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    Leaving practice, but not the profession

     

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    Leaving practice, but not the profession

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    You're probably making careful plans for financial security in retirement. But what about the rest of your life?

    By Lauren M. Walker

    "It amazes me at medical meetings when 10 percent of the doctors say they've just retired and another 10 percent say they can't wait to get out," declares Vermont child psychiatrist and author Stuart A. Copans. "It used to be that physicians didn't retire; they'd practice into their 80s. But retirement for physicians has changed because medicine has changed."

    A recent survey of 300 doctors age 50 and older by the physician search firm of Merritt, Hawkins & Associates in Irving, TX, found that 38 percent plan to retire in the next one to three years. Another 16 percent plan to close their practices to new patients or significantly reduce their workloads, 12 percent intend to do locum tenens work, and 10 percent will seek employment in a nonclinical or nonmedical setting. Only 18 percent intend to continue as they are.

    "When I started in this business," says longtime practice management consultant David C. Scroggins of Clayton L. Scroggins Associates in Cincinnati, "doctors didn't have the kind of retirement funds that would let them quit early. It wasn't until the 1970s that the laws on retirement plans really opened up for them. The doctors who are reaching their late 50s and early 60s have the financial resources to get out."

    But that doesn't mean they're emotionally ready to give up their professional lives. "If people treated the emotional preparation for retirement with as much care as they give to the financial side, they'd be in great shape," notes psychotherapist Phil Rich, co-author of The Healing Journey Through Retirement (John Wiley & Sons, 1999). "People who retire may have 20 years or more ahead of them. If you haven't prepared for those years, it can be depressing."

    A retirement that didn't take

    Donald R. Germann, a retired radiologist in Leawood, KS, and author of the book Retirement is Over-Rated (Leathers Publishing, 1998), learned firsthand what happens when a doctor doesn't give adequate thought to the life he'll lead when he stops working.

    Germann retired in 1992, at 68. But after a six-month teaching assignment in China, he found "there were more hours in a day than I could do with. I felt lost. All at once, I was no longer Dr. Germann. I was the old man who lives up the street. And that hurt. I also found out that the relationships I had with my employees, colleagues, and patients were really rather important to me."

    Germann first took a part-time job at the local Merrill Lynch office, doing clerical and proofreading work for minimum wage. But he left when he was asked to become a broker, because he wasn't interested in such stressful work. Finally, he says, "I got tired of trying to fill my time with games and traveling. I had my health and my experience, and I decided I might as well use them." So Germann took some postgraduate refresher courses, renewed his license, and in 1995 went back to work part time in the radiology department of Research Medical Center in Kansas City, MO. He's still there.

    Not surprisingly, Germann believes that retirement is not always the best choice. "Think about all the options," he advises. "Whether it's starting a new career, or working part time, or volunteering. After a few hundred Saturdays in a row, Mondays may not look so bad."

    Planning a successful retirement

    Preparing for life after practice means taking a hard look at the nonfinancial benefits of working. Therapist Phil Rich poses a number of revealing questions: Does "work" mean a creative outlet to you? A necessary evil? A way to help others? Does "retirement" mean a loss of income? A loss of meaning?

    A successful retirement may depend on identifying what really matters to you about working, and then keeping those aspects alive. "There are things you take for granted that you may end up missing," says Copans.

    "You need to start planning three to five years out," advises Rich. "Ask yourself: Where do you want to live? How will you use your time so you feel productive and inspired? What are your interests? What role will your family play? Do you want to be closer to your children—or farther away? You also need to prepare for a possible decline in health—your own and that of your family and loved ones."

    Shelly Liss, who specialized in physical medicine and rehabilitation before his retirement, became one of the founders of the Harris County Medical Society Retired Physicians Organization, in Houston, because "one of the things I enjoyed in practice was managing and motivating my staff. So I organized the retired physicians. I do most of the work myself, including putting out the newsletter and arranging meetings and speakers. I'm doing the thing that I like best, without the stress."

    In the current environment, a lot of doctors want to do just the opposite: shed the administrative aspects of medicine, but keep on helping patients. Daniel R. Sullivan, an FP who left practice in 1998, now works half the year as a locum tenens. His assignments have included six months as a bush doctor in the Australian outback, a stint at the Indian Health Service facility on the Standing Rock Sioux reservation, and shorter assignments closer to his Sylvania, OH, home.

