Posts in category: Leaving Medicine

As outlined in the previous post, it wasn’t long after I became an ex-MD before I became more focussed on trying to redefine my identity in this new stage of life. I was pleasantly surprised by how much I found to read on the topic–books, articles, and TED Talks that were provocative enough to help me start charting my unique retirement path. It quickly became clear that the questions I had I would ultimately need to answer for myself.

To better understand retirement, I started with the history of the word itself. I wanted to be sure I was getting it right, after all. What is retirement supposed to be for? What are you supposed to be doing in this period? What kinds of goals should I start focussing on?

And as I researched, the questions became more personal. What is important to me? Who am I? What makes me tick? How do I figure that out? What was it about a career in medicine that attracted me so strongly? What basic itch will I need to keep scratching to have an enjoyable and fulfilling retirement? Is there anything else I want to do or see or experience before I die? How much time is there to get my life rounded out?

What was retirement supposed to be for?

The concept of retirement was originally German: In the 1880’s, Chancellor Otto von Bismarck’s newly-united Germany was facing multiple social challenges. Weary from several wars, the new republic had the growing threat of out-migration to better opportunities in the Americas. And there were intriguing socialist reforms being proposed by a Marxist wave spreading across Europe.

To stave off these challenges, and appeal to both the German working class and large numbers of ex-soldiers (many of whom were either disabled or getting older), Bismarck was the first to propose a national pension program (in 1889), for those aged 70 or more, recognizing that “those who are disabled from work by age and invalidity have a well-grounded claim to care from the state.” By granting social rights he was able to forge a bond between workers and the state, and stimulate German economic growth by giving workers greater security and a reason to stay. Shrewdly, though, he selected 70 because he knew few workers would attain it, and thereby it would cost the state very little. It was only about 15 years after his death in 1898, that the age of eligibility was rolled back to 65.

In Canada, Old Age Security pension was enacted in 1951, when an amendment in the BNA act allowed the federal government to operate a pension plan. It was also initially available to Canadians after age 70, although it currently serves seniors age 65 and up. In the USA, 65 was also selected as the age to begin distributing social security payments, when President Franklin D. Roosevelt signed the Social Security Act on Aug. 14, 1935. He had looked at existing examples (such as Germany) and similarly noted that, since the average American lifespan at the time was only 61, the cost to the US Treasury to cover these social security payments would be minimal.

Interestingly, not every country or culture has the luxury of a retirement, and some do not even have a word for it. Some writers make a distinction between a job (a source of income), and your work (a pursuit that gets something accomplished, which blurs the meaning of retirement, inasmuch you can retire from a job, but continue your work. In Spanish, the word retirement can be translated to “la jubilación”, which, when translated back to English, suggests a time for jubilation or celebration.

Old Age Security vs longevity.

Obviously, with a revolution in longevity in Western countries in the last 50 years, things have changed considerably; governments have started to sweat as to how to cover this burgeoning financial obligation. Starting in 2023, federal OAS eligibility in Canada will be raised gradually to 67 by 2029.

It is now pretty clear that most of us will have many, many functional and productive years at our disposal after age 65, a luxury that previous generations really never even dreamed of. Up until just 20-30 years ago, a human life span could have been easily looked at as having primarily two stages: The dependent years from birth to adulthood, that include the formative years of education and training, until the transition to independence; and adulthood itself, the productive and procreative working years, until work was no longer possible, whether due to disability, infirmity or death. For the lucky few who made it to 65 unscathed, and actually retired, it was still thought of as little more than a brief bonus, with the grim reaper waiting in the shadows. With such little expectation in mind, retirement has been thought of, and even defined as, the end of one’s productive life, and the downward spiral of infirmity; for the rest who didn’t make retirement age, adulthood generally meant working until you dropped, whatever your career.

What is retirement for–today.

Things are different now in this, now, 21st century. It appears that you can have your cake and eat it too–you can make it to age 65 with many years, even decades of functionality still in the tank, while being eligible to collect an old age security cheque for the duration. An overwhelming majority of us can all expect to have a true, self-directed,third stage of life–one that is both significant in length and opportunity–to define for ourselves, a luxury never before possible.

Defining your retirement.

