Retirement’s emotional impact on the psychiatrist
Published guidance on concluding a psychiatric practice is sparse, considering that all psychiatrists are mortal and stop practicing at some point.12Not thinking about or planning for retirement is a psychiatric tradition that started with Freud. He saw patients until shortly before his death and did not seem to have planned for ending his practice, despite suffering with jaw cancer for 16 years.13
Practicing medicine often is more than just a career; it is a core aspect of many physicians’ identity.14 Most of us spend a large fraction of our waking hours caring for patients and meeting other job requirements (eg, teaching, maintaining knowledge and skills), and many of us have scant time to pursue nonmedical interests. An intense prioritization of one’s “medical identity” makes retirement a blow to a doctor’s self-worth and sense of meaning in life.15,16
Because their work is not physically demanding, most psychiatrists continue to practice beyond the age of 65 years.12,17 More important, perhaps, is that being a psychiatrist is uniquely rewarding. As Benjamin Rush observed in an 1810 letter to Pennsylvania Hospital, successfully treating any medical disease is gratifying, but “what is this pleasure compared with that of restoring a fellow creature from the anguish and folly of madness and of reviving in him the knowledge of himself, his family, his friends, and his God!”18
Physicians in any specialty that involves repeated contact with the same patients form emotional bonds with their patients that retirement breaks.14 Psychiatrists’ interest in how patients think, feel, and cope with problems creates special attachments17 that can make some terminations “emotionally excruciating.”12
Psychiatrists with serious illness
What guidance might Dr. F find regarding whether to broach the subject of his illness with patients, and if so, how? No one has conducted controlled trials to answer these questions. Rather, published discussion of psychiatrists’ serious illness is found mainly in the psychotherapy literature. What’s available consists of individual accounts and case series that lack scientific rigor and offer little clarity about what the therapist should say, when to say it, and how to initiate the discussion.19,20 Yet Dr. F may find some of these authors’ ideas and suggestions helpful, particularly if his psychiatric practice includes providing psychotherapy.
As a rule, psychiatrists avoid talking about themselves, but having a serious illness that could affect treatment often justifies deviating from this practice. Although Dr. F (like many psychiatrists) may be concerned that discussing his health will make patients anxious or “contaminate” what they are able or willing to say,21 not providing information or avoiding discussion (especially if a patient asks about your health) may quickly undermine a patient’s trust.21,22 Even in psychoanalytic treatment, it makes little sense to encourage patients “to speak freely on the pretense that all is well, despite obvious evidence to the contrary.”19
Physicians often deny—or at least avoid thinking about—their own mortality.23 But avoiding talking about something so important (and often so obvious) as one’s illness may risk supporting patients’ denial of crucial matters in their own lives.19,21 Moreover, Dr. F’s inadvertent self-disclosure (eg, by displaying obvious signs of illness) may do more harm to therapy than a planned statement in which Dr. F has prepared what he’ll say to answer his patients’ questions.20
That Dr. F has continued working while suffering from a potentially fatal illness seems noble. Yet by doing so, he accepts not only the burdens of his illness but also the obligation to continue to serve his patients competently. This requires maintaining emotional steadiness and not using patients for emotional support, but instead obtaining and using the support of his friends, colleagues, family, consultants, and caregivers.20