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

My brother bought a black suit when he married at 45, remarking, “I’m going to be attending a lot of funerals,” a reasonable proposition at my age. We lost several people close to us last year, prompting me to reflect on my own mortality: how would I like to be remembered; what music I’d like at my memorial; whether to leave an estate or spend it all before I go.

I remember wakes more than funerals. It’s not the line of people waiting to comfort the bereaved and pay their last respects to the dearly departed. Rather, it’s the visual tribute and chronology of a life that leave more of an impression, particularly if one had been acquainted for a relatively short time. We used to assemble photo collages on poster board; now images can be digitally uploaded to a computer and played on a wall-mounted monitor, complete with soundtrack.

It usually starts with the square black and white glossy snapshots from the 1940s or 1950s, shot with a Brownie box camera. We were babies or little kids and death was an abstraction that never crossed our minds. I notice the backgrounds more often than the subject, recalling my own childhood. Living rooms with obnoxious floral wallpaper that was once trendy. The sturdy couch, armchair and ottoman, covered in a short-napped, rust-colored upholstery that felt like a fresh buzz-cut when you ran your hand over it. Sometimes there was a heavy mantle clock which required winding with a key. It was made with wood and the chime was real, not electronic.

Kitchens had refrigerators with rounded corners and latches, white gas stoves with pilot lights, and gleaming six-inch ceramic tiles (ours were yellow with black trim). Most average folk didn’t have a formal dining room like the Cleavers or Dr. Stone and his wife. More often a chrome and laminate dinette set with vinyl-covered chairs sat in the middle of the kitchen. At least one photo had a kid in a high chair, or, as with my sister, sitting ON the table while pouring out the sugar bowl. Often a little one sat on the lap of a father or grandfather, dressed in a white T-shirt and dungarees, both of them smiling for the camera. Or the look was more subdued, suggesting Dad wasn’t quite used to having a squirming tax deduction. Grandmothers with short silver hair wore a severe, disapproving look behind those black, butterfly eyeglasses.  They always wore dresses; no jeans, slacks or pant suits. 

Photographs evolved with the lives they recorded, becoming color prints or Kodachrome slides, which held up much better than the Instamatic pictures from the 1980s that would fade into various shades of red and brown. Siblings sat beaming in front of a real Christmas tree with those big clip-on light strings, surrounded by toys we’ve forgotten ever existed. There were snapshots of First Communion and Confirmation if you were Catholic, or the full-body dunk if you were Baptist. (I’ve never been to a Jewish funeral but I’m sure Bar Mitzvah pictures are prominent.) The years roll on with memories of family vacations; eight grade graduation; the first car if the parents had money or, more likely, a shot of the first driver’s license. High school prom if you were one of the cool kids. High school graduation and impending adulthood. Be careful what you wish for.

The paths often diverged from here. Some went to college, then got married. A few married right out of high school and went to work. The bride and groom looked so young in those photos. Then they started having their own kids, assuming the mantle of parenthood from those now content to be grandparents. As one photographic cycle continued another one began. Before they knew it, those kids were grown with kids of their own and the roles shifted yet again.For the most part everyone turned out OK. Occasionally a wayward child turned into a troubled adult despite the best efforts, something no one wants to talk about. Even more tragic was a child lost to illness, accident or war, a premature departure that remains painful and triggers tears.

Photos became larger and sharper in the twilight years. Digital cameras eliminated the trip to the developer for prints. Smart phones then surpassed digital cameras and entire albums were a finger-swipe away. Many a parent converted a shoe box full of memories to a digital archive; but they would never be anything like the originals.

By now our grandparents are long gone. Our parents are leaving us one by one, sometimes later than expected as they live into their eighties and nineties, instead of having the big one in their sixties like they did when we were kids. Ironically that’s where we find ourselves now. We’ve come full circle.

The final episode of the original Twilight Zone was “Passage on the Lady Anne.” A young couple boards an aging cruise ship only to discover the other passengers are all quite elderly and find their presence unsettling. The pair is eventually forced off the ship and into a lifeboat, because this trip is, for them, premature. The others are sailing towards the Final Destination

We’re all booked on the Lady Anne. Sooner or later we’ll find a ticket in our hand, waiting our turn to board.