Layout 1 Before you can become a good storyteller, you first must be a good listener. Practicing clinical ophthalmology for 38 years allowed me to absorb the stories of my pa- tients. Showing them signs of trust - a firm handshake, a smile, a facial expression of concern - let them know that I was there for them from the beginning. They appreciated that they had my undivided attention as they described their symptoms and their fears. Worrying about going blind can shake you to your core. As a physician, I con- sidered myself a teacher, as well as a healer. I worked hard to explain the nature of a patient’s condition so that we both understood what was going on and the plan to correct or ameliorate the problem. After a long and rewarding ca- reer in private practice, I concluded that the next greatest gift a physician can give a patient, other than a complete cure, is following this formula: provide an understanding of what is going on, delivered in simple terms with com- passion. Fundamentally, the job of giving care to others begins by showing respect while listening to the patient before arriving at a judgment. Recently, I discovered the book In Search of Wisdom1 written by a monk, a philosopher and a psychiatrist. Christophe Andre, a French psychiatrist who writes self- help books, describes the characteristics of true listening that consist of: i) respect for the other’s speech; ii) letting go; and iii) the ability to allow oneself to be touched emo- tionally. He observes that listening is a process similar to humility, in which one puts others before oneself. In true listening, you do not prepare your response - you just listen and let go. As a doctor in a large group eye care practice, I viewed my responsibilities to my patients to include not just professional competence but empathy. However, in the twilight of my career, certain stressors of life in general, and of medical practice in particular, challenged my inner- most thoughts of personal strength. They ultimately forced me to seek a professional who would listen to my story. In 2015, I began to think seriously about winding down my practice. I had lost my father the year before. My mother required constant help at her home in Arizona. I felt the emotional tug of a distant son as I discussed her medical condition, complicated by falls and recent major abdominal surgery, with her physician. An extended leave of absence from my practice might have been granted, but as a partner, being away from work meant that I would continue to pay for my share of the overhead expenses of the entire practice. Moving toward part-time work would help free me from the obligation of paying for practice overhead. Tension grasped me each night as I struggled to envision myself as a part-time employee rather than a managing partner. Rather than opting for a salary, as our office docu- ments stated, I preferred to receive a percentage of col- lections for my services. In that way, I would have an incentive to earn more, and the practice would not be pe- nalized for paying an inflated salary if I had a light sched- ule. Such an arrangement would make a leave of absence easier. The lawyer I met with asked me for my wish list, a package of wages and benefits that he would bring be- fore my partners in a letter to our practice’s attorney. By the summer of 2015, I received verbal assurances from my partners that a mutually acceptable contract was imminent, once the practice’s attorney spelled out the de- tails. From July until December, I waited. When the pro- posal finally arrived, I objected to the language for part-time work. Unlike the provisions previously agreed to, the proposal allowed for my termination at the discre- tion of the partners, whether or not for cause. That was a deal-breaker for me. According to the proposed agree- ment, I would become an ‘at will’ employee with no guar- antee that I would not be fired or replaced by another physician. The back and forth between the lawyer repre- senting the practice and my counsel created an atmos- phere of ‘us versus him’. The resulting uncertainty kept me awake at night. Just before Christmas in 2015, I in- formed my attorney and my partners that I would remain a full partner. I maintained that status until I later signed Winding down, facing up: Insights gained on the road to retirement Paul Pender Medical Doctor, USA Correspondence: Paul Pender, Medical Doctor, Bedford, New Hampshire, USA. E-mail: paul@paulpendermd.com Received for publication: 20 September 2019. Accepted for publication: 11 October 2019. This work is licensed under a Creative Commons Attribution Non- Commercial 4.0 License (CC BY-NC 4.0). ©Copyright: the Author(s), 2019 Licensee PAGEPress, Italy Qualitative Research in Medicine & Healthcare 2019; 3:120-123 doi:10.4081/qrmh.2019.8572 [page 120] [Qualitative Research in Medicine & Healthcare 2019; 3:8572] Qualitative Research in Medicine & Healthcare 2019; volume 3:120-123 No n- co mm er cia l u se on ly a part-time employment agreement that contained terms I could live with. I felt considerable stress leading up to that final doc- ument. Delays and vague language characterized the at- torney’s emails as we looked to finalize an employment agreement for both a new partner and for me as a part- timer. Both