My Turn to Present

To keep retirement from becoming too unstructured, I've enrolled in the Osher Lifelong Learning Institute, acronym OLLI, where I take classes two mornings a week and learn to play Mah Jongg late Wednesday afternoons.  One class, which I also took last semester, has the title Of Minds and Men.  At one time it was for men, but not wanting to jeopardize any access to funding, it has been co-ed for a while.  The enrollment is restricted to as many people as there are weeks in a semester so that each person leads the discussion one time.  I wanted to learn about Echo Chambers, but the sign up sheet got to me last.  Procrastinators being what they are, people captured their date from latest to earliest, leaving me with date at the beginning, which means picking a topic that already has familiarity.  Last time I chose exorbitant drug pricing.  This semester it's Electronic Medical Records.

It's one of those subjects that divides emotion and intellect.  It is hard to overlook the potential of maintaining data in an organized retrievable way.  With little effort I can see lab trends over years, know exactly which xrays are on file and review the reports easily and the images with a little more effort.  Calling up the notes, I know who saw each patient when, though the reputation of the note writer often screams Ignore this One.  Handwriting problems disappear.  Spelling is left incorrect so that future readers can figure out what I typed myself and what falsehoods were generated by the computer which performed better in spelling bee than I did.  Since most people have most of the elements of their exams normal and I pretty much examine everyone the same way, I can create a generic exam, leave what's normal, change what's not, and delete those things I did not examine on that individual.  I should be a great enthusiast, but like most clinicians, I am not.

It's tedious.  And since work is generally task based, the time distribution of the individual tasks that comprises with work day has redistributed in a less satisfying way.  I generally do not like telephone sessions for going over lab work or revising medicines.  The computer requires use of a template to document the call, expanding a one minute telephone encounter to a four minute telephone encounter, most of it filling out the template.  That means call time has to be more scheduled than previously, where a 1-2 minute span on the telephone could be squeezed into an odd moment, to say nothing of expanding the time that I like doing the least.  My records are not adequately maintained, particularly among shared users.  It is common to have a medicine list with three different doses of the same medicine.  The medicine list works on the Roach Motel principal, the pills check in but they don't check out.  Huge amounts of data to tease out successful from unsuccessful processes should capture my professional imagination, but that task and the design to do it goes to somebody else.

I do not know how much credibility I will have among the class, when the other doctor will not be there.  But I will convey the good, bad and ugly in its the most objective way that a person who sees himself as victim can overcome.

They're Mostly Gone

It had been a while since visiting the medical center from which I retired, maybe about six months when I attended a Grand Rounds there.  This time I dropped off school supplies purchased a little at a time at Back to School Sales over maybe twenty years.  As I organized My Space, loose leaf paper and binders at that volume would be classified as clutter.  The Sisters, though, collect stuff like this for the school children of the neighborhood so I transported a few boxes of this stuff to her.  The environment looked the same, not especially active but with enough people inside the building to require me to park on the garage's roof.  My old office had nothing going on other than a new neurologist joining in the previous month and one of the Medical Assistants nearing the completion of her pregnancy.  I learned that the hospital's CEO would be retiring soon and sent her a mixed congratulatory and thanks note when I returned home.

Recently the administrative alignment of the network subsidiaries had changed, an initiative of headquarters a few hundred miles away.  My guess is that it would make no difference to operations, as it is not the first shuffling, none of which have dripped down to the level of patient care.  However, among Physicians Network, the two head honchos had been figuratively beheaded.  Looking back, we've had several CEO's, Exec VP's, Chief Medical Officers for the network.  They seem to arrive as a group and mostly depart as a group, often suddenly enough to suggest the exit was not a voluntary one.  I suppose the salaries they pay are rather good but the duration of the salary not very long.  Moreover, nearly all who depart suddenly are at mid-career, or at least well short of customary retirement age.  I have no idea what type of Golden Parachutes are in their contracts but it would seem prudent to ask for one given the predictably short tenure.

The clinicians seem much more secure.  Since my exit, one hospitalist moved on, one orthopedist concluded his contract, and two more clinicians came aboard.  Perhaps we protest about the management more than we need to.  Time is on the side of the clinicians. 

Retired One Year

One full year has elapsed since turning in my pager and employee ID tag en route to retirement.  I've not been able to identify anything substantial about traits or activities that might make endocrinology specialists unique in retirement other than a paragraph from a 2008 review of the strained endocrinology work force:  https://www.healio.com/endocrinology/diabetes/news/print/endocrine-today/%7B511d7427-678b-42e0-9b7b-4e374fabc62a%7D/us-endocrinologist-shortage-affects-access-to-care-physician-satisfaction  It estimated that about 10% of endocrinologists at the time identified themselves as retired but did not elaborate beyond that.

