Monthly Archives: August 2016

Closing Up Shop

Every physician eventually faces the decision to hang up one’s spurs and walk into the sunset to a life of less stress, less money and more time to aggravate one’s spouse by getting underfoot.  Sometimes, because of physical infirmity or loss of mental capabilities, that decision is out of one’s hands. An old surgeon under whom I trained who was nearing retirement said, “I’d rather be missed than dismissed.” Others have either amassed a considerable personal fortune or, as a classmate who worked for a state medical school for 30 years and retired at 54, a comfortable public sector pension. But some of us wake up one day, decide “this isn’t fun anymore” and just quit.

I started thinking about getting out a couple of years ago after I overheard a nurse say, “Anyone who does an abdominal hysterectomy these days should be sued for malpractice.” I trained long before the era of the laparoscopic approach to everything and I’m comfortable with the abdominal approach. I’ve never liked vaginal hysterectomies; it’s like operating in a tunnel. I haven’t done major gynecologic surgery in almost ten years and I don’t miss it.

While I love obstetrics, it is a physically demanding specialty. Staying up all night becomes more difficult as one ages and near impossible by the time one reaches mid-fifties. My back doesn’t tolerate 8-hour surgery marathons like I did when I was in my thirties.

It can also be emotionally draining. I’ve had to tell more than one mother her baby has died, and I’ve cried with her and the nurses after the delivery. Our receptionist and her unborn son were killed when she was 38 weeks pregnant. An elderly man ran a stop sign and broadsided her car in a rainstorm. A colleague’s 18-year-old patient died from Group A streptococcal sepsis two days after delivering her baby. We’ve lived long enough that we know all the bad things that can happen and the prospect fills us with dread.

I’ve also known physicians who’ve gone through their entire careers with a clean record only to find themselves being sued when they are within a few months of retiring. That alone scares me more than anything else; like waiting for the walk down the Green Mile.

Medical practice has changed since I started and often not for the better. New physicians are likely to be corporate drones working 9 to 5 for large health care groups, potentially succumbing to a shift mentality, something I saw during my days working for a staff-model HMO. “It’s five o’clock and time for me to go home. You’re now someone else’s problem.” I always stayed until the last patient was seen, worked in emergencies and sometimes met patients after hours because it was more expedient than sending them to the emergency room, which would call me several hours later anyway. Now they call it “old school.”

Many physicians no longer take call or see patients in the hospital. They’ve been replaced by hospitalists who work 24-hour in-house shifts and go home. This arrangement might be preferable to having an overworked, sleep-deprived physician trying to juggle office and inpatients, but that personal connection many of us felt with our patients has been lost.

Smaller hospitals are not immune. As costs continue to rise and competition increases, they become “affiliated” with tertiary centers, if not bought outright, and the bean counters want a sizeable return on investment. One physician confessed, “I have men in three-piece suits telling me what to do—and I do it.” The hospital in which I worked in the early 1970s as an orderly closed recently, having held out too long against the regional behemoth’s advances.

Technology and guidelines derived from academic studies are making us obsolete. Seeing women every year for a pelvic and breast exam, Pap smear and a mammogram for older used to be the bulk of an Ob/Gyn’s office practice. Now, if a woman has a negative Pap and negative HPV testing the guidelines recommend another Pap in five years, even though I’ve seen women go from a negative Pap smear to invasive cervical cancer in a year. We no longer need to do an internal examination on a woman coming for birth control pills if she has no symptoms.  The National Breast and Cervical Cancer Early Detection Program told us our clinical breast exams only “modestly improved” early detection of breast cancer. The United States Preventive Services Task Force (USPSTF) says we should teach women “breast self-awareness” rather than breast self-exam, because “the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older.”

A nurse practitioner can do eighty percent of what I do. A Certified Nurse Midwife can do ninety percent. So why the hell do you need me?

I can rise to the occasion when circumstances require expedient action, such as a woman with a liter of blood in her abdomen from an ectopic pregnancy or a baby needing to be delivered immediately to avoid certain death, even though it often leaves a knot in my gut. I probably have a few useful years left but that evening stroll along a beach looks more inviting every day.

Image (C) CanStockPhoto