Finding retirement traction (part 1): Ending the freefall

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.

The Immediate Aftermath of Quitting

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.

The First Route of Medical Departure

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.

Life After Medicine: what Roadburg missed (part 2)

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?


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 suicidehigher 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.

Life After Medicine: what Roadburg missed (part 1)

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.

BOOK SUMMARY: Life After Medicine–The secret to retirement happiness

In 2005, Alan Roadburg, PhD wrote, “Life after medicine: The secret to retirement happiness”, a guide endorsed by the Canadian Medical Association’s MD Financial group of companies, and subsequently shared with Canadian physicians nearing retirement.  Written as an easy weekend read, in a similar style to David Chilton’s “The Wealthy Barber”, the book’s underlying premise is that, unlike financial planning, the non-financial side of retirement is uncharted territory—often left to chance—yet equally important for structuring a successful and happy transition to life in the slow lane. His book creates a framework (“Life Goal Planning”) for the process, one that complements, and ultimately defines, the financial plan for retirement.  Just like planning a vacation, you have to consider first where and when you are going, and how you are going to get there, before you ask how much it costs.

Change the concept of retirement.

In creating a framework to better understand retirement, Roadburg’s overarching concept is to simply rework the  “R-word” (retire), to what he calls, “retire with a dash”: To “re-tire”, a concept analogous to  “getting a new set of wheels to embark on a new life journey,” or essentially, “a (newly created or revitalized) career earned from, and following, work.”  Roadburg’sre-tirement” is a clear departure from some older concepts–such as being “put out to pasture”, or simply giving up working in favor of being rewarded with daily leisure time—by gardening or playing golf every day. Instead, he emphasizes that it can actively focus on one or several worthwhile pursuits that bring enjoyment; unlike retiring, where you are giving something up, in re-tiring, you are gaining a new direction in life. Your re-tirement can also be thought of as your next, and best, career, because it can integrate the best features of both work and leisure time, can be crafted with a lifetime of accumulated experience, and with the benefit of plenty of time to formulate it.

Money concerns are less important than we think.

Interestingly, research has shown that, among pre-retirees, 75% reported they would most likely be working for pay after they retire; yet only 44% said they needed the income.  Staying mentally alert (93%), maintaining social interaction (86%) and feeling useful (74%) were more popular reasons to continue working—essentially to avoid boredom.  And among dissatisfied retirees, another study showed the main reasons they missed work were exactly the same (lack of stimulation and feeling useful), with only 9% mentioning money as a problem.

Recognize the common mental roadblocks to re-tirement.

In dispelling some myths, Roadburg first emphasizes the need to avoid conflating health and aging issues with re-tirement.  While health is, of course, important to enjoying re-tirement, this premise is true at any stage of life.  Re-tirement should not be likened to a terminal disease, as the beginning of the end. Similarly, being a “senior citizen” it is not a reliable harbinger of physical or mental decline—rather, it might be more constructive to associate “senior” with increased wisdom, experience, and maturity.  Symptoms often seen in some retirees—depression, loneliness, boredom, poor health, decreased vitality, among others—can also occur at any age. The common story heard about retirees dying shortly after retiring are actually uncommon, and ignores a large number of people who probably lived longer because they retired in good time.  As for memory decline with aging—studies have shown that memory can actually improve when given memory training sessions, even in the elderly.  Hence, re-tirement only affects memory adversely if the mind stagnates.

Second, Roadburg dispels the notion that re-tirement is just a tipping point to extended free time, or the beginning of secondary or trivial pursuits that lack purpose or meaning. Rather, this staging point is when you change from a work to a re-tirement career—by drawing on past experiences to plan a new path that integrates the best of work and leisure, you can re-introduce goals, draw on well-established needs and skills, and create new challenges. With this perspective, any malaise you might have had being stuck with a lack of direction will soon be replaced by optimism and creativity.

Third, although it is well acknowledged that a physician’s life focus is central and consuming while working, and difficult to compete with, or replace, in re-tirement, Roadburg makes clear that satisfactions derived in a medical career can still be found in alternative activities, even if it takes more than one life focus to replace it. Medicine need not be looked at as the job you can never leave, or the be all and end all as a source of happiness and satisfaction for physicians.

