I worked as primary care internist until I was 66. EMR added hours to my day, and I was past exhausted. I had the joy of working per diem off and on for 5 years after leaving my full panel. Then I was diagnosed with cancer, which has recurred. I am on "maintenance" chemo, but unclear how long that will control the disease. Having cancer and seeing that death is not just something out there in some vague future, but in my foreseeable future is quite an altered perspective. With pacing, I am able to do most of what I want at this time. I have hope and faith, which sustain me. As to when to retire, remember, no one is irreplaceable, so chose what works for you. I worried about my patients when I retired until I remembered that they were not puppies and I did not have to find them all homes.
A geriatric physician has fewer total patients but a similar number of patient encounters. 800 patients would be considered to be a full time geriatric patient load. I myself, after 45 years in practice, have evolved into a geriatric practice doing house calls and assisted living only. My patient load is about 500. It is about a 75percent of full time practice but I am satisfied with the income. Decision making is easy, and much less stressful than seeing middle age patients in the office. I don’t think my situation is reproducible.
Occasionally I experience a very vivid dream in the early morning. These are so life-like that when things go awry, as they inevitably do, the nightmare feeling of a real-life situation spiraling out of control leaves me waking up terrified.
The other day I woke from one of these, in my dream I was in an exam room with new patient, a late middle-aged woman, she was there for her annual PE. As I took her history and filled in her empty EMR I became aware of TIME. The enormous job (completing the EMR, addressing the mandated screening requirements plus the all-important "issues" the patient wanted to discuss, then doing the physical exam, placing the appropriate orders and renewing her meds) was too much for the time slot we had.
In the real world I would have prioritized what had to be done now and would finish the rest later. As my practice matured these time deficits kept growing. Older, more complicated patients, more (and more complicated) screening recommendations, proper coding and the great "time-hog," navigating the EMR, each took more time. In the dream I could neither complete the job nor leave it unfinished so I woke up (in a cold-sweat).
In 2022 I turned 65 and I retired after 33 years of practice. Though I hadn't yet recognized the job I had once loved had morphed into something that still gives me the occasional nightmare I knew it was time to move on. In retirement I do a host of things that were impossible when my free-time went to finishing up what could not be completed in the exam room. I miss my patients and colleagues, I miss the satisfying feeling of making a diagnosis. But, I don't miss the pressure-cooker feeling that has evolved in the world of providing Primary Care.
800 patients--that's something! As someone not in the medical field, I may be laughed at for my personal perspective but here it goes. My best friend died at age 42 of a brain tumor. My dad died in 2020. I receive all kinds of signs from them and it's impossible to be coincidence. I think it was Einstein who said energy can neither be created nor destroyed. "I have never been more comfortable with the idea of my own death." A very thought-provoking post!
I'm your older brother. 79 next month and still working. Have always mixed practice and teaching with a good bit of administration. I think the mix has allowed me to avoid burnout. I did a med ed fellowship at U of C and loved it. I've been fortunate in family (6 "kids" and 14 grandchildren) and in health. I skied 10 day this year, always with family. I ride my bike daily and really like the next 6 months when I can ride outside.
I always had in interest in old people and now I've become one. Taking care of mature people, my colleague labeled me "the leading cause of death ." Yet there's something special about taking care of people til the end.
Yes, I think more about my own age limit. But nothing I can do about it and I try to think less about it.
Like many physicians I hope to die doing what I love, If my body and mind hold up. Our profession/vocation is a glorious one and we have been blessed to practice in what was the golden age of medicine.
You’ll know when it’s time to retire. Just do it, and start delivering Meals on Wheels. After five years of MOW, it’s hard to imagine anything more engaging and rewarding.
During my tenure as a hospice nurse, it is uncommon to encounter patients who are willing to endure any means necessary to prolong their lives, even if it entails being connected to life-support machines that maintain organ function. Even many of my younger patients, who are in their twenties and thirties, appear to be accepting of the knowledge of their impending demise. It is not that they desire death, but rather that hospice care provides an opportunity for them to discuss their mortality, formulate plans, contemplate their situation, and find peace. Conversely, the families of hospice patients often experience the most difficulty in letting go. They tend to advocate for every life-saving treatment, regardless of the patient’s wishes, and often prefer that their loved ones remain awake, even if it means withholding sedating pain medication.
