Scott R. Steele, Justin A. Maykel, Bradley J. Champagne and Guy R. Orangio (eds.)Complexities in Colorectal SurgeryDecision-Making and Management10.1007/978-1-4614-9022-7_42
© Springer Science+Business Media New York 2014
42. Knowing When to Say “When”
Division of Colon and Rectal Surgery, Department of Surgery, Creighton University School of Medicine, The University of Nebraska College of Medicine, 9850 Nicholas Street, Ste 100, Omaha, NE 68114, USA
Alan G. Thorson
Knowing when to retire from a practice of medicine is perhaps one of the most vexing problems you as a physician will face during your career. For most physicians, your life has been devoted to caring for the sick, comforting the weary, relieving suffering, and promoting good health. Reaching that stage of your career where you see that there might be an end to your life’s work can be discouraging at best and overwhelmingly frightening at its worst. This chapter deals with some of the complexities of winding down a medical career, with an emphasis on surgery, providing some insight into thought processes and planning that can make the decision to retire manageable, and even exhilarating, when placed in the proper context.
The best and least traumatic retirements result from key planning long before retirement is expected, including financial planning for postretirement income and developing a diversity of interests that will hold your attention when the practice of medicine is no longer feasible.
Surgeons need to be the primary assessors of their competency, and any decline thereof, as they progress through their active practice years and be the ones to recognize the need to begin the transition process.
There is life after medicine.
When one door closes, another one opens, but we often look so long and regretfully at the closed door that we fail to see the one that has opened for us.
–Alexander Graham Bell (Scientist)
Walking away gracefully. The perfect end to a storied career at the right time. No matter the stage of your career, it is something that you’ve likely thought about, or for some, hopefully experienced. We all want to exit on top, go out in style. The clichés are bountiful because it is a crucial aspect to our professional lives. Sports are littered with examples. Would you rather be John Elway “riding off in the sunset” following two consecutive NFL championships or Michael Jordan—arguably the greatest NBA player in history—who may be more known mockingly for his three retirements and inability to give it up than his multiple on and off-the-court accomplishments? And what about all the “end of the bench” players who simply fade away? Does it make their accomplishments or careers any less significant? These questions probably have different answers for each of you, as well as varying degrees of relevance. We would all likely agree that caring for patients and the opportunity to practice surgery are what brought us and kept us in our chosen paths. Yet, how do we measure success and how do we know when to call it quits? For some, a career is left unfulfilled without having “X” number of publications, becoming chief/chair of surgery or president of a society. For others, it is simply doing your best, enjoying life and family, or serving in any capacity to make your hospital a better place. Regardless of ambitions, each of us eventually will end our surgical practice. The question is will we know when to say “when?”
The decision to retire from a practice of colon and rectal surgery merits discussion as a complexity in surgery due to the inherent controversies and inconsistencies that exist within that decision. Many issues arise that may impact the timing of retirement. Although the following discussion is not meant to be comprehensive, an evaluation of these issues will go a long way in determining when retirement might be desirable or even necessary. Such issues are represented by both internal and external forces. Those internal forces include the paradox of a patient’s reliance on their physician coexisting with a physician’s reliance on their patients. These might also be termed soft factors, emotional in nature or products of passion. External forces include all of the physical and mental changes that occur naturally with aging as well as economic and workforce implications for the individual’s practice and profession. These represent hard factors.
For any profession, the decision to retire can be, but isn’t always, difficult. Some individuals have predetermined dates for retirement and have well-planned goals and objectives to allow them to meet their desired ends. They may actually be anxious to retire to move on to other interests and personal goals. Soft factors have the least impact on these individuals. The hard factors have been recognized and dealt with long ago. Others have laid the foundations necessary for a comfortable retirement and are simply awaiting the appropriate confluence of events to make the final decision. They are prepared for retirement but still derive a great deal of satisfaction with their current practice. The hard factors have been dealt with in this group as well, and the soft factors are manageable. Yet for others, the decision is much harder. They may or may not have dealt with the hard factors affecting their decision, and the soft factors may lead to irrational choices and decisions when it comes to self-evaluation and suitability for continued practice.
