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A Piece of My Mind
November 23/30, 2021

Taking Down the Shingle

Author Affiliations
  • 1West Central Behavioral Health, Lebanon, New Hampshire
JAMA. 2021;326(20):2011. doi:10.1001/jama.2021.20106

I wake to sleep, and take my waking slow.

I learn by going where I have to go.

“The Waking” by Theodore Roethke

I first read the poem “The Waking” in Mr Day’s 10th-grade English class. The poem was written in words I didn’t yet understand but that spoke directly to my heart.

I have posted this poem next to every desk in every office or study carrel throughout my life, including the office that I am about to raze.

I have served as a psychiatrist for 30 years, dividing my time between a community mental health clinic and private practice. I have served colleagues who entrusted their patients, family members, neighbors, and themselves to my care. The goal has always been to build and to expand my reputation, expertise, skills, caseload.

Now the goal is to tear things down.

I had been thinking of closing my practice for a while with the intention of passing it along to another psychiatrist. Having built this practice with my own hands, I figured I would pass it on to someone else.

I networked and asked and invited, but no one came forward.

It turns out that fewer and fewer physicians are choosing to hang out their own shingle. According to survey data collected in late 2020, 42% of physicians aged 55 years or older were employed by someone else compared with 51% of physicians aged 40 through 54 years and 70% of physicians younger than 40 years.1

On top of that, I’m one of those truly single shops where I did everything myself, including scheduling appointments and billing, as well as calling patients back within 24 hours, scheduling evening or weekend appointments when needed, talking with family members, and meeting with family when tragedy occurred.

A friend from medical school who recently left her group primary care practice reminded me that it’s not just private practitioners who experience loss when closing their practice. She recalled that leaving was very bittersweet. “I took care of the same families for 27 years, and cried every day at work for the final 2 months.”

Growing a medical practice is not like raising children who, if all goes well, leave home and make you proud. If one is blessed, one’s children exist beyond one’s self.

Growing a medical practice is not like owning a home which, when you are done, can be lived in by someone else.

Growing a medical practice is not like performing a play which, when the season ends, posters and playbills remain.

This is the closest I’ve personally come to death.

The medical record files will become old bones stored for 7 years in a metal crypt to protect them before they are destroyed. The lives that are in them, the relationships, the struggle, the growth—only dust.

I remember when my husband and I shopped for office furniture, just 2 months after our second child was born and I had completed residency training. We selected matching Pompanoosuc Mills chairs with beech armrests, this design a reflection of the community in which I was setting up care.

I added a bentwood rocker that was made using only hand tools by an Amish farmer whom I met during a fourth-year medical school elective with a family physician in Viroqua, Wisconsin.

The hardest item to find was an Oriental carpet that was just the right size, shape, and color to bring the room together. We looked long and hard before finding the perfect one.

All this, I am going to destroy. Is the lesson about impermanence? About the transience of all things? About humility? About gratitude?

In this process, as when I first considered what to do professionally, I find myself asking, “What is life about?” “What is the lesson here?”

The late psychiatrist and author Irvin Yalom, MD, in The Gift of Therapy,2 reminds us that, “One of our chief modes of death denial is a belief in personal specialness, a conviction that we are exempt from biological necessity and that life will not deal with us in the same harsh way it deals with everyone else.”

Perhaps I’m not so special after all. Perhaps I am just lucky.

Theodore Roethke’s poem now speaks a language I begin to understand. “I wake to sleep and take my waking slow.” I am gradually awakening to the reality of sleep, of death, of the quiet end.

“I learn by going where I have to go.”

It is time to take apart what I have built, to go forward to what comes next, to learn by going.

Perhaps I will still find someone to take over the practice. Regardless, with luck, I will take down the copy of “The Waking” that is taped on the side of the file cabinet next to my desk and tape it to another desk someplace else.

Section Editor: Preeti Malani, MD, MSJ, Associate Editor.
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Article Information

Corresponding Author: Diane Roston, MD, West Central Behavioral Health, 85 Mechanic St, Ste 2, Lebanon, NH 03766 (dr@dianerostonmd.com).

Conflict of Interest Disclosures: None reported.

Kane  CK. Recent changes in physician practice arrangements: private practice dropped to less than 50 percent of physicians in 2020. American Medical Association. Published 2021. Accessed October 22, 2021. https://www.ama-assn.org/system/files/2021-05/2020-prp-physician-practice-arrangements.pdf
Yalom  I.  The Gift of Therapy: An Open Letter to a New Generation of Therapists and Their Patients. HarperPerennial; 2003.

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    4 Comments for this article
    Taking Down the Shingle
    Karl Stecher, A.B. Harvard, M.D. Maryland | Retired, CO State Senate Candidate

    A very nice article. The significance cannot be felt by younger doctors. We all have written timelines, and this bittersweet piece exposes that. A difficult time for us, as we go from sunset to twilight.

    We have all done so many good things as physicians, and it is helpful but difficult to focus on the good we have done instead of the personal agonies of things that went wrong, or administrative attacks on our campaigning for even better medicine.

    Our Art
    Daniel Krell, M.D. | Retired PCP
    An elderly artist friend was selling his house and most works in his studio in preparation for moving cross-country and downsizing. Looking at his work, it struck me that his children and other descendants could look at and hold his pottery and paintings and know that "his hands were here and molded this shape, made this pattern.” I simultaneously recognized that our work, as doctors, is “performance art,” although we don’t produce anything tangible that our descendants can hold in their hands or say "We made this, we shaped this."  Our patients, their families, and other health care providers see us work and see the results of our work. But upon the deaths of these, our only witnesses, our work is no longer documented; there is no tangible product or proof of what we did, what our hands touched and shaped. Many of our experiences with patients were humdrum and routine, and many were elegant and precious, and beneficial. Even with the humdrum and routine visits, we modeled caring, comforting, validating, and a host of other behaviors that are important in our world. We hope that there are ripples that emanate from our activity, influencing the patients, their families and their friends; among people we’ve taught and mentored, the ripples spread out as attitudes, perspectives, skills that we hope bring benefit to other providers and their patients. If we’re conscious of this, and lucky, we become part of the local lore: “There once was a doctor here, who.…”
    Carol Gerson, M.D., D.Be. | Tulane University
    This is the perfect description of my emotions when closing the private practice I built from nothing. I sold it to the hospital for a pittance, 26 years after starting from scratch, buying very expensive ENT equipment, building out a lovely office with flowered wallpaper and matching exam chairs in different colors for each room. 26 years of families and children going into those rooms with the little brass knockers on the doors. It was like a little death, but it was time. I miss the families. I miss the staff. I miss the OR and the camaraderie. I miss surgery when it was going really well, but not when it was stressful. I do not miss the pager, at all! You made me think about all of this, though I did it 13 years ago and moved into a new career with two degrees in bioethics and lots of teaching and lecturing to seniors. Thanks for bringing me back to all of those mixed emotions and the memories of my office and my practice.
    Daniel Urbach, MD | Legacy Health System
    Thank you for this article. You have done good work by helping people who needed help. Your work has had meaning. You will continue to help people, I'm sure, since that is clearly who you are. It is painful to close a chapter, of course. Thank you for sharing that. I will feel it too, as will we all.
    Dan Urbach, MD