Dying is a profoundly intimate experience, and if at all feasible, patients should have the autonomy to determine the manner, companions, circumstances, and so on of their passing.
I believe that Dr. Cifu may have been referring to our perspective as healthcare providers regarding our own end-of-life experiences. I do not believe that my chosen specialty influences my views on life and death, but rather that my advancing age has tempered my anxieties, increased my tolerance for others, and granted me a more contemplative perspective on the world.
Numerous spiritual traditions believe that preparing for death is one of the best ways to live. The Bhutanese Buddhist practice is to meditate on death five times daily (5 minutes each time). There's an app for that, believe it or not. I can't recommend it enough. Reviewed here: https://www.theatlantic.com/magazine/archive/2018/01/when-death-pings/546587/
The quote I wish I could add to the app:
Stephen Colbert: What do you think happens when we die, Keanu Reeves?
Keanu Reeves: I know that the ones who love us, will miss us.
I've always been somewhat comfortable with my own mortality. I used to think it was an atheist thing, but after seeing the hysterics atheists performed during Covid, I dunno anymore.
I find LIFE AT ALL COSTS people very strange.
If someone attacks me I will defend to the death of either, but I absolutely do not expect my Canadian expensive healthcare to be obsessed with my life/death.
Personally, I've come to understand that "healthcare" has become a ridiculous concept. Our Canadian *not free* (we pay for it from our pay checks) should be fixing the easily and quickly fixables, like broken limbs, and easily remediated ailments.
"Public" healthcare should have nothing to do with chronic illness, other than palliative, ending, and changing the society that causes the chronic ailment, studying those.
Take myopia. 99% of myopia is lifestyle. It's ridiculous.
We should not be creating lifestyles which require medical interventions.
Really well written, as an Oncologist I only realised in retrospect how frightening it is to be faced with death , it took a close family member to realise my shoes can change, and Boy they did.
Thank you sincerely for your wonderful posts , Bless You
I don't think the issue here is truly if we are momentarily terrified or not. I think the real unexpressed concern of this post is if that terror should be made policy, or should it remain a character trait.
Boy do I hear you! I honestly literally nearly died last week. Rushed to the hospital. No my life didn’t flash before my eyes. All I thought of was how much it would devastate my family if I died. I’m not ready. There are things I need to get done first to provide for my family. Don’t wait! No matter your age or your health. Get your affairs and documents in order. Do that one simple thing for your family. Tell a trusted family member where everything is and what to do and who to call. Please don’t leave it to them to figure out on their own.
I've worked with primarily older adults and the elderly during my second career as an RN. Memory care and now inpatient rehab for strokes and spines. Been through a blood cancer and the challenging (LOL) treatment to come out the other side with the expected complications. I still have my ADLs - activities of daily living - those basic, mundane functions we all take for granted until we can't. Some people want to live as long as possible and others - probably me - don't want to depend on others to toilet or feed me. I've seen people graduate from hospice and others who have had good deaths that I have attended and provided hands on care for during those last weeks and days. A good death? Family and friends visiting, expressing their love and respect, comfortable w/ the transition, even if the dying are unable to respond and are perhaps are unaware. Breathing soothed w/ morphine, anxiety soothed w/ benzos. Other meds that also provide comfort. Attentive and calm care for the dying's dignity. Change. Transition. Comfort. Dignity.
I'm one of those vax injured people. Can I prove it? No. But in a span of 16 months, I went from being perfectly healthy to having a heart issue, then having a lung issue, and then having a brain issue. Seems illogical to say it's just rotten luck given the conditions for heart, lung, brain, have sky rocketed. I'm 59. But it lit a fire under my ass to get my affairs in order. Trusts, wills, health care proxy etc. Also....I use Quicken's Lifehub and uploaded every instruction, password managers, documents, deeds etc so my wife/kids don't have to figure out everything. I hope to live a little longer, but my odds diminished greatly. So better to be prepared than not. And on this Good Friday, I've finally let go of the HATRED that I had for Fauci, Collins, Marks and his ilk.
