How do you know when it’s time to retire?
“What’s this I hear?” said the CA-1 resident earlier this year as we were setting up for our first morning case. “You’re going to retire?”
“Why yes,” I said. “That’s correct. In April.”
He shook his head. “No,” he said firmly. “I know you have another two years in you.”
That was very kind, and I appreciated it, as I did this text message from a senior resident: “If you try to leave before July, I’ll report you for resident abandonment.” It’s always better to leave while they still want you to stay, as opposed to lingering long past your sell-by date, right?
Even two years earlier, if anyone had told me I’d be ready to retire from clinical anesthesiology in spring 2022, I would have laughed at the idea. I always felt that the many sacrifices my parents made (and all the tax dollars the public spent) to give me an excellent education conferred an obligation to use it for good – to continue practicing medicine and caring for patients even after I became eligible for Medicare. Is that an antiquated concept? Maybe, but I believed in it nonetheless.
I also think it’s a shame that when an anesthesiologist leaves clinical practice all those years of practical bedside experience – all the tricks you can’t learn from the books – go to waste. There really isn’t a way in American anesthesiology practice for an emeritus anesthesiologist to contribute clinically once you’ve pushed that last syringe of propofol and you walk out of the operating room for good. You can see senior surgeons or internists making clinical rounds with a team to observe and impart some of their hard-earned wisdom, but there’s no comparable role for a senior anesthesiologist other than to come to Grand Rounds occasionally and pontificate.
Easing into retirement?
Some people advocate “easing into retirement” as a way of slowing down without leaving the profession completely. What does that mean? It could mean cutting back on clinical hours or working part-time. It could mean opting out of the long, difficult cases in the main OR, or going to work in an ambulatory surgical center. Those options appealed to me about as much as plunging a toilet.
What’s always been fun for me in anesthesiology – maybe “fun” is the wrong word – is dealing with the unusual cases that call for actual decision-making as opposed to following a protocol. I never minded managing a difficult airway or staying to finish a tough case when I felt it would be irresponsible to turn it over to a harried, overburdened call team. Vascular, bariatric, pancreatic, thoracic – I was happy with any of those case lists. To handle those cases well, in my opinion, you should do them all the time, not just occasionally.
Once in a while it wasn’t bad to have an easy morning with a plastic surgery free flap, but by lunchtime I longed to be elsewhere. Would I care to spend the day drawing up syringe after syringe of propofol in an outpatient center and rushing to turn over rooms in five minutes – no, thank you. I’m delighted that there are people who enjoy outpatient work, but I’m not one of them.
Yet in the autumn of 2021, a switch flipped and suddenly I knew I was ready to stop doing what I had been doing since the start of my CA-1 year in July 1984 – practicing clinical anesthesiology full time, day after day. It would be a full stop, not a gradual easing out.
What flipped that switch?
Naturally, more than one factor influenced the “full stop” decision.
Health system policies may be well-intentioned, but I refuse to spend time ever again on recurrent, mandatory “e-learnings” about sexual harassment or implicit bias. If that’s the price of employment, I respectfully decline. Life is short.
Physically, I knew I was tired. As the years creep by, all of us develop our share of physical woes. A lumbar compression fracture – sustained as I lifted the head of a 300-lb patient being turned to the lateral position – was a warning call. Anesthesiology, as I’ve noted in a previous ASA Monitor column, is more demanding physically than it should be, and that problem won’t disappear any time soon. Today’s clinical practice calls for stronger bones and more stamina than I have.
Did the pandemic have anything to do with it? Perhaps. It’s been a rough two years for all of us.
But I think the most important question weighing on my mind was how I could be sure to know if my cognitive ability started to slip, if my reaction time wasn’t as quick, if I started to lose my clinical edge.
“Conditions that undermine cognition may erode insight,” as neurologist Gayatri Devi, MD, MS, and colleagues noted in their 2021 article, “Cognitive Impairment in Aging Physicians.” Many of us have known colleagues who should have left clinical practice long before they actually did. I was determined not to be one of them.
During the last few months and especially the last weeks of my pre-retirement countdown, I remember thinking how dreadful it would be if a patient of mine suffered a bad outcome, and if I were forced to ask myself if it would have been the same in the hands of a younger colleague. Mercifully, that question never arose. When I took the last patient to the PACU, I felt a tremendous sense of thankfulness and relief.
But don’t you miss working?
Do I miss my job? Six months later, I can honestly say that the answer is no. I don’t have to set an alarm unless I’m heading to the airport. I’m still writing and serving on editorial boards. I’m going to the gym more often. I see more of my grandchildren. I’m honored to be chairing the California Society of Anesthesiologists’ January meeting in Maui. (Don’t miss it! We have a fantastic lineup of speakers!)
And to the apparent surprise of many of my friends, I’m back in school – I’ve started a master’s degree program in theological studies, reading so many wonderful books that I’ve never before had time or energy to read. Truthfully, I feel as though I’ve been let out of jail.
Many of us, though, want to keep working clinically longer than I did for a multitude of reasons. Interestingly, in the United States anesthesiologists historically have tended to work far longer than they do in the United Kingdom. A 2021 article in BJA Education reports that in the UK, only 17.2% of anesthesiologists work clinically beyond the age of 55, whereas in the US 40% continue working. (Those numbers are based on pre-pandemic survey data; they may be lower today in both countries.)
