Joel H. Merenstein, MD

Being in practice for 42 years was like running a marathon. Things seem easy and pleasant at first, but then as time goes by, you hit the “wall” and you feel like you can’t go on. “It’s just too hard,” you think. And you wonder: “What am I doing here?”

In an actual marathon, you hit that wall somewhere around the 20-mile mark. (At least that’s what my son tells me.) But in my family medicine practice, I hit the wall at the 10-year mark.

If, like me, you decide not to quit, the endorphins kick in. You feel a high and know you could go on like this forever. You wonder to yourself: “Can life really be this good?”

And then, as the years pass by, you and your patients change and you know the race is coming to an end. It’s time to stop running. Yet, there are many losses in giving up practice. After spending nearly a lifetime as a doctor, it’s hard to give up that identity. That’s who you are, and who you have been.

In my case, I saw the doctor-patient relationship as a “covenant, not a contract,” as Gayle Stephens, MD, described it, and my role as a physician was to prescribe myself as my most potent therapy, as taught by Michael Balint.¹

David Loxterkamp has written about “being there” as the prime service of the family doctor.² But in retiring you are not there—at least not the way you once were.

How about lunch, doc?

When I retired 5 years ago, many patients wanted to “go out to lunch” or in some way maintain our relationship. I avoided this, saying that I thought it was important for them to develop a relationship with their new doctor. This was (and is) true, but I’ve come to realize that it is not the most important reason to pass on such invitations.

Lovers breaking up say they can “still be friends,” even though they know that is impossible. They can neither give up the special feelings they have had, nor the memories of those feelings that will always be a relevant part of their lives. Similarly, I have too much invested in these relationships to “just be friends.”

Moving on
I have moved on. My wife of 52 years and I travel and visit our children and grandchildren. I take and teach classes at a program for retired people. I have more free time than I have ever had, and I don’t miss the constant sense of responsibility for others, or the time spent agonizing over mistakes. But it was the right time to leave practice when technological advancements were accelerating at lightning speed, and my energy level was no longer keeping pace.

Mixed emotions when I talk to patients

Despite not wanting to have lunch with my former patients, I must confess that I periodically call some of them to see how they are doing. I realize that it is really more for me than for them—but I try not to make that obvious. Our conversations leave me with such mixed emotions.

Feeling guilty
Bob and his family were patients of mine almost from the day I started. I attended their daughters’ weddings, shared in their tragedies, cared for multiple illnesses, and counseled the children. When Bob was diagnosed with Alzheimer’s disease, I told him it was very early and we would go through it together and learn from each other. Then I retired.

I know through my conversations with him and his family that he has gone on with good care. But he has gone on without me.

I feel guilty.

I realize that some of this is ego—a loss of importance. But mainly I feel badly that I am not fulfilling that promise I made to him. And I have “cheated” myself out of the pleasure of learning and giving.

Feeling incomplete
I was particularly close with Marylou and her family. I attended birthday parties, cared for her and her husband’s chronic illnesses, supported them through the illness and death of their daughter, and listened when that’s all I could do. Last year, Marylou called me when she was diagnosed with breast cancer. I stayed in touch and expressed my pleasure when she did well. But, I wasn’t involved in the therapy decisions and I wasn’t there when it was time to cry or talk to the family.

It made me feel incomplete.

Feeling humbled
Recently I got a letter from a urologist regarding a former patient of mine, Robin.

Robin was diagnosed with prostate cancer about 10 years ago, when I was still his physician. Obviously, the new urologist didn’t know that I had retired. So I forwarded the note to Robin’s new family physician and called Robin to see how he was.

I still felt a tremendous sense of responsibility for Robin’s diagnosis. I had never screened him for prostate cancer. But as he reminded me at the time of his diagnosis, he and I had discussed screening. It’s just that Robin, who knows much about medicine and was always involved in his own decisions, had chosen not to pursue it.

Now 10 years later, Robin and I were catching up. As we talked, Robin revealed that he had multiple complications requiring permanent catheters and that he’d had to give up work.