As an older citizen , considered geriatric for many years now, I no longer even have a doctor and somehow ,it doesn't bother me: perhaps being in good health for many years after almost 20 years as a nurse in big teaching hospitals, then in the 80's, leaving that type of system and following the more natural approaches for good health choices and taking full responsibility for those choices ,I've come to a similar conclusion regarding the idea of death . Part of my grounding in these ideas are helped by my reading of the stoics and their ideas about many issues , one of which is health and certainly about death .
I’m not a caregiver, but I’ve watched a lot of people die. I’m always amazed by how tenaciously some/many of them clung to life. My parents died in their early 80s without lingering too long. I’ve lost 5 of 8 siblings, including my twin brother. He died as he wished, quickly, walking his dog. I’ve also lost a nephew and two nieces, one who clung to life on a ventilator for 6 months. There was never any hope for recovery but her children and parents simply couldn’t “pull the plug.” I have a sister, age 87, and SIL, a few years younger, with dementia, the SIL is advanced, doesn’t even recognize her husband. My sister’s husband, age 85, is completely disabled, can’t get out of bed, stand, or walk. They have to use a lift/transfer device (hover?) to move him to a chair. My sister and his daughter, a nurse, feed him because he can’t lift his hand to his mouth. He’s getting home physical therapy through the VA, but it’s clear to me and should be to all his caregivers he will never be even minimally much less functionally independent. Yet, he clings to life. I don’t understand it. I don’t approve of euthanasia, suicide, or assisted suicide, but if I were to get a life-terminating diagnosis, I would refuse treatment. I hope I go like my twin. In the meantime, I want to be as active and healthy as I can. I don’t mean to offend anyone, but I think doctors in general fail in encouraging patients to focus on remaining physically active. It’s like your purpose is to treat illness rather than promote health. Watching my BIL’s deterioration in the last 6 to 7 months has changed my perspective on healthcare.
I worked as primary care internist until I was 66. EMR added hours to my day, and I was past exhausted. I had the joy of working per diem off and on for 5 years after leaving my full panel. Then I was diagnosed with cancer, which has recurred. I am on "maintenance" chemo, but unclear how long that will control the disease. Having cancer and seeing that death is not just something out there in some vague future, but in my foreseeable future is quite an altered perspective. With pacing, I am able to do most of what I want at this time. I have hope and faith, which sustain me. As to when to retire, remember, no one is irreplaceable, so chose what works for you. I worried about my patients when I retired until I remembered that they were not puppies and I did not have to find them all homes.
A geriatric physician has fewer total patients but a similar number of patient encounters. 800 patients would be considered to be a full time geriatric patient load. I myself, after 45 years in practice, have evolved into a geriatric practice doing house calls and assisted living only. My patient load is about 500. It is about a 75percent of full time practice but I am satisfied with the income. Decision making is easy, and much less stressful than seeing middle age patients in the office. I don’t think my situation is reproducible.
Occasionally I experience a very vivid dream in the early morning. These are so life-like that when things go awry, as they inevitably do, the nightmare feeling of a real-life situation spiraling out of control leaves me waking up terrified.
The other day I woke from one of these, in my dream I was in an exam room with new patient, a late middle-aged woman, she was there for her annual PE. As I took her history and filled in her empty EMR I became aware of TIME. The enormous job (completing the EMR, addressing the mandated screening requirements plus the all-important "issues" the patient wanted to discuss, then doing the physical exam, placing the appropriate orders and renewing her meds) was too much for the time slot we had.
In the real world I would have prioritized what had to be done now and would finish the rest later. As my practice matured these time deficits kept growing. Older, more complicated patients, more (and more complicated) screening recommendations, proper coding and the great "time-hog," navigating the EMR, each took more time. In the dream I could neither complete the job nor leave it unfinished so I woke up (in a cold-sweat).