    "They don't pay much, but I don't really care about that," Sullivan says. "It keeps me busy, and it's not stressful, because I don't have to worry about the business of practicing medicine. I just go in and take care of people. The people are glad to see me, and the staffs love me."

    FP Wesley H. Ryd of Evergreen Park, IL, does medical missionary work through a religious organization, Christian Medical & Dental Associations' Global Health Outreach. He went to Uganda and Honduras last year. "When I'm out on a medical mission," he says, "I really enjoy working like a dog again. I feel blessed by it."

    "A lot of doctors who leave practice relatively young want to find a way to keep the doctor identity but play a different role and cut down on administrative stress," says consultant David Scroggins. There are a variety of choices. "You may be able to do nursing home work, cover for former partners, do Social Security disability evaluations, or work for a hospital run by the Veterans Health Administration," he suggests.

    Building up the rest of your life

    Retirement is easiest if work isn't the only thing that gives you satisfaction in life. "If you just work at a job your whole life and suddenly you retire, that's an acute loss," says Sullivan. "If you're involved with your family, have hobbies and multiple interests, participate in your religious community, and you retire, you lose only part of your emotional investment.

    "Doctors tend to focus. Some have socialized only with other doctors and haven't spent that much time with their family. And now their family is grown and gone. That can make for a difficult retirement."

    One aspect of preparation is to incorporate part of your future life into the present. That can be hard for a full-time physician, but the benefit is a smoother transition. As you begin to plan for retirement, "don't just make a list of what you want to do," says Mary McGrath, a CPA and consultant with Cozad & Associates in Champaign, IL. "Start to put feelers out. Get more involved in whatever interests you.

    "I have one client who was interested in a local not-for-profit agency. So a year before he retired, he got on the agency's board of directors. Although he wasn't terribly active that first year, when he did retire he was in tune with the organization and ready to step forward at a higher level."

    Sullivan, whose novel, Ripples in the Wind, was published in electronic form by iUniverse.com in November, attended summer writing workshops at the Iowa Summer Writing Festival for several years prior to retiring. He devotes his nonpracticing time to writing, under the pen name Bushdoc Sullivan.

    Although it's important to plan ahead, the change in your daily routine may change what you like. Retired Texas physician Shelly Liss recalls one colleague who had always enjoyed an annual summer vacation in Maine. Once freed of the pressures of practice, that break was too boring. "He needed a more active vacation," says Liss. Trying out your future activities may help you predict how well they'll suit you. But don't be reluctant to reassess your choices if things aren't going as planned.

    Paying heed to family concerns

    For married doctors, it isn't only the retiree whose life will change. "You need to think of it as our retirement, not just my retirement," says Germann.

    "The relationship with the spouse takes on a different dynamic when both are home all the time," says McGrath. "Most typically, in the group that's now at retirement age, we're dealing with a male doctor and his wife. Because of the demands on the physician's time, the wife has been accustomed to having her own life and providing her own entertainment. And now her husband is home, and he's kind of in her way. She may want to do what she's always done, but now he expects her to change her plans for him."

    Attitudes carried over from the office may interfere with domestic harmony, as well. "He's used to having people get things for him, and now he starts putting those demands on his wife," says McGrath. "That's not a role that she wants. That's something the two of them need to work out." Couples need to sit down and discuss how the retirement will change life for both members, share expectations, and be willing to revisit issues as they arise.

    Child psychiatrist Copans points out that for many, work provides a daily place to go. "If you suddenly have no place else to be, it can be a loss. If, as part of winding down, you start bringing work home, you may need to carve out an office area to keep from invading your family's home with work needs."

    Retiring doctors may also want to move. While that can be right for some, it adds more stress. "Moving takes away another whole aspect of identity," says Copans, who co-authored a book on the stress of moving, as well as one on job loss. "You lose your ties to the community, and the house where you've lived your life, and it affects your spouse and your whole family. My co-author, Audrey McCollum, found that moving is especially stressful for women, because of their attachments to the home and community. So moving may put additional pressure on a marriage, just at the time when retirement is already changing things."

    If you're planning to move in order to set up practice in your retirement community, think carefully. "Doctors may decide they want to move to Florida or some other retirement destination, and be a doctor down there," says Scroggins. "Then they get there and find it's not so easy. They can't build a practice or join one, and two or three years later, they're back home trying to pick up the pieces. Relocation is not a decision to be made lightly."

    Will you phase down?

    Although winding down gradually may be the best way to adjust to retirement, it, too, has to be carefully planned. Don't assume the option will be there if you haven't set it in motion ahead of time.