On the contrary, re-tirement now, especially as a Boomer, can be thought of as winning a lottery–it can provide you the time and opportunity you never had when you were working, to find other forms of happiness and fulfillment that may have previously eluded you.  Today’s re-tiring Boomers are generally richer, better educated, and live longer than any group before them, and, by virtue of the size of this cohort, will retain political and economic clout–a bandwagon if ever there was one!

The secret to re-tirement happiness for physicians

As physicians approach their retirement years, most will start to identify at least some goals and directions for life after medicine, even if only in broad strokes. If you are in this cohort, you should consider listing these as best you can–they are preliminary or anticipated plans that will be reviewed after the next exercise and then refined further.

In his book, Roadburg’s primary theme is stated as, “The secret to retirement happiness is to find alternative activities that will replace the satisfactions lost that used to be satisfied through practicing medicine.”  Most of us have looked at work as simply an activity, instead of as a means of satisfying some of our deeper needs, which, in turn, dictates if our work is enjoyable.  The more complex the activity, like a career in medicine, the more needs it is likely to satisfy. Re-tirement activities should be looked at similarly–they are simply vehicles of enjoyment through which we can satisfy our needs, and these are often ones that our work once satisfied. So, to find satisfaction and enjoyment in re-tirement, we will need to find these activities. But since these activities don’t usually fall into your lap, we will have to create a process to discover them. But how?

How to get there.

So what are these satisfactions, these personal core needs that make working as a physician worthwhile? Essentially, why do you go to work? Money, for sure, but what else? Create a list identifying some common needs–such as the one below–you may well be able to add to it:


After creating a work-related needs list (such as the list above), you will need to build a skills list as well. Skills are also important because enjoying an activity is often a satisfying opportunity to use our skills. Many of your general work skills are often taken for granted because they are second nature—business skills, problem-solving skills, communication skills, etc. If you are having difficulty, imagine having to hire someone to replace you—what skills would they need? E.g., computer skills, problem-solving, teaching, leadership, time management, writing, etc.

And then, for more ideas for your needs and skills lists, also identify your current leisure activities, and ask, specifically, why you enjoy them–these are needs and skills you satisfy that are different than work–and add these to your lists. These skills could include carpentry, cooking, mentoring, parenting, writing, sports, music, languages, art, coaching, volunteering, etc. Do the same with any recalled leisure activities that are from your distant past, even before you were beginning adulthood and working for the first time–to supply more entries for your lists. Finally, list the things you are looking forward to when no longer working, e.g., regular sleep, working out, home cooking, travelling, reading the paper, more time for friends, spouse, kids, etc.

Now review your preliminary anticipated plans list and compare this with your needs and skills list.  You may notice that some of your needs may not be satisfied by your current plans and activities. Identify the needs and skills that are not being met by your plans, which will cause you to change something, to search for, or create alternatives….in re-tirement, you have the time! Even if the list looks well covered, there may be a “honeymoon” period after which your plans lose their appeal, and revisions are necessary.  You may have to wait until after you re-tire to better assess if your plans actually do satisfy your needs and skills. The development and progress of your re-tirement career is much like sailing a boat (or even your working career)—you may have a good idea of the destination, but you may not know the exact route until you are on your way. You likely have to make several adjustments to your course of discovery, since replacing satisfactions lost from work can be a tall order, and opportunities and interests also change over time. What you wind up doing may be far removed from where you set out—but just an alternate route to get to your re-tirement destination.

What about working in re-tirement?

Some people, including many physicians, will want to continue to work, whether full or part-time in re-tirement—there is nothing wrong with that, as long as their non-monetary needs and skills are ALL being met. For some it may be justified as a transitional step. For others, it may be fear of letting go of the familiar over a willingness to explore new activities; or perhaps it may be pessimism or even laziness –not wanting to commit time and energy to consider other options. It is important to consider than working in re-tirement is not always a panacea, and that it may remain a barrier to accessing other important needs that have not been met–it is worth asking, is a career in medicine the only way to be happy?

When to leave.

For most physicians, there is no magic age to retire, whether by choice or by decree. So what does the critical mass look like, the tipping point for the determined decision to re-tire?

