Medicolegal Issues

The end of the line: Concluding your practice when facing serious illness

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Dear Dr. Mossman,
I have a possibly fatal disease. So far, my symptoms and treatment haven’t kept me from my usual activities. But if my illness worsens, I’ll have to quit practicing psychiatry. What should I be doing now to make sure I fulfill my ethical and legal obligations to my patients?
Submitted by “Dr. F”

“Remember, with great power comes great responsibility.”

- Peter Parker, Spider-Man (2002)

Peter Parker’s movie-ending statement applies to doctors as well as Spider-Man. Although we don’t swing from building to building to save cities from heinous villains, practicing medicine is a privilege that society bestows only upon physicians who retain the knowledge, skills, and ability to treat patients competently.

Doctors retire from practice for many reasons, including when deteriorating physical health or cognitive capacity prevents them from performing clinical duties properly. Dr. F’s situation is not rare. As the physician population ages,1,2 a growing number of his colleagues will face similar circumstances,3,4 and with them, the responsibility and emotional turmoil of arranging to end their medical practices.

In many ways, concluding a psychiatric practice is similar to retiring from practice in other specialties. But because we care for patients’ minds as well as their bodies, retirement affects psychiatrists in distinctive ways that reflect our patients’ feelings toward us and our feelings toward them. To answer Dr. F’s question, this article considers having to stop practicing from 3 vantage points:

  • the emotional impact on patients
  • the emotional impact on the psychiatrist
  • fulfilling one’s legal obligations while attending to the emotions of patients as well as oneself.

Emotional impact on patients

A content analysis study suggests that the traits patients appreciate in family physicians include the availability to listen, caring and compassion, trusted medical judgment, conveying the patient’s importance during encounters, feelings of connectedness, knowledge and understanding of the patient’s family, and relationship longevity.5 The same factors likely apply to relationships between psychiatrists and their patients, particularly if treatment encounters have extended over years and have involved conversations beyond those needed merely to write prescriptions.

Psychoanalytic publications offer many descriptions of patients’ reactions to the illness or death of their mental health professional. A 1978 study of 27 analysands whose physicians died during ongoing therapy reported reactions that ranged from a minimal impact to protracted mourning accompanied by helplessness, intense crying, and recurrent dreams about the analyst.6 Although a few patients were relieved that death had ended a difficult treatment, many were angry at their doctor for not attending to self-care and for breaking their treatment agreement, or because they had missed out on hoped-for benefits.

A 2010 study described the pain and distress that patients may experience following the death of their analyst or psychotherapist. These accounts emphasized the emotional isolation of grieving patients, who do not have the social support that bereaved persons receive after losing a loved one.7 Successful psychotherapy provides a special relationship characterized by trust, intimacy, and safety. But if the therapist suddenly dies, this relationship “is transformed into a solitude like no other.”8

Because the sudden “rupture of an analytic process is bound to be traumatic and may cause iatrogenic injury to the patient,” Traesdal9 advocates that therapists in situations similar to Dr. F’s discuss their possible death “on the reality level at least once during any analysis or psychotherapy.… It is extremely helpful to a patient to have discussed … how to handle the situation” if the therapist dies. This discussion also offers the patient an opportunity to confront a cultural taboo around death and to increase capacity to tolerate pain, illness, and aging.10,11

Most psychiatric care today is not psychoanalysis; psychiatrists provide other forms of care that create less intense doctor–patient relationships. Yet knowledge of these kinds of reactions may help Dr. F stay attuned to his patients’ concerns and to contemplate what they may experience, to greater or lesser degrees, if his health declines.


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