“I wish you were still in practice,” he said to me. “I miss our talks.”

With that, I felt humbled.

Talking to Robin got me thinking. As doctors, we spend so much time worrying about doing the right thing and giving the right advice that we sometimes forget that we need to have confidence in our patients and their ability to make their own decisions. We need to know when to let go.

“Being there”
Jane was another person who emerged from my professional past. I had known her for years. Not only was she my patient, but I saw her when she came in with her father, sister, and mother for their appointments. Together, we had cared for her family members through their illnesses and deaths.

One day after my retirement, she called to get some advice for a problem she was having with her stepson. I listened, gave some suggestions about whom to see, and offered to stay in touch. She thanked me, saying she didn’t know who else to call.

I hung up thinking how hard it is to “be there” when you are not there.

Jane’s call reminded me of a lesson I’d given years ago to a class of first-year medical students. I had brought in a patient of mine and together, in front of the class, we discussed the doctor-patient relationship.

I asked my patient what was most important about our relationship. She said that when she was diagnosed with diabetes, I gave her my private home phone number.

I responded, “Mrs. E, in our 15 years together, how many times have you used that number?”

“None,” was her reply.

Med students, take note

I really don’t know if my retirement has been easier for my patients than for me. I certainly hope so. Part of my job was to encourage their independence and self-sufficiency. My emotional dependence on them is my problem and I suspect one that is not that uncommon among doctors. I am still teaching and doing some research. Some of my retired friends still go to grand rounds and travel to medical meetings, even though they don’t see any patients.

I have few regrets in retiring from my practice. It was the right thing to do at the right time. Do I miss it every day? Yes, but I also feel so lucky to have worked as a family physician for 42 years.

I once heard a British family physician define the family doctor as someone you can go to and talk to about anything you want. To me, the family doctor is someone who knows you—really knows you—in a way that no one else does. A family doctor is someone who can cry with a patient about a loss, not because the physician can appreciate the loss, but because the patient’s loss is the physician’s loss, too.

I wish more young medical students understood the depth of the connections we make as family physicians, and just how rewarding the work can be. If they did, there would certainly be more students choosing a career in family medicine.

Acknowledgement
I thank Nancy W. Merenstein, the first reader of everything I write and my constant supporter; Paula Preisach, manager and organizer of my academic career; and Jonathan Han, MD, David Loxterkamp, MD, Jennifer Middleton, MD, MPH, and Allen Shaughnessy, PharmD, for helpful comments and suggestions on earlier drafts of this paper.

CORRESPONDENCE
Joel H. Merenstein, MD, UPMC St. Margaret, 3937 Butler Street, Pittsburgh, PA 15201; merensteinjh@upmc.edu

Being in practice for 42 years was like running a marathon. Things seem easy and pleasant at first, but then as time goes by, you hit the “wall” and you feel like you can’t go on. “It’s just too hard,” you think. And you wonder: “What am I doing here?”

In an actual marathon, you hit that wall somewhere around the 20-mile mark. (At least that’s what my son tells me.) But in my family medicine practice, I hit the wall at the 10-year mark.

If, like me, you decide not to quit, the endorphins kick in. You feel a high and know you could go on like this forever. You wonder to yourself: “Can life really be this good?”

And then, as the years pass by, you and your patients change and you know the race is coming to an end. It’s time to stop running. Yet, there are many losses in giving up practice. After spending nearly a lifetime as a doctor, it’s hard to give up that identity. That’s who you are, and who you have been.

In my case, I saw the doctor-patient relationship as a “covenant, not a contract,” as Gayle Stephens, MD, described it, and my role as a physician was to prescribe myself as my most potent therapy, as taught by Michael Balint.¹

David Loxterkamp has written about “being there” as the prime service of the family doctor.² But in retiring you are not there—at least not the way you once were.

How about lunch, doc?

When I retired 5 years ago, many patients wanted to “go out to lunch” or in some way maintain our relationship. I avoided this, saying that I thought it was important for them to develop a relationship with their new doctor. This was (and is) true, but I’ve come to realize that it is not the most important reason to pass on such invitations.

