William E. Byrd, MD, FACP

Editor’s Note: The following is a fictional memoir demonstrating the problem of more physicians having to practice medicine longer, well after their clinical skills and mental faculties have declined, because of the continuing recession and dramatic changes in our healthcare delivery system. We hope that you enjoy reading this special commentary, and we welcome your comments.

So Pharaoh awoke, and indeed, it was a dream. Now it came to pass in the morning that his spirit was troubled…. Genesis 41:7-8

At age 58, I began experiencing a series of repetitive dreams. I would be studying in my dorm room for college finals. Although I did not attend classes regularly and was not the most conscientious student, I became disturbed when I could remember neither the times of my classes nor the buildings where they were held. However, since I remembered that I had 2 weeks before my first exam, I simply sharpened my pencils and sat down at my desk. This is where the dream abruptly ended. Although I could not extract any deep meaning from the dream, I was puzzled by its recurrence.

At age 60, the dream changed. I would find myself stranded in a deserted industrial area or on a country road at 3:00 AM. I could not remember my name, address, or the names of my family members. Occasionally in the dream, a car would stop next to me and the driver would ask if I needed help. I would simply tell him that I was getting some fresh air and that I was fine. I would then awake in a cold sweat. I began to worry. Around this time, my internal medicine practice was very busy, and recovering from all-night medical calls was taking its toll, both physically and mentally. On several occasions, I had mental lapses, forgetting important details of a patient’s history and frequently confusing doses of standard medications. Because I had always treated nurses well, they would cover for me, suspecting that I was stressed and overworked.

Fortunately, our medical center had recently acquired hospitalists, allowing me to devote myself exclusively to outpatient medicine. I had been in practice for over 25 years, and so, I had a large stable of patients, many of whom I had been treating for 2 decades or even longer. I was essentially on autopilot. New patient consultations, however, became a concern. I could no longer offer an extensive differential diagnosis, and occasionally, I confused one patient for another. As these problems started to arise, the words of one of my residency attendings came back to me: “You are not a surgeon who can rely on motor skills; you are an internist and the only thing that you can bring to the table is your intellect. If that is faulty, you need to quickly get out of the profession before you harm patients.” I took this sage advice and began to refer more of my patients to specialists for medical problems that I had been able to handle easily in the past. At that point, however, I wasn’t thinking about retirement. Financially, I needed to work 2 or 3 more years due to my recent heavy losses in the stock market, which could not be reversed overnight.

I became concerned that I was developing Alzheimer’s disease. None of my family members had experienced early-onset dementia, although both of my grandmothers became senile in their mid-80s. I remembered that my father, who retired as an executive, had become distraught when he no longer had a photographic memory; however, at that time, he had metastatic colon cancer requiring chemotherapy, radiation, antidepressants, and narcotics for pain. I thought briefly about getting a brain magnetic resonance imaging scan, but decided that it might be career-ending, particularly if it demonstrated severe cerebral atrophy or multiple lacunar infarcts, which, most assuredly, would adversely rate me for insurance purposes. I had a shelf full of donepezil, memantine, and rivastigmine in my clinic, but decided against self-medication. Despite referring many of my patients, I was still having problems. Certain questions from patients began to alarm me, such as “When are you going to retire?” I didn’t know if they were preparing to find another physician or if they thought that I was slipping. This made me realize that I needed to start thinking about an exit strategy.

I certainly did not want to experience a late-career malpractice suit or have to respond to the State Medical Board regarding perceived inappropriate behavior. I thought of celebrities who had stayed in the limelight beyond their prime. Mark Spitz, for instance, won 7 gold medals in swimming at the Munich Olympics when he was in his 20s, but could not qualify for the Olympic team in his 40s, despite an intense training regimen. I had an obligation to my patients to cease practice when I became impaired, but how was I to exit gracefully?

I was uncertain of my financial future and had hoped to work longer to replace some of my stock market losses, but that was not to be. The hospital—surprising to me at the time—made me an attractive offer out of the blue, guaranteeing my salary for 1 year after the expiration of my contract. As a younger physician had already been hired to take my place, there was no offer to work part-time after my contract expired. As I had not expressed any of my concerns or problems to anyone, I couldn’t help but wonder whether one of my patients had contacted the hospital administrator about the erosion of my clinical skills. And I also questioned why no one asked me to help search for a replacement for my practice after almost 3 decades of practice. These questions remain unanswered. At my retirement party, many of my patients came up to me and expressed gratitude for the care rendered to them over the years. I remembered most of their medical problems, but not their names. It was the right time to leave.

Dr. Byrd is in private practice in Roanoke Rapids, NC.