Approaching retirement: Asking, ‘Am I OK to keep working?’

There’s an old surgical axiom: You’re only as good as your last case.

This is meant to reign in lethal hubris by reminding clinicians that success can be fleeting and not every case is going to go well.

It applies to every specialty, really—suggesting we’re only as good as our last office day, our last procedure, our last patient. While we know that one day or one patient cannot truly measure up against the accomplishments of an entire career, there is wisdom in the words nonetheless.

I’ve opined a lot on retirement over the course of these columns. That’s my assignment. But I’ve tried to be consistent about one aspect—know when it’s time to walk away. My specialty, cardiac surgery, was one of the first to comprehensively track individual clinicians’ results—and share them with the public. I was constantly aware that along with my last case, I was literally only as good as the last data harvest said I was.

There’s a lot of discussion these days about physicians practicing longer and the impact of cognitive decline, waning physical stamina and the erosion of clinical skills. Inconvenient truths, to be sure—but truths, I believe, nonetheless.

For all of us, there comes a day when we are doing our last case, seeing our last patient or doing our last procedure. It should be a time of reflection, a time of satisfaction and a time to take a seat and rest on those hard-earned laurels a lifetime in medicine allows us to accrue.

But there is another way to go out—and it’s tragic. Not to mention avoidable.

Making a plan: Is it necessary?

It’s a safe bet to say that somewhere, right now, there are physicians practicing who shouldn’t be. There are surgeons operating who should have put down the knife a few miles back on the trail. As I sailed into my 60s, I began to worry that even with all my faculties intact, my once cutting-edge training was now 25-plus years old and my skill set, which I did my best to keep updated, couldn’t necessarily keep pace with exponentially expanding information and the latest technical advances. I gave myself a “hard stop” date and planned to stick with it.

That plan was short-circuited by a physical disability—one which might seem minor but which, in my specialty, was likely going to end up being career-ending. I quickly sought out the best specialty medical advice and help I could get—and after each visit I asked the same question:

“Am I OK to keep working?”

It’s a question, as we age, we should probably ask ourselves more often. We can and often do come up with a litany of reasons to ignore the question. Or we come up with a rationalized answer:

“I need health insurance until I reach Medicare age. I need health insurance until my spouse reaches Medicare age. I need to save more money. I have to work until my kids are out of college. I want to buy a private island in the Bahamas. I don’t know what else I’d do if I stopped working.”

The validity of such arguments is in the eye of the beholder.

Most of us do not practice in a vacuum. Our skills, our decisions, our notes can be and are all closely observed by others. Competitors are quick to note our deficiencies but, sometimes our partners (those who should truly be looking out for us and our patients) are loathe to acknowledge them. I’ve heard stories about groups who didn’t know how or were afraid to ask their senior, and often founding, physicians to hang it up. I’ve heard other stories about physicians who refused to admit that they’d “lost a step” or were making errors, even when confronted with the evidence.

Obviously, it is of paramount importance that physicians do not practice while impaired, as their actions could potentially have life-altering or harmful effects on their patients.

Exit pathways

A career spent practicing medicine typically includes years of hard work and long hours. The miles we put on our professional chassis are hard ones and they do inevitably take their toll. I once humorously proposed that we should measure our age not chronologically but in “doc-years,” a parallel to pack-years for smokers.

To me, the worst scenario is to keep working until the whispers start. The questioning looks, the raised eyebrows and the hushed break room conversations. I watched more than one of my boyhood sports heroes finish a gilded career ignominiously—as a bench rider or a sideline afterthought. Still in uniform but woefully out of the game. I did not want that to be me.

I pulled off the practice highway several exits before I’d planned to—and I still think it’s one of the smartest decisions I’ve managed to make. But it was emotionally wrenching—both for myself and the team I headed for a long time. Hospitals tend to have a “plug and play” mentality when it comes to physicians—simply swap out Dr. X for a replacement part with equivalent specs. Or, worse, keep Dr. X working as long as he or she continues to rack up the RVUs.

There should be a “glide path” for physicians—a way to make that final approach to the end of our careers so that we finish with a smooth touchdown and an uneventful taxi to the terminal. Some systems may have these mechanisms in place. But for most of us, we have to do it, stretching the aviation analogy to its breaking point, by the seats of our pants.

Autonomy is one of the things we cherish most—I’ve often said most docs operate under the mantra “You’re not the boss of me.” But the trend to work into what is essentially “old age” brings with it a host of uncomfortable issues. None of us wants to admit we’ve lost a few mph off our fastball or can’t run the pitch with the rookie legs like we used to. I do believe most of us would seek to exit practice gracefully and at the top of our game—but maybe not all of us.

Plan accordingly

Airline pilots have a mandatory retirement age of 65. There’s talk about mandatory cognitive evaluation for practicing docs after age 70. It’s a thorny issue, to be sure. I don’t have any hard answers. Just a few suggestions.

We’ve all seen patients who presented with an advanced or an incurable problem because they were afraid to ask what was happening to them when it started. Think of aging and its vagaries as a disabling physical impairment that everyone eventually faces. Think about asking a trusted (younger) colleague to watch for the telltale signs of slippage and to be honest with you if and when they appear. At a certain point, perhaps you owe it to yourself and your patients to get an objective opinion. Go to a world-famous medical center, miles away from prying eyes and administrators, and ask an appropriate expert the hardest question:

“Am I OK to keep working?”

If the answer is yes, may God (in whatever manifestation you favor) bless you and keep you doing good for as long as you can. If it’s no, be grateful for the foreknowledge, accept the reality and plan accordingly. Walk off the mound to raucous applause. Do it before you give up that grand slam and the manager walks out and asks for the ball.

You’re only as good as your last …

Related reading:

Retiring from medicine: The pain of losing our mentors and role models

The ‘doctor’ treatment: How to vet physicians for ourselves and those we love