There are “push factors”—things you are happy to give up at work—and “pull factors”—things you will look forward to in re-tirement, that will have to be analyzed to determine when you are ready to retire.  Consider retiring when your needs—pull factors–met in retirement are equal or greater than those currently met at work. If they are not, then re-tiring could be a mistake. Just like buying a car, planning to re-tire requires doing your homework—advantages, disadvantages, needs, health issues, family issues, working environment issues, etc–a thorough analysis may yield different results as circumstances change.  Generally, the 3 main factors to weigh can be reduced to push, pull, and money issues.

Some unexpected considerations in re-tirement.

Retirement can affect friendships and spousal relationships, especially when they are people still at work.  The ground rules in a marriage may be challenged as well—the daily rhythm of time together and at home usually changes—therefore communication becomes vital to clarify your feelings about the transition, your goals of shared experiences, and your goals of time together and apart.

To keep your relationships strong, respect others’ space and their needs.  Re-tirees are going through a transition, including lost satisfactions from work.  Retirees may now feel a need to get more satisfactions from home, and that can upend the balance at home.

Retirement, though, is a good time to expand your friendship circle.  You may find you have less in common with some friends once you do not have work in common, so you may need to be willing to find new friends in some of the new areas of interest that you have.

On whether to retire together with your spouse, there are many factors that play in to whether that is even possible, but it requires complete discussions of mutual expectations, what you want to plan to do together, and what each person’s central life focus will be in re-tirement, not just what they will be busy with.

Regarding a major change in scenery, Roadburg suggests to not be in a rush to burn your bridges by moving to a new community before you know the new community is right for you. If you can, do a trial run by renting—you may not initially realize the things you might miss—your doctor or dentist, certain friends or shops, parks, etc.  Individual needs vary: Not everyone needs to move, although some may want to return to a childhood community, or move to a community that offers more opportunities for satisfying needs and skills; others may want to build a bigger home, or to downsize (some may need the money to support their re-tirement goals).  To be a successful move, both spouses need to be in favor of it in terms of push and pull factors.


Roadburg’s book is one of several he has published that provides a clear, if overly simplified, framework for transitioning into “re-tirement“. However, since Roadburg is a Ph.D. and not an M.D., his guidelines fall well short of recognizing the many unique difficulties that physicians have with retirement, both in their “push” and “pull” factors. For example, he makes no mention of the many unique skills that physicians have developed in their career that are simply not transferrable to a non-medical activity, and he provides no commentary on how to transition from the high level of sustained commitment physicians have to maintain throughout their career. The next post will unpack some of these issues–from a retired physician’s perspective. Stay tuned.

The Question that Changed Everything

After almost 10 years of accumulating pressures, seeded doubts and diminishing joy while working (see the previous post, “The seeds of retirement”, Dec 11, 2018), I had become pessimistic that things could somehow improve–and increasingly disillusioned with my medical Faustian bargain.  Younger physicians had cemented my impressions with their similar clinical experiences in training, epitomized by a recent Facebook post by a fresh medical graduate, on the “Humans of New York” page (December 14, 2018):

“I just finished medical school. Now I’m heading to residency, which is supposed to be even tougher. I’ve been working sixteen-hour days. Then I’m expected to study every night when I get home. Some of my classmates only sleep three hours per night. I tried that for a few months during my surgery rotation, but I ended up getting really depressed. I felt completely depersonalized. Everything seemed like a dream. To make matters worse, a lot of the instructors are jerks. I think they went through hell when they were students, so they feel like they should put us through hell. On the first day of rotations, my attending physician told me: ‘I’m an asshole, but I’ll make you a better doctor.’ He made fun of me in front of other students. He put me down in front of patients. He’d threaten to kick me out every day. I guess they’re trying to weed people out and make strong doctors. But they’re just traumatizing people. They’re making us apathetic. I got into medicine because I really wanted to make a difference in people’s lives. But after going through hell, I just don’t care anymore.”

Although I had almost forgotten these frustrations in my own training, it has long been self-evident that young doctors have to be thick-skinned to survive the process, and it doesn’t get much better after, given that the chronic sleep deprivation, extreme performance demands and criticisms remain common throughout a career.  Most physicians do find a way to inoculate themselves from the worst of the abuse, in order to salvage a career and maintain a livelihood, but they often pay a personal price for long-term survival. 