We need to now vigorously redefine retirement. In a 2015 CBS 60 Minutes story about a Harlem seniors singing group, Alive: 55+ and Kicking, Executive Director Vy Higginson was quoted as saying. “The first 50 years are for learning, and the second 50 years are for living. Life just begins when you’re in your 50s”. That seems never more true than it is today.

Jane Fonda’s TED Talk of 2011 also provided a similar opening salvo to understanding this new perception of retirement. She posited that, after age 60, we can expect to live as much as three full decades. She calls it “Life’s Third Act”, a time for a whole other career or adult lifespan–a period of time previously thought only to be heralded by declining physical and mental health–“decrepitude”, or, “aging as pathology”, as she referred to it. She exhorts us to look at this period as a developmental stage of life with its own significance, and ask, how do we use this time, to live it successfully?”

“Life’s Third Act.” I thought she nailed it–for those who have made it to 60 in reasonably good health, another 30 years of life is not only possible, it is likely. And she had some excellent ideas as to how to embrace these years–more on that later. As Confucius said so long ago, “We have two lives, and the second begins when we realize we have only one.” So, if you are starting retirement, carpe diem!

An important caveat.

However, the ex-MD in me would be inclined to include a caveat: While getting to age 80 with full functionality is now a good bet, the decade after that may be a bit more of a crapshoot, given that Alzheimer’s becomes common in an estimated 30% of seniors by age 85. And the other age-related diagnoses are also more common by then as well: cardiovascular disease, cancer, Parkinson’s Disease, type II diabetes, degenerative osteoarthritis, osteoporosis, to name a few. So, I have come to accept that most of us have until age 80 to get every life goal accomplished, while not relying on the premise that there are more functional years after that. If you retire at 60, as I did, that leaves 20 years–about 7300 days of good health and physical capability–to get it all done before all bets are off.

Since 20 years–7300 days–doesn’t sound like much, this calculation is really intended to introduce urgency into the project of fulfilling one’s “Third Act”. And when you consider which 5 years in those 20 years are the most likely to have good health and vitality in, to succeed in doing your more adventurous pursuits, it is the next 5 years! Time is fleeting, indeed–so it is time to get your retirement going, and there is little time to be too introspective. If you have a bucket list, go for it. If you have unfinished business in your life–some music, reading, sport, hobby, volunteer work, education or training you had to abandon in your previous life, some long lost friend or family to reconnect with, your own health or spartan social life to revitalize, some travel destinations you have long fantasized about–whatever–time to get at it, and the sooner the better. This is your time. All of these pursuits should be personally satisfying, but will they be enough?

Completion. Fulfillment. Embracing your authenticity.

Just as Higginson postulated that life begins in your 50s, Fonda had a similar take on this. She thinks of life’s third act’s metaphor as a staircase, “the upper ascension of the human spirit, that brings us into wisdom, wholeness, and authenticity”– the completion of life’s journey. Such personal growth may well really be, at its root, a recovery process of the unique human spirit that we were born with, which is often suppressed with the decades of everyday life challenges, many of which are stressful, oppressive and even toxic. As your spirit reawakens, so will your sense of direction, and so will your life’s purpose.

Recovering your spirit.

Fonda observed that most people over 50 feel better, are less stressed, less anxious, and less fearful. Perhaps it is because their mortgages have been paid, their children are grown and independent, their financial security assured and their personal lives have long become stable. Or perhaps it is because they have survived the toughest parts of their lives, and it dawns on them that they can finally feel proud of what they have accomplished. As the shroud of expectations, stressors and obligations lifts, their suppressed human spirit and essential identity finally have a chance to return. These become reminders of what they once were, and give clues as to who they still are, and ultimately, where they still want to go.

Reconnecting with one’s lost human spirit is often a re-embrace of a vitality last felt in youth; it is perhaps what Ashley Montagu referred to when he said, “I want to die young at a ripe old age”, or what Pablo Picasso lamented in longing for this lost identity when he said, “It takes a long time to become young.”  So, is the primary purpose of life’s third act to finally”… finish the process of finishing ourselves?” Great question, Jane.

To succeed at retirement, then, is to find your essential human spirit, to redefine yourself in your own terms, not anyone else’s. The new retiree’s path will be defined by this journey: As Fonda puts it, “to know where you are going, you need to know where you have been”.

