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.