Here is the letter I sent my colleagues upon my retirement from active practice in December 2015.
Ten years ago I couldn’t imagine even thinking about retirement. A mere five years ago, I still saw retirement as too far away to be real. But things change, and it is time. I retired from active patient care at Family Health Care Associates as of December 31st, 2015. I have spoken one:one with my patients over the past year, and have communicated with as many colleagues as I could. I can’t possibly talk to everyone, so here is my explanatory message on my retirement.
I have been an active participant and consistent contributor to the Central Maine Medical Family since I arrived in Lewiston-Auburn during the summer of 1977. I am both sad and excited about my retirement.
Lest there be rumors or concern, all is well with me. There is no crisis or tragedy. My love for family medicine - and the magic that happens when the door closes and the patient and I start to collaborate on health care - are undiminished from my very first day in primary care. It was simply time.
Medicine is an increasingly complex and demanding profession. Some years ago, I stopped getting younger, stronger, and faster, and I lost my unlimited endurance. External pressures increasingly distract from the patient. Over the last few years, I have faced some pretty significant personal and family stresses. My working environment at CMMG was one where patients and clinicians were not part of the decision making process in any meaningful way, where communication was primarily channeled and one-way, and where there was ever more ‘friction’ from systems that were institution-centric and not designed to facilitate the actual patient care process. Individuals who advocated for alternative approaches were at risk. In this setting, I found it harder and harder to be quiet and accepting of mediocrity. Inside the exam room with patients all was fine, but elsewhere I was increasingly frustrated and angry. Despite my attempts to hide it, I know that some of my friends and colleagues saw my struggle.
In this setting, I decided about 15 months ago to retire from active patient care at the end of 2015, and have been working with FHCA to make as smooth a transition as possible. I had planned to continue working at the residency part time as a preceptor, but was told in October that CMMG had changed its mind and would not offer me that option. There were no concerns about my clinical skills, my relationships with patients, or my teaching. The explanation given was that my obvious and often vocal frustration in my passionate and persistent advocacy for patients and for alternative approaches to management made me a poor fit for the institution.
My True North since I became part of the Central Maine community in 1977 has always been the question: how will this help the patient? My active advocacy for patients, and my willingness to pursue patient-care and quality issues outside of standard channels (‘outside the box’ as I was told), have often made management and leadership unhappy. (I see that as a feature, not a bug.) Thomas Jefferson is reported to have said that the most important voice in the room is often the one that disagrees with you. The ‘loyal opposition’ plays an essential role in all successful organizations. I believe it is essential to seek out - rather than avoid - alternative perspectives. My advocacy for transparency, communication, and collaboration has been based on my firm belief that what Etienne Wenger terms a collaborative community of practice (i.e., a loose hierarchy of strong networks, sharing common values, and pursuing shared goals) is more creative, adaptable, resilient and powerful than the traditional organization, even when run by highly skilled and dedicated leaders.
I was told many years ago that, while I often have good ideas, I am a lousy salesman - a criticism I think is accurate. High quality patient care in an environment focused on the patient has always been my goal, a goal for which I have been willing to fight hard, but for which I have not always fought effectively. I have served CMHC for nearly four decades, with loyalty and dedication, and in many roles. Despite my loyalty to CMHC, I have always focused above all on what is best for patients. For me, the impact on the individual patient always trumps the impact on the institution.
Actions have consequences. Being a visible and vocal voice for patients and collaboration has meant, at times, being a pain in the ass, and has led my erstwhile employer to deem me not fit to help educate residents. I think CMMG has made a poor decision, but it is what it is. While I am sad and disappointed that CMMG will not let me contribute going forward, I cannot say I am surprised. Epistemic closure and an oligarchic approach to leadership and management have been growing weaknesses at CMHC and CMMG for a number of years. Despite the pain of being told I have no further role here, I am at peace with what has happened: I can look back without guilt or regret, knowing I have not kept silent or let things go.
I will sorely miss all the fine people I have worked with. I will especially miss the patients I have grown to know and love. Working with and learning from my patients and my colleagues, as we share the thrill of collaborating so patients can help themselves, has been a joy and a privilege. Given the quality and commitment of the people I have worked with and gotten to know, I have every confidence that CMMG will continue to thrive, and I wish you all well. If you see me around, please say hello and update me.
Be well, take good care of yourselves and your patients, and remember: if clinicians don’t advocate for their patients, who will?
Peter Elias, MD