Although this may be easier said than done, knowing who you are, at your most core level, is fundamental to building the solid foundation for the journey of life’s third act, the time in which we can finally finish ourselves. This may be particularly difficult for doctors, who have been all but buried in a lifetime of obligations and stressors, beginning with their first desires of becoming a doctor, their consuming careers, and their chronic duty to put the needs of others first, ahead of any recognition of their own personal spirit. Ikigai anyone? More on this in part 2 of this post.

So, you have decided to cut the cord–you have resolved the important ambivalences around the decision to leave. You have set a date, you have sorted out where your mail will go, and you have found someone who will follow up with your patients. All the appropriate notifications–to hospitals, partners, call groups, patients, pharmacies, licensing bodies, among others–and transitional paperwork is done. For all the anxiety over taking these steps, you will note that it was not particularly complicated. Your last days are at hand. Now what?

And then it is over. A day after your last day at work, and for the first time in memory, you are about to go to bed at a decent hour, having had time to relax all evening (although you probably didn’t) and without regard to a morning alarm. No one is expected to phone you. It feels like the end of an era, perhaps bittersweet, or perhaps with the feeling of having something considerable accomplished. It is, though, the beginning of a new, but an uncertain stage of life. After a few days of this, the realization hits you–that you have really done it. You seem to have more time!–to read the paper, to grab a book, to walk the dog, for some idle conversation, and to catch up on a backlog of projects.

You may or may not feel persisting guilt about leaving, about who and what you are leaving behind. You may find yourself ruminating about any number of things, retracing your logic, and justifying to yourself (again) whether you have really made the right decision leaving. Perhaps you will wonder how your patients and colleagues will cope without you. You may need to reassure yourself regarding your decision; or you may seek counsel of a trusted friend, or colleague, or spouse.

In these early work-free weeks, you will eventually notice that no one has called you “Dr.” for a while–whether you will you miss that personal acknowledgment of respect over time will remain to be seen. The upside, though, is that there have been no new medical responsibilities surfacing, no one addressing you as “Dr.” on the phone by a health professional needing your clinical decisions. Over a few months, you may notice a modest but perceptable change in relaxation. Will it be welcome? Or will you cope by taking your natural type A driven personality to bury yourself in any number of projects at home?

But what, exactly is your retirement going to look like? How are you going to adjust to this new reality? Although the early going will no doubt feel unremarkable, albeit with some mixed emotions, and with many distractions to cloud the momentousness of the occasion, the new professional void will be difficult to ignore. You may ask yourself if this feels like a bereavement. At times, it may even feel like a freefall, complete with anxiety and an amorphous uncertainty–will there be a thud at the end of it all, or is this the beginning of a whole new flight you have never experienced before? You may have no real idea as to how to proceed, without a structure or a plan.

Thoughts during freefall.

I have been through it. There were many adjectives of how this transition felt that came to mind, and occasionally still do. And yet, I survived–at least I am over the worst of it–without any acute anxiety, any need for counseling, or a massive rethink or regret over letting my medical license lapse. But there were many more intrusive thoughts than I expected about my definitive exit. Perhaps some of this will resonate with you.

Staying in touch?

I thought about the professional associates and colleagues that I was leaving. Should I make the effort to stay connected with my (now former) staff and colleagues? How will they see me now? Do they really care that much about staying in contact? Do I? Were these friends by proximity or necessity, or were they more than that? Outside of medicine, do I have any friends that I can, or would like to, now spend more time with? Do I even need more time for friends at this time of my life? I decided I didn’t–I had plenty to keep me busy. But I had no definitive themes within my preliminary plans.

Did my financial planners really have it right?

They better have! I thought several more times about how much faith I had in my retirement planners. What if they got it wrong? What if there is a massive stock market crash? What if I have unexpected legal or medical bills that could derail my best-laid financial plans? I decided that, given that the advice I received had remained consistent (even from independent sources), it was time to truly stop worrying about my financial future; it was reassuring to know that the amount I had set aside was well within the average range that 60+-year-old physicians successfully retired with. And I decided not to hold onto some dark scenarios, that, while possible, were very unlikely; and even if they did occur, they might have other forms of financial recourse. I also thought it possible that I could almost certainly find some other source of income in the coming years if I truly needed to.

