Cover Story
Retire...or not?
Some physicians are hanging up their stethoscopes to do what they never had time to while practicing. Others are staying on the job well into their 80s. What influences their decisions?
By Kim Palmer
As medical director of St. Mary’s/Duluth Clinic for the past six years, Joe Leek, M.D., has accepted retirement announcements from many physicians. But one recent departure stunned him. The retiring internist, at 57, was young enough to be Leek’s son.
“There were no evident problems,” Leek says. He urged his colleague not to retire completely and to reduce his hours instead. But the internist stuck to his decision, one that Leek, 82, can’t imagine making for himself.
It never would have occurred to Leek to retire when he was in his 50s. Even now, in his 80s, retirement holds little appeal.
“Medicine, to me, is a joy,” he says. “Retire? Never! I’m not built that way. I have too much energy. Playing golf every day would be my idea of hell.”
The recently retired internist, Alan Peterson, M.D., now 58, has an entirely different perspective on retirement. “I still enjoyed my job,” he says of his work in the general internal medicine department at the clinic. “I still liked dealing with patients. But medicine is a jealous occupation as far as time is concerned. It doesn’t leave a lot of time for other things.”
Peterson yearned for the freedom to devote himself to other priorities and interests, including his children and grandchildren, personal fitness, and the study of nonmedical subjects. He says he’s been “exercising like a madman,” including training for a triathlon, since retiring in May and is looking forward to taking history or philosophy classes at the University of Minnesota-Duluth this fall. As for his retirement decision, “I haven’t regretted it for one minute,” he says. “So far, it feels like summer vacation. I’m loving it.”
Different Practices
How did two physicians from the same clinic come to such divergent decisions about retirement? Individual makeup is a major factor, of course. “Joe was born with more energy than I have,” says Peterson with a laugh. Leek, who earned an M.B.A. degree in his 40s, is notoriously energetic. The octogenarian is currently pursuing a bachelor of fine arts degree at the University of Minnesota-Duluth. “I love the challenges of being in school with young people and competing for a grade. And just think, I get to do painting, ceramics, sculpture, and photography,” he says.
Also, the doctors’ specialties presented them with different practice choices. Leek, an otolaryngologist, has been able to ease into retirement. He stopped performing surgeries in 1990 (“Because I was old,” he says. “A 68-year-old should not be cutting anymore”) and gave up seeing patients last January. But he sees no reason to leave his half-time position as medical director, an administrative position with responsibility for the clinic’s staff of physicians. “Every six months I go to my boss and say, ‘Anytime you think I should step down, I want to hear it from you directly.’ Invariably, he says, ‘Not yet.’ Personally, I think my gut will know when it’s time to stop or I will plop over dead in the fitness center.”
Internists have a harder time breaking away from the demands of day-to-day practice, Peterson says. “With general medicine, it’s very difficult to turn it off and turn it on. One of the responsibilities of being a primary care physician is to make yourself available to your patients. Patients expect their primary physician to be available most of the time. You can’t really do that if you are working half-time.”
And the ongoing needs of their patients make it difficult for some physicians, especially those in rural areas, to retire at all. A 1995 study of 33 Minnesota physicians of retirement age found starkly different retirement realities. “Specialists with no continuous patient contact had a tendency to retire early,” says psychologist James Boulger, Ph.D., of the University of Minnesota Medical School-Duluth, who worked on the study. They also tended to have much higher incomes to support their early retirement.
“But if you’ve got a community dependent on you, it’s harder and harder to retire,” Boulger says. Doctors in smaller communities had longer careers because it was difficult to recruit a successor. “It’s almost universal: ‘I don’t know what will happen to my community if I leave. We’ve been recruiting for two years and no one wants to come.’ Nobody wants to be a rural solo doctor anymore,” he says. “That’s a 24/7 commitment, and most people now are not looking to work 100 hours a week. It’s not like the old days when people were willing to kill themselves.”
Retirement as Flight?
Americans, as a group, are retiring younger than they used to, but the picture for physicians is less clearly defined. The average retirement age in the United States has decreased from 65 to 62 years over the last three decades, according to 2003 data from the National Bureau of Economic Research.
Although trends are difficult to assess, physicians appear to retire later than other professionals. But even so, they too are retiring younger than they did previously. According to one unpublished American Medical Association (AMA) study cited by the Tulsa World newspaper in 2000, physicians’ average retirement age dropped from 69.8 in 1980 to 67.4 in 1995. Since 1996, AMA data continue to suggest a possible trend toward younger retirement, according to a 2003 study by the Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill.
Such data have raised concerns about flight from the profession and a coming shortage of physicians. A well-publicized 2004 survey by Merritt, Hawkins, and Associates, a physician search and consulting firm, found that a large percentage of physicians ages 50 to 65 years planned to leave the field or cut back on work. In that survey of 436 physicians from across the country, 8 percent said they would retire within three years, 10 percent said they would seek nonclinical work, 6 percent said they planned to work on a temporary basis, 17 percent said they planned to close their practices, and 7 percent said they would seek other careers. (More than half of the doctors in that survey said they would not choose medicine as a career if they had it to do over, and only 36 percent said they would recommend medicine to their children. The primary source of dissatisfaction was rising malpractice insurance rates compounded by frustration with managed care constraints and the pressures of running a business.)
