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WTA Presidential Address NO MORE MR. KNIFE GUY: Early Observations on Early Separation From Surgery

2006; Lippincott Williams & Wilkins; Volume: 61; Issue: 6 Linguagem: Inglês

10.1097/01.ta.0000244163.99259.fe

1529-8809

Harold F. Sherman,

Trauma and Emergency Care Studies

Members and guests, I stand before you humbled; humbled by the honor of serving this organization, and humbled by the auspicious group of past presidents to which my undeserving name will be added. First, I want to say, Thanks. Thanks to the teachers and mentors whose guidance led me through my career. Thanks to those who introduced me to and got me involved with the Western Trauma Association (WTA); to those who encouraged me and helped me to become more active; and, especially to those who have, over the years, become and remained my friends. If I'm half the friend I hope, you know who you are. It is to you that I dedicate my presidency and this talk. There are many in the audience who know more about trauma care than I do. Rather than attempt to teach the teachers, what I want to talk about is not doing trauma care. It is always safe to begin with some disclaimers and definitions. I do not claim to be an expert on retirement, financial planning, psychology, human resources, or any of the other disciplines that one might look to in thinking about retirement. I'm just a guy who quit surgery, earlier than many. And, although it may seem otherwise, I'm not trying to be an evangelical retiree. My intent is simply to share some thoughts, observations, and values based on my own experience and process, and offer them as fodder for consideration. I'll consider my talk a great success if I engender some introspection, thought, and, maybe discussion. If you define your own terms, you can say anything you like within those constraints. So, first a definition: The word retire comes from old French, meaning to withdraw into seclusion. When I speak of retirement, I'm not speaking of grandpa's retirement, of days spent rocking on the front porch, waiting for the inevitable. What I mean is leaving surgery. I'm speaking of life change in the context of the early 21st century, what is often called, in the popular jargon, the third act, second adulthood, or prime time. When I shared with friends my intention, not my desire, but my intention to actually retire, I was met with a whirlwind of questions. The questions made it clear to me that retirement, like many other things in life, is something people think of and dream of in the abstract, often without concrete concepts of its meaning or implications and, often with the concomitant fear of an unknown. Surgeons, and physicians in general, are a unique group of people with some unique qualities; qualities that make and allow them to do what they do and drive them to keep doing it and to be good at it. That's the first hurdle that needs to be overcome before one can give serious consideration to leaving the field. You must be able to separate who you are from what you do. Allan Watts, in The Wisdom of Insecurity, observed that “When man can name and define himself, he feels he has an identity”.1 If your first answer to “who are you” is “I am a physician”, you're not ready to quit. Doing so would leave you with an identity crisis, and portend an unhappy transition. That's not to say you have to have stopped loving, enjoying, or being interested in your work. It just has to cease being the defining focus of your identity. I didn't leave surgery because I hated it. I loved it. But, there are so many other things in life to love. There are very few who can truly say they to live to work. If you are one of them, keep working, if you can. The next, and for some, the biggest, obstacle, real or perceived, is money. According to the AARP, there is a 40% chance that someone over the age of 60 will be poor. I don't think that extreme is something this group needs to worry about specifically. But, the issue begs the question, how much is enough, really? For me, the answer had always been what I expect it is for many others: Just a little bit more. So, for me, the journey had to begin with some reality testing. I had to recognize and accept that I would never be as rich as I'd once dreamed and that my retirement funds would never reach the lofty goals I'd once hoped for. But, when I stopped to look at what I had, I realized that life, as it was, was pretty darn good. I could go on chasing financial dreams and goals or accept that it wasn't going to happen. To quote Allan Watts again, we “… fail to live because we are always preparing to live …”. Thus, for me, the question became, could I, without major, significant, and uncomfortable disruptions in lifestyle, maintain? Was I willing to stop expanding and acquiring, and readjust and refocus the assets I had on those things most important to me? For each of us, the implications of that would differ. For some, it might mean living with last year's perfectly adequate technology rather than upgrading. For others it might mean traveling coach instead of first class, but still going where you'd like and having the time to get there. For others it might mean not buying another vacation home, just taking the time to enjoy the one already owned. It might even mean deciding that state schools and scholarships could provide a satisfactory education for the children