Psychiatry can help us understand what layers of the onion exist that need to be peeled away, but the power to discard them once and for all resides within each and every one of us.
PORTRAIT OF A PSYCHIATRIST
– Series Editor, H. Steven Moffic, MD
My decision to close my office practice was a result of being on call 24/7 for several years, but my consultation work continued. When I walked out the door of the hospital, I was free again. This was not so with my outpatients. (Yes, I call them patients, not clients.) Often, I would leave my office at 5 PM only to be met with several voicemails a couple hours later that required my attention. If certain tasks were left hanging during the day, I attended to them in the evening or early morning hours from home.
Often, instead of reviewing the day with my wife after we both returned home, I was stuck making phone calls to patients or doing various types of paperwork. Plus, it was not just voicemails on my office landline. There were messages on my emergency-only line; text messages on my cellphone; and emails. One night, as my wife and I sat on the couch together, she (kiddingly?) told me she was jealous I was returning messages from patients instead of interacting with her. This definitely planted a seed.
Path to burnout
Examples of “off-hour” duties (non-reimbursable tasks) included but were not limited to the following:
“I need to change my appointment.”
“I’m feeling more depressed (or anxious, or suffering adverse effects, etc).
“Can we change my medication?”
“It’s that time again, Dr Green. Can you mail out a prescription refill?”
“Can you fill out this 4-page form so that I can be approved for free transportation?”
“I need a letter excusing me from jury duty.”
“Can you send a letter to my boss excusing me from work for medical reasons?”
There were disability forms to fill out. Patients couldn’t get the medications they were already on or that I wanted to prescribe for them without my jumping through idiotic hoops in the form of “Prior Authorizations.” I needed to arrange authorizations and referrals for their visits with me. A stack of faxes from pharmacies for medication renewals had to be dealt with. So, a fax machine and a landline at home was a necessity. Otherwise, I would have canceled the household line and saved some money.
Yes, it’s true, I have brought some of this on myself as people say, “Why don’t you have a secretary do this stuff for you?” I always wanted to keep my practice simple, and that, to me, included not having employees, which would require yet another list of responsibilities and complications. I had adequate vacation coverage with a couple other psychiatrists earlier in my career.
In the last 15 years or so, however, my coverage had been a nurse practitioner friend who did the hospital consults for me when I was away. She had no office of her own and could not write scripts for benzodiazepines or stimulants. Therefore, before going on vacation, I ran through my list of patients who were on stimulants or benzos and mailed out prescriptions to those who would run out during my time away. On vacation, I checked my emails, texts, and voicemails for patients who contacted me, even though my outgoing message clearly said not to leave a message but to call back after my return or to call my coverage. Additionally, all these extra patient communications needed to be documented, copied, and pasted into their charts. More time.
Interestingly, easy accessibility was one of the things my patients loved about me. “You always get back to me.” “I know you’re always there if I have a problem.” I seemed to have a great reputation in my community as a psychiatrist, or at least that is what patients and colleagues told me.
Bottom line: I was burned out. I was on my own little pity pot of fatigue and despair. I felt like I had no “free time,” although that is a bit of an exaggeration. After 30 years of being responsible for more than 200 people’s lives at any given time and 24 hours a day, I just couldn’t do it anymore. Hence, the letter to my patients included the following excerpt:
“I am writing to inform you that, after 30 years in solo practice and recently much deliberation, I have decided to close my office practice on July 1, 2019 and will not be seeing anyone in the office after that time. Please know that helping you to care for your mental health has been a remarkable and gratifying experience for me, and I thank you very much for trusting me enough to play such an important role in your life. You have taught me much, just as I have tried my best to employ my knowledge base and caring motivation to assist you in improving your journey through the limited time we have on this earth.”
The responses have been enlightening. Certainly, this brings up issues for patients: feelings of loss, abandonment, jealousy, anger, fear, and anxiety. Many people tell me they are both “sad and glad.” They are happy for me in being able to move on to a new chapter in my life, but sad about the end of what, for some, has been a long and therapeutic relationship. Many use the word “friend.”
All my life I have used exercise to maintain physical and mental health, and if not for that, I probably would have suffered emotional collapse long ago. I used to be an avid runner, even including a few marathons. Then I had to stop running due to arthritis and a knee replacement. In my early 40s, I became attuned in Reiki and also decided to pursue my long-held interest in martial arts. I started practicing karate, eventually attaining a 4th degree black belt.
Along with that came an involvement with meditation and lots of reading about Eastern philosophy. After stopping running I was also looking for something else to replace its benefits, so I started doing “Power Yoga.” Then came an interest in teaching yoga. I became a CYT (Certified Yoga Teacher) and started teaching yoga on the side. Yang (karate) complimented by Yin (yoga), in rough terms.
My email address became: “healingpowerwithin,” signifying the belief that what we actually need in order to unveil the inner light and love, which is our true being, lies within us and requires a journey within that we have to take on our own. Psychiatry can help us understand what layers of the onion exist that need to be peeled away, but the power to peel them off and discard them once and for all resides within each and every one of us. Sometimes when patients see my email address, in addition to their spontaneous comments about it being “pretty cool,” it serves as a jumping off point for talks about meditation and spirituality.
While my psychiatry training back in the 80s involved learning the traditional therapeutic modalities, fresh ideas were added to the therapy tool box as I delved more deeply into Eastern traditions. I started teaching meditation workshops. I started recommending yoga, Tai Chi, acupuncture, and certain yoga asanas to my patients to practice in order to help them correct chakra imbalances that were contributing to their psychological issues.
My book recommendations changed. I still recommend that patients get certified in Reiki Level One, at least, so they can do self-Reiki. If I could make a living teaching yoga and self-defense classes, running meditation workshops, and doing Reiki, I would probably have gotten out of psychiatry years ago-but it is hard to replace with these other practices the income that a medical degree yields.
Filling in the cracks
As the process of extricating myself from the responsibilities of outpatient psychiatry continues, I find myself beginning to realize just how much of my identity resides in the fact that “I am a psychiatrist.” The transition will necessarily result in a reframe. Now it is more evident that I am “a man” (as Grasshopper in the Kung Fu series used to say, “I am just a man”) who has worked as a psychiatrist for 30 years and who is now involved in other activities in addition to continuing consultation work.
There is a certain feeling of emptiness and, to some degree, worthlessness creeping in. What am I if I am no longer “a psychiatrist”? What will it be like when I am no longer needed in this capacity? Certainly, I know of people who just kept practicing until they died, or at least until they were much older than I. One close friend admits that he continues in part because he doesn’t know what else he would do with his time.
Fortunately, not only will I still be doing hospital consultations for several more years, but I have these hobbies, as well as an interest in woodworking, music, gym, hiking, long walks, and relearning what used to be a fairly fluent knowledge of both Spanish and French. Volunteering at a local peer recovery facility would also help to fill the service aspect of life after private practice. Writing a book or two is also in the cards.
For those doctors about to embark upon their psychiatric career, I would recommend some thoughtful consideration of whether private practice is a good fit with your personality make-up. Make sure you have adequate coverage and consider whether you want an assistant for administrative tasks. Also, for those already practicing, it would be advisable to have some fallback avocations or hobbies in your repertoire before considering closing out a private practice. Take care, and Namaste.
Dr Greenis an office-based psychiatrist with hospital consultation/liaison responsibilities. He resides in Hingham, MA.