Psychiatry – Page 25 – Go Retire Psychiatrist

Back on the Wards

I was back on the wards today. It was pretty busy in the hospital over the weekend as usual. Mondays are almost always days when psychiatry consultations are pretty heavy, and Fridays are about the same. I got 2.3 miles and 17 floors on the step counter today.

I’m trying out adjusting my exercise and mindfulness practice—mindfulness in the morning and exercise in the evening. Since I get up pretty early anyway, I tried the yoga this morning and after the day was done, I did my exercise routine. It might be hard to stay awake through sitting meditation tomorrow morning. We’ll just have to see how it goes.

In my off-service time, I’ve been trying to work on cooking—sort of. I’m fair at best even with frozen pizzas. That’s a shame for someone who used to make pizza.

Home-made pizza I made–not that long ago.

I’m just OK with microwave popcorn. On the other hand, I managed not to ruin Jiffy Pop popcorn. Remember that?

What Happens When I Retire?

I’m still trying to find more information in the literature about retirement for psychiatrists. What happens to psychiatrists who retire? In fact, there is an article published several years ago with an interesting title: “A psychiatrist retires: the happening.” It was written by Dr. Norman A. Clemens, MD, a psychiatrist who was a psychoanalyst for many decades and retired in his mid-seventies. Dr. Clemens writes from the psychoanalyst’s perspective. He had many psychotherapy patients with whom he had developed long term therapeutic relationships. He was in private practice. His situation is vastly different from mine in those respects.

As a consulting psychiatrist in the general hospital exclusively, I have no long-term relationships with patients. I am so busy that I have no time for an outpatient clinic practice in the academic medical center where I work. I see my patients in the general medical wards, the critical care units, and, less often, in the specialty medical clinics.

My role is to, above all, understand the interaction of medical illness with psychiatric symptoms and to find some way to ameliorate them. My time is limited because I’m paged from all over the hospital throughout the day. Often, I see patients for only one or two visits—and never see them again. The C-L Psychiatrist is the fireman of psychiatry. My colleagues in medicine and surgery call me for help in putting out fires: suicide statements or attempts, the terror and agitation of delirium, the medically unexplained physical symptoms, the depressed and demoralized.

I don’t conduct formal psychotherapy like Dr. Clemens did. I do my best to sit and listen to the patient. It’s the main part of supportive psychotherapy, which underpins all others. My main prop is a chair (not a couch), any chair I can find in the room. If there are none, either I or a medical student or resident trots out to the hallway and fetches one for me. A few years ago, a colleague gave me a folding camp stool that I now carry around, slung around my shoulder. It’s very handy.

After a consultation, I then speak with the physicians who called me for my help. Frequently, nurses, social workers, medical students, residents, and other learners are present. I often sit down for that, too. I teach them and they teach me.

And also, I think about the larger perspective, which is the shortage of psychiatrists generally. About 60% of psychiatrists are over the age of 55 and many of them, including me, will soon retire. This will augment the need to replace us.

So, what happened finally to Dr. Clemens? How did he cope with retiring? Did he really retire? At the end of the paper, he confesses that he mourned for the patient relationships but relished the freedom. And he frankly admitted he’s not “totally retired,” still engaged in teaching. He says he doesn’t know if he could ever fully retire from being a psychiatrist or a psychoanalyst.

I spend a lot of time ruminating about how retirement will affect me. Dr. Clemens’ practice and mine differ in many ways.

However, there is this similarity. My retirement will no doubt affect many others.

Clemens, N. A. (2011). “A psychiatrist retires: the happening.” J Psychiatr Pract 17(6): 425-428.

The author uses his own recent experience as a basis for discussing the actualities of retiring and closing a private, solo, psychiatric practice of psychotherapy and psychoanalysis. The extended process includes a personal decision about whether, when, and how to retire; preparation of patients and arrangements for their ongoing care; dealing with legal requirements and professional obligations; and the mechanics of closing an office one has occupied for decades. Not the least of concerns is one’s own personal transitions in lifestyle, professional persona, attachments to patients, and engagement in psychotherapeutic or psychoanalytic treatment relationships.

Mindfully Retiring from Psychiatry

I’ve been off service for months and I’ll return to staff the general hospital psychiatry consultation service on Monday. It can be a stressful role and I’m “mindful” of how helpful mindfulness meditation has been. The featured image above shows my yoga mat and some might say a much too comfortable chair for sitting meditation. And of course, mindfulness is not really about relaxation; that’s just an old pillow.

About 5 years ago the editors of the Arnold P. Gold Foundation Humanism in Medicine Blog saw one of my blog posts (from a previous blog) describing my path to mindfulness practice, which included burnout, a problem for nearly half of all physicians, the causes of which include the health care system itself as well as physician vulnerabilities. It was posted under the title “How I left the walking dead for the walking dead meditation.” I was also the recipient of what was called in 2007 the Leonard Tow Humanism in Medicine Award, sponsored by the Gold Foundation.

This has me thinking about my motivations for retiring and what I’m going to do after I’m fully retired. Interestingly, the phased retirement program I’ve been in has given me a strong sense of how difficult this transition from full-time doctor to retired doctor entails. The meaning and purpose gap require more than a bridge made of recreational pastimes. The breath of relief after the great escape from work can soon become the sigh of boredom. On the other hand, my work as a psychiatric consultant has also been an enormous source of personal satisfaction. The video below gives a sort of Pecha Kucha account of what a Consultation-Liaison Psychiatrist does.

What C-L Psychiatry is about

It can get pretty hectic. Over the last two years of the phased retirement schedule, I’ve struggled to craft a daily routine at home that replaces the sense of accomplishment my work schedule provided—despite the pressures it exerted on my sense of well-being. Only now, in my third and final year am I starting to wonder the opposite.