No one was calling me “Doctor” anymore.

Yes, I missed this–but only somewhat. It became clear that I was still being called “doc” affectionately by some friends who continue to see me with an admirable skill set (they probably also like having a medical connection to bounce questions off of once in a while). By those who had me as a client–banks, financial management companies, and the like–my “Dr.” title also continues unabated. The only time the “Dr.” title wasn’t being used was when it was part of an implicit medical responsibility–by a nurse, a ward clerk, or a pharmacist–and I didn’t really miss that. And since I could still put the educational moniker of “M.D.” at the end of my name when it suited me, I came to feel more comfortable with a preserved medical identity. This despite my College’s immediate request to remove any reference to anything medical in my incorporated name.

So if I am not a doctor, what am I?

This has been the most persisting and insidious question, one that became even more perplexing over the first 6 to 12 months of retirement. Beyond the title of “Dr.”, it was the feeling of being a doctor–the proud self-identity of being someone who could embrace and solve almost any medical problem, any time–that proved most difficult to shake, especially as there was no new or obvious identity to take its place. What am I now if I am not the reliable “buck stops with me” styled helper I always prided myself as being? How will I replace this feeling? Or will I be unable to? Or will it matter after a while? The introspection needed to settle these uncertainties was deeper and longer than expected (see more in the next post); for me, adequately answering such questions would prove to be the linchpin to a successful transition–to the point where I could look back with a “been there, done that” perspective.

“So how is retirement?”

Variants of the question, “So, what are you doing with yourself these days?” started to surface regularly, and have since continued, sometimes in future tense. Although I initially deflected it with something flippant, such as “…crosswords, sudokus, soap operas and golf magazines”, it has been self-evident at the outset that I really didn’t have an organized “plan” for retirement, nor was I even sure I needed one. But these questions eventually felt less intrusive, as it often seemed that they were as much about a genuine curiosity over what people do in retirement, for which, unfortunately, I had little to add–at least, at the time. I have come to believe that most people really have no idea how to look at retirement, how to prepare for it, or what they will pursue once their retirement threshold is at hand. But that is okay!

Is there a good book on this?

So, I eventually admitted to myself, I really had no good idea of what I was doing, or what I was actively doing in those early days. Ever the one to take an academic interest in the question, I found myself looking for a template, or a set of guidelines to at least steer me in the right direction. (It seems that we physicians have become so used to following academic ladders, protocols and algorithms in our training and working career, that, when faced with the threshold to an apparent abyss–the doorway to retirement–guidelines would be actively sought). The definitive textbook has yet to be written, but I was surprised how much discussion was already in print. Reading a few books and a few articles seemed to help.

After just the first month of not working, I felt increasingly driven to take a more active role in my new stage of life. How I did that, and how I developed the necessary traction to move on in the months and years following my departure date is the subject of the next post.

Leaving a life in medicine can sound a little like smoking cessation. Whether at the beginning, or the end, of a career, there are really just three approaches: you can quit “cold turkey” (completely pull the plug); “wean down” (ease out by working part-time); or use “replacement therapy” (by finding non-clinical work to partly or completely replace your medical career). They all work. So which one is best for you? Well, it depends.

Leaving medicine cold turkey.

So let’s start with the easy-to-understand clean break from your medical habit–leaving “cold turkey”–the one-step transition from your regular clinical routine, to resigning from your hospital affiliation, giving up your office and patients, and giving up your medical license. Most physicians do not choose this path by choice (it is too scary!), perhaps intimidated at least in part because of its finality (it is usually an irreversible step), and the uncertainty of the expected void that follows it. For many, it seems easier to “ease my way out of it.” More on this later.

However, for those that take this absolute and definitive plunge, their decision has to start with a pretty clear and sustained feeling that the party is finally over, and is based on a thorough and frank review of the risks and benefits taking this step. The minuses outweigh the pluses of staying, most uncertainties have been laid to rest, and that to ease your way out at this point would somehow be more painful. Breaking up is hard to do, especially for such a long term and meaningful relationship; but it can be done, and it can be the right thing to do, especially if “just hanging in there” indefinitely no longer feels like a goal.

