The letter

It seems that I have been writing letters all my life. This was not a discipline covered in the curriculum way back “in the day.” History-taking was a didactic art form punctuated by bullet points and blanks that required fulfillment. Narrative reports, however, allowed me to transcend mundane clinical information and transform it into a more creative and readable platform. Medical-legal reports in the early decades provided the opportunity to be detailed, descriptive and succinct while avoiding the pitfalls of embellishment. There could be repercussions lurking both for the patient and physician: The patients’ price was itemized in the settlement agreements, the physicians’, in the dreaded subpoena and court appearance. During the 80s to late 90s, I served as a peer assessor and independent contractor for the College of Physicians and Surgeons of Ontario. Narrative reports were an adjunctive component to the litany of questions included in the peer assessment protocol. I found myself writing pages of observations accrued during the chart reviews and interview session following an intensive dissection of “25 randomly selected patient charts.” This was meaningful and revelatory and reflected the “story of the doctor” just as the charted records were expected to tell the “story of the patient.” We have all been asked (sometimes coerced) to write a letter of support for a plethora of purposes. Although most are reasonable requests, some defy logic and deny respect for our professional values. “You have to write me a letter,” is a directive that still echoes today. My response was always, “Why do I have to write a letter for you?” The subject matter was variable and frequently questionable: reinstatement of a licence following suspension for DUI, “special” housing accommodation, employment letters usually with a variation on the theme of leave-of-absence, exemption from jury duty (one of my favourites), child custody letters, work accommodations based on perceived physical limitations or interpersonal conflicts in the workplace, confirmation of being “alive and well” for a variety of European pensions, and the very demanding long-term disability claims letters for motor vehicle accident “victims” who had clinically established the absence of any physical or psychological injury but were looking to avail themselves of the largesse of the insurance industry, in some cases, for life. Of all the letters written in all my years of practice, there is one that I struggled with the most. In the run up to my retirement, initially scheduled for June 30, 2020, and subsequently postponed to September 30, 2020, on account of an unexpected pandemic dropping, I enlisted the services of a record management company. In our discussions, an extensive checklist was reviewed. We touched on the necessity of writing the ever-daunting patient letter, announcing the impending retirement and providing the logistics of record acquisition/retrieval and storage as well as the mandated legal requirements for medical record maintenance and ultimate disposal. There was a “form letter,” a template provided in the package, direct and factual but neither appropriate nor sufficient, considering a retirement in the time of COVID. I elected to write my own letter, one that was personal and reflective of my sincere feelings. I was cognizant of the anticipated response that such a sudden and unexpected pronouncement would have on the patients. I was not wrong. There were tears and fears and even some jeers in the aftermath. The letter that follows was sent to a computer-generated list of 1500+/- patients. It is dated June 22, 2020, just over a year ago. “Dear Patients, For the past several months our world has been in turmoil as a result of the sudden arrival of the Coronavirus pandemic. The global impact has been unprecedented, our healthcare system stretched to its limits. We have been called upon to make extreme sacrifices and we have responded with one voice and a singular purpose. Acts of mitigation and containment have been embraced, sustained and ultimately will see us through to a successful and healthy conclusion. As you are no doubt aware, COVID-19 has changed the practice of medicine dramatically. We have accepted the necessity to practice remote and virtual medicine. Telephone and email communications have allowed regular contact for advice and reassurance but fail to replace the fundamental doctor-patient relationship. “Routine” examinations have been postponed or cancelled. Physical distancing measures and fear of contagious viral exposure present obstacles for access to every aspect of healthcare. My office has been in lockdown mode since mid-March and although it is expected that we will slowly introduce limited and restricted visits, I do not anticipate a return to business as usual in the foreseeable future. As you can well imagine, this situation is far from ideal, a major departure from what I have experienced in my professional life for the past 50 years. On March 23, you were to have received a letter from me announcing my intention to retire from medical practice, effective June 30. The precipitous arrival of COVID-19 and the extreme measures that have since been undertaken to mitigate the pandemic and its repercussions and consequences forced a change in plans. Since then, I have been in my office six days a week and available 24/7, responding to your calls, emails and ensuring that your prescription needs are met. These virtual services will continue and support your immediate needs as we move forward to some form of re-opening. My practice, however, will look much different in the coming months and will require your understanding, patience and acceptance that we are facing an imposed transition and a “new normal,” which will likely not resemble anything that you have become accustomed to previously. On September 30, 2020, I will officially retire from active medical practice and the office will close. This decision has been carefully considered, and despite the current situation, there will be no perfect time for an exit strategy. For many of you, our relationship spans decades and for some, dates back to the early 70s. I have delivered your beautiful babies, and in many cases, continue to look after your children and grandchildren, fulfilling the true definition of family medicine. I have seen you through illness but have always emphasized wellness. We have shared the heights of happiness and have survived the depths of sadness together. You have entrusted me with your care unconditionally. Your respect has strengthened our bond and provided me the gift and privilege of being your doctor. For this, I am forever indebted. For over 30 years, Angie has worked with me and on your behalf. She has considered you her extended family and has always ensured that your appointments, consultations, investigations and navigation through our complex health system is seamless and less complicated. Her personal, compassionate and professional approach has allowed me to focus on what I do best, while she has done everything else that relates to your immediate and personal needs. Angie has been an invaluable asset to all of us. Retirement will be a novel and challenging adventure. I appreciate that these times further complicate my decision. I will miss the daily patient contact. Your personal stories have always stimulated, enlightened and enhanced my clinical experience. These are the lasting memories I will take with me. The path ahead presents a level of uncertainty for my retirement plans but I will persevere. I intend to enhance my skills in writing and technology, travel with my wife Ellen when the world permits, exploring new horizons not previously attainable because of the demands of solo medical practice. We will dedicate more time to our children and grandchildren and sit in awe of the magnificent sunsets at our Kawartha-area cottage where Mondays are just another day of the week. I wish you the best any doctor can wish his patients. Good health, much happiness and a rich and fulfilling life. It has been the honour of a lifetime to have cared for you and your families.” Dr. Howard Goldstein A year in the life. At career’s end and tomorrow’s beginning, this year has had a lot of everything. From a world ravaged by an opportunistic viral pandemic to the final chapter of a long and satisfying medical career. I could have written the story long ago, but then, it would have been considered fiction. The reality was encapsulated, written and delivered in a simple and time-tested format. The letter. Dr.H.Jaye Goldstein (Ret.) June 18, 2021

The letter

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HOWARD GOLDSTEIN

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