In 2022 I turned 65 and I retired after 33 years of practice. Though I hadn't yet recognized the job I had once loved had morphed into something that still gives me the occasional nightmare I knew it was time to move on. In retirement I do a host of things that were impossible when my free-time went to finishing up what could not be completed in the exam room. I miss my patients and colleagues, I miss the satisfying feeling of making a diagnosis. But, I don't miss the pressure-cooker feeling that has evolved in the world of providing Primary Care.
800 patients--that's something! As someone not in the medical field, I may be laughed at for my personal perspective but here it goes. My best friend died at age 42 of a brain tumor. My dad died in 2020. I receive all kinds of signs from them and it's impossible to be coincidence. I think it was Einstein who said energy can neither be created nor destroyed. "I have never been more comfortable with the idea of my own death." A very thought-provoking post!
I'm your older brother. 79 next month and still working. Have always mixed practice and teaching with a good bit of administration. I think the mix has allowed me to avoid burnout. I did a med ed fellowship at U of C and loved it. I've been fortunate in family (6 "kids" and 14 grandchildren) and in health. I skied 10 day this year, always with family. I ride my bike daily and really like the next 6 months when I can ride outside.
I always had in interest in old people and now I've become one. Taking care of mature people, my colleague labeled me "the leading cause of death ." Yet there's something special about taking care of people til the end.
Yes, I think more about my own age limit. But nothing I can do about it and I try to think less about it.
Like many physicians I hope to die doing what I love, If my body and mind hold up. Our profession/vocation is a glorious one and we have been blessed to practice in what was the golden age of medicine.
You’ll know when it’s time to retire. Just do it, and start delivering Meals on Wheels. After five years of MOW, it’s hard to imagine anything more engaging and rewarding.
During my tenure as a hospice nurse, it is uncommon to encounter patients who are willing to endure any means necessary to prolong their lives, even if it entails being connected to life-support machines that maintain organ function. Even many of my younger patients, who are in their twenties and thirties, appear to be accepting of the knowledge of their impending demise. It is not that they desire death, but rather that hospice care provides an opportunity for them to discuss their mortality, formulate plans, contemplate their situation, and find peace. Conversely, the families of hospice patients often experience the most difficulty in letting go. They tend to advocate for every life-saving treatment, regardless of the patient’s wishes, and often prefer that their loved ones remain awake, even if it means withholding sedating pain medication.
Dying is a profoundly intimate experience, and if at all feasible, patients should have the autonomy to determine the manner, companions, circumstances, and so on of their passing.
I believe that Dr. Cifu may have been referring to our perspective as healthcare providers regarding our own end-of-life experiences. I do not believe that my chosen specialty influences my views on life and death, but rather that my advancing age has tempered my anxieties, increased my tolerance for others, and granted me a more contemplative perspective on the world.
Numerous spiritual traditions believe that preparing for death is one of the best ways to live. The Bhutanese Buddhist practice is to meditate on death five times daily (5 minutes each time). There's an app for that, believe it or not. I can't recommend it enough. Reviewed here: https://www.theatlantic.com/magazine/archive/2018/01/when-death-pings/546587/
The quote I wish I could add to the app:
Stephen Colbert: What do you think happens when we die, Keanu Reeves?
Keanu Reeves: I know that the ones who love us, will miss us.
I've always been somewhat comfortable with my own mortality. I used to think it was an atheist thing, but after seeing the hysterics atheists performed during Covid, I dunno anymore.
I find LIFE AT ALL COSTS people very strange.
If someone attacks me I will defend to the death of either, but I absolutely do not expect my Canadian expensive healthcare to be obsessed with my life/death.
Personally, I've come to understand that "healthcare" has become a ridiculous concept. Our Canadian *not free* (we pay for it from our pay checks) should be fixing the easily and quickly fixables, like broken limbs, and easily remediated ailments.
"Public" healthcare should have nothing to do with chronic illness, other than palliative, ending, and changing the society that causes the chronic ailment, studying those.
Take myopia. 99% of myopia is lifestyle. It's ridiculous.
We should not be creating lifestyles which require medical interventions.
Really well written, as an Oncologist I only realised in retrospect how frightening it is to be faced with death , it took a close family member to realise my shoes can change, and Boy they did.