The mechanics of leaving–easy.

The mechanics of such a step are pretty straight forward: set a date of your departure, let your hospital, colleagues, and staff know with appropriate notice, and hand in (or not renew) your medical license with an explanatory note. You may need to redirect your patients somewhere and/or find a buyer for your practice; you will need to arrange and secure longterm protection for your medical records, and create a process to deal with incoming medical mail that will continue to appear months, and even years after you leave. There may be some College and registration issues that include eliminating all references to the word “doctor” in your professional company name once you are unlicensed. And you will likely find yourself explaining your rationale to surprised colleagues and co-workers many times, even brushing off rumors that you might have some kind of terminal disease. Otherwise though, this is the easy part.

The internal dialogue to walk away–difficult.

What perceptions compel a doctor to break off a career they have so deeply invested in? Here are a few personal narratives that physician retirement-contemplators have that commonly surface after a couple of decades of clinical work (they have also been embraced at any stage of a career). The more of these that resonate, the more clear will be the decision to quit medicine–the doctor’s exit (“Drexit“?!) arguments:

Why it is time to go

I feel like I have nothing left to give, my empathy is all but gone, and “I cannot go one more day”;

I am chronically tired and sleep-deprived, I have done my bit, I have given my all to my community and to my patients, and it is time for someone younger to take over;

There is now no joy left in Mudville–the time pressures and burdens of my work now routinely outweigh the satisfaction–it has become noticeably more stressful, more litigious, more bureaucratic, more chaotic, and more technically demanding;

I am practicing defensively with every patient I see, more worried about making a mistake, and I can no longer keep up to my ongoing obligation to maintain continuing medical education, the technology of medical information systems, and the constant changes in the pharmacopiea. 

I am exposed to too much suffering and death that I cannot help–it is a wearing, psychological burden that continues to grow, some of which I am being unfairly blamed for;

I am not having fun, I am no longer learning or growing, and I am losing tolerance to patient’s continuing unrealistic expectations of both me and the profession;

I am no longer under any illusions that I am irreplaceable;

I am worried about impending personal health or family issues looming larger than before, and I now need to clearly prioritize me and my family’s needs over the demands of medicine.

I have already outlived some of my colleagues, many of whom never spent any quality time for themselve–the writing is on the wall for me;

Many of my medical friends and colleagues have retired or moved on, and I am feeling less connected to the newer hospital staff;

The altruistic desires that drove me to become a doctor have eroded, leaving only a drive to make money–the missionary in me has become a mercenary;

My financial managers have reassured me that I have enough to retire on, and therefore do not need the office cashflow.

Now that I am getting older, I still want some quality time for other life goals, including travel and reconnecting with my growing family while I still have the health and vitality to enjoy them.

The dialogue to remain–also difficult.

However, you may have some conflicting messages also echoing through your head, to remain in your career, to stay the course; these are headwinds that can impair you with ambivalence in your decision-making as you contemplate retirement.

Parenthetically, the process of intentional behaviour change–first introduced in 1983 as “The Stages of Change”— identifies this ambivalence as the “Contemplative Stage”; it is when an individual weighs strong arguments on both sides of a decision (such as quitting smoking or, in this case, retiring), prompting the ambivalence. And as long as these countering arguments have purchase, definitive decision-making is impaired, at least, until they can be somehow discredited or devalued. Ambivalence equals inertia–the status quo is preserved–and you will do nothing.

Not ready to go.

The (“Remain”) arguments–to continue with your career–can be equally pursuasive. Perhaps you will also recognize some of these thoughts in your process of contemplating retirement:

I get a strong feeling of importance and usefulness in my medical career that I may struggle with finding elsewhere, and I foresee this will be important to me going forward. So I may regret leaving.

I have spent my whole adult life training and the refining my skills as a physician–but am I ready drop it all, to walk away from all my training and hard-won experience, what is so valuable to the community, and for which I am so deeply invested, even defined by?

I may get lonely or bored with long hours at home, without much need for medical discussions, and without contact with my colleagues and long time associates.

I don’t really have any hobbies or interests to fill my time if I completely leave medicine. What would I do with myself? Is there anything out there that is as enjoyable, stimulating and meaningful as my medical career? I am never going to be a golfer!