How Old Is Too Old?
For most physicians, deciding when to retire is a personal choice. Although many retire at age 50, the American Medical Association, as of 1999, had identified at least 1,200 physicians age 90 and older who were still seeing patients, according to the Los Angeles Times.
Age is irrelevant to credentialing at some Twin Cities medical facilities. At Park Nicollet Health Services, which includes Park Nicollet Clinic, Methodist Hospital, and TRIA Orthopaedic Center, “age is never a factor,” says Raquel Barnett, director of credentialing services. Physicians are initially credentialed and privileged for one year, then re-evaluated at least every two years thereafter. Barnett says Park Nicollet’s credentialing and privileging is not based on age but rather the practitioner’s education, training, experience, and ability to perform.
Similarly, age is not a factor in credentialing at the University of Minnesota Medical Center or its affiliated Fairview hospitals. But Jim Breitenbucher, M.D., vice president of medical affairs at the University of Minnesota Medical Center, Fairview, thinks it’s time to reconsider that policy. “I’ve raised the issue of whether we should have some requirements to demonstrate physical competency and cognitive skills,” he says.
Breitenbucher believes age should be considered when determining whether a physician is fit to practice medicine, just as it is for pilots in the commercial airline industry. (Currently, commercial pilots face mandatory retirement at age 60 under FAA rules. However, the International Civil Aviation Organization is considering a worldwide standard that would raise that age limit to 65; the proposed change is scheduled for review in November 2006.)
“There’s a public safety issue that should override an individual doctor’s right to practice,” Breitenbucher says.—K.P.
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Some research, however, indicates that many physicians who intend to retire early end up changing their minds. The Sheps study found that the majority of physicians are living and working longer than ever, even if they indicate they plan to retire early. The findings contradict common views that the working life expectancy for physicians has declined as a growing fraction of doctors are women, salaried, and challenged by managed care or malpractice concerns. “Physicians’ expressions of retirement intent are not a highly accurate predictor of future behavior,” the study concluded.
James Brueggemann, M.D., a Minnesota neurologist who retired in 2000 at age 58 and now conducts retirement-preparation seminars for physicians and others, sees no evidence that mounting frustrations are driving physicians to seek earlier retirement. “There was a fair amount written about 15 years ago that managed care was pushing people to leave, but that didn’t happen,” he says. “I don’t hear physicians talking about that.”
As for retirement patterns across specialties, they’re fairly consistent, according to AMA data cited in the Sheps study, although surgeons, family physicians, and internists tend to retire earlier.
Medical specialty groups, however, report wide differences in the average retirement age. For example, the average retirement age for ob/gyns, the practice area hardest hit by rising malpractice insurance rates, is just 50, according to the American College of Obstetrics and Gynecology. Meanwhile, the average retirement age for rheumatologists is 64.7, according to the American College of Rheumatologists, and the average surgeon retires at age 63, according to the American College of Surgeons.
‘A Gradual Wind-Down’
One surgeon who defies those statistics is John Najarian, M.D., organ transplant pioneer and emeritus Regents professor of surgery at the University of Minnesota. Now 78, he still performs “one or two surgeries a week,” he says. “I’m not in the OR as much as I used to be. As I’ve gotten older, many of the people who sent me patients have died or retired.”
His lighter surgical schedule has been a pleasant transition, he says. “I’m happy slowing down. I was running at a pretty fast pace.” He’s doing more gardening, writing, and lecturing; serves on the editorial boards of about a dozen medical journals; and is planning to start writing his autobiography.
Najarian has made some concessions to age. “I gave up doing liver transplants some time ago because it’s a six- or eight- or 10-hour procedure. The last thing you want is a tired surgeon.”
But he has no immediate plans to give up surgery entirely. “I like a gradual wind-down,” he says. “When you retire, you should do things you enjoy, and one of the things I enjoy is doing surgery. … I worry about a person who’s always thinking about retirement. I enjoy my job. I’ve loved every minute of it from the moment I started.”
The Reluctant Retiree
Najarian has been able to choose the level of career involvement he wants; but some physicians find retirement thrust upon them. Ken Hodges, M.D., 80, a family physician, retired reluctantly when his Edina group dissolved last September. “Two doctors withdrew, and we didn’t think we could maintain the practice,” Hodges says. “It was a painful experience.”
He looked into joining other groups. “My chief concern was the number of patients I’ve had for 45 or 50 years,” he says. “It’s more difficult to retire from being a family physician. You have that continuity of care and emotional attachment.” He’s deliberately left his phone number on the group’s Web site so that his patients can contact him and he can continue to refer them to other physicians, he says.
Retirement has been an adjustment, Hodges acknowledges, but for the most part, an enjoyable one. “It’s fun having available time to do things.” He volunteers at St. Mary’s free clinics and recently went to Honduras with a group of medical professionals to staff a clinic there. He also enjoys skiing, placing third in his age bracket at the National Standards Ski Race in Colorado last March.
