The Seeds of Retirement

I had always wondered when I was “supposed” to retire. Was it like contemplating when I am supposed to get married?  Would I just know?

The idea of retiring, at least as a viable alternative to career building, began in my 50s, when my financial advisors would routinely bring it up as a hypothetical endpoint to my regular income. Since I had never considered actually, voluntarily, stopping work, it caused me, for the first time, to consider the proverbial light at the end of the tunnel, the last day in the office; although quite noncommittal to the idea,  I could easily put a number to how many more busy Monday clinics there would be before, say, turning 60, or 65. (My daughter (wrongly!) thinks I am an autistic savant.

I was tired.

The first indication of a true need to retire came about the same time–I was becoming more noticeably weary–where the idea of seizing the day had given way to more simply, surviving the day. Those once interesting, stimulating, and fulfilling days at work were giving way to more difficult cases, more routine and repetition, mounting paperwork and, at times,  irritating bureaucracy–in retrospect, my career path was becoming a beaten path. And yet, the high volume of work continued–there was always pressure to cover shifts, to find regular time for continuing medical education (a requirement for licensing), unexpected reports to write, endless new drug rep spiels to hear out, and seasonal clusters of illness and injury pushing the community’s capacity.  Weekend work, along with irregular and extended hours, were still as common as ever; as a result, opportunity to rest and recover was similarly erratic, and vacation time difficult to plan, even to carve out just one week at a time.  How much longer could I keep this up?

The work was harder.

Besides fatigue, other increasing work pressures began wearing me down.  Patients were getting crankier due to lengthening wait times and briefer visits; they had also become more inquisitive (health care has become an accessible consumer commodity), and more likely to be armed with Google-derived science needing some extra discourse. As rapport and connection was being lost, patients were also more likely to complain about you.
And while some were less tolerant to protracted investigations or treatments, oversights, poor treatment responses, or, perhaps, vague diagnoses (whiplash injury, anyone?), others demanded every latest test under the sun. Many of those with drug plans would lobby for the best drug, while others refused to consider any prescription, whether because of limited resources or a “natural” belief system.  Sifting through patient preferences, frustrations, and life narratives, to build and maintain patient rapport, in less time than ever, was harder than ever. And both the joy and job satisfaction associated with meaningful clinical encounters was waning, as the push to perform better and quicker continued to grow.  Were these the early signs and symptoms of “burnout”?

The expectations were growing.

Being a physician wouldn’t be so bad if the only important focus was on patient’s needs while getting enough time off.  Enter the regulatory bodies–Colleges, WCBs, insurance companies, government–all adding, in their own way, to the challenges of every doctor in practice. 
Licensing authorities (Colleges) have significantly increased their physician oversight since 2000, meaning more policies, protocols, and clinical algorithms to review and adhere to; more clinical practice competency reviews to endure, especially after age 55 (these are never fun); stricter prescribing guidelines and audits for many drug classes; more frequent requests for clinical reports regarding patient complaints; and increased demand for better record-keeping, requiring often steep learning curves and costs to embrace ever-evolving electronic medical record-keeping. 
Other institutions have also been gnawing on physicians.  As illness and disability claims have increased, so has the need to complete forms or write medical reports, whether for insurers, lawyers, WCBs, employers, schools, or government. And as a high wage earner, physicians have long expected regular federal government income tax audits, as well as occasional medical service plan billing audits.  Little wonder that so many physicians feel under a paralyzing microscope, a siege of almost constant scrutiny (not fun either). Ugh.

Was I losing my identity?

For me at home, too, ill winds were blowing. Initially, I had hardly noticed that work obligations were competing with, and regularly undermining, my other life (Is a doctor even allowed to have one?). When I allowed myself some reflection, it was clear that I had very little work-life balance–I was living to work more than I was working to live–although I had chosen my career for many positive reasons, my identity, even my soul, was now being lost in the title of doctor.
The signs were everywhere. I often desperately needed family vacations–as an opportunity to re-establish my sleep-wakefulness cycle–yet most were only a week long, and were not long enough to completely unwind, let alone rebuild family connections. And sadly, the rest and relaxation gained was increasingly short-lived on returning to work–I would be coming home from work grumpy within just days.
 Sleep, generally, seemed ever more fragile–whether it was due to aging, stress, chronic sleep deprivation, teetering burnout, or some combination of these, I never had much time to think about it.  When it got really bad, an occasional zopiclone would usually save me, but I worried that drug dependence was just a few doses away.  And my waking hours were not what they could be either–I recall once playing tennis in a numb daze, without enjoyment or really even being sure why I was there. 

