Critical reflection on physician retirement

Financial concerns

Physicians know that it can be difficult to estimate how long one will live, thus complicating financial planning concerns such as how much one needs to live on in retirement. Further, like many professionals, physicians tend to have myriad financial obligations. Most physicians are self-employed, thus lacking an employer-sponsored pension plan, and most retirement planning models factor in reduced consumption in retirement. So getting one’s finances in order can mean more than regular meetings with a financial advisor; it can also mean practising living on a reduced income and finding alternative models for retiring. Despite the advantages of retirement from procedure-based fields that are physically strenuous and increasingly complex, many physicians face strong financial incentives to continue working. This is particularly true for physicians who incur expenses from their children (eg, educational expenses), from caring for aging parents, and owing to divorce. It is also true for physicians who start their careers later or have career interruptions, as is often the case for women, who reach retirement age with a lower base salary.

Work identity, personal identity, and physician health

However, financial concerns are not the only reason many physicians face challenges when retiring. The negative association with retirement emanates, instead, from the social construction of a physician’s identity as being consumed almost entirely by medicine. For many physicians, work identity is synonymous with personal identity. Many cannot imagine life without practising medicine.¹ The medical institution can be a “greedy institution” that demands total commitment from physicians, thus prioritizing institutional demands over participation in other non-work spheres.² Because medicine is often about life and death, being a physician requires full commitment, focus, and often self-sacrifice. Therefore, retirement can be seen as being role-less, disorienting, and even selfish. Leaving medicine can feel akin to betrayal or to a soldier abandoning his or her squad.

Demands for strong commitment begin long before retirement. The lengthy and difficult training process required to become a physician can leave little time to think about, or develop, outside interests. Further, the process of assimilation to medicine, the structural demands imposed by medical institutions, and the dedication required to persevere cultivate a culture in which physicians learn to prioritize work above all else.^3,4 During their working lives, many physicians sacrifice personal relationships and obligations for their careers. It is not uncommon to hear the story of the neglected physician’s spouse who holds the family together while patient needs are attended to. The physician couple who outsourced household duties and family needs, the physician whose first or second divorce was related to work-life balance issues, and the individual who never found a life partner but was described as married to his or her work are also not unfamiliar stories.

Burnout^5,6 is another contributor to physicians’ retirement decision making. Progressive weariness in physicians can be induced by stressors such as the constant need to keep up with new techniques, technologies, medications, treatment protocols, and continuing professional development standards. In addition, one must deal with the demands of maintaining a practice and staff turnover. Family physicians must also learn how to deal with chronic disease management as their patient population ages with them. The burnout induced by these stressors can lead physicians to ignore their own need for a physician and to turn instead to self-diagnosis and self-treatment. When it all becomes too much, or health issues become overwhelming, physicians can be forced into abrupt and sometimes unfortunate retirement situations.

Social responsibility

The sacrifices physicians make are often justified by the social good that physicians deliver. There can be strong pressures not to retire when there are physician shortages and high demand from patients.⁷ Retirement decisions can be particularly challenging for physicians who practise in rural settings where there might be no one to take over,⁸ versus an urban setting where newer physicians struggle to get their foot in the door. Those who have built strong relationships with their patients over time feel personally responsible for their care and well-being. These concerns about patients are compounded by a work identity that prioritizes service to patients and communities above a well-rounded life that finds meaning in multiple spheres. When equated with leisure, retirement can appear to be devoid of meaning for physicians who based their sense of meaning on service and devotion to others’ health and well-being.

By the time physicians begin to contemplate retirement, they have fully assimilated the ideals of their work identity. They are often, moreover, at the height of their careers in status. This is more true in some specializations than others—age and seniority might be particularly beneficial for the family physician who has followed his or her patients over long periods of time or the geriatrician who is likely to have become more skilled over time and whose own advanced age creates a commonality with patients. Factors such as region, specialty, and gender shade the meanings and implications associated with retirement. The pressures to publish that academic physicians face can pose another barrier to retirement because the additional layers of work identity sometimes overshadow life outside of work.

Social implications

Ironically, physicians’ commitment to the public good can create serious difficulties for the health system. Unlike many other professionals, physicians’ retirement decisions not only have personal implications but also broad implications for society.⁹ Serious concerns about patient safety can arise when physicians continue working well past their physical or intellectual prime.¹⁰ Physicians who waver about the decision to retire or who abruptly retire can be difficult to replace, which can also raise patient safety concerns and be a source of discontinuity in patient care. From the perspective of the health care institution, the implications of retaining a physician for too long are also complicated. On the one hand, hiring a more experienced physician can be costly and hiring a newer physician can reduce expenses. On the other hand, a more experienced physician’s skill, efficiency, and willingness to take on a higher volume of patients can reduce costs. It is not uncommon to hear about senior physicians who had to be replaced by 2 newer physicians upon their retirement.

Another perspective to consider is that of the earlier career physician, for whom a colleague’s retirement can mean an increased workload when there are shortages. In contrast to communities that are grateful when new recruits choose their area, there are regions where a more senior colleague’s delayed retirement can mean there is no work or the only work available is piecemeal, at odd hours, or in multiple locations. This situation can create problems in the continuity of patient care given the difficulties that can be associated with patient follow-up. There are clear negative implications for patients if the next generation of physicians is overworked, unable to acquire the necessary experience, or unable to obtain stable work that facilitates follow-up with patients.

Creative solutions

After a career of helping people at their most vulnerable, it can be hard to know when to leave, particularly for aging physicians who have become vulnerable. Physicians ought to take advantage of financial services available at all stages of their careers and develop retirement plans that go beyond financial planning. These involve recognizing the values inherent in one’s medical work identity, actively seeking less intense medical or more flexible community roles before retirement, and seeking meaningful pastimes outside of medical work. It means accepting that self-sacrifice is not always warranted, particularly when it comes to physicians’ own health, and that ceasing to practise medicine in no way negates the contributions one has already made. Options to consider include having job boards that offer flexible or part-time positions and pension plans that are open to arrangements such as job sharing (eg, between physicians returning from parental leave and those who want to gradually transition out of practice). Medical institutions and organizations could also consider ideas such as late-career mentorship programs as an additional means of creating models for transitioning out of practice.

The medical profession invests years in developing an all-encompassing work identity among physicians. Medical institutions ought to invest time and resources into facilitating late-career succession planning strategies that honour the physicians’ lifelong commitment to medicine. Wherever possible, it is important to find flexible roles that acknowledge aging physicians’ deep repository of knowledge and experience.