But I digress. Knowing that the indoctrination process had not changed much in the decades since I had graduated solidified my skeptical perceptions for the future; and now, in the face of developing personal health problems in my 50’s, the reasons for wanting to leave my career had become clear and defensible. 


Yes, defensible.  As I ruminated over what would eventually be the biggest career decision of my life, curiously, it became suddenly vital to be able to defend my argument to leave my medical career–whether to my friends and family, my colleagues and support staff, or even to my patients.  Most likely, I sensed a necessity to overcome a sense of guilt over even thinking about such a decision–after all, is primary care medicine not an honorable, well-paid profession, with a central role in the delivery of a community’s health care? Does it not demand years of arduous training, along with considerable financial investment and support from governments, medical schools, communities, and families?  Well, yes. But there is room for more than one perspective here–am I to remain community-obligated and duty-bound forever?

First, I would have to challenge my own assumptions.  Since most doctors do not appear to be struggling, is it really all that bad?  Was it really just some more regular time off, a change in scenery, or a slightly different role that I needed? Was I really turning away from my obligation to my community (which already had a doctor shortage), and from the training program that provided me this unique opportunity? Am I going to just walk away from the most reliable income stream I have ever had? Would I miss working with my colleagues and support staff? Am I going to regret this decision within a short period of time, knowing that returning to the fold can be very difficult?  Am I just being selfish? Although I would have to make a lasting peace with each of these questions, the answers to all eventually became pretty clear, no matter how many times I reviewed them.

Avoiding pain, seeking pleasure.

Although I was first preoccupied with ending negative or painful experiences, I did eventually allow myself to consider some of the upsides of retiring. Yes, allow: you see, most physicians, including me, have had extensive training and experience in extended hours on call, making it easy to feel chronically duty-bound to put others’ needs ahead of our own–always, always, and forever.  But, in a shameless moment of daring, I found the courage to think outside the box, by asking myself this question: Outside of medicine, are there things I want to do before I die, and, if so, when was I planning to get around to them?  Although I did not really have much of a list at the time, I knew that my best lived life would not just be defined by a medical career; the question of how I wanted to ultimately define myself would be the most personally relevant exploration I needed to pursue.

Who am I?

This introspection sent me down a few rabbit holes.  Since time is a non-renewable resource, I first needed to confirm–and now, promptly– that I had a direction, an identity outside of my medical career, or at least, an inclination to build one, otherwise I may as well work as a doc until I drop. Or would I be lost without the M.D. rubric?   

This was initially quite difficult.  The last time I was not medically inclined was more than 30 years ago, and back then I struggled with any confidence in any direction.  Back then, I loved sports and the outdoors, education, and traveling, and I had some occasional hobbies. But I would have to go deeper.

Over time, it was evident that I strongly identified with health, with helping people, with constantly learning, with supporting my community–could I find other ways to satisfy these inclinations? Did I have other basic characteristics that were not germaine to the role of physician, but nonetheless needing some outlet or recognition? Were there other skills or experiences that I wanted to explore once medicine was behind me? These questions were much more fun to contemplate, and over time, the answers went from a trickle to a torrent.  I fantasized over writing a book, blogging on health (and the process of retirement!), learning a second or even a third language, traveling and living in Europe, becoming an entrepreneur, developing my cardiovascular fitness, becoming a bodybuilder, learning to kiteboard, volunteering in a third world country, developing my woodworking and landscaping skills, going back to university, improving my IT skills, resuming piano or guitar lessons, improving my culinary skills, reading classic books for pleasure, joining a volunteer organization in my community, doing health workshops for schools or businesses….and so on.  Clearly, in finding many worthwhile pursuits, without needing to pick just one, I had my first look at a retirement “smorgasbord”. This would keep me happily busy for quite a long time–so, would I have to let some of these ideas go?

A new found urgency.

Since I was approaching 60 years old, I cannot expect my health to remain trouble-free indefinitely, so what would be a reasonable time frame to count on for good health to get some of those bucket list items done?  Since my clinical career has offered me a unique vantage point, to see how health problems develop over time, it was pretty easy to come up with the following synopsis: If I continue to take reasonably good care of myself– regular exercise, a healthy diet, good sleep, etc–I could reasonably expect to make it to age 80 with close to full functionality, before the odds start stacking against me.  Dementia, Parkinson’s Disease, diabetes, stroke, heart disease, joint problems–all in evidence in my family tree–would all be good bets by then, and maybe even before.  And I haven’t factored in cancer risk or accidents.