A Faustian bargain?

With these reflections, I had come to recognize the Faustian bargain I had made choosing a clinical career–medicine was essentially demanding that I give up just about everything else. Yet I soldiered on, not really believing I had any other option–or at least, not much time to think of one. Perhaps it was cynical to think it, but I came to look at medicine is essentially a dead end job–there are no natural progressions into the boardroom.  No one is knocking on your door to offer you a new career; no medical associations have a job posting board or vocational counseling, since everyone assumes you have already made it to the top. Your pay is the same as everyone else’s, irrespective of skill level.  Sure, you can get extra training, or become political, but neither are based on seniority or even experience.  I felt stuck where I was–a medical public servant, chronically rushed, and while constantly under surveillance.  So it became one day at a time, one day at a time.

The tipping point.

I could have carried on.  But what changed everything was developing a heart problem in the midst of all of these machinations and revelations.  It started unexpectedly, with an isolated stressful day that triggered a 24-hour long, dizzying atrial fibrillation event, treated in hospital with anti-arrhythmics. Two years later, a second bout occurred, before eventually giving way to monthly, then weekly, then almost daily events over several years, while slowly becoming more resistant to treatment.  Each of these events had to be aggressively treated, since they did not resolve spontaneously.  And since they were always symptomatic, with dizziness, shortness of breath, and anxiety, it became more difficult to do just about anything, whether work, travel, drive, or even read.
Was my condition just age-related?  Did work stress have anything to do with it? Despite preventive interventions like regular medications, weekly yoga, trials of various supplements, dietary changes, alcohol avoidance, and even a three month sabbatical from work, nothing changed.  Both my work and my personal life was being progressively encroached upon. I felt my world closing in on me–for the first time in my life, I felt disabled, and worse, dependent on drugs that hardly worked.  After several hundred episodes, each lasting half a day or more, an ablation was my last real option– if it was not successful, I would have to accept myself as having a permanent disability. Given how generally healthy I had been for so long, it was sobering to think that I would need a surgical intervention.  This was my watershed moment–hard evidence that my job was killing me slowly.  Was I man enough to admit it?

The case became clear.

With my recurrent atrial fibrillation symptoms, it was clear that my work routine was no longer sustainable unless several things changed–a lot–both with my health and at work, and maybe my attitude towards both.  Questions came in bunches. Was there a reasonable possibility that I would fully recover from my ablation? And even if so, would that change anything? Was my unassailable youth and resilience now forever behind me either way? Was there any possibility that my work parameters would improve or at least, not change, or be modifiable?  Any point to stick it out for a better day? Should I pursue another career? If so, what? Could I afford to retire?  How much of a nest egg would I need?  What are the assumptions built into that estimate?

Nothing is gonna change.

As I started answering some of these questions, two things became clear: First, I no longer had faith that any of the clinical stressors I had noted were going to improve, and, since the health care system I worked in was too big and too well established to try to affect change from within, it was time to move on. Second, although my ablation proved to be completely successful in both eliminating my events and the need for medications, the experience left me with a more realistic, down-to-earth appreciation of my health- that it would again be vulnerable, and more likely sooner rather than later, given my age.  I decided that I had no interest in dying at my desk–and that I had better things to do for the time on the planet I have left (even if I don’t exactly know what they are yet).

Time to act.

It was time to ask my financial advisors the big question. Can I retire now? Or do I need to keep going? Or somehow change direction? I was now ready to listen, more intently than ever before, to their assumptions and conclusions (You can probably guess where that conversation went). That conversation in my next blog.

So, how about you?  Are you still in love with your medical career?  Is it still enriching and worthwhile?  Are you still getting the feeling you are making a difference, and that you look forward to your work day?  And your health and wellbeing, including your family connections, are thriving?  If so, carry on.

Or are you struggling with similar issues mentioned earlier? Are you mostly in it for the income, or the prestige and stature provided by your community identity as a doctor?  Or the colleagues who have become your primary social group? Are these the only net positives left? Or are you at a loss as to what to do with yourself if you weren’t working as a physician? Is it time to ask some important questions of yourself?