    "Phasing down is wonderful to the extent that you can do it," says Mary McGrath. "But it's getting harder. The overhead costs make it more expensive for a physician to work part time. Malpractice insurance doesn't go down in price because you're not working a full schedule. In larger practices, they may not be willing to carry you. Where winding down used to be the norm, I see more doctors having to go cold turkey."

    There may be ways to convince your superiors that your reduced schedule will be an asset. "There are a lot of new female physicians who have just completed their course of training and are torn between needing to start their practices and wanting to start their families," notes consultant David Scroggins. "Partnering with a doctor who's phasing down may be a win-win situation for both. For specialties with a surgical component, like ophthalmology or orthopedics, Dr. Senior may be able to take over the nonsurgical care, keeping the patients flowing and the exam rooms full, while the younger doctors handle the procedures. That arrangement can boost the practice's productivity overall."

    What if you don't want to work a shorter day or shorter week, but want to take off a month or more at a stretch? In a large practice, it might be possible to arrange to fill in for the other doctors taking summer vacations in exchange for blocks of time in the winter. If your goal is to remain active in medicine, and income is less important, locum tenens work or volunteering may be attractive options.

    Finally, the best preparation may be simply to expect some stress from the transition. "For many doctors, that first year is a difficult period," says Liss. "After that, most of them have integrated themselves into the new life." But physicians can adjust happily to life post-practice. "The first time someone calls you 'Mister' instead of 'Doctor' and you don't correct them," says Liss, "you'll know you're doing okay."

    The author is a freelance health care writer based in Cambridge, MA, and a former senior editor of Medical Economics.

    Helping patients (and their doctor) survive retirement

    By Charles Morrison, MD
    Family Physician/Colbert, WA

    The attractive, immaculately dressed elderly woman shuffled slowly and sadly from the exam room. At the nurses' station, she paused. "I'm going to miss my doctor so much," she told my nurse. She took another hesitant step, then turned back to the nurse. "What was his name again?"

    We doctors may feel irreplaceable as we prepare to leave a practice where we've delivered children, and maybe their children as well. We've weathered so many crises with our patients—emotional, physical, and others—and helped them go on. Can they, will they, survive without us? The precious old lady with dementia, for whom I had been a stable landmark in an increasingly foggy world—would she do okay without me?

    And then there's the other side of the equation. After more than 30 years in clinical practice, could I survive without the appreciation of my patients? The struggles of a career in medicine had all been made worthwhile by the trust of the families I attended along the way.

    But it's important to put the patient's needs ahead of my own in this transition. The fact is that we doctors tend to land on our feet in retirement, but patients may not do as well. Studies suggest that patients' morbidity and mortality may increase when they change doctors. What can we do to help them cope? Here are my suggestions:

    1. Don't encourage dependency. We physicians foster dependency more than we like to admit. In part, it's because we know that treatment is more effective when patients have confidence in us. But we must guard against a dependency that's not in the patients' interest. Do we really need to give our obstetric patients our home phone number to call when labor starts, or are we just implying that our partner's care won't be quite as good as our own?

    I learned my lesson about dependence with my patient Fred. I don't think I helped him as his heart failure became unstable. He trusted me, but didn't trust the system enough. Although I left him in good hands when I retired, he didn't take advantage of the care available, and was in full-blown heart failure before he saw a doctor again.

    2. Help them find the right doctor. Too often, changing to a new doctor is only a matter of calling the health plan's appointments clerk and being assigned to a new physician. But if you can refer patients to a colleague you think will be a good match for them, it can be a first step in making that new relationship a good one. Especially in primary care, we really know our patients and can assess whose style will fit them best. Some patients are brusque and businesslike, and appreciate the same in a doctor. Some need more gentle treatment.

    My patient Abby is cranky and loves to terrorize folks with her brisk, unsociable, shocking comments. So does my colleague Dr. Smith, who intimidates some of my more ordinary patients. But both Abby and Dr. Smith have hearts of pure gold, and a depth of kindness and insight that might be lost on most of the rest of us. I could see the relief in Abby's eyes when I "warned" her about Dr. Smith. But what she said was, "He can't be any worse than the rest of you!"

    3. Stay accessible. You will no longer be your patients' physician in times of medical need, but that doesn't mean you can't still be a friend, interested in the successes of their lives. It doesn't breach the professional boundaries to say that you'd like to continue to get a holiday card, birth announcement, or graduation photo.