I worry that I may find myself in accelerated physical or intellectual decline if I leave medicine.

I still like certain aspects of what I do, and am not ready to give that up, since it took me many years to get to these medical niches and access to these kinds of patients.

I enjoy and even thrive on the respect I get for the role(s) I play in the medical community I am in. Will my sense of identity be undermined by leaving medicine?

Will my family or friends think less of me or be disappointed in me if I leave medicine? Will such a decision initiate family worry over finances, the need to sell our house, or move?

I worry that being home all the time might even become a stress to our marriage, since we have not usually been in the house together for extended periods up to now.

I think it would be better if my spouse and I retire at the same time, so that we could continue to be on the same page for our immediate and future plans. This is a conversation we have not had yet, since I am still not sure I am ready to retire.

I am still not that old, I still have gas in the tank, and I can still contribute my unique skills to the community’s cause.

Despite assurances from my financial advisors, I am still hesitant to pull the plug on my medical income, since there are so many uncertainties that could come up that require more money than expected.

Since quitting medicine, and not renewing a medical license is almost an irreversible step (given the hoops you would have to jump through if you wanted to return), I would have to be more than just “pretty sure” about quitting cold turkey.

Am I really that unhappy in medicine–am I just whining and overstating my unhappiness? Most of my colleagues are hanging in. And there are few jobs that offer as much challenge and diversity, much less as good a pay scale.  I  might regret leaving.

There are almost certainly many more variations of these. When you ask yourself these, are some holding you back? How ambivalent are you about quitting? What do you still have to resolve to make it happen? This is the first battleground on the path to a successful retirement.

Should you get past this, as you lose your ambivalence and become determined to retire, what happens next? Will it be easy street and singing in the rain? In the next post, I will review some of the unexpected “withdrawal symptoms” that physicians may have to suffer through when they leave their profession completely.

In my previous post (part 1), I outlined some of the many reasons why doctors have become so deeply invested in their careers, even after just completing their training. Since this initial medical bonding process can span a decade or more, it is easy to see why physicians would already have such difficulty leaving their career, even several decades later.

Life in medical practice.

After training, embracing medical practice only deepens these themes. In the controlled chaos of a developing clinical career, there are many continuing challenges: Long and erratic hours; a persistent need to stay academically current; chronic sleep deprivation; the need for eternal patience; always putting others’ needs first; making and living with difficult medical decisions, some of which have to be made quickly and without enough information; the frequent need to be in two places at once; balancing patient needs and demands with limited resources; meeting hospital, College, and billing obligations in a timely fashion; and practicing defensively, with a growing awareness that, with every passing year, there is ever more to lose. For some physicians, it means giving up almost everything personally meaningful–hobbies, sports interests, time with family and significant others, personal downtime–usually to their detriment, but all in the name of career preservation.

The unending desire to help.

It doesn’t help that most physicians chose their career because of their desire to fulfill their personal learning potential, along with a desire to be both needed by, respected by, and useful to, individuals and communities; it all makes saying no–to one more patient, one more shift, one more OR case, one more nighttime phone call, one more journal article to read or CME talk to attend–all but impossible, even when there is nothing left to give. Because these continued sacrifices reflect, and add to, the already deep commitment to medicine, it becomes ever more difficult to walk away, whether early, mid-, or late career, even as additive stresses mount. As the physician’s outside life atrophies to a shell, there is no where else left to go.

It doesn’t help either that a mid- or late career physician has developed significant skill sets that allow a comfortable income. Since there are few other careers that can come close to providing the same level of income, physicians may feel stuck and dependent on their island should they start feeling the need for a career change, especially once they have become dug in to the financial obligations of building a career and supporting a family and a mortgage. Quick changes of direction that would have been easy early on, are now all but impossible.

Trapped in a medical career

This difficulty is enhanced when it is recognized that the skills that physicians have developed may not be readily transferrable to another career. Doctor’s skills–most unfortunately very unique to medicine–include suturing, surgical skills, obstetrical skills, interventional radiological skills, history taking, risk assessment, pharmacological prescribing, bedside manner, and physical examination. But where are the transferrable skills in all of that? Other physician skills, like knowledge of anatomy, interviewing skills, medical shorthand, problem solving, business skills, may be more transferrable, but are not usually associated with work as satisfying, as respected or as high paying.