I know a few others who have taken this gamble, though never exchanged updates.  At the Endocrine Society Annual Meetings, there are certainly people senior to me in attendance, largely men with successful research careers suggesting that the glory of science may be more alluring than contemporary exam room EHR medicine which requires a more defined end point.  While the daily pageant of the hospital and multispecialty Physicians Network goes on without me, though I still get an occasional phone request for some guidance, the interests pursued and the experiences acquired over most of my adult lifetime continue to express its imprints, sometimes in unanticipated ways.

My journals still fill my mailbox, one paid subscription, one as part of a professional membership, and a few others unsolicited.  I actually read more New England Journal of Medicine articles now than when I was working, not having the distractions of office appointments, lab reviews, phone calls, commuting, et al.  I especially enjoy the many endocrinology studies and reviews along with the opinion perspectives and Case of the Week.  The Cleveland Clinic Journal and the Mayo Clinic Proceedings get some attention most issues.  The authors are more my colleagues in absentia perhaps.

Grand Rounds, which was too inconvenient for me most weeks while juggling patient responsibilities, has become a destination.  I am on the notification list of the center from which I retired and a closer one nearer to my home.  Having attended those that interest me, more about the practice of medicine than endocrinology or any other clinical subject, the audience has changed.  People at mid-career seem woefully under-represented at both institutions, likely for the same reason that I rarely went.  In its place I see residents in a swarm of white coats who would get a demerit if they read charts or examined patients in this alloted time and physicians of late career or post-career.  To restrain my often wandering mind, I jot down some questions as the presentations proceed and usually ask one after the lecture.  The answer from the speaker may be all the professional verbal interaction I get for quite some time.

Professional society memberships pose a dilemma, since they cost money that exceeds tangible benefits.  I was going to let the Endocrine Society Membership lapse.  They do not publicize their post-retirement discount which I learned about only after sending a note to their membership VP that I could no longer afford renewal.  Their retirement age exceeds both Medicare's and mine, so they will likely be forced in the near future to adapt to physicians who call it quits prematurely as burnout creeps into Endocrinology as it has with ER or primary care.  We came to an agreement, pony up full dues one more time and then half-dues.  I receive their Journal, not read much beyond titles,  and some on-line updates that are especially well done.  Philadelphia also has the first regional Endocrine Society in the USA.  That one I maintain.  Nominal membership, great presentations each month, OK buffet dinner with a glass of wine, and most importantly colleagues to entertain me with the travails of being a doctor, for which I can now be fully sympathetic.

And when I take a class at the Osher Lifelong Learning Institute, I find myself frequently the useful doctor in the room, that person who understands the difference between vaporized nicotine and combustible tobacco, how AIDS in Africa affects the population differently than AIDS in America, and why their prescriptions have become prohibitive in price.

Among my most valued possessions as a functioning physician, not adequately appreciated at the time, was my privacy in the form of a big desk in an office with a closable door and mezzuzah on the doorpost, that personal Holy of Holies.  It took six months of decluttering and rearranging furniture but My Space has become a reality at home too.

While it can be difficult for physicians who were challenged by the demands of their careers to escape its imprints, a certain amount of cerebral decluttering needs to occur.  This begins as retirement is being prepared.  Marie Kondo of popular streamlining culture asks, "does it spark joy?"  ABIM modules and the fear of a high stakes exam did not.  Phone requests for peer to peer reviews when the right thing to do was rejected by somebody less capable than me never sparked joy.  It's hard to think of anything less a source of spiritual ecstasy than our office Electronic Record.  All delegated to the professional shredder.

Even after exiting the medical workplace, the clock and customary waking times remain the same.  Some physicians developed passions rationed by their clinical responsibilities.  Fishing or the motorcycle could easily expand.  I suspect, though, that most people are like me, the medical identity remains paramount, though not exclusive.  There are limits to how much I want to visit my kids who have first entered the medical orb.  If  I wanted to see Australia,  my job provided me vacation time and ample funds.  Not going there had nothing to do with my work schedule.  As consuming as professional obligations were, I never felt that other interests were seriously neglected as a result.  I have maintained my two blogs, each started years ago: http://consultmaven.blogspot.com for the medical thoughts and http://furrydoc.blogspot.com for the non-medical, neither expanded in a meaningful way.   This makes replacement of the daily schedule, once largely specified, now not so much, all the more challenging.  When I would head home on the interstate each evening, I knew I accomplished some very worthwhile things through my diligence.  That forced accomplishment transitioning to voluntary achievements may be the most difficult element of retirement for me this first year, and likely for many other physicians.

