Early in the pandemic, we began using yellow cloth isolation gowns, environmentally superior, perhaps, to the paper gowns that preceded them, but not without complications. The strings at the neck were invariably tied and tightly knotted after going through the wash. If you’re a smallish doctor or nurse, the pre-tied neckline hung down around the tip of the xiphoid. I stood outside my patients’ rooms on long, weary days and picked at those knots with my fingernails, growing increasingly exasperated and thinking, this is the last knot! Tomorrow I retire!

I did retire, but not for another five years. It turned out it was complicated, in the end, to find the right time. After practicing medicine in a variety of settings, as a nephrologist and in primary care, for about the first 20 years of my career, I landed in academic medicine for the next, and last, 20 years. Initially, the new environment seemed like a protected habitat, relatively insulated from the evolving imperatives of productivity standards. I went to work at an independent community teaching hospital with physician leaders who had vision and integrity, joining the faculty of a thriving internal medicine residency program. How could this possibly go wrong? Then, the hospital, faltering financially, was bought by another institution, and among an assortment of reductions and changes in business operations and culture the residency was closed. I left, along with others on the faculty, and became program director of an internal medicine residency in another local community hospital. Then two years after I arrived, that hospital was bought by a private-equity-invested company.

The private equity playbook is grimly familiar to anyone who follows the fate of financially unstable community hospitals, or Toys-“R”-Us or Red Lobster, for that matter: the extraction of wealth, the piling on of debt, the non-payment of bills and taxes, the selling of the building and the ground under it in what is blandly termed a “sale-leaseback” arrangement, and then, within several years, the sale of the institution.

The hospital was on track to be purchased, and therein saved, by an academic health care system, until it wasn’t. Local and national press warned ominously and repeatedly of the hospital’s closure, calling to mind Mark Twain’s comment that the report of his death was an exaggeration. We weren’t closing, at least not yet; we were working harder with less. The anxiety experienced by residents, most of whom were international medical graduates on visas, was intense, only amplified by the immigration actions of the new administration in Washington. Layoff of a faculty member was threatened, and some faculty left. Departures of staff occurred throughout the hospital and clinics, including in key positions in various departments and the administration. Institutional memory dwindled. Because payments to vendors were delayed, supplies of all descriptions ran short. On rounds with my resident team one morning, a patient looked me in the eye and said, “You people need someone to save you.” We laughed together for a moment, with a shared subtext of bitterness. Laughing with patients, which generally happened when health improved and hopefulness was restored, had always been one of my biggest joys in practice. This was something else. Save us so we can save you. That, and teaching the next generation, were all we were there for. Eventually, the parent company filed for bankruptcy. We bobbed like the frogs in the proverbial pot of slowly boiling water.

We were, all of us (doctors, nurses, all clinicians, and all employees of the hospital and its clinics, our patients and the community) caught in the protracted, inscrutable maneuvering of for-profit owners, large health care systems, state regulators, a real estate company, and a faraway bankruptcy court.

Along with faculty members, I had participated in building the residency program from its beginning. We graduated 10 classes of categorical and preliminary residents and recruited several of our residents and chiefs to the faculty. We took pride in our wonderfully diverse trainees and the collegial, academically rigorous culture we created and sustained together. Private equity is all about the short-term returns, the opposite, of course, of medical education. Negotiating for the personnel and resource needs of the residency as staff and resources shrank around us, and figuring out how to continue to meet requirements and maintain our curriculum became my main preoccupations, consuming an ever-increasing amount of time. In this I had the assistance of the associate program directors and faculty members. The care we had taken over the years to develop a culture of mutual respect and commitment to the educational mission paid off when private equity applied the screws. But as one colleague on the faculty sagely observed, it’s not healthy to fight all the time. Everyone continuously recalibrated their personal limit as they worked under progressively more difficult conditions to care for patients, waiting for the hospital to be purchased and revived. I had recruited some of the faculty from among my former residents at the hospital where I previously worked, so this was their second experience, like mine, of being employees with negligible power as ownership of their institution changed hands. Our residents, many of whom had overcome daunting challenges just to arrive at our hospital, demonstrated remarkable resilience as we navigated a series of setbacks, including the academic institution’s decision to sue the hospital owner and the subsequent threat of bankruptcy.

A frequent dialogue in my house at night went like this:

My husband: Did you announce the date?

Me: No.

Husband: The sooner you tell them the better. And then it will be real.

Me: That’s the thing.

Yet there was another thing. I had reached my limit, and I was ready to retire.

Finally, the right, or perhaps what seemed the least problematic, moment crystallized: I would announce in September, before intern recruitment began, that I was retiring at the end of the academic year. To the good fortune of everyone, during that interim one of the associate program directors decided to apply for the position and was selected as the next program director.

My last week on service, the team was led by a third-year resident whom, by coincidence, I had supervised on her first rotation of internship. This gave me the opportunity to observe, close up, the transformation of a timid, terribly self-conscious intern into a curious, capable, and confident graduating doctor. So it has been since the time of Galen, I imagine, or at least Sir William Osler, in this job of medical education. This, in the end, was the real knot, bittersweet to untie.

Ruth E. Weissberger is an internal medicine physician.