will inform the therapeutic decisions ahead. I can’t afford to be distracted by the “soft” data: the sadness of someone being struck suddenly by sickness, or sometimes the relentlessness of the condition. Some conditions are eminently predictable, but others are just sheer bad luck. Many are degenerative, and their frequency increases with age.
As a young physician, I was able to compartmentalize illness: it was something that happened to my patients, not to me. I could understand their illnesses, but I never saw myself in their place. I would try to alleviate their suffering, but my primary task was to diagnose and treat their condition. Patients were almost a different species from me: they developed different conditions, and we had different problems.
There was a certain egalitarianism to this approach: all patients were treated equally, no matter how sad their plight. I’d been taught to avoid identifying too much with my patients, for both our sakes. My patients wanted a cool head to be responsible for their treatment, not someone who was as scared and overwhelmed as they were; and I needed the distance from their suffering to be able to face the same situation with the next patient. Empathizing was not considered “professional,” but I think the real reason for avoiding it was that it undermined our defenses against the disappointment of failing in our mission to cure disease.
Objectivity helped me cope with the stress of dealing with my patients’ life-threatening and life-changing situations. It enabled me to see my work in a more intellectual and less emotional light. Did I make the right diagnosis? Did I choose the best treatment? Did I explain the condition to the patient and the family well enough? Rather than: How does he cope with not being independent anymore? How does her family survive without a breadwinner anymore? How does he feel knowing he has just a few months to live?
But as I grew older, this distinction became harder to maintain. The typical description in my chart of a “70-year-old elderly gentleman” could suddenly be me. My patients and their problems became more difficult to compartmentalize as separate from me. I started to feel the “extra-medical” aspects of their illnesses much more acutely than I had when I was younger — the unfairness of disease, the inevitability of age and the breakdown of the body. Now there was an extra dimension to treating my patients: each of them was a reminder of where I could be going. I identified with them on a new level, feeling each progression of their illness in a personal way that I hadn’t before.
During the Covid pandemic, rates of physician burnout increased dramatically. Many factors contributed to the stresses causing burnout, including long working hours, increasing administrative burden, and rising caseloads, all of which worsened during Covid. But Covid also carried the additional personal risk of infection, potentially leading to serious illness or even death. The patient lying in front of me was not only someone who could have been me, but now also someone who presented a distinct danger of infecting me and causing me to develop the very illness I was treating. The shelter of objectivity was never less evident than during the pandemic, producing a situation not unlike what I was experiencing.
Over the course of my career in clinical cardiology, the part of the job that brought me the most satisfaction was my interactions with my patients. Sure, I loved the challenge of constructing a coherent narrative from a series of disparate clues and then working out how to test the validity of that narrative. I loved the feeling of being “knowledgeable,” albeit about a very small section of the human condition, and being asked to weigh in when a problem arose in that section. But what really sustained me throughout my career were the relationships I built with my patients. We had a contract whereby I would listen to them, examine them, direct the appropriate testing, explain their condition, and suggest the best options for their treatment. It was a professional relationship. I was taught that as little as possible of my personal story should be shared with my patients. The purpose of our interactions was to address patients’ problems, not my own, so I knew much more about their lives than they knew about mine.
About 6 months before I retired, I wrote a letter to my patients explaining that I was going to retire and telling them somewhat personally what being their doctor meant to me. My subsequent visits were more personal, took longer, and were more emotionally laden than previous visits, but they were also more satisfying and helped me see my career from a slightly different perspective.
Our relationships with our patients are complicated. On the one hand, the lack of time, the number of patients, and the administrative burden associated with caring for patients all interfere with our relationships with them and contribute to job dissatisfaction and burnout. On the other hand, when those relationships become more personal and more intense, our work may also become more stressful because holes have been poked in our armor of objectivity.
As I grew older and more susceptible to the conditions I had spent my professional life combating, that armor became increasingly porous, ironically permitting more fulfilling relationships with my patients but also causing increased stress and perhaps leading to earlier retirement. Should I have developed more personal relationships with my patients all along, or would that have made me less effective professionally and more stressed personally? I really don’t know the answer to that question.
I often think of Lennie’s answer to my question about his retirement some 25 years ago. As usual, Lennie was spot-on — it just took me a while to understand why.
Funding and Disclosures
Author Affiliations
Supplementary Material
PHYSICIAN JOBS
OCTOBER 11, 2023
More Perspective
PERSPECTIVE OCT 12PERSPECTIVE OCT 12A Reason to Retire?
N. BermanPERSPECTIVE OCT 12The New Over-the-Counter Oral Contraceptive Pill — Assessing Financial Barriers to Access
C. Robertson and A. Braman