For many surgeons who have celebrated their sixtieth birthday, aging and retirement hang over their practice like the sword of Damocles. A retiring orthopaedic surgeon has to consider the circumstances and transition from a surgical career to retirement, which may require a substantial amount of thinking, planning, and consultation with friends, family members, and other professional people who may help with this transition. Many surgeons electively retire early just to enjoy their life and family. Others wish to retire early and seek another career, totally unrelated to the field of surgery. The proper age for this transition is from forty-five to fifty-five years old, when the physical attributes, intelligence, and knowledge are at their peak and the surgeon is capable of adapting to the new career in an efficient manner. In addition, a large number of those who are sixty and beyond would like to continue to practice. The remarks in this article pertain to the latter group. There is a dramatic and startling contrast between the emotion and circumstances of transition into a surgical career compared with transition out of a surgical career into retirement1,2.
Many of us, when we begin our practice, go through various stages. The first is the period of professional growth, which may last ten to fifteen years. During this stage, one is learning and developing and is physically and emotionally very strong. The next stage is a second ten to fifteen-year period of maturation and excellence. During this period, the surgeon rises to the maximum level of achievement, success, and satisfaction.
The third stage applies to those who want to continue to practice surgery beyond the age of sixty to sixty-five years. This phase could last from one to ten years or more and is a period of contemplation, uncertainty, and emotions, including both fear and a sense of success. Planning, support, and advice from people with more experience are needed to create a sense of fulfillment and continued satisfaction from this phase to retirement3,4.
The emotions of fear and uncertainty and the lack of realistic planning for the transition to retirement are real issues and raise questions about whether a surgeon can, in fact, judge his or her own competence, the appropriate time to retire, and whether the interests of society and, specifically, his or her patients are being served properly. This can be done only by objective peer evaluation of competence in four distinct areas: (1) intellectual ability, (2) emotional toughness, (3) physical fitness, and (4) professional competence.
Most thoughtful individuals would agree that there is a divergence between chronologic age and objective levels of intellectual and technical surgical performance. As one considers the proper parameters of competence and who should measure them, it should be emphasized that the definition of professionalism is that the patient's well-being must remain paramount to that of the surgeon. As with most biologic functions, there is a bell-shaped curve of competence that embraces the physical, cognitive, emotional, and psychomotor skills and the ocular realms. Fortunately, objective methods to measure these functions within the medical field are widely available1,5.
The physical parameters of strength, coordination, and vision peak during the third decade of surgical practice and then diminish at a variable rate. Endurance also begins to ebb with time. As the human visual system ages, the lens and cornea begin to opacify and increased light is needed for proper visualization.
Emotional factors, such as courage, decisiveness, and the ability to focus, need to be considered as well. Fatigue can be intellectual as well as physical.
The decline of cognitive function is widely variable and embraces knowledge, integration, and judgment. It is obvious that as time passes there is a prolonged period from the surgeon's formal education, and his or her fund of knowledge depends in great measure on continuing self-education and the environment in which the surgeon practices. The surgeon, who is somewhat isolated, has less opportunity to build a knowledge base than does the individual who remains in an educational environment. Self-education is crucial so that the surgeon can diagnose complex problems and manage them effectively by making correct evidence-based decisions. Our challenge is to recognize, through accepted peer-reviewed standards, when health—encompassing both physical fitness and mental fortitude—may be failing.
It is generally considered illegal under federal law to mandate retirement on the basis of chronologic age alone1. Although some key positions in society, such as U.S. Supreme Court justices, are not regulated on this most important matter, a few professionals, such as airline pilots and key crew members, are asked to retire at the age of sixty years6. Surgeons who wish to continue to practice after sixty-five years of age should be expected to have a periodic objective evaluation of the key parameters every two years. This would include an evaluation of general health by an internist, evaluation of visual performance by an ophthalmologist, evaluation of neurologic status and cognition by a neurologist, and, finally, evaluation of integrated surgical skills by a fellow specialist or subspecialist in the surgeon's field. These individuals should be neither adversaries nor friends but unbiased individuals who can evaluate surgical performance and intellectual competence in the real-world setting. This evaluation should consume no more than two days of time and be of great help to the surgeon personally in the evaluation of his or her skills, health, and competence. Additionally, the usual type of peer review of patient-related data should reveal unusual patterns of complications or extraordinary surgical times.