    Recently I received a letter from a young family with a picture of their beautiful, happy 4-year-old daughter sitting on a sled. The smiling face of that normal child enjoying a winter's day showed no sign of the night she was born with a giant congenital pigmented nevus covering the middle third of her body, or the multiple surgeries that followed. Her parents are happy with their new doctor, and expecting another child. But I am still a friend of the family.

    Maintaining relationships helps patients feel better in a medical system that can sometimes seem distant. This is good for the patients, but may be even better for us doctors. It was in this case.

    4. Respect their gratitude. It is sometimes hard for physicians to receive patients' thanks and good wishes graciously. It's our job to take care of them, not vice versa. When a patient expresses regret that you're leaving, remember to say "Thank you."

    I expected a difficult transition with my patient Margaret. She had been abused as a child, and had been a particularly dependent patient as she worked through the relationship problems, clinical symptoms, and feelings of inadequacy that so often follow childhood abuse. I remember late Friday afternoon calls in which she talked about thoughts of suicide when facing a weekend of insurmountable isolation.

    But now Margaret is functioning reasonably well, with a new job, restored relationships with her children, and a comfortable social support system. She scheduled a last visit with me—not in panic, but as an adult—to say goodbye and wish me well. I had to restrain my own impulse to reassure her. It was very awkward for me to accept this mature, adult-to-adult communication from her after so many years of taking care of her. But that was what she needed, to celebrate her own transition. All she needed from me was a thank you, and a goodbye.

    5. Respect your colleagues. After you're gone, those complicated patients will show up in the new doctor's exam room expecting him to know everything you learned in years of treating them. You can help prepare your colleagues with a longer visit note, a little more detail, and a bit of relevant family history included in the chart. The patients may not see these contributions, but they'll make the transition easier on both parties.

    I called Dr. Smith to "warn" him about brisk, unsociable Abby, as well as to pass on some relevant medical background. His understanding chuckle left me feeling that he would appreciate her as much as she would him.


    Too much energy to retire

    By Ronald L. Knaus, DO
    Psychiatrist/Seminole, FL

    At age 62, I felt overwhelmed by the rapid changes in medicine over the past decade. The stress of being in practice was beginning to wear on my nerves, and the prospect of retiring was tempting. When I visited my internist, he began to count up my negative risk factors for cardiovascular disease. He got to seven before I made him stop. Maybe it was time to leave medicine.

    I could have made a clean break. I was within a month of completing my work agreement with a residential treatment center for children and teenagers. I had helped found the center in 1988, and had been out of mainstream practice for almost 12 years. But when I thought about it, I realized I wanted to remain productive. Although I was 62, I still felt like I was 32. So now what?

    First, I decided to return to the office where I practiced psychiatry years ago, to provide backup medical management two to three days a week. The office is only 20 minutes from my home, the staff is solid, and the psychologists are excellent. The staff was happy to have me back.

    Then I set about catching up on developments in psychopharmacology. I had general knowledge, but the new information on neurotransmitter systems was moving fast. To refresh my knowledge, I attended local lectures, dinner meetings, and seminars. I read a few books and started listening to the pharmaceutical reps who visited the office. I became so fascinated with the new approaches to depression that I decided it would be my new area of specialty, and resolved to learn all I could.

    My goal infused new life into the office practice. The PhDs were happy to have someone provide backup and discuss medication and treatment interventions. And I got really excited about the new approach I was taking with patients. I loved telling them that medicine had made great strides toward treating depression, and that we had more options than ever to help them recover. The hope this gave them energized me.

    I received unexpected confirmation that I was back in the swing of things when a physician I had known for 20 years called to ask me to lunch. As I suspected, he was depressed and seeking solutions. By relating what I had learned in the past six months, I was able to point him in the right direction.

    Eventually, I revised my intake form to include a depression history, which explores the patient's childhood, adolescence, early adulthood, and present life. I obtain an abuse history and a sexual history. Watching my patients closely as we talk about what they've circled often provides me with clues for interventions. Many times, this history opens the floodgates.

    I have trained my staff to make them knowledgeable about the new directions for treatments, the new antidepressants, their side effects, and potential interactions with other prescription medication so I've also prepared quick reference charts for the staff to use.

    As for me, I'm having the time of my life. I've been able to channel the skills I developed over the past 30 years in a fresh direction. This is much better than retirement.

     

    Lauren Walker. Leaving practice, but not the profession. Medical Economics 2001;3:96.

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