with the added bonus of a parent who had the time to fully share their experiences and attend their graduations. Some might consider converting previously acquired material possessions to useful capital for living expenses. I think I've made the point. Many of us save for a rainy day. Sometimes the hardest thing to say is it's raining, now. For most of us, in cold, harsh terms, our working life is defined by two commodities in a zero sum game; time and money. And, every day, but, perhaps, more so as one approaches the end of a career, one has to ask and answer the question, which is more important? Where does the balance lie? In reality, and in the end, both are out of our control. I don't have to tell this group how hard it is to make more money or about the difficulties of controlling your time in the careers you've chosen. You all know all too well about the merry-go-round of being a good and caring physician, trying to make enough money, having a personal life, and finding the strength, energy, and time to enjoy the rewards each of the facets of life provide. The key to quitting is changing the balance point, seizing the controls of the merry-go-round, putting the emphasis of your life where it's most important to you, and taking your life, not just your career, in a direction you choose. For those earlier in their careers but, perhaps already dreaming of retiring, I offer a bit of observational advice. Live a little below your means for at least a couple of years. Take a bit of your discretionary income, after taxes, after retirement contributions, after fixed expenses, and don't spend it. Stash it. In very short order, you'll have a nice little war chest. If you then find you have unexpected expenses, you can handle it without creating financial havoc. If you're fortunate enough to escape the unexpected, you'll have a fund you can draw on for other matters, like pleasure. And, if you don't spend that all at once, it'll grow back. It's a little like earlier generations' retirement concept of living off the interest. Instead it's enjoying off the interest while the principal grows, long before you reach “retirement age”, whatever that is. So when you do seriously consider quitting, there's this little pile of money to help back up that decision. On another practical matter, I'd like to say something about leaving a partnership. For better or worse, the solo practitioner who could just close the office door and slide quietly into obscurity, is a thing of the past. And, while the decision to leave surgery will certainly have major impact on loved ones, remember that our professional partnerships are a lot like marriages and the impact on partners will also be significant. Communication is key. If you want out, let your partners know and seek their thoughts, early in the process, not as to whether or not you should leave, but on how they'd like to see it happen. Work with them, if you can. You're going to leave them holding the workload bag. In most settings, you won't be quickly and easily replaced. Consider and discuss the possibility of a phased transition. Although this may seem perfectly logical to you, it may be less than acceptable to your associates. But, when all is said and done, remember, it is not a marriage. It's business and, what were warm and seemingly close relationships while it was business as usual, may, under the strain of differing business goals, devolve into just business. The expected handshake and gold watch may end up a swift kick. Prior understandings and verbal agreements aren't worth the paper they're printed on. Protect yourself. Plan ahead, in detail, in writing. Planning ahead is another much discussed subject and one of the areas in which I disagree with some experts. Regarding the experts, remember, if you will, the experts who are giving advice on how to be retired are, for the most part, still working at giving that advice. It seems to me a little like getting wine suggestions from a teetotaler. Allan Watts wrote, “… we live in the future, and the future is an abstraction… which exists only in the brain …”.1 No matter how you plan, you don't know, and can't know what retirement will be like for you until you are in that moment. Ellen Freudenheim, in her book Looking Forward: An Optimist's Guide to Retirement, suggests that without work as a central focus, one needs to find an “anchor activity” or ballast to provide balance or structure.2 Respectfully, I disagree, at least as far as prior planning goes. Remember, no matter how much you plan, when you stop being a surgeon you still wake up one morning with a totally changed life. In fact, it's what you probably have in mind when you consider retiring from surgery. That change can, of course, be quite unsettling. Consider the last time you woke up with nothing out of your control on your schedule. The year before you started kindergarten, maybe? That's not a bad thing. We are a group of intelligent, inquisitive, fertile minds. Here's where a choice comes into play. You can, of course, plan activities every day from day one and rebuild your emotional comfort zone of living with a tight schedule, or not. I'd suggest trying not, for a while, at least. Andre Gide observed, “One doesn't discover new lands without consenting to lose sight of the shore …”. I remember, shortly after I first left surgery, sitting in the back yard reading, and feeling uneasy. I soon