With regard to these aspects, it is difficult to create absolute guidelines; however, a substantial decline in vision; the diagnosis of a tremor or related conditions, such as Parkinson disease; or physical findings of a change in fine motor skills could be taken into consideration by the committee7. Although many recent surgeon surveys have reported different results, they do not provide guidelines for retirement8.
Many surgeons, for better or worse, define their self-image and meaning through their surgical career. The thought of retirement brings with it the concept of involution, disease, irrelevance, and, finally, death. Ultimately, all of these events and processes occur, and the ability to deal with them is philosophic, ethical, and religious. The lack of preparation and thought given to retirement worsens all of these issues and suggests the need for counseling.
Retirement Options
Few activities give a surgeon the self-esteem and satisfaction of surgery; after all, this is the great attractiveness of a career in surgery. Nonetheless, alternatives and equally satisfying activities, such as education, philanthropy, and community service, can be developed to allow continued involvement and a meaningful life. Surgeons who wish to retire but want to maintain an adequate level of satisfaction should consider the following options. Health-care-related activities that could fulfill the desire of a retiring surgeon include functioning as an administrative member in a medical society or academic center and participating in continuing medical education conferences and seminars, academic teaching, and grand rounds. Other health-care-related hobbies include publishing medical books and peer-reviewed papers or participating in research such as implant design. We now recognize that ongoing education is a healthy and positive intellectual stimulus, and it can continue with a broader focus toward the liberal arts or even a business education. These educational exercises are not only healthy in and of themselves, but they can also lead to gratifying activities. Philanthropy and community leadership activities require competent intellectual ability, physical fitness, and desire.
Non-health-care-related activities vary on the basis of individual interests and talents. They may include hobbies that can transfer surgical skills and require hand-eye coordination, such as creating artwork, painting, or sculpture crafting; playing musical instruments; and pursuing carpentry or even car mechanics. Other activities include writing books or novels, involvement in charity programs, spending time with family and grandchildren, and vacation or travel9,10.
An element of denial frequently prevents surgeons from adequately preparing for a transition into a nonsurgical lifestyle that is meaningful and enjoyable. Financial planning is essential and should allow for a wide variety of unexpected contingencies. Activities that are not dependent on material resources, including community service, family activities, and education, should be sought.
Meaningful activities need to be developed well in advance to fill the surgeon's time after retirement in a dignified, productive, and exciting way. Physical and intellectual inactivity is destructive and results in atrophy and anxiety. Developing these activities through a network of friends and associates can provide for and lead to a meaningful lifestyle after a surgical career. Retirement with proper planning minimizes the psychosocial effect of leaving the orthopaedic surgical practice and not being involved in the community.
Financial Considerations
Financial planning is one of the most important areas to address, and proper retirement planning is based on the standard of living desired after retirement. A prudent rule could be to estimate twenty times the current cost of living. This current cost of living can be estimated as the annual personal cost without the business expenses. This is part and parcel of life, and, unfortunately, surgeons and nonsurgeons often inadequately prepare for retirement, forcing them to work beyond an ideal date. An austere and nonmaterialistic lifestyle is certainly helpful for this particular challenge11.
Obtaining the services of a professional adviser or an experienced accountant may be integral to achieving this goal. Financial planning early in one's career and estimating the cost of living after retirement, on the basis of annual expenses and investments, can certainly help with this matter. However, financial stability may not be easily achieved and the impact on a surgeon's retirement planning will be substantial. Therefore, adverse financial circumstances require considerable judgment to reduce personal needs and lower the bar with regard to the desired standard of living. Nevertheless, these circumstances should not be a reason to postpone retirement if the cost is compromising the interest and safety of one's patients.
As with all transitions in life, surgeons should force themselves to look at retirement in a positive way as yet another opportunity. This will take preparation, a willingness to change, and a considerable amount of effort and perhaps counseling by peers.
It must be remembered that the well-being of the patient is paramount as surgeons are professionals. Because of the inherent conflicts of self-evaluation, we suggest that, after reaching the age of sixty-five, a surgeon should undergo an objective evaluation by enlightened peers with regard to his or her integrity of judgment and intellectual competency as well as physical health and fitness, including proper vision and motor skills. Preparation and thought are key. Remember: "Step out of the ring intact—when in doubt, do it!" and always protect your patients.
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