My exit ramp from medicine

One day, I was full of moderate despair, overworked, befuddled by the EHR with a tinge of burnout, staring at my computer, I treated myself to something I’ve not done before. It was my 62nd birthday that day, and I gave myself a birthday present. Before rising from that swivel chair, I had written down on a sticky pad the day that would be my retirement date, exactly one year after the expiration of my contract which I would be willing to extend no more than another year.

We try to keep ourselves productive in life because it is finite. Having my professional years identifiably finite would keep the remaining time focused on the things wish I had done but didn’t. Contract renewal came up. I announced the date I had chosen, asking for a one-year extension instead of the customary three. So they knew I was serious. We opted for three with an escape clause for everyone’s convenience, which turned out useful as my intended replacement fell through. It is now six months beyond the original date, still no replacement by headquarters decision to redirect my pay slot to some other medical network priority, and I will proceed from lame duck physician to retired physician in just a few weeks.

There we be no endocrinologist on site at my building, though we are a two-campus hospital, so some outlet exists a few miles away for those who can get there. For the past two months, as patients come for their follow-ups, I seem unusually attentive to what has been accomplished for them during my time here. Some have been coming five years or more. To my pleasant surprise, I came to appreciate what attracted me to endocrinology in the first place. People recovered from what originally brought them to referral.

Visits might be quarterly to annually depending on the underlying disorder, their medicines and lab status were reviewed with new appointments at the usual interval. Could they have returned to their primary physician three years earlier having been declared stable? I guess so, but there is a certain inertia that goes with stable medical care. These visits for low-grade hypercalcemia that has been static, hypothyroidism once with a TSH >100 but normal long enough to require only annual assessment, stable diabetic care that distorts my quality data in a favorable direction. These are straightforward follow-ups for me, the patients arrive apprehensive of what the lab they had done the week before showed, and generally leave reassured until next time. And a lot of them remember the good old days of pre-insulin polyuria, relentless palpitations at the initial hyperthyroidism evaluation or the doctor who made them into a new person by figuring out they had hypopituitarism and treating it. These patients are your friends until the day you retire and beyond, even if somebody else could have renewed their prescriptions just as capably.

At the other extreme, some of the patients have disorders that make them ne’er-do-wells. There really isn’t great treatment for pancreatectomized diabetics. Not every spherical phenotype patient can have or wants a gastric bypass. Some report some type of adverse symptom to whatever medicine gets prescribed. Some refractory blood pressure patients test normal for secondary hypertension but their pressure just doesn’t go down until they start minoxidil and get hirsute at the next visit. These people probably still need the endocrinologist, maybe a different one who can get them a fresh perspective.

And then you have the other attractive feature of endocrinology. Our diseases — diabetes, in particular — have long natural histories. The treatments provided improve the outcome, only to have a setback at some future visit as a few more islet cells get clipped off or the insulin I gave them generated more adipose. You don’t think a hyperparathyroid patient needs a parathyroidectomy, but at the next visit — they do. As you taper the methimazole on consecutive visits the hyperthyroidism gets more severe and it is time for radioiodine ablation. These evolution times are often longer than an entire internal medicine residency so it is really the office practitioner who makes important assessments at serial points in time.

In their wisdom, the executives decided endocrinology here was not the best use of resources, but the patients who need treatment will still exist and need attention someplace else. Fortunately, there is a camaraderie among members of our specialty, friendships that have been made, and no colleague that I have called has declared him or herself too backed up to absorb some of my cohort.

Modern medical care has mushroomed far beyond patient contact, even though that is all that generates our fees. There are signatures to be written, lab reports to be acted upon, residents to be mentored, phone calls to return, meetings to attend. But for the last two months, it has been decisions of what to do with the patients that has dominated my focus. And that may be what separates the MD or DO from the person at network headquarters who has to look at data and directives but never gets forced to consider the consequences to the people.

Of course, people ask what I plan to do once I’ve truly driven off that exit ramp. Life as a physician has never really deprived me of my personal pursuits. I already have raised a family, visited most of the places I want to visit and probably could upgrade my angling skills a little. There is retirement, coming at the right time for me, planned in advance and pursued, but there is also repurposing. If you are a doctor long enough you think like a doctor, analytical problem solving mostly. And while most of us have upgraded the lives of countless individuals, including me I think, few of us have made medical care better. For the most part, many of us have watched the professional stature of the physician deteriorate inexorably from that ecstatic day when our first medical school acceptance letter arrived. These are the challenges to be pursued, exposing if not correcting, becoming a muckraker when needed, imagining what should be and at least asking why not?

Exit ramps either take you to completion of a journey or they direct you to a destination not yet arrived. Retirement will put the patients aside, put the quest for financial comfort that is already ample aside, but never end an indelible medical imprint.

Richard Plotzker is an endocrinologist who blogs at Consult Maven.

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