I would be the last to suggest that there should be a mandatory cut-off age for American clinical anesthesiologists the way there is for airline pilots, at 65. In an excellent editorial, “Cognitive Screening in Aging Physicians,” psychiatrist Lawrence Whalley, MD, argues that no system is foolproof for detecting mild cognitive impairment, and that coercion to undergo neurocognitive testing at any specific age is unwarranted. “Repositories of knowledge (crystallized intelligence) are well preserved and can increase with age,” he believes.
Given the current demand for anesthesiology services, it makes sense to consider how we can do a better job of keeping older anesthesiologists in the workforce, of creating new roles for them, without jeopardizing either their own physical health or the safety of patients. Many of us still have much to teach and contribute. A number of retired anesthesiologists volunteered to help staff ICUs in New York City at the worst of the COVID-19 pandemic, doubtless saving many lives in the process.
In Dr. Whalley’s words, “Although public safety must remain a priority, fellow physicians share a collegial responsibility to care for and support older physicians who wish to continue in practice. This can never be overlooked and should be embedded in future health care systems.” I hope that’s a concept we all can embrace.
This article appeared first in the ASA Monitor issue of December, 2022
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References
1. Devi G, Gitelman DR, Press D, Daffner KR. Cognitive Impairment in Aging Physicians: Current Challenges and Possible Solutions. Neurol Clin Pract. 2021 Apr;11(2):167-174. doi: 10.1212/CPJ.0000000000000829. PMID: 33842070; PMCID: PMC8032410.
2. Garfield JM, Garfield FB. The ageing anesthetist: lessons from the North American experience. BJA Educ. 2021 Jan;21(1):20-25. doi: 10.1016/j.bjae.2020.08.007. Epub 2020 Nov 5. PMID: 33456970; PMCID: PMC7807987.
3. Whalley LJ. Cognitive Screening in Aging Physicians: Faith in Numbers. Neurol Clin Pract. 2021 Apr;11(2):89-90. doi: 10.1212/CPJ.0000000000000833. PMID: 33842058; PMCID: PMC8032417.
6 COMMENTS
Some very well-expressed thoughts, on a topic that bedevils me, too (though I never had a patient’s welfare to worry about. I just had to wonder if I should inflict another book on the world.)
I think that you and your husband should meet me for dinner soon, to discuss further.
Robert / Bob
[Reply]Nice piece.
The idea of retiring when you will still be missed versus when the announcement will elicit a sigh of relief from your peers is critical.
Thank you for a thoughtful and well written article. I retired at the end of 2019. I was fortunate that my practice allowed me to reduce my work obligation to 2/3 and ultimately half. I found the reduced hours model allowed me to acclimatize to retirement.
We are utterly entwined with our anesthesia identities and disentangling takes time. Ultimately the question becomes “do you want to leave by the front door or the back door?” Best of luck with your future life plans. Sam
Excellent perspective. Best to you in “retirement”.
I belonged to a large anesthesia group in upstate NY.
At age 57, after 2 back surgeries, i knew it was time to
retire when the 6th or 7th kid we were putting ear tubes into wasn’t waking up at the end of the 5 minute procedure and i realized i had neglected to turn off the Enflurane vaporizer. Was it the need for constant pain medicine?
I really don’t know, but I did know that something wasn’t right with me, and i abruptly walked away.
Fortunately, I had a side gig as an Aviation Medical Exa.iner, which I’ve been able to pursue to this date.
You mentioned the mandatory pilot retirement age(which is about to be raised), and after all these years, I’ve seen ,
Im convinced that some sort of cognitive assessment should be done starting,at least for aviators, at age 45.
As you said, it’s better to be remembered fondly than with a sense of relief that you’re gone.
As usual, your prose and insight are outstanding! Thanks for a thoughtful and important discussion on the topic of “retirement”. I “retired” from many things over the years. Private and then academic full time clinical practice, residency director, vice chair, system chief of staff, ASA officer, and other roles are all part of a long and rewarding career as a physician. Each of these experiences added insight and perhaps a modicum of wisdom along the way. I still work in a preoperative evaluation clinic part time because I am able to work and interact with young anesthesiologists in training. I certainly do not miss the rigors and stress of daily OR practice, but I do miss the people I worked with for many years. There is one thing I hope we all consider. Older physicians usually have a vast wealth of knowledge and wisdom that is simply abandoned when they leave practice. It is my hope that future leaders of medicine have the foresight to seek opinions of those who may help. And to all the “retired crowd”, enjoy this next and interesting phase of life!
[Reply]I retired from EM 10yrs ago after 40 clinical years booted out by the time dilation that the electronic record foisted on primary care and EM physicians. It was no longer feasible to dial it down by occasional shifts at low volume hospitals as the electronic record chewed up so much time. The last place I worked had a single desktop computer for the MD so all info had to be taken in notes during the pt encounter and then transcribed. No biggie for a URI or simple lac, but a sick or injured geriatric was another matter. The final day I discovered that free typing info on one pt was memorized by the system and shotgunned onto another patient’s chart. It was a nightmare as both were sick geriatrics and even an hour late stay did not sort out the debris. A few days later my wife had a subdural and I retired. (She is fine).
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