documents were completed and signed by the end of 2016. The difficult, drawn out process of becoming a part- timer left a bad taste in my mouth. Within a few months of that major step toward winding down, I was notified that two surgeons planned to do their surgery outside our practice facility in a larger Ambulatory Surgery Center (ASC). The new entity could accommodate procedures more efficiently with two operating rooms, rather than a single room in the Surgicenter I had built. Their decision ultimately led to the closure of my center, the first ASC established in New Hampshire in 1984, which had served as the facility for thousands of successful eye surgeries. The disappointment I felt was profound. I felt blindsided by their decision. Lack of consideration for my investment in equipment and in the facility infra- structure hurt me personally and financially. “It’s all about the numbers” was the conclusion of the surgeons who were abandoning the facility I built as a solo surgeon. The de- parting surgeons were under no financial or contractual ob- ligation to use the facility I had established a generation ago. They had simply outgrown the space. If I were to con- tinue doing surgery, I would have to become credentialed at the new facility and compete with my partners for block time on the surgery schedule. With self-interest paramount, my partners expressed the hope that the surgical staff would remain at my Surgicenter until it officially closed and the new facility opened. They had been given an ‘offer they couldn’t refuse’ by the director of the facility owned jointly by a hospital and group of surgeon-investors. I learned to my chagrin that my partners’ plans for their future did not agree with my plans for winding down. I felt anger for not having received some indication of their thinking before it was a fait accompli. I was at the top of my surgical skills and experience, and I resented having to quit my surgical practice prematurely. I at- tempted to maintain my equilibrium at the office, but my emotional state was volatile. After work, my wife would weather my complaints about the future of my practice. The incremental disappointments and setbacks seemed to have a cumulative effect, stealing the pleasure I once felt going to work. My sense of a loss of control reached the level of professional burn out, and I told my wife that I would seek counseling. Knowing how low my spirits were sagging, she thought it was a good idea. I called the confidential hot line at the New Hampshire State Medical Society reserved for doctors looking for so- lutions to their personal problems. Although I had expe- rienced neither substance abuse nor compromised care of my patients because of my state of mind, I understood that I had to get out of my funk. On the hotline, I spoke to a doctor I had previously met at a county medical society meeting. She gave me the name of a counselor in the Boston area who specialized in dealing with members of the medical profession, especially those feeling the effects of professional burn out. Before my appointment with the behavioral psycholo- gist, I reflected on my altered professional status over the preceding several months. Winding down meant having to accept a lesser role in the management of my practice, something my ego resisted. Giving up surgery was another blow to my self-esteem. And referring my patients for their operations to the same people whose decision drove me to quit doing surgery was especially humiliating. I drove around the psychologist’s neighborhood until I found the correct address of her home office. I parked on the street, looking at her front door, thinking about how I got to this point. I had reviewed an online checklist2 for symptoms and signs of depression: persistent sadness, self-loathing, loss of interest in activities, irritability and isolation, anxiety, loss of energy, disturbed sleep, change in appetite or body weight, reckless behavior and suicidal tendencies. Although I did not think about self-destruc- tion, I figured I scored on half of them, and that frightened me. Each night I consumed junk food while watching meaningless sports on television to escape my dark mood. I was embarrassed to admit I needed help. Despite all my training and surgical experience, I no longer felt like a bulletproof control freak. I waited until my appointment time, then locked my car and walked to her front door. The counselor welcomed me and showed me to her living room where the only other occupant was a Golden-doodle the size of a pony. We became instant friends, that dog and I. Is it a good sign that your dog likes me? I asked the psychologist. She smiled and said, Sure, but don’t raise your voice. We had a good conversation, or more accurately, I got a lot off my chest. I felt the disappointment of shattered plans for succession at my Surgicenter. I felt slighted for not having received an apology for the disruption my part- ners caused by their decision not to become investors in my facility. While their decision appeared selfish to me, the psychologist suggested that all businesses have a cycle and mine was coming to the end of its cycle. That com- ment gave me a new perspective on my predicament. I thanked her for her time and support. She asked how I ex- pected