For example, I’ve been exercising daily as well as practicing my mindfulness meditation. I’ve actually lost a little weight and my wife has noticed my shrinking paunch. I’m not laboring on my workouts by any means; my quads are not flopping over my knees. But I used to think that by climbing all those stairs and running all over the hospital I was staying in pretty good shape. It looked pretty impressive that my smartphone step counter logged around 20 floors and 2-3 miles a day. However, the consult service work demand can run hot and cold. It just doesn’t beat daily exercise.

How do I keep my daily exercise routine? I can hear myself saying that I won’t have time for it. I think my mindfulness teacher would probably remind me that my response could be to make time for it—just as I learned how to make time for mindfulness.

I’m looking for guidance in the literature on retiring psychiatrists, especially C-L specialists, and it’s pretty scant. So far, the best summary of it I’ve found were a couple of blog posts by H. Steven Moffic, MD on the Psychiatric Times web site. You can easily view them for free. In the first one, “Mental Bootcamp: Today is the First Day of Your Retirement,” published in 2012, he highlights the difficulty of psychological adjustment to retirement for psychiatrists. He advises, “Plan how to replace financial, personal, social, and generative needs that work has fulfilled.” There is no doubt I could do a better planning job.

In the second one, “Reviewing Retirement,” which was posted in 2014 (two years after he retired), he advises “Retire, even if you are not retired. Take enough time off periodically, and completely, with no connections to work, so that you can feel emotionally free from concerns about patients and practice.”

That speaks to me. In fact, the title of my blog site, Go Retire Psychiatrist, actually echoes this suggestion, although I never made the title with that connection in mind. I wish it were that easy to follow. You would be very lucky in today’s work environment to pull that off, even in academia. Phased retirement programs are one approach to preparing for retirement and could be effective for preventing burnout.

Go retire, psychiatrist.

Lifelong Learning “Not Excessively Rare”

As I get ready to go back on service at the hospital as a psychiatric consultant, I’m trying to get my head back into the game by reading papers like Psychiatric News. The March 15, 2019 issue (volume 54, number 6) has an interesting article about how medical students are learning these days, entitled “Wright State Adopts Curriculum Without Lectures,” written by Mark Moran. You can easily access this article on the web for free by just searching with the term “Psychiatric News.”

The article mentions the pathology textbook, Robbins’ Pathologic Basis of Disease. My class used the nearly 7 pound red 3^rd edition containing 1,467 pages. This book is hailed as an outstanding foundational text, which it is. Dr Stanley Robbins has been eulogized as an exacting editor who championed writing of the type espoused by Will Strunk in The Elements of Style.

Not to be picky, but the book contained the phrase “not excessively rare” in reference to some process or disease which I can’t recall. I do recall that a majority of our class howled about this verbiage, which seemed the antithesis of what Strunk tried to teach.

Robbins book is described as “dense” in the article. It’s probably still pretty tough to wade through. I admire any medical student who can teach peers about its contents using only a study guide. I saw a used copy for sale a few years ago in a bookstore in Madison, Wisconsin.

Wright State University is using Team-Based Learning (TBL) which allows medical students to teach each other in small groups. They prepare by reading on their own about topics and come prepared to teach their peers who participate in discussions. This is thought to promote a better way to promote lifelong learning and to be more effective than the lecture style—which is how I learned.

Another point in the article is that the lecture-based approach is pretty inefficient, which is true in my opinion. I remember it often resulted in poor lecture attendance and cramming before exams. It spawned the sometimes-controversial Note Service (which I think a lot of medical schools had and may still have), in which class members take turns taking notes in lectures, which are then cleaned up and distributed to the rest of the members of the class who sign up for the Note Service.

Wright University also has a problem-based learning exercise in which small groups discuss a clinical case with a faculty facilitator. Students come up with learning objectives, search the medical literature, and then present to each other about evidence-based approaches to real-world clinical challenges which physicians encounter in practice.

It turns out this problem-based learning method is not really new and not excessively rare. It happens to have been the approach used by one of my teachers during my residency rotation through the consultation-liaison psychiatry service. It was eventually called Clinical Problems in Consultation Psychiatry (CPCP). I continue to use this model, although general hospital psychiatry has gotten very busy over the years, making it difficult to do regularly. Medical students and residents have given many outstanding CPCP presentations, often using PowerPoint slides and generating stimulating discussions. The video below is an example to give you the idea of one component.

And this post reminds me that the phased retirement process involves periodically flipping between my work identity and my retiree identity. I suspect this experience is not excessively rare.

Yates, W. R. and T. T. Gerdes (1996). “Problem-based learning in consultation psychiatry.” Gen Hosp Psychiatry 18(3): 139-144.

Problem-based learning (PBL) is a method of instruction gaining increased attention and implementation in medical education. In PBL there is increased emphasis on the development of problem-solving skills, small group dynamics, and self-directed methods of education. A weekly PBL conference was started by a university consultation psychiatry team. One active consultation service problem was identified each week for study. Multiple computerized and library resources provided access to additional information for problem solving. After 1 year of the PBL conference, an evaluation was performed to determine the effectiveness of this approach. We reviewed the content of problems identified, and conducted a survey of conference participants. The most common types of problem categories identified for the conference were pharmacology of psychiatric and medical drugs (28%), mental status effects of medical illnesses (28%), consultation psychiatry process issues (20%), and diagnostic issues (13%). Computerized literature searches provided significant assistance for some problems and less for other problems. The PBL conference was ranked the highest of all the psychiatry resident educational formats. PBL appears to be a successful method for assisting in patient management and in resident and medical student psychiatry education.