RE: Staying Active in Retirement

Surveys have attempted to address the reasons that physicians retire.  Frequently the healthcare provider "just wanted to retire".  They had worked, saved, and had various reasons wishing to retire.  Some retire as a result of an adverse malpractice experience.  Others retire because of a fear that they have lost mental or physical competency.  Some retire to spend more time with family or to pursue a passionate hobby or avocation.There are a number of podiatric physicians like myself who would prefer to remain active in the practice of medicine. 

I suspect that a large number of the readers of PM Pulse, as well as the former PM News, are "seasoned" podiatric physicians.As one gets older the question is what you have to offer as a physician.  I still enjoy my time working with the residents, both in the operating room and during chat sessions in the doctor's cafeteria.  I enjoy addressing residents in educational programs. As an older or senior podiatric physician, you must remember that you have invaluable experience, invaluable insight, and invaluable wisdom to be shared with younger doctors and training. 

Einstein stated that "the only true knowledge is experience". Rather than retire, one can continue to practice with certain modifications.  You can elect to perform less complex procedures.  It may be difficult to do at first, but you can refer less common complex procedures to the younger, extraordinarily well-trained podiatric physicians that we now have in the profession.  If you wish, you can also assist in the performance of these surgical procedures.

Another alternative is to transition to a primary care podiatry practice.  Primary care podiatry he is relaxing, challenging, and fun.

Yet another option is to remain in practice but to reduce your hours or have a more flexible schedule. I would like to think of it is having a "mature practice".  You have put in your time and you are going to sit back now, pick your clinical fights, and enjoy practice avoiding stressful or unrewarding situations that you might have taken on when you were younger.

Participating in academics is certainly worthwhile, providing young doctors with your knowledge, experience, and insight. I recently had a radiation oncologist tell me how much he admired me because of my continuing participation, not only in practice, but also participating in educational activities.  You can share your knowledge by teaching fellows, residents, or students, or even other MDs, DOs, RNs, and nurse practitioners.There also is the option of joining a government-supported podiatric clinic practice.  I would think it would be also possible to participate in the VA healthcare system.

A good number of older doctors sell their practice to a larger group.  However, it must be understood that this will have a loss of autonomy.  You are no longer the boss.  Once you sell the practice there is no going back.  You give up that which you built for so many years.  Decision-making will be slower, you will have more oversight, and there will be a loss of certain benefits that you always took for granted.  You will have to deal with the issues of corporate ethics versus your own ethics and the depersonalization of what was your practice.  You will also be subject to the capability and competency of the new owners of your practice.

We are seeing more private practices sell to venture capital ownership.  On one hand, there is the advantage of completing the sale of your practice and not having to worry about that in the future.  You now have your money in your wallet.  However, you may find that the short-term gain will leave you chronically unhappy in a practice you previously enjoyed.  Venture capital is associated with a higher rate of incorrect billings and out-of-pocket expenses for your patients, and increased cost of healthcare. It also has been shown to be associated with a higher rate of Medicare fraud and poor doctor-patient communication. Patients you cared for now become the target of strictly for-profit thinking.

All podiatric physicians will eventually face the issue of confronting retirement if they live long enough.  The great medical educator Sir William Ostler spoke about the "comparative uselessness of men over the age of 40" and called for mandatory retirement of doctors at 60.There are questions regarding the effects of aging on your skills and cognition, although these changes do not equally affect all podiatric physicians.  We would like to assume that we have the ability to assess our own physical and mental capabilities, but the question is whether self evaluation of clinical skills and cognition is reliable.

Age alone is not a reason for retirement.  The famous heart surgeon Michael DeBakey venously noted, "I would not mind being operated upon by a surgeon age 91.” The neurologist Howard Tucker continued to practice neurology past the age of 100.  He offered the following advice for longevity; delay retirement, stay mentally active, stay in shape, do not smoke, live in moderation, and share your knowledge. Then again, it has been said that good advice is something men give when they are unable to set a bad example. Personally, I always wanted to be a doctor such as Galen Adams in the television show Gunsmoke, or David Zorba, the chief of neurosurgery on Ben Casey.