Lovers breaking up say they can “still be friends,” even though they know that is impossible. They can neither give up the special feelings they have had, nor the memories of those feelings that will always be a relevant part of their lives. Similarly, I have too much invested in these relationships to “just be friends.”

Moving on
I have moved on. My wife of 52 years and I travel and visit our children and grandchildren. I take and teach classes at a program for retired people. I have more free time than I have ever had, and I don’t miss the constant sense of responsibility for others, or the time spent agonizing over mistakes. But it was the right time to leave practice when technological advancements were accelerating at lightning speed, and my energy level was no longer keeping pace.

Mixed emotions when I talk to patients

Despite not wanting to have lunch with my former patients, I must confess that I periodically call some of them to see how they are doing. I realize that it is really more for me than for them—but I try not to make that obvious. Our conversations leave me with such mixed emotions.

Feeling guilty
Bob and his family were patients of mine almost from the day I started. I attended their daughters’ weddings, shared in their tragedies, cared for multiple illnesses, and counseled the children. When Bob was diagnosed with Alzheimer’s disease, I told him it was very early and we would go through it together and learn from each other. Then I retired.

I know through my conversations with him and his family that he has gone on with good care. But he has gone on without me.

I feel guilty.

I realize that some of this is ego—a loss of importance. But mainly I feel badly that I am not fulfilling that promise I made to him. And I have “cheated” myself out of the pleasure of learning and giving.

Feeling incomplete
I was particularly close with Marylou and her family. I attended birthday parties, cared for her and her husband’s chronic illnesses, supported them through the illness and death of their daughter, and listened when that’s all I could do. Last year, Marylou called me when she was diagnosed with breast cancer. I stayed in touch and expressed my pleasure when she did well. But, I wasn’t involved in the therapy decisions and I wasn’t there when it was time to cry or talk to the family.

It made me feel incomplete.

Feeling humbled
Recently I got a letter from a urologist regarding a former patient of mine, Robin.

Robin was diagnosed with prostate cancer about 10 years ago, when I was still his physician. Obviously, the new urologist didn’t know that I had retired. So I forwarded the note to Robin’s new family physician and called Robin to see how he was.

I still felt a tremendous sense of responsibility for Robin’s diagnosis. I had never screened him for prostate cancer. But as he reminded me at the time of his diagnosis, he and I had discussed screening. It’s just that Robin, who knows much about medicine and was always involved in his own decisions, had chosen not to pursue it.

Now 10 years later, Robin and I were catching up. As we talked, Robin revealed that he had multiple complications requiring permanent catheters and that he’d had to give up work.

“I wish you were still in practice,” he said to me. “I miss our talks.”

With that, I felt humbled.

Talking to Robin got me thinking. As doctors, we spend so much time worrying about doing the right thing and giving the right advice that we sometimes forget that we need to have confidence in our patients and their ability to make their own decisions. We need to know when to let go.

“Being there”
Jane was another person who emerged from my professional past. I had known her for years. Not only was she my patient, but I saw her when she came in with her father, sister, and mother for their appointments. Together, we had cared for her family members through their illnesses and deaths.

One day after my retirement, she called to get some advice for a problem she was having with her stepson. I listened, gave some suggestions about whom to see, and offered to stay in touch. She thanked me, saying she didn’t know who else to call.

I hung up thinking how hard it is to “be there” when you are not there.

Jane’s call reminded me of a lesson I’d given years ago to a class of first-year medical students. I had brought in a patient of mine and together, in front of the class, we discussed the doctor-patient relationship.

I asked my patient what was most important about our relationship. She said that when she was diagnosed with diabetes, I gave her my private home phone number.

I responded, “Mrs. E, in our 15 years together, how many times have you used that number?”

“None,” was her reply.