And he still attends medical meetings, including Grand Rounds at Fairview-Southdale Hospital in Edina. “I like to keep up with medical things,” Hodges says. “Our meetings are 90 percent retired physicians. I used to laugh at them; I’d say, ‘Hey, you didn’t come when you were in active practice.’”
Identity Crisis
Dick Magraw, M.D., a retired professor of psychiatry and internal medicine at the University of Minnesota-Twin Cities, has a theory about why retired physicians continue attending medical seminars. “They’re hanging on to their identity,” says Magraw, 86, who gave up his license to practice at age 80. He continues to write and teach, but he wishes he hadn’t surrendered his license. “I felt at 80 that I hadn’t any business hanging in there, but that meant I can’t even write prescriptions anymore for family members.” Magraw retired earlier than he might have, in part to accommodate his wife’s wish to spend more time with him. “Retirement is a couple’s decision,” he says.
And it can be a difficult transition for physicians. “For professional people, our personal sense of worth is so tied up in our professional role that to surrender that, to lose your identity, is a deprivation,” Magraw says.
He thinks that may be changing, however, for the next generation of physicians. “There’s less engulfing identity in the profession now. Doctors my age invariably talk about the Golden Age of medicine, when the individual physician was thought to embody medical knowledge. Now it’s a giblet approach. A physician is a technician of eyes, of bones, or of joints. That’s different from walking through society anointed as the possessor of medical knowledge. I would expect someone in their 60s to do less looking back, to be less reluctant to relinquish that identity.”
Peterson, the recently retired internist, too thinks many physicians struggle with their sense of identity when they leave medicine. “I’ve heard secondhand that leaving medicine is difficult, that it takes away the source of your identity,” he says, then adds, “I must be a special case.” And he, too, expects the next generation of physicians to make an easier transition into retirement. “In my generation, you got in the saddle and worked as hard as you could for as long as you could,” he says. “Younger physicians are much more insistent on having a personal life.”
Some speculate that the recent influx of women into the medical profession will significantly alter retirement patterns. But research suggests that although female physicians tend to retire earlier than their male counterparts, they experience the same feelings about leaving the field. Women physicians and other high-profile professional women have a harder time adjusting to retirement than women in clerical and hourly jobs, according to a recent article in the Journal of the American Medical Women’s Association. Professional women report a sense of loss, while nonprofessional women feel relieved when they retire.
This wasn’t the experience of Judith Shank, M.D., a Twin Cities dermatologist who retired from active practice in 2000 when she was almost 57. But Shank understands that sense of loss. “Most physicians are married to their work, and a lot of our sense of self comes from what we do,” she says. “I felt relief.”
Her practice was facing a major transition, and she realized that she didn’t have the energy to continue working 10- to 12-hour days and attend meetings in the evening. “I was exhausted, and my feet and legs hurt so badly that I couldn’t sleep,” she recalls. Since her retirement, she’s served on a number of medical boards and also works as a substitute dermatologist at a worksite clinic for employees of General Mills. “I don’t have any of the regulatory concerns, and if patients have ongoing needs, they are transferred to someone else,” she says. She also enjoys spending more time with her family, including her 3-year-old granddaughter. She’s never regretted retiring early, she says. “It was the right decision.”
Women physicians may adapt more quickly to retirement, says Brueggemann, the retirement consultant. “The women physicians who have retired trained in an era when being a woman physician was much less accepted. From early on, they had to be more flexible.”
Consider It a Career
Brueggemann, who retired from practice because he wanted to travel for two to three months at a time, both for pleasure and as a volunteer, believes that having a plan is the secret to a fulfilling retirement.
“Retirement is another career,” he says. “If you retire at 60, you have another 15 to 20 years—that’s a lot of time. If you don’t have a strategy, you float, and physicians are usually uncomfortable with that after the first week. In clinical practice, you’re driven by a schedule. People might think it’s freeing to give that up, but it’s pretty much your life. It’s an extremely significant life transition.”
There isn’t a lot of literature about physicians and retirement, Brueggemann says. “But generally, when you poll physicians, several interesting things pop up. Generally, they’re pretty satisfied with retirement. People have to go through the issue of giving up something that has been a source of extreme stress but also very ego-
fulfilling. They have to reinvent themselves.” Physicians who have prepared emotionally are better able to do that successfully, he adds.
“People can be so consumed with medicine they don’t know what they want to be. Lots of retired physicians tell me people are always on them for committees.” But a satisfying retirement requires not just filling time but finding meaningful ways to spend personal energy, he says. “People need to choose and not feel they have to do everything they’re asked.”
Ultimately, retirement is an opportunity, Brueggemann says. Even physicians who truly love what they do need new challenges and experiences. “Lots of people get to a point in their career where they feel, ‘I did this already.’ People bring them problems, and the problems don’t look fresh, they feel like they’ve solved them before.” Brueggemann thinks physicians need to pay attention to those feelings and realize that they may be a sign that “maybe it’s time to do something else.” MM
Kim Palmer is a frequent contributor to Minnesota Medicine.