While the realization that doctors may paradoxically come to see themselves as being stuck in a job with limited options for upward mobility, some who need a change may consider adding to their training, to learn new skills, to reinvent themselves. However, there may be little appetite, time or money for some form of retraining; sadly, then, because this barrier is a bridge too far, it only doubles down the commitment to their existing career, since they may also feel that they are too old or too tired to learn anything new, or they simply have no other directions of interest. For a professional group that was once chosen for their superior academic abilities, intelligence and determination, the perception that they are now trapped in their career, having to survive it since they have nowhere else to go, can be both shocking and depressing. Can a medical career be thought of as a dead-end job?

Burnout

Clearly, a career in medicine is hard to leave. In fact, most don’t, preferring to soldier on until they are either forced out for mental or physical health reasons, for failing to keep up with their many obligations, or until they all but die at their desks. Others can’t seem to find their way out, unfortunately to their own detriment; recently, the 2017 Medscape Physician Lifestyle Report suggested that 50% of physicians in the United States were reporting signs of burnout, a trend that has been steadily increasing in the last decade.  Although burnout can take years to become recognized, it is associated with increased risk for cardiovascular disease and shorter life expectancy, problematic alcohol use, broken relationships, depression, and alarmingly high rates of suicide—higher than any other profession. And not surprisingly, it adversely affects patient care.

Given the disturbing rates of physician burnout and suicide, many physicians need help to preserve their dignity and wellbeing, and be able to envision a fulfilled life beyond an unhappy medical career. Changing medical careers, finding a non-clinical career, or retiring from medicine completely, are all viable options, yet there is very little mentoring or guidance available for those who need it most. Most of those who have been successful at such a transition have been lucky to find a meaningful option available. The next few blogs provide some strategies for how to start the escape process–to a lighter load, an alternative career (either in or out of the medical realm), or to an outright departure.

In my last post, I collected the essential principles that Roadburg’s Life After Medicine book outlined–his strategy on how to plan for happiness and fulfillment after a medical career. However, as I read it for my own purposes, I found the approach overly simplistic; I had been expecting more resonance with the essence of physician training and experience, with a better distillation of the contributors that render physician retirement uncommonly difficult. Perhaps it is because Roadburg is a non-medical academic (a Ph.D. and not an M.D.) that the book’s strategies fall short–his many general descriptions make clear that he has not, first-hand, walked the unique path of a physician’s career.

Does it really matter what you did before retirement? After all, as Roadburg asserts, life in retirement may bear little resemblance to the hectic, focused life of a practicing physician, and is really about finding happiness and fulfilling personal needs, much of which may have little to do with a medical career.

Physicians understand their colleagues best.

I submit that, for retiring physicians, a retirement expert’s understanding of a career in medicine does matter–a lot. There is a natural rapport that physicians share that is less common in other professions. As a College registrar once commonly stated, it can only be a physician who, with their intimate knowledge of the medical selection and training process, can understand the thought processes and experiences of another physician. Although he was specifically referring to the assessment of their every day clinical encounters, it is likely also true of their needs post-medicine. It is only a medical colleague who could fully understand how deeply the vicissitudes of a medical career are etched into the soul of the average doctor, how tenaciously the many elements of this career are held, and thereby, how challenging it is to even contemplate leaving it. To get a sense of the difference that only physicians understand, Caroline Elton’s 2018 book, Also Human provides a haunting, at times troubling, but fascinating discourse of the unique crises and pressures that only physicians face in their working careers. (Full book reviews are here and here).

Where does it all begin?

The roots of being driven to learn, and of being deeply invested in a medical career start early. Some may have dreamed of being a doctor since childhood; others may have drifted into it as an extension of other health or science interests or academic abilities. Either way, pre-medical students eventually get obsessed, even tenacious, with maximizing their grade-point averages, the mirage of perfectionism, and ever more time in the library. In the process, these driven people are prioritizing their academic performance and their anticipated medical career over social distractions–well before they become a doctor. And if it all goes well–with their sustained scholastic efforts, and the hurdles of medical school entry (MCAT, admissions committee interviews, etc)–they will be rewarded with being chosen, out of a sea of also-rans, for the career of their dreams.