to transition to the role of a part-time doctor who no longer performed surgery. I felt that I was still at my peak of surgical skill, but if I had to give up my surgical practice due to closure of my Surgicenter, I would con- centrate on what still gave me pleasure - patient care. She then gave me some advice that would change me forever. I think it would help you to write. You articulate your situation very well, and others could gain from your ex- perience, she said. [Qualitative Research in Medicine & Healthcare 2019; 3:8572] [page 121] Special Issue on Physician Mental Health No n- co mm er cia l u se on ly Thanks. I’ll give it serious thought, I replied. The drive from Boston to New Hampshire gave me an opportunity for greater reflection. I turned off the radio. On the highway, I drove in the slow lane for a change, uncon- cerned by the speeding cars on the left. As I drove home, in the solitude of my car, I had a wake-up call. I had a choice: either I could remain miserable in my attitude and finish my career in a negative state of mind, or I could face up to real- ity. Winding down came with the advantages of more free time, but it required a lessor role in decision-making in my practice. Not having to attend partners meetings as a part- time employee meant others would be running the practice. Letting go of major partner responsibilities necessitated handing those duties to others, and I had to accept that fact. My partners, free agents to choose where to do their surgery, were beyond my influence. The “wow!” my patients had expressed the day after I removed their cataracts would dis- sipate by the time I examined them postoperatively as a re- ferring ophthalmologist. Sure, they would appreciate my attention to their needs, but mine would become a support- ing role in their surgical journey. If I truly cared about the experiences of my patients, I had to accept that my care would become more limited in scope. I was determined to get back on my horse after being thrown. I had not suffered serious damage from the fall, but I had been shocked and stunned for a time. I had suf- fered from events beyond my control, but I chose not to remain a victim. And I began writing about my thoughts, feelings and experiences as a physician and how they helped to shape the person I am. I received a statement from the psychologist for my only session, and I paid it with a sense of finality. She said that I could FaceTime her if needed, and I thanked her for her offer. The most important attitude adjustment for me was to once again feel comfortable in my own skin. Worry is very destructive. Anger uses up a lot of energy. The fight or flight response is natural, but when it occurs at inconvenient times it makes for a long, sleep-deprived night. I vowed to finish my tenure in practice by deliver- ing the best care I could offer my patients. As I was winding down my career as a doctor, I envi- sioned myself as a successful writer, and I took steps to reach that goal. I attended annual meetings in 2018 and 2019 on Writing, Publishing, and Social Media for Healthcare Professionals directed by Julie Silver, MD, of Harvard Medical School. My impressions of the 2019 meeting were published on KevinMD July 21, 2019, an excerpt3 of which follows. After finishing the pitch for my book, Making Lives Better: How Mentors and Patients Inspired a Doctor’s Work at the recent Harvard Writers’ Conference in Boston, I felt relieved and encouraged by the judges’ com- ments. As I waited for my turn at the podium, I glanced above my notes over the faces of 300 of my fellow atten- dees who had accomplished so much in their respective fields of medicine, nursing and counseling. “The pitches made by these would-be authors re- vealed an amazing resilience to the human condition. One attendee had been put up for adoption and became a pros- titute in order to survive his surroundings. Another speaker, a physician father, reported his son’s road to ‘re- covery’ from heroin addiction, captured in his late son’s journal. He proposed ways for parents to intervene before it is too late. The meeting erupted in applause when he finished his pitch. Women described ways for becoming ‘badass’ to face discrimination and attempted sexual ha- rassment. How to overcome psychological and physical wounds became a recurrent theme. The challenge for many of those pitching an idea for a book in 70 seconds or less involved relating individual stories of triumph over tragedy. Often, the presenters ex- posed themselves to an emotional cauldron to bare their hearts and souls to fellow attendees. Pitch coaches labored unselfishly to strengthen what we proposed to write without a hint of condescension. These committed professionals led us on a journey of cre- ation, improvement and commitment. They gave us confi- dence in our work and mission. If we do not believe in our work, who will? The course organizer created a support- ive environment for stretching our talents and for surren- dering control to the experts. The energy level of attendees was unlike anything I have experienced. Dr. Silver assembled a dynamic faculty and scheduled time for interaction with publishers and agents. Returning in 2019 for a second helping of how to write nonfiction gave me a greater appreciation of