COMMENTARY

Closing the Office Door for the Last Time

Adieu Full-time Practice

Melissa Walton-Shirley, MD

Disclosures

October 01, 2018

October 19 will be my last full day in a cardiology office setting. I have requested and have been granted a PRN contract as a hospital cardiology rounder. There were many factors in my decision, but mostly I feel the need to be more available for my elderly parents, who live 90 minutes away and whose health is in rapid decline. My retired husband of 34 years is delighted (he thinks). My adult children worry that it’s still too much and wish I’d retire altogether. But I cannot fathom that notion because I am as much a physician today as I’ve ever been, and I am just not ready to let go.   

Dread and Tears

I look forward to doing more of what I truly love in medicine: acute and critical care. But as my final office day looms, dread steals any opportunity for exhilaration. Some patients who followed me from Kentucky to Tennessee have been under my care since 1991. Many bring small gifts during their last visit as tokens of appreciation. Genuine tears flow often, betraying any pretense of professional separation. I am grateful because I know during those moments that I have been blessed beyond measure. But I am also devastated. As with most physicians, my career is my identity.  

When asked what I was going to be at age 3, my reply was “a doctor.” I started working in hospitals and holding retractors at age 17, and I sutured my first patient at age 18. I loathed the first 2 years of medical school, but once in the hospital setting, I found my footing. I accepted an offer for a cardiology fellowship that I didn’t apply for (yes, that’s how it was done in those days).

I joined a wonderful partner, and together we opened a cath lab and with our associate helped champion primary percutaneous coronary intervention for our state. We convinced our city council to vote to become a smoke-free community. That was no small achievement in what was once the largest tobacco-producing county in the United States. My early practice life was great.

After 24 years in private practice, following upheaval in our medical community, I started a new job in a different state. This new physician group and talented partners restored my faith in medicine. I fell in love with my fantastic office staff. It has been a wonderful second career. But there were factors that started to impact family responsibilities.

Lost Control and RVUs

In private practice, I successfully reinvented myself a hundred times to meet the demands of life for a maturing female cardiologist. I navigated homeroom responsibilities for my daughters and hospital stays for my husband’s and parents’ illnesses with complete control over my schedule. I’ve enjoyed enormously my 14 years as a medical blogger, which requires attendance at international and national meetings. The downside of nearly all corporate models is that they don’t allow nearly as much latitude. 

The lack of a crystal ball to predict whether a patient will require 20 minutes or an hour-long visit has also taken its toll. I rarely finish on time and often run behind, but my patients have kept coming. They tell me they are happy to wait their turn because they know that I will look them in the eye, listen to them, and perform my exam without distractions. There has never been a laptop between us. “I’m afraid my next doctor will be a ‘Hi and Bye,’” worried one patient, waving to emphasize his point. No one intends to be that kind of physician, but we all feel the pressure to stay on the move. The massive construct that towers over the head of every acquired physician, a veritable Winchester Mystery House that never stops expanding, contains lots of hungry mouths that must be fed. In our group, though, I know he will find the right physician.

My lack of respect for the RVU model of office practice also makes me a Tyrannosaurus rex because I insist the word “value” should be removed from the initialism “RVU.” As we mature, we must accept that knowledge and experience are less valued than productivity is. Patient satisfaction and good outcomes, once the cornerstones of medicine, have been replaced by the pillar of reimbursement. The majority of physicians feel the same way, but we continue to allow ourselves to burn out, thinking the exit is always there if we need it. Tragically, some of us do not find it in time. Perhaps I have.

Betty and Stanley Walton. Courtesy of  Melissa Walton-Shirley, MD

Dutiful Daughter

…but the greatest of these is love. I Corinthians 13:13

My 88-year-old mother is suffering from dementia. She is living in the house where she was born and expects her parents to be in the next room. She will sometimes look inquisitively at my father and ask me, “Is he your father or mine?” When I reply, “He’s my father, Mom,” she is as disappointed as a 6-year-old, almost to the point of tears.

My mother’s physical health is also precarious. When a transient ischemic attack temporarily robbed her ability to speak, Dad had to spit aspirin into a teaspoon and force her to swallow it. In late August, while I was attending the European Society of Cardiology meeting in Germany, my father experienced an anterior vitreous hemorrhage in his left eye and an ischemic optic arterial occlusion in the right. He was left legally blind in the course of a month.

Our once-bustling 180-acre farm is going up for auction. The previously pristine fence rows are bordered by unruly thistle and broom sage. The stones that bolstered the old chimney of the original homestead erected in the early 1800’s are falling away.

We have a live-in sitter who works 24-7, refusing respite because she makes additional money for a little housekeeping and meal preparation on top of all her other tasks. She recently fell, though. Clearly, the mechanism for my parents to be able to continue to stay in their home is now a three-legged stool, with all three legs wobbly and unreliable.

Stanley Walton. Courtesy of Melissa Walton-Shirley, MD

My brother, a busy Realtor, and I are helping my father to make end-of-life decisions on a weekly basis. Dad accepted a do-not-resuscitate status for both he and Mom a few months ago. That decision prompted me to stop being selfish and to shift the balance toward being a daughter. I admit it is a sacrifice to give up some of what I love most in the professional world, but it is the right thing to do.

Because of my decision, I might get the chance to hold my mother’s or my father’s hand and comfort them as they pass from this life to the next. In their own way, they will provide a welcome distraction and comfort as I navigate my own transition. I am trying to be brave, but sometimes, the weight of my decision spills like a waterfall, sending me to find a place to hide my vulnerability.

My husband and daughters often remind me of the old saying that when one door closes, many more will open. On October 20, 2018, I will take a deep breath, step through another door, and begin the journey to find out if that is really true.

 

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