7000 days.

So, from 60 to 80–that is 20 good years, to get done everything I want to get done to feel I have lived a life well lived.  It seems like lots of time, until you translate that to about 7300 days.  And when you ask, “Of this time period, which are likely to be your healthiest 5 years?  The answer, obviously: the next five years.  And as there are many pursuits on my list that will require being both physically and mentally fit, I really need to get on with things–and the sooner the better.  And when I framed it this way, the decision to retire ASAP was very easy.  And, like getting married, I probably should have done it even sooner than I did.

Have you thought about who you are, or what you would be if you were not a doctor? It is not enough to have reasons to get away from medicine–you need to be drawn toward something as well. To pull you toward retirement, or even just a change to a non-clinical career, you may need to answer this question clearly, since we have all heard of people who have retired for a few months to play golf before they get bored and return to some kind of work.  

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? 

I Can’t Believe it.

I can’t believe I actually made it all this way–to the threshold of retirement of my medical career.


Looking back at my early twenties, with so many other capable candidates, I felt incredibly lucky to be accepted to medical school; fortunate to survive 5 years of training;  and then, truly blessed to be essentially handed an honorable, respected career that would pay me well, support all of my aspirations, and give me stature and a sense of purpose in every community I worked in. 

A precarious upbringing.

It still seems to be too good to be true.  I was a first generation Canadian, the product of post-war German emigrants looking for a better life, who managed to start their Canadian lives and then a family with the modest incomes of a truck driver and a nurse’s aid.  By the time I was starting school, my parents went their separate ways, and my sister and I would become dependent on just my mother, a precarious existence with constant moves to new neighborhoods to accommodate job changes. For our mother, the paycheck-to-paycheck existence while working grinding shiftwork and supporting two young children ended only when she had a modest inheritance, although that came through only just before she became medically disabled with Parkinson’s disease. 

Having survived the near-constant uncertainty of my upbringing, I came to taking very few things for granted as an adult; for better or for worse, it seemed to serve me best when I tended to take a pessimistic view on most things, even when things were going well, be it jobs I had, medical school, my sports interests, even my relationships. 

Uncertainty has an upside.

Even as I launched into my career, I always felt that some kind of failure was all but inevitable eventually, and my ride could all come crashing down on me in a second—a medical misadventure, a lawsuit, a change in government policy of how physicians are paid, a catastrophic illness or injury, or someone discovering that I was incompetent.  So I always saved everything I could for that probable day. 

MD Management to the rescue.

When, as a young doctor, I bought into a medical building, hired medical support staff, bought our first home, got married and started a family (all in the same year), I felt the weight of the world on me, which worsened when my wife stopped working to raise our kids.  When I realized that the first 3 weeks of every month’s salary went to cover my now considerable overhead, it became easy to understand the importance of life and disability insurance, let alone staying healthy. It also became easy to see the value of getting sound financial advice, and so it was a no-brainer to approach MD Management for all of my financial needs–a service covered by my medical dues, and 100% dedicated to Canadian physicians like me.
As it turned out I was extremely fortunate. My family thrived. And although my 30-year career was rife with ups and downs, I survived it–all of it, with the help of some solid decisions and a sound roadmap to reduce the impact of uncertainties. I slept better knowing I had MD Management in my corner. 

But now what?

However, having reached the threshold of retirement, the roadmap is less clear.  MD Management is still at my beck and call, but somehow that doesn’t seem to be enough.  What is a successful retirement? It’s gotta be more than just having a sound financial plan. What resources can I draw from? Are there no guidelines out there for such an important chapter of life–or, in asking this, am I just reflecting the life of a nerdy, protocol-driven physician? Regardless, is there anyone who understands the unique angsts of the retiring physician? 
Since there is less written on this than I had expected, I thought I would create this website–to explore the issues firsthand, and to invite colleagues to share their stories–so that physicians still in the trenches will have the support they may need–from their fellow physicians–when taking their last great leap of their careers.  Read on–there is much more to come. And feel free to join the conversation.