Closing RItual

by Barry Bub, MD

Joan, come in, we’re waiting for you!" I had called her for the third time.

Then it struck me. There is no need for her to be scurrying around the office cleaning up and emptying trash cans. We are not coming back. She knows that. This is resistance, she must be feeling so uncomfortable at the thought of what we are to do, that she is delaying coming into the room. I feel a wave of empathy for her. It has dawned on me that I am not the only one struggling to keep my emotions in check.

It is 5:00 p.m. September 9, 1998. The last patient for the day and possibly my career, has left the office. I feel emotionally drained - it’s been very difficult explaining to patient after patient, the need for me to quit my family practice.

I am sitting in Exam room one. The room is set up just the way I like it. The walls were long ago stripped of their charts depicting the unhealthy gut, or semi- closed coronary arteries. Replacing them are poster- sized photographs of landscape scenes, ones I had taken on my travels. The desk is bare except for photos of my family and figurines from exotic locations. On the small side table, is a vase with flowers. Classical music plays softly from the intercom system. The environment is intentionally designed to be calming to nervous patients.

Today the room is filled with chairs arranged in a semi circle around the desk. Occupying them are former employees who were either fired or resigned in disgust, an elderly couple representing the two thousand or so patients in the practice, and Mary one of my two remaining employees. Joan is the other.

We are gathered together to have a closing ritual, to produce closure to the years of working, playing, laughing, even crying in a what we had come to feel was a very special place - 1800 Hampden Boulevard. It had taken years to build a team of very well trained, motivated people who worked well together. We like each other, we respect each others ability, we love the patients. Our spouses and children visit. Patients stop by to bring goodies. So why are we disbanding?

Four years previously, I recognized that with the revolution taking place in health care, there was very little future in solo family practice. My attempts at organizing fellow family physicians to collaborate in support of one another had failed. A window of opportunity to create security for myself and have "professional" management for the practice arose when a hospital network went on a practice buying spree.

Two frustrating years later, we were relieved when another practice management group bought us out. The feeling of relief didn’t last very long. Management degenerated into a case study in how to destroy a practice. My suggestions were ignored, valuable employees were fired or left the practice demoralized and upset. I was very concerned about patient satisfaction and safety. The final straw came when I was given two weeks notice, by fax, that the practice would be closed and patients and I would be moved to a site across town. Notably, that site had recently lost four of its six physicians because of dissatisfaction with management. A fifth was due to retire soon. I was given a letter to review and sign. This letter described in glowing terms my approval of the move.

At a final meeting with the vice president, administrator, and medical director with my wife carefully taking minutes of the meeting, no one asked my opinion regarding the effect of the move on my patients, staff or me. I left the meeting feeling that I was being forced to quit.

My mind having been made up, my principal objective was to stall the relocation of the practice long enough so that I could explain the situation to most of my patients, many of whom I had known for more than twenty years. I wanted to personally say goodbye and not have them feel that they were abandoned. To those who could or would not move to the other facility, I wanted to offer suggestions regarding other practices they might go to.

I was unprepared for the outpouring of empathy and sadness expressed by my patients. Comments ranged from "I know there are other doctors, but will they listen to me?" to "Shit, shit, I was just getting used to you." and "You want to be an old country doctor, I mean young. You know what I mean."

Someone asked who would care for the flowers (the perennial garden.) Another acknowledging the personal touches I had made: "Will the next doctor have little woodcarved cats on the window sill?" One elderly man burst into tears and gave me a bear hug - surprising me because he had extensive arthritis minimally improved by my efforts over the years. He then asked to buy one of my photographs. Of course I gave it to him. Even some hardened drug reps seemed shocked and saddened.

My last remaining employees quickly found themselves other jobs. They had remained out of loyalty to me and the patients. They seemed relieved to be rid of their relationship with dysfunctional corporations.

I too felt a sense of relief mixed with apprehension at the thought of leaving the office for the last time. How would I cope, walking out of the office not just on vacation, but never to return?

There was a time in my life that I would have shrugged off these feelings. Now, at fifty-one, I knew enough to realize that I needed to honor them. I had recently completed a three- year training program in Gestalt therapy. One session with my friend and teacher Mark, the psychiatrist, helped me recognize that I was not being a quitter or a loser in taking this step. I could see how in creating a sacred safe space for patients, and helping them with their emotional issues as well as their physical symptoms, I had actually incorporated a great deal of spirituality in my practice. Clearly a ritual to deconsecrate the office would help create closure for me and members of the staff.

Everyone finally settles down and we can begin. I welcome them and read a vignette about a recent, particularly touching patient interaction. This is about a patient who at her last visit confessed to never following my advice and neglecting her health because she was so anxious about her chronically ill husband. I helped her understand the connection between that behavior and her life - long fears of abandonment. Then I connected with her on her feelings about me leaving and "abandoning" her. We spoke about strategies she could use to work through that issue.

I thank everyone present for their loyalty, friendship and caring. I then ask each in turn to share her feelings about the time she has spent here. In particular, I ask for one quote that will summarize her experience in this office, and what she will take away with her.

With teary eyes, Terry tells of some of the difficult times we have had. It’s true, at one time I had her transferred to another practice because of insubordination. She recalls with much emotion how, despite that, I visited her in the hospital after her automobile accident. She then returned to my office and has been a model employee ever since. Her quote is one she often says in her new job: "That’s not the way we do it at Dr. Bub’s!" Joan recalls her fear at her initial interview. She quotes: "I learned to value myself." Liz says that she has accomplished her dreams. The Kleenex box makes its way around the room as they continue. Anna, our elderly patient selected because she had been particularly distressed on hearing the news we were leaving, hands out gifts to all of us and shares her feelings. Her husband John has Alzheimers, so he remains smiling and seems to be enjoying himself.

We end with a blessing and with hugs. Down come the photographs and I give them and the little carvings away as mementos. We remove the sign from the front. Later I will mail a large card with all the quotations to each one.

As I leave the office, I am conscious of feeling very privileged and very complete. Never mind that I am going to be unemployed. The ritual has been healing for all of us. But we have very little time to let that sink in. We’re off to a restaurant to celebrate our connection.

Postscript: Not two months had gone by. The corporation that owned my practice has announced it is getting out of the practice management business.

Barry Bub, MD founded and directs Advanced Physician Awareness Training, process medicine.com. He is author of Communication Skills that Heal: Toward a New Professionalism for Medicine (Radcliffe Medical Press)