Professionals are used to serving. As physicians, our lives have been devoted to serving our patients and communities, and retirement may have implications for life and death issues—literally and figuratively. Concerns for our patients are real. Patients who have lost their primary care physician through illness, retirement, career change, or systems change express feelings of loss, abandonment, frustration, and anger directly related to losing their physicians. They describe concerns about the difficulty of getting prescription medications, lack of continuity of care related to medical records, and loss of continuity with preventive care . At least some of these feelings undoubtedly transfer to colon and rectal surgeons and loss also, particularly for issues relating to preventive colonoscopy and cancer follow-up. I can only imagine the strength of some of these feelings in hereditary colorectal cancer families where in many cases long-term transgenerational relationships are established. For some physicians, the recognition of such patient perceptions and reliance may delay a decision to retire, as they do not want to “hurt” their patients.
Then there is the physician’s reliance upon their patients and colleagues. Many physicians need the daily feedback from their patients; for without it, they feel a sense of emptiness or they may feel unfulfilled. Their commitment to their patients over the years has left them with little time to develop other interests and hobbies. When they look at retirement, they see only a life without purpose and subsequently fear entering that stage of their life.
Age as a Factor
In addition to this internal turmoil, there are a host of external forces that contribute to retirement decisions. For individuals practicing within health systems, retirement may be forced upon them through indirect actions or incentive changes. Age may be a factor in a system’s decision to terminate a surgeon for a number of reasons including the desire of a health system to hire someone younger with the capacity for higher production and the prospects for longer employment. As a French proverb states, “A surgeon should be young, a physician old.” There may be a perception that newly trained surgeons will be more likely to adopt the newest treatments that a system may desire for a number of reasons including marketing and patient recruitment.
Presently in the United States, for employed surgeons, the use of the surgeon’s chronologic age as a determinant of when he or she must retire is clearly in violation of the Age Discrimination in Employment Act (ADEA). Nevertheless, it is still possible to establish economic incentives or other environmental constructs that “encourage” retirement in the absence of documented age-related competency issues. Such competency issues are difficult to prove given the fact that there is no agreement on what skills we should test or how to test them. Although it is safe to say that age does ultimately affect competency, various studies have given mixed results depending on the population being tested and a host of variables within those populations that can impact outcome. Age alone is a poor test, no doubt, but the issue of competency deserves closer scrutiny.
A study of senior and younger surgeons attending annual meetings of the American College of Surgeons compared computerized cognitive tasks measuring visual sustained attention, reaction time, visual learning, and memory administered to both practicing and retired surgeons. The majority of practicing senior surgeons performed at or near the level of younger surgeons on all cognitive tasks, as did almost half of the retired surgeons. The authors concluded that older age does not inevitably preclude cognitive proficiency. Furthermore, the variability in performance across age groups suggests the need for formal measures of objective cognitive functioning to detect changes in performance to aid in retirement decisions , measures that have not yet been developed.
The story behind cognitive decline with age involves complex interactions between different types of intelligence  leading to variations in practice that, up to a point, may actually have beneficial effects . Adults as old as in their 70s may have an advantage in cumulative information acquired through a lifetime of clinical practice (known as professional expertise and wisdom) but may take twice as long to process the same tasks as adults in their 20s . In this situation, an older physician may have an advantage in efficient diagnostic skills through pattern recognition, while experiencing a decline in analytical skills, with subsequent overreliance on clinical first impressions . Studies supportive of this have demonstrated that senior physicians experiencing competency issues have shown errors related to premature diagnostic conclusions following incomplete history and data gathering, coupled with limited differential considerations .
Despite the ultimate conclusion of the natural aging process, the timing of that process is highly variable. As mentioned, other studies show that many older physicians can compete effectively with at least a significant cohort of their younger colleagues [2, 8]. Many factors may modify the impact of age on competency including innate intelligence, continuous self-improvement and education , self-directed learning and practice at technical skills , as well as maintenance of healthy lifestyles through proper diet and nutrition, participation in health screenings, avoidance of tobacco products, and by staying physically active .