what I want to accomplish and the confidence to try something I did not attempt during my medical career. Both writing and public speaking put your personality and intelligence out there for public consumption. There is risk to such efforts, but the associated psychological re- wards can provide a sense of fulfillment. In writing my memoir, I express gratitude to the mentors who helped me in my professional journey and to the many patients who inspired me with their warmth, humility, determination and humor. I’ll never forget the quip made by a patient facing eye surgery. Don’t worry about me, Doc. I have a high tolerance for pain. I attended parochial schools! The story does not end here. What makes this tale meaningful is how a personal voyage may instruct others to avoid dangerous shoals and to discover a successful pas- sage. Experiencing burnout, leaving a medical practice and finding another calling are among the challenges physicians may struggle with on the road to retirement. Other voices besides mine have sounded the alarm. Recognizing the symptoms and causes of burnout4 may drive us to seek help, as the work of Maslach5 and Oldenburg6 suggest. Not all episodes of dark mood must be treated with medication. Although it is uncommon, a single counseling session (Drukteinis A. Personal communication, 2019) may help manage stress, resulting in a new perspective. As Kagan7 has pointed out, simply having an explanation of one’s [page 122] [Qualitative Research in Medicine & Healthcare 2019; 3:8572] Article No n- co mm er cia l u se on ly symptoms can be therapeutic because an understanding of the reason for uncomfortable feelings mutes uncertainty. Separating the thought from the thinker allows our reason- ing to take control of an emotional situation8, as described by Susan David. Expressive writing acts to diffuse unpleas- ant feelings, as the work of Pennebaker has demonstrated.9 With his typical eloquence, Abraham Verghese describes how writing clarifies his thinking.10 I celebrate such writing and the impulse to write, the impulse to share some transformative incident that I am privileged to have witnessed. In my own writing, I often feel that I write in order to understand what I am thinking. Mysteriously, insight comes (when it does come) in the very act of writing as if only by sitting with pen and pad can we snatch it out of the ether. In writing my memoir,11 I used a device inspired by one of the speakers at the Harvard Writers’ Conference to describe the arc of my professional life. Taking a legal pad, I marked major events along a time continuum. Some episodes noted on my diagram dealt with my struggles to gain command of difficult ma- terial as a student. Other events on the timeline listed pro- cedures I had learned as a surgeon and later abandoned. I spent hours listing items I could recall that I felt were worthy of further discussion. I held my carefully con- structed diagram at arm’s length to gain some perspec- tive, an image of the big picture of my professional life. My arc of life was constructed from multiple stacks, the outline of which resembled a roller coaster track. The mini-arcs were composed of stacks of blocks, each piece standing alone, but when seen from a distance, they ap- peared part of a cityscape of buildings, some taller than others. The disappointments in life I envisioned as holes in the ground before something good was erected. Writing has given me a new purpose and a source of pride, things I needed going forward after leaving medical practice. In the arc of my professional life, I look forward to adding a new dimension to my cityscape. Mine is a newly found passion for writing nonfiction. The transition from doctor to writer is a work in progress, but the groundbreaking for the enterprise has begun. References 1. Ricard M, Andre C, Jollien A. In Search of Wisdom. Sounds True Inc 2018. 2. Facty Health [Internet]. 10 Signs of Depression. Available from: https://facty.com/conditions/depression/10-signs-of- depression/ Accessed: October 2019. 3. Pender P. A physician writes for catharsis. KevinMD 2019. Available from: https://www.kevinmd.com/blog/2019/07/a- physician-writes-for-catharsis.html 4. Fred HL, Scheid MS. Physician burnout: causes, conse- quences and (?) cures. Tex Heart Inst J 2018;45:198–202. 5. Doulougeri K, Georganta K, Montgomery A. “Diagnosing” burnout among healthcare professionals: can we find con- sensus? Cogent Med 2016;3:1237605. 6. Borysenko K. Burnout is now an officially diagnosable con- dition: here’s what you need to know about it. Forbes 2019. 7. Kagan J. Psychology’s Ghosts: The Crisis in the Profession and the Way Back. Yale University Press 2012:223. 8. David S. Emotional agility: get unstuck, embrace change, and thrive in work and life. Avery. Penguin Random House 2016. 9. Pennebaker JW. Opening up: the healing power of express- ing emotions. Guilford Publications 1990. 10. Verghese A.The Power of the Personal Essay in Health Pol- icy. Narrative Matters. (Foreword). Johns Hopkins Univer- sity Press 2006. 11. Pender P. Making lives better: how mentors and patients in- spired a doctor’s work. In press. [Qualitative Research in Medicine & Healthcare 2019; 3:8572] [page 123] Special Issue on Physician Mental Health No n- co mm er cia l u se on ly