Med students, take note

I really don’t know if my retirement has been easier for my patients than for me. I certainly hope so. Part of my job was to encourage their independence and self-sufficiency. My emotional dependence on them is my problem and I suspect one that is not that uncommon among doctors. I am still teaching and doing some research. Some of my retired friends still go to grand rounds and travel to medical meetings, even though they don’t see any patients.

I have few regrets in retiring from my practice. It was the right thing to do at the right time. Do I miss it every day? Yes, but I also feel so lucky to have worked as a family physician for 42 years.

I once heard a British family physician define the family doctor as someone you can go to and talk to about anything you want. To me, the family doctor is someone who knows you—really knows you—in a way that no one else does. A family doctor is someone who can cry with a patient about a loss, not because the physician can appreciate the loss, but because the patient’s loss is the physician’s loss, too.

I wish more young medical students understood the depth of the connections we make as family physicians, and just how rewarding the work can be. If they did, there would certainly be more students choosing a career in family medicine.

Acknowledgement
I thank Nancy W. Merenstein, the first reader of everything I write and my constant supporter; Paula Preisach, manager and organizer of my academic career; and Jonathan Han, MD, David Loxterkamp, MD, Jennifer Middleton, MD, MPH, and Allen Shaughnessy, PharmD, for helpful comments and suggestions on earlier drafts of this paper.

CORRESPONDENCE
Joel H. Merenstein, MD, UPMC St. Margaret, 3937 Butler Street, Pittsburgh, PA 15201; merensteinjh@upmc.edu

Being in practice for 42 years was like running a marathon. Things seem easy and pleasant at first, but then as time goes by, you hit the “wall” and you feel like you can’t go on. “It’s just too hard,” you think. And you wonder: “What am I doing here?”

In an actual marathon, you hit that wall somewhere around the 20-mile mark. (At least that’s what my son tells me.) But in my family medicine practice, I hit the wall at the 10-year mark.

If, like me, you decide not to quit, the endorphins kick in. You feel a high and know you could go on like this forever. You wonder to yourself: “Can life really be this good?”

And then, as the years pass by, you and your patients change and you know the race is coming to an end. It’s time to stop running. Yet, there are many losses in giving up practice. After spending nearly a lifetime as a doctor, it’s hard to give up that identity. That’s who you are, and who you have been.

In my case, I saw the doctor-patient relationship as a “covenant, not a contract,” as Gayle Stephens, MD, described it, and my role as a physician was to prescribe myself as my most potent therapy, as taught by Michael Balint.¹

David Loxterkamp has written about “being there” as the prime service of the family doctor.² But in retiring you are not there—at least not the way you once were.

How about lunch, doc?

When I retired 5 years ago, many patients wanted to “go out to lunch” or in some way maintain our relationship. I avoided this, saying that I thought it was important for them to develop a relationship with their new doctor. This was (and is) true, but I’ve come to realize that it is not the most important reason to pass on such invitations.

Lovers breaking up say they can “still be friends,” even though they know that is impossible. They can neither give up the special feelings they have had, nor the memories of those feelings that will always be a relevant part of their lives. Similarly, I have too much invested in these relationships to “just be friends.”

Moving on
I have moved on. My wife of 52 years and I travel and visit our children and grandchildren. I take and teach classes at a program for retired people. I have more free time than I have ever had, and I don’t miss the constant sense of responsibility for others, or the time spent agonizing over mistakes. But it was the right time to leave practice when technological advancements were accelerating at lightning speed, and my energy level was no longer keeping pace.

Mixed emotions when I talk to patients

Despite not wanting to have lunch with my former patients, I must confess that I periodically call some of them to see how they are doing. I realize that it is really more for me than for them—but I try not to make that obvious. Our conversations leave me with such mixed emotions.

Feeling guilty
Bob and his family were patients of mine almost from the day I started. I attended their daughters’ weddings, shared in their tragedies, cared for multiple illnesses, and counseled the children. When Bob was diagnosed with Alzheimer’s disease, I told him it was very early and we would go through it together and learn from each other. Then I retired.

I know through my conversations with him and his family that he has gone on with good care. But he has gone on without me.

I feel guilty.