Although some professions such as airline pilots, FBI agents, air traffic controllers, and physicians in other countries are limited by imposed age-related mandatory retirement, in the United States the age discrimination and employment act is enforced.

Can a podiatrist or any healthcare provider remain competent as they age? After all, as we become older we are more remote from our medical education, our residency, or fellowship training.  Frequently, the older podiatrist is also not “technologically savvy”. In general, older podiatrists had a less-intensive prior educational experience than the podiatric graduate today.  There have been changes in podiatry school education.  Most all of the older podiatrists had no residency or a 1- or 2-year residency.  We have seen rapidly changing technology in areas such as surgery and wound care as well as primary care medicine.  There are changes in medications available, testing available, all in the face of increasingly complex pathology now being evaluated and treated by a podiatric physician.  We have seen changing standards of care for the treatment of many conditions.

Many doctors tend to practice the way they were taught in residency; if they have been successful, they will continue to practice in that manner.  The philosophy is quite simple: Why change what works? If patients are satisfied and outcomes are satisfactory, why consider alternative therapies or approaches. Scientometrics has demonstrated that facts have a half-life and are not eternal.  They say that today's truth is tomorrow's fallacy. Ostler is said to have started his internal medicine class on day 1 by stating, "Ten years from now half of what I am about to teach you will be proven not to be true. The problem is I do not know which half that will be". 

Surgical skills decline with aging, as most surgeons demonstrate peak performance in their late 50s.  It has been demonstrated that the actual deterioration of surgical skills likely begins in the late 30s. Older surgeons will compensate for declining skills using experience.  Older podiatric physicians are more likely to recognize less common pathology and unusual presentations or circumstances of disease. Older doctors are also more likely to recognize difficult patients or potentially problematic patients than a younger podiatric physician.

Older podiatrists are more resistant to corporate influence and "thought leaders" than are younger podiatric physicians.  They have seen medicines and various surgical procedures "come and go".  When is the last time you performed a Youngs tenosuspension in the treatment of a flexible flatfoot, or a DRATO or HISS bunionectomy?  The older podiatrist is better able to sort out conflicting and confusing information.

Why then do podiatrists like myself continue to practice beyond the age of 65?  The answers are easy.  They provide a sense of value and a sense of satisfaction.  Few things bring me the satisfaction that I obtain when participating in educational activities with my colleagues, residents, or students.

Some continue to practice because of inadequate retirement planning or other financial considerations.  Others fear retirement because it brings them "nearing death".

It has been shown that the age of a surgeon is not a good predictor of operative risk, with the exception of complex procedures in surgeons with a low surgical volume. When retired physicians are surveyed and asked what would have made retirement better, the majority of the answers had to do with more savings and better retirement planning, spending more time with family, or having a hobby or interest beyond medicine. Ostler also noted, "The young doctor should look about early for an avocation, a pastime, that will take him away from patients, pills, and potions".

So when should a podiatrist retire?  It is our duty to retire when your skills and cognitive functions have deteriorated. This may be a difficult problem to confront. Retirement from medicine can be associated with a feeling of lesser self-esteem or self-worth, or a feeling that perspective has been lost. There will likely be decreased income. I often see retired doctors hanging out in the doctor's lounge because they missed the interactions with colleagues and the other interactions that occur in the hospital or healthcare setting.  There is the issue of a lack of intellectual stimulation and, of course, focusing on what could be declining health and fear of death.

In reality your skills and cognitive functions will fade over time.  Good financial planning will make retirement satisfying.  Retirement is not the end of your self-worth, and it does not the end of your enjoyment of life.

As Benjamin Franklin said, "Life’s great tragedy is that we get old too soon and wise too late."

—Allen M. Jacobs, DPM