Being chosen.

The recognition of academic and personal strengths implicit in a letter of acceptance to medical school is a very big deal–the perception of being called to a career in medicine may feel almost biblical, and one that few could ever turn their back to. Since few other academic programs can match this feeling of privileged acceptance, it should not be surprising that such an invitation would become an adverse influence on the process of retiring–walking away from being chosen–even several decades later.

Medical school.

Following acceptance is the intense process of medical indoctrination. I remember fondly those heady first days of medical school, as we all proudly embraced and conformed to our new identity as the “Class of ’85”. These were now “our people– our like-minded and equally determined new classmates and future colleagues. We did not think of it much at the time, but our classmates would become our primary peer group as our non-medical relationships withered. Since our new title of medical student was already carrying considerable cache wherever we went, the medical identity quickly gelled, further galvanizing the feeling of being chosen.

Medical school would significantly reshape our identities–first by the academic challenges, the medical/hospital environment, and the new mentors in our lives; and later, by the burdens of increasing responsibility of patient’s lives and wellbeing, the on-call-related sleep deprivation, and the unsettling first-hand, hands-on encounters with the raw nature of serious disease, trauma and death. All of these exposures would challenge us young physicians in many ways–to work harder, to dig deeper, to fight cynicism, and harden up to demanding work that was as interesting as it was stressing. We didn’t immediately notice that, to survive, we would need to increasingly detach our emotions, our soul and our identity from our developing career. The chronic fatigue made one good for little else when we did have time off, while our deepening investment into our career left other vocational options behind. There only remained hope that, with more experience, control of our lives would somehow get better.

Internship and residency.

It has been said about several internship and residency programs that “they eat their young,” and that only the most determined can survive the often grueling years of training that all but eliminate work-life balance. Even from the very first days of becoming a fledgling intern (or in the UK, “junior doctor”–the next step after officially graduating, and thereby deserving of the title, “Dr.”), the transition is decidedly harsh, with these inexperienced medical graduates immediately thrown into the deep end of the hospital setting. They are usually and quickly overwhelmed by their life and death responsibilities, uncertain of ward and hospital protocols, and unsure where to find help when needed to make difficult medical decisions. It is only the beginning of a wild ride that only a few can thrive under.

Residency just perpetuates this process. One dean of an orthopedic training department, when asked what the 75% divorce rate among his residents says about his program, stated tersely, “It only means that 25% of them aren’t working hard enough.” ‘Nuff said. But surviving an 80+-hour per week training program that progressively eliminates any outside supports or interests you may have had is not only depersonalizing, but is also a significant “all-in” investment that most physicians could not easily leave–at any point of a career. And that speaks nothing of the shaming, humiliation, or self-blame that often occurs when a clinical outcome doesn’t go well, or the progressive loss of confidence and increasing defensiveness that inevitably follows.

The psychological assault does not end there. Although one might expect that the completion of a residency or internship could herald improved career control, significant challenges continue to appear. Many of these are can become quite toxic to well-being: Being chronically exposed to emotional aspects of patient care, as well as untreatable pain and suffering, and more death; regularly being the bearer of bad news; minimal opportunities for collegial debriefings; dealing with unconscionable referral delays; being at constant risk of overlooking a diagnosis; difficulties assessing multiple co-morbidities; being humiliated by more senior staff physicians for overlooking even the smallest of details; grinding extended hours work; frequently missing important clinical information; dealing with patient complaints and the constant risk of being named in a lawsuit or formal College complaint; remaining dedicated to completing endless paperwork and hospital obligations; adapting to changing College obligations; remaining aware of billing limitations; accepting the loss of personal connections and vacation time.

Pre-medical school determination, medical school indoctrination, internship/residency survival, and the challenges in starting a career; taken together, they spell a deep investment of time, money, and personal sacrifice. And all of this to reach, and stay in, the dream of the “promised land”–the riches, both monetary and in stature, that would ensure the underpinnings of a successful life. However, for most physicians, these stressors continue and often accumulate, becoming a way of life for the next three (or more) decades of a career. More on this in part 2.