I realize that some of this is ego—a loss of importance. But mainly I feel badly that I am not fulfilling that promise I made to him. And I have “cheated” myself out of the pleasure of learning and giving.

Feeling incomplete
I was particularly close with Marylou and her family. I attended birthday parties, cared for her and her husband’s chronic illnesses, supported them through the illness and death of their daughter, and listened when that’s all I could do. Last year, Marylou called me when she was diagnosed with breast cancer. I stayed in touch and expressed my pleasure when she did well. But, I wasn’t involved in the therapy decisions and I wasn’t there when it was time to cry or talk to the family.

It made me feel incomplete.

Feeling humbled
Recently I got a letter from a urologist regarding a former patient of mine, Robin.

Robin was diagnosed with prostate cancer about 10 years ago, when I was still his physician. Obviously, the new urologist didn’t know that I had retired. So I forwarded the note to Robin’s new family physician and called Robin to see how he was.

I still felt a tremendous sense of responsibility for Robin’s diagnosis. I had never screened him for prostate cancer. But as he reminded me at the time of his diagnosis, he and I had discussed screening. It’s just that Robin, who knows much about medicine and was always involved in his own decisions, had chosen not to pursue it.

Now 10 years later, Robin and I were catching up. As we talked, Robin revealed that he had multiple complications requiring permanent catheters and that he’d had to give up work.

“I wish you were still in practice,” he said to me. “I miss our talks.”

With that, I felt humbled.

Talking to Robin got me thinking. As doctors, we spend so much time worrying about doing the right thing and giving the right advice that we sometimes forget that we need to have confidence in our patients and their ability to make their own decisions. We need to know when to let go.

“Being there”
Jane was another person who emerged from my professional past. I had known her for years. Not only was she my patient, but I saw her when she came in with her father, sister, and mother for their appointments. Together, we had cared for her family members through their illnesses and deaths.

One day after my retirement, she called to get some advice for a problem she was having with her stepson. I listened, gave some suggestions about whom to see, and offered to stay in touch. She thanked me, saying she didn’t know who else to call.

I hung up thinking how hard it is to “be there” when you are not there.

Jane’s call reminded me of a lesson I’d given years ago to a class of first-year medical students. I had brought in a patient of mine and together, in front of the class, we discussed the doctor-patient relationship.

I asked my patient what was most important about our relationship. She said that when she was diagnosed with diabetes, I gave her my private home phone number.

I responded, “Mrs. E, in our 15 years together, how many times have you used that number?”

“None,” was her reply.

Med students, take note

I really don’t know if my retirement has been easier for my patients than for me. I certainly hope so. Part of my job was to encourage their independence and self-sufficiency. My emotional dependence on them is my problem and I suspect one that is not that uncommon among doctors. I am still teaching and doing some research. Some of my retired friends still go to grand rounds and travel to medical meetings, even though they don’t see any patients.

I have few regrets in retiring from my practice. It was the right thing to do at the right time. Do I miss it every day? Yes, but I also feel so lucky to have worked as a family physician for 42 years.

I once heard a British family physician define the family doctor as someone you can go to and talk to about anything you want. To me, the family doctor is someone who knows you—really knows you—in a way that no one else does. A family doctor is someone who can cry with a patient about a loss, not because the physician can appreciate the loss, but because the patient’s loss is the physician’s loss, too.

I wish more young medical students understood the depth of the connections we make as family physicians, and just how rewarding the work can be. If they did, there would certainly be more students choosing a career in family medicine.

Acknowledgement
I thank Nancy W. Merenstein, the first reader of everything I write and my constant supporter; Paula Preisach, manager and organizer of my academic career; and Jonathan Han, MD, David Loxterkamp, MD, Jennifer Middleton, MD, MPH, and Allen Shaughnessy, PharmD, for helpful comments and suggestions on earlier drafts of this paper.

CORRESPONDENCE
Joel H. Merenstein, MD, UPMC St. Margaret, 3937 Butler Street, Pittsburgh, PA 15201; merensteinjh@upmc.edu