recognized that I was feeling guilty. I wasn't doing anything. Surely there were things to be done. And there were. But once I gave myself permission to just enjoy sitting out in the sun reading and do something another time, the day became glorious. Once you allow yourself the freedom for which you've worked so hard and dreamed so long, each day can become a blank canvas on which you can paint the rest of your life, or the rest of your week, or just the rest of the day. The openness allows you, if you allow yourself to be receptive, to seize and follow opportunities that arise or that you create. How often have we all found ourselves in the position of saying, I'd love to …, fill in the blank, but I have to …, fill in the blank. Well, once you stop working you don't often have to. Proust wrote, “The voyage of discovery lies not in seeking new vistas, but in having new eyes”. So, instead of racing directly home you can take that other road about which you always wondered. Or stop in that little specialty shop that always looked interesting but for which you never had the time. Or walk down that footpath you've seen a million times but never followed. Or take the time to really chat with that neighbor or shopkeeper who you always thought might be interesting. Or, to expand the concept: Perhaps there's someplace you've often wondered about visiting, but which always got passed over for the greater certainty of a vacation in a known place? There's a concept in gambling, or investing for that matter, called playing with scared money. That means, when you have a limited stake, you're less willing to take the chance on a longer shot, the bigger bet, and consequent big win. It's a sure way to come out a loser. That's how most of us, in our working years, deal with time. We only have so many weekends off and so many vacation weeks but so much to choose from, and so much responsibility. We really should go visit the family, but the kids really want to go to Disney. We could surely use a restful romantic week at a luxury resort with our significant other, but there is so much to do at home and besides we need to get some CME. And wouldn't it be nice to just hang around the house for a weekend and sleep late, read books, putter … you get the picture. That's what I call playing with scared time. And that's how most of us live most of our working lives. Imagine having a bigger pot of time, big enough to make the less certain bet. And, what about all that time on your hands? Again, we're intelligent, creative people. You can reinvent yourself as often as you like. Once may be enough to take you in a direction that satisfies. But daily is an option. Learn things you've always wanted to learn, or never before considered learning. If you're open, receptive, and observant, and want to do something the opportunities are there. You can be creative in finding ways to use your skills, intelligence, and passions or in finding new ones. In her book, Retire Smart, Retire Happy: Finding Your True Path in Life, Nancy Schlossberg divides retirees, into five categories: continuers, adventurers, searchers, easy gliders, and retreaters.3 The group names pretty clearly imply the paths likely to be chosen. The group most at risk of unhappiness in retirement are the retreaters; those who wind up sitting around watching television and waiting for mealtime and the mailman. I don't believe I know many physicians who'd fall into the retreaters category. One more from Allan Watts: “The art of living in this predicament is neither careless drifting on the one hand nor fearful clinging to the past on the other. It consists in … having the mind open and wholly receptive”. For those who are confirmed continuers, please don't be disappointed at my lack of specific recommendations. Several books, many articles, and the Internet, including the American College of Surgeons (ACS) Website, address these areas. To my mind, a forum on retirement held at the ACS clinical congress in 2004, did a nice job in the area of continuing, but fell short in other respects. It seemed almost as if the college members couldn't imagine any other approach, presenting, to my mind, a narrow focus. I'd also like to say a couple of words about quitting early, from a professional perspective. How many of us have known a senior staff physician, long beyond his prime, who continues working. Whether out of respect, fear, or any of a number of considerations, no-one will tell it's time to quit. But it is. Patsy Hendren was a beloved English cricket player in the 1930s. When asked why he stopped playing at the end of his best season, he responded “I'm going to quit while you still ask me why. I'm not waiting until you ask why not”. Isn't it better to quit at the top of your game, before your colleagues have to grapple with the question of whether to tell you it's time to go? In his poem, “To an Athlete Dying Young”, A.E. Hausman, put it well: “…Smart lad to slip betimes away. From fields where glory does not stay …” Returning to the issue of all that time on your hands is a good opportunity to make another point about the zero sum game of time and money. Ultimately, even more than the money side, the time side of the equation is, most assuredly, finite and beyond our control. How often have each of us visited a sick friend, heard one of those horror stories about the guy who died the week after he retired, or attended a