Dysart, Christian, M.D., License #7265 (Salem, Marion County, Oregon)

The board and the physician entered into a Retired Status Agreement without Findings and Order. The effective date of retirement was January 1, 1992. RETIRED STATUS AGREEMENT WITHOUT FINDINGS AND ORDER SIGNED: December 27, 1991

That is the exact wording in the Bulletin of the Medical Disciplinary Board of the Board of Medical Examiners of a neighboring state. It comes to me four times a year.

But Chris Dysart is not just another name in the Bulletin. He is a long-standing friend. We have shown each other slides of our journeys into the Karakorums or the Galapagos, squired each other's wives to the country club, even taken a cruise together. And in his Christmas card, which announced his impending retirement, he had said nothing of the reasons for it.

That was his privilege, of course, but inevitably I had to wonder what he had done to earn his sanction. I hoped that it was only because he had become physically or mentally unable to handle his work. Still, I knew from reading the Bulletin over the years that there were only a few ways a physician could lose his license, and gross incompetence was rarely one of them. And I also knew that Chris was not too impaired to practice. Like most of us he had had a by-pass, but his mind was as alert as ever; he was still in the category of "young-old; " and in a recent conversation he had denounced my own early retirement as a cop-out, proclaiming his intention to hang on for at least another 5 years.

I was and am in no position to determine my friend's competence to practice his specialty for we are social friends only. We have never worked in the same hospital, referred patients to each other, or asked each other for advice on the phone. But I have to assume from his obvious success that he was thought competent by referring physicians and agencies. With considerable regret, I moved on to the more common indications for sanction.

The Bulletin had taught me that most physicians who are disciplined seem to have been so for either personal substance abuse, a sexual offense, or Medicare fraud. Knowing Chris as I did, knowing the strength of his marriage and his lifetime abstinence from drugs and alcohol, it seemed the only one of the usual charges that might fit was fraud, abuse not of patients but of the governmental agency that rules our lives. But he hadn't told me that; it would be discourteous to ask, and so I will never know. Yet I will do him the disservice—and probably the injustice—of wondering for the rest of my life.

That led me to ponder how I should behave toward a colleague who has been sanctioned. Although I have no problem accepting someone who has been convicted of fraud by the rather dubious standards of Medicare auditors, I must, of course, excommunicate from professional contact someone who has been guilty of abusing a patient. But what about the addict, no longer fit to practice medicine, who is perhaps as much a victim as criminal? Do you address him as "Doctor"? Is it proper to discuss cases with him or fill up the conversation with gossip about reimbursement policies and denials by PSROs? May I take him to a party sponsored by Devon Pharmaceuticals? In other words, is he, although sanctioned, still one of us? Sometimes he is, I think, but the line for that decision is fine.

I am told that a defrocked priest, forbidden to administer the sacraments, is still a priest, that the ordination cannot be undone even by the Pope. Perhaps that is also true of a sanctioned physician, especially if all he has done has been to run afoul of some minor regulation enforced by a third-rate bureaucrat. Or misinterpreted a fee directive. Or been falsely denounced by a deranged or vindictive patient.

In the case of Chris such musings will not matter. We are social friends only, and I will treat him as I always have, but sooner or later the same sanction could be imposed on someone to whom I once referred a patient or from whom I received referrals. Would I stop talking medicine to a former colleague who had lost his license? Probably not, but our talk might lose much of its meaning.

One thought leads by leaps and bounds to unrelated issues. I began to wonder if we weren't all sanctioned ultimately by time, fading powers, obsolete knowledge, the inevitable drifting away of patients, and diminution in status that comes with simple old age. At what stage in our careers do we cease to be doctors and become undeserving of the honorific "M.D." after our names?

Perhaps guidance could come from those who took the degree but never practiced. When do we become doctors in the first place? Are Somerset Maugham, Armand Hammer, Michael Crichton, part of our guild? Obviously, Armand Hammer thought he was for he used the honorific for nearly 70 years. But Maugham seems never to have referred to himself as "Dr." nor does Michael Crichton. They lived and live as literary men. Justly so. Medical authors who practice medicine, Lewis Thomas, John Stone, Perri Klass, Richard Selzer, William Ober, Gerald Weissman, always seem to be proudly doctors first. I believe it is the actual contact with patients and colleagues that makes us see ourselves as doctors and not as writers or business persons. It is active medical work that makes us members of the guild.

So, more to the point then, is do we cease being doctors when we no longer see patients? When should we stop expecting from others the special respect an active doctor is usually granted?

For some the answer is "never!" Dr. Glass insisted on the privilege until he died. When I practiced in Iowa, he was the only physician in a small neighboring town who, at age 85, finally gave up his last few, very loyal, elderly patients. He was an honorable man who had always practiced within his limitations and maintained the affection of his peers until the day he died. But by the time I knew him he had gone from being a busy, competent, useful physician to a trembling old man, far gone in dementia. He lived in a chair at the nursing home, his withered hands holding an AMA News he could no longer read or understand. Yet even in the home, he was not "Jim" or "Bill" like the other patients; he was "Dr. Glass" until he died in his sleep, and he is "Dr. Glass" still, for his tombstone proudly portrays "M.D." after his name.

Many of us are different from Dr. Glass. We retire young and build another identity so we need not cling to our status, need not insist on being greeted as "Dr." wherever we move. In fact, for those of us who spend our time away from practice on a retirement hobby, a second career, on managing investments, on being the beloved patriarch of a growing family, the appellation, "M.D.," becomes irrelevant. More and more I find myself leaving it off when I type a signature line or a return address. Yet, there are still moments when I want to be a doctor, accepted as such by my contemporaries, and granted the respect the young guildsman should have for his elder. I reserve the right to dress in that elegant, but understated way we have inherited. If invited to walk in an academic procession, I would still proudly wear the three green stripes on my sleeve and the doctoral hood of my alma mater. But I am not really a doctor any more. I do not practice. I have given up my licenses before they could be taken from me. And perhaps, in the eyes of some, my insistence on "M.D." for the tombstone makes me as much a fraud as my friend, Chris, disciplined, presumably, for overbilling.