Thank you sincerely for your wonderful posts , Bless You
Love this!! I’ve also thought I wasn’t afraid of death….until I actually faced it. I was terrified.
I don't think the issue here is truly if we are momentarily terrified or not. I think the real unexpressed concern of this post is if that terror should be made policy, or should it remain a character trait.
Boy do I hear you! I honestly literally nearly died last week. Rushed to the hospital. No my life didn’t flash before my eyes. All I thought of was how much it would devastate my family if I died. I’m not ready. There are things I need to get done first to provide for my family. Don’t wait! No matter your age or your health. Get your affairs and documents in order. Do that one simple thing for your family. Tell a trusted family member where everything is and what to do and who to call. Please don’t leave it to them to figure out on their own.
I've worked with primarily older adults and the elderly during my second career as an RN. Memory care and now inpatient rehab for strokes and spines. Been through a blood cancer and the challenging (LOL) treatment to come out the other side with the expected complications. I still have my ADLs - activities of daily living - those basic, mundane functions we all take for granted until we can't. Some people want to live as long as possible and others - probably me - don't want to depend on others to toilet or feed me. I've seen people graduate from hospice and others who have had good deaths that I have attended and provided hands on care for during those last weeks and days. A good death? Family and friends visiting, expressing their love and respect, comfortable w/ the transition, even if the dying are unable to respond and are perhaps are unaware. Breathing soothed w/ morphine, anxiety soothed w/ benzos. Other meds that also provide comfort. Attentive and calm care for the dying's dignity. Change. Transition. Comfort. Dignity.
I'm one of those vax injured people. Can I prove it? No. But in a span of 16 months, I went from being perfectly healthy to having a heart issue, then having a lung issue, and then having a brain issue. Seems illogical to say it's just rotten luck given the conditions for heart, lung, brain, have sky rocketed. I'm 59. But it lit a fire under my ass to get my affairs in order. Trusts, wills, health care proxy etc. Also....I use Quicken's Lifehub and uploaded every instruction, password managers, documents, deeds etc so my wife/kids don't have to figure out everything. I hope to live a little longer, but my odds diminished greatly. So better to be prepared than not. And on this Good Friday, I've finally let go of the HATRED that I had for Fauci, Collins, Marks and his ilk.
As an older citizen , considered geriatric for many years now, I no longer even have a doctor and somehow ,it doesn't bother me: perhaps being in good health for many years after almost 20 years as a nurse in big teaching hospitals, then in the 80's, leaving that type of system and following the more natural approaches for good health choices and taking full responsibility for those choices ,I've come to a similar conclusion regarding the idea of death . Part of my grounding in these ideas are helped by my reading of the stoics and their ideas about many issues , one of which is health and certainly about death .
I’m not a caregiver, but I’ve watched a lot of people die. I’m always amazed by how tenaciously some/many of them clung to life. My parents died in their early 80s without lingering too long. I’ve lost 5 of 8 siblings, including my twin brother. He died as he wished, quickly, walking his dog. I’ve also lost a nephew and two nieces, one who clung to life on a ventilator for 6 months. There was never any hope for recovery but her children and parents simply couldn’t “pull the plug.” I have a sister, age 87, and SIL, a few years younger, with dementia, the SIL is advanced, doesn’t even recognize her husband. My sister’s husband, age 85, is completely disabled, can’t get out of bed, stand, or walk. They have to use a lift/transfer device (hover?) to move him to a chair. My sister and his daughter, a nurse, feed him because he can’t lift his hand to his mouth. He’s getting home physical therapy through the VA, but it’s clear to me and should be to all his caregivers he will never be even minimally much less functionally independent. Yet, he clings to life. I don’t understand it. I don’t approve of euthanasia, suicide, or assisted suicide, but if I were to get a life-terminating diagnosis, I would refuse treatment. I hope I go like my twin. In the meantime, I want to be as active and healthy as I can. I don’t mean to offend anyone, but I think doctors in general fail in encouraging patients to focus on remaining physically active. It’s like your purpose is to treat illness rather than promote health. Watching my BIL’s deterioration in the last 6 to 7 months has changed my perspective on healthcare.