Guest Blog: Tips on Retiring: A Massachusetts Psychiatric Society Member’s Experience
*This piece is a re-print from the Massachusetts Psychiatric Society’ Issue 224 July/August 2022 Newsletter.
As part of PRMS’ ongoing commitment to behavioral health, PRMS is pleased to feature Dr. Judith Feldman, psychiatry specialist and Massachusetts Psychiatric Society member, as one of the guest bloggers this month. Dr. Feldman shares her journey to retirement and the steps she took to close her psychiatric practice in the summer of 2022.
Four years ago at the first meeting of the Massachusetts Psychiatric Society (MPS) Retirement Committee, I told the group I didn’t believe I could ever retire because everyone I knew who might accept my patient referrals was old enough to retire themselves! I started my solo practice in 2002, after a previous 25-year career at the Lahey Hospital and Medical Center and a few years in a small group practice. Over the last couple of years in preparation, I gradually decreased my patient panel, no longer taking new patients; I was working four days-a-week, seeing about 35 patients for a combination of psychotherapy and psychopharmacology each week; and had a panel of close to 100 active patients. I slowly started dropping out of private insurance networks and Medicare, billing a few patients out of network and giving many patients reduced fees so that they could continue with me.
I enjoyed my work, but as the pandemic dragged on – and it became clear that I would not be returning to my office – I found it less satisfying. I also enjoyed being at home and felt the pull of other interests and activities. So in June of 2021, I made the decision to retire by the end of the following June. At the MPS Retirement Committee meetings, I listened to stories from others trying to find referrals for their patients and realized I was faced with a daunting job. As my colleagues recommended, I gave myself a year to plan for retirement, and I vowed to myself to take it slowly and stay calm.
I printed out a list of patients who had visits within the last year, adding a few from the past whom I knew might call and would want to know. I began telling my regular patients the news as I saw them for appointments, and processed the initial reaction to the news – which ranged from “I’m so happy for you!” to “what do you MEAN, you’re retiring?” and everything in between. At that session or soon after, I asked each patient what they might need going forward. The answers seemed to fall into several categories:
- Wants ongoing psychotherapy and medication
- Not on medication, wants continuing psychotherapy
- Stable on medication; not interested in psychotherapy; Would be fine with primary care provider (PCP) prescribing or very intermittent psychiatrist or psychiatric NP
- Needs more specialized care (geriatric, chronic pain, eating disorder)
- Wants (not always realistically) to finish psychiatric treatment and terminate
We discussed whether they would want to use their insurance to pay for care, as well as the reality of the referral situation, taking inventory of what resources they might already have. These included:
- An organized care network (teaching hospital, HMO)
- A relationship with PCP or other specialist (e.g. neurologist)
- A psychotherapist (MSW, PhD) who might know other psychiatrists or NPs
- An insurance company with case managers or useful websites
Early in the process, I asked patients to investigate their own referral sources and set the expectation that this could be a difficult, frustrating process, worsened by the pandemic. They might have to make multiple calls and not hear back or sit on a waiting list for several months. Several patients were able to get referrals from their psychotherapists for other prescribers and many were able to transfer prescribing to their PCP. There were surprises: some PCPs were very comfortable with a complicated regime; others were reluctant to continue even a low dose of lorazepam. I also discovered that many psychiatric clinicians were reluctant to continue ongoing benzodiazepine treatment, despite documentation of difficulties or side effects with other medications.
Then I started looking at my own resources. I had a few patients in intensive treatment who were attached to me and would need an overlap with another clinician for a couple of months during the transition. I had been supervising a few NPs for many years and was able to refer two patients to one of them, and one to a close MSW colleague.
Next, I made a list of everyone I knew – mental health clinicians of all disciplines, primary care doctors, and other specialists, including:
- Colleagues whose business cards I had collected at meetings over the years
- Colleagues who had shared my office suites at my two private practice offices
- Colleagues from long ago at the HMO
- Colleagues in my address book and contact list
I emailed or called them all, asking if they or anyone else they knew had referral time. Whenever I talked with a colleague about a patient, I would let them know I was retiring and ask if they or anyone they knew might have availability, and when I talked with a friend inside or outside the profession, I did the same. For instance, when I met with my financial advisor about my retirement, his assistant had a good social worker friend with connections to a psychiatrist. My patient was discharged from a psychiatric hospital and referred to a geriatric psychiatrist. While that referral didn’t work out, that psychiatrist has since taken on three of my other patients. Two colleagues, one a PCP and one a LICSW, gave me suggestions for other providers they knew, so I called them as well.
I began to use the Psychology Today website myself, finding that patients had trouble navigating and choosing providers there, while I could look through bios and get a pretty good idea of who might be appropriate. I emailed and called some of the more promising clinicians and developed ongoing referral relationships with two NPs and one geriatric psychiatrist. I also found a couple of geriatric NPs who offer home visits or consult to assisted care facilities through the website and the activities director of the facility.
By that point, my list of patients had possible referrals penciled next to almost everyone, and I had a page of clinicians with 15-20 MDs, NPs and a couple of MSWs who were ready to take patients.
When asking a clinician about a referral, I made sure to mention that it was not immediate and that my patients could wait a few months for an opening. I took care to only refer one or two patients at a time, and if those worked out, I might go back to the same clinician in a couple of months with another referral. I asked if the clinician would be willing to have a brief conversation with a patient to determine a match before scheduling a time for intake. Other patients were able to secure a place on a waiting list. Large group practices and teaching hospitals often kept months-long waiting lists, so I encouraged patients to take a referral when it was offered, even if it meant transferring early, since the new clinician might not have time if they waited until I retired. Patients began leaving my practice when they felt comfortable with their new clinician, which freed up more of my time to call people and write treatment summaries when needed.
While most of my patients paid out-of-pocket and were willing to continue this with a new clinician, I did not anticipate that many early-career psychiatrists and NPs would have higher fees than I had charged, as I had not raised my fees for several years and offered reduced fees as I resigned from insurance networks. Most patients were willing to adapt, but some continued to look for practitioners with lower fees or insurance coverage.
I still have a short list of patients who have not found referrals, for several apparent reasons:
- The patient moved to another town or state, because of COVID or other reasons, where I have no connections or resources are thinner.
- The patient, older and frail, is unhappy with the clinician I found but unable to arrange for other care.
- The patient wants to use insurance with a limited network.
- The patient is young and juggling life changes - moving, changing jobs, or getting married.
- The patient does not want to start with another therapist despite needing to do so.
I have had to make peace with the knowledge that I wouldn’t get everything perfectly wrapped up before retirement. For the most part, I have enjoyed the process and have met or re-met several lovely people along the way. My advice to clinicians planning to retire from solo practice is to give themselves at least a year, try to empower their patients to do some of the work, and make peace with a “good enough” referral rather than a perfect match.
To learn more about the superior psychiatry-specific insurance program and comprehensive services offered by PRMS, click here.