Would I have it any other way, though?  Not a chance.

Visiting Command Central

Sometimes to my credit, sometimes to my detriment, I've never been timid about expressing my thoughts when I've done enough homework to surpass any threshold of expected knowledge.  Not at committee meetings, not on Social Media, and in recent years not in writing.  There is no shortage of medical and science schmutz getting generated for the susceptible readers who have their own agendas.  Anybody, including me, can bypass an editor via the blog option where all but the most venal commercial deception gets free speech protection.  We lack appropriate filters, sometimes restraints, sometimes learned rebuttals.  Everyone who knows the letters on a keyboard can pretend expertise, reinforced by spell-check to add the illusion of education.

My good friend and his daughter, accomplished authors and scientists in their own right, established an organization which they named Critica to intercept some of the scientific drek, whether well intentioned or malignant, that finds its way to people's minds via the screens that we now all have.  As he seeks associates, he connected with the operator of a kindred mind and soul who created Retraction Watch to organize science reports that are mostly intentionally flawed, or at least fall far enough below honest errors to arrive at public journals prematurely.  Since this might be a good shidduch for his project, he set up a meeting and invited me along.

Retraction Watch might be the baby of this rising star of medical journalism, but his day job is VP of Medscape.  We met at his headquarters.  While I have been submitting monthly essays to Medscape for my Hormone Happenings series, I had never been to headquarters.  Impressive place and impressive person.  Being a subsidiary of WebMD, the business occupies two floors of a Lower West Side building in Manhattan in a neighborhood that has a gentrified look.  Major security at the front door where they took our pictures and gave us badges.  On to the 3rd floor.  Figuring this was a NYC business, I carried a tie in my jacket pocket but my friend advised me no ties.  It really was no ties.  The reception area appeared plush.  They had a snack bar right out front where employees would saunter by and take what they want.  Nobody wore a tie.  Some did not even have a collar to be kept open.  No shorts, though.  And everyone looked young, most in a hurry to get their soda from the fountain and move to their next place.  An escort took us to our meeting place, the office of the VP.  Ultra sleek, along a side wall of a big space with computer flat screens lined up cheek to jowl.  Surprisingly few people sitting at the screens.  Walls were white, art sparse but colorful.  Our host did not wear a tie either but he had a dress shirt with buttons.

Our meeting proceeded for its allotted time, then we were given a shortcut back to the lobby.  En route, we stopped at one of the many white circular tables to plan our next step, again a modern, tasteful space undoubtedly created to float important ideas.

I've always like the places I worked as a physician.  They have a certain formality, whether office, exam room, conference room, or hospital.  But even at a university, I've not worked at a place designed for collaboration.  Increasingly medical work, or the patient care element, is formally defined by appointments per hour, a fixed conference schedule, an administrative half-day.  The more free-wheeling environment of Medscape, and I understand other creative enterprises that depend on savvy young people hired to generate and implement ideas, is something I might have found very alluring in my younger years, maybe now.  As physicians burn out more largely by the restricted working conditions with their unwelcome impositions, perhaps some of the senior policy makers of the medical world should schedule their own meetings with places like Medscape for better options to keep a young work force more enthused about what they do.

Research Subject

When I was on staff at a large medical center, the CEO established four core values for the institution which he arranged in a diamond pattern, safety at the apex, think of yourself as a patient at the bottom corner.  While it seems hard to assess how seriously this mission statement was taken, or if anyone really remembered which value went in which corner, the institution expanded and he got to retire shortly after my departure to a different institution.  Thinking of yourself as a patient usually includes not wanting to be one.  Fortunately, medical care is not all rescue from misfortune.  Research abounds.  If American health care underperforms markers of access and outcome of other countries, our laboratories sparkle like no other.  We have assigned once dreaded diseases to the medical history books, made pneumoencephalography obsolete, and have transformed our biochemistry courses from understanding metabolic pathways to understanding the molecular basis of diseases.

Having watched patients on Medicare assign their too frequent doctors' visits to their prime social outings, I resolved on retirement that I would find other reasons to venture out of my house.  The Osher Lifelong Learning Institute became a valued destination.  While the ties to the state university are generally loose and subordinate, they are not absent.  As our health varies from unimpeded to not entirely independent, we make for a good pool of research subjects to enroll in several ongoing projects at the university's expanding health institute, which does not yet have a medical school but promotes allied health professions training in a big way.  Seeing a project on mental acuity, my son's neurology fellowship pursuit, I opted to sign onto one of the research protocols.  Since I can drive my car safely in all but highly flooded weather and never have to hit the alarm option on the key to find it in the parking lot, they designated me a Control.

While I've done mental status assessments as part of history taking for my entire career, I was not prepared for the sophistication of the battery that came my way.  Lists of words, unrelated, floundering at first but able to put the unrelated single words into a few categories.  My memory is mediocre, attention span so-so, ability to learn verbally very good.  They showed me shapes and had me place them back in order.  I named each shape, then put each back on the screen.  Right sided spacial reasoning did not go as well.  I had to find an object but could not relate fixed landmarks that would enable me to find it when hidden.  I was also not allowed to move the joystick backwards.  What I did instead with limited success is the fishing technique of fanning.  Having no idea where the fish are in the pre-electronic age, we would cast repeatedly in a semicircular pattern from our starting point.  It got me to the target about a third of the time.  I'm just not right-brained but my spacial orientation is adequate to drive safely, though I still struggle to parallel park.

Finally the uncontrasted MRI.  An hour's relaxation with a supine posture, slightly itchy nose that had to wait, noises that reminded me of a confined contraption at an amusement park and an occasional instruction from the technician as there were some dynamic elements.  At the end, I read my scan.  An empty sella, I think, More cerebral atrophy than I might have predicted from my still pretty decent intellect, and no masses or asymmetry.

In another month we get to part 2, an exercise test for which I am self-training on my treadmill with decent compliance and another battery of psychometrics.

Medicare folks whose office visit is their periodic home escape often make a day of it.  I thought about doing that too, especially since I still had 40 more minutes before the next parking surcharge.  Looked for lunch on campus.  Too expensive.  Went into their 5&10, a dying breed, dominated by University logo items.  More than I wanted to spend.  Paid the parking fee and went home.

Medical School Scholarships

Having retired and wanting to stay busier than a Maytag repairman but not as busy as and endocrinologist, I volunteered to review college scholarship application that a local charitable foundation manages for a variety of donors.  It was one of my more fulfilling tasks, 61 submissions, every one of them worthy of consideration.  There really are some terrific young folks floating around.

While the scoring of the applications was done on my computer on my kitchen table, a meeting was held to decide who gets the monetary awards.  At the conclusion of the session, I received eight more applications to review, these from current or entering medical and dental students seeking assistance from two available sources.  Each awards $2-4000 a year, which probably would allow the student to choose between a microscope and auto insurance but still leave each with a lot of loan debt.

While the high schoolers entering college had transcripts and SAT's, medical students with one year under their belt have a series of Passes.  High school transcripts have honors and AP courses.  Medical students all take the same curriculum and the description of the curriculum has lost much of its delineation to anatomy, physiology and histology, instead being lumped as either an organ system or the more amorphous introduction to being a doctor with no discernable curriculum.  As a result, I was left to evaluate personal statements.  Everyone wants to become a doctor for similar reasons.  Where the applications separated was by intended specialty and the background that generated that decision.  Again, some very good kids.  I was asked to rank them 1-8, which I did.  Probably 6 of the 8 would be competitive for the awards.  Choosing which is somebody else's task. 

Batting 1.000

Somebody did a study, or maybe did a meta-analysis of multiple studies, on how physicians view their work.  We get enthused about 25% of the time, despise 25% and the broad middle takes up the rest.  What goes at each end varies a lot.  I did not like returning phone calls or reporting lab results over the phone.  I basically dreaded the phone.  I did find the residents energizing, even when exasperating.  On occasion one doing an elective with me would request a letter of recommendation for fellowship.  I never turned anyone down.  Most but not all were for Endocrinology fellowships, but if somebody was knowledgeable and diligent, the specialty did not matter if they were pursuing their 25%.

From the first in 1993 all the people I sponsored matched to a fellowship, often their top choice.  Only one ever called me a few years later to let me know of successful specialty board results, but I have seen a few at the Philadelphia Endocrine Society meetings, some as invited presenters of their fellowship research, to know that the good things I predicted for them were true.

My last letter, however, was left in limbo.  A fine second-year resident spent a few weeks sharing the office and hospital.  At the end she requested a letter which went off with the assistance of the residency office that had to guide me through the current electronic submission system.  I retired, heard nothing, and really did not think about it until last week.  Did my letters still score 100%?  I sent a note off to our program director who got back to me with the good news.  A match at one of the universities in Philadelphia.  Not endocrinology but something else of interest to her, a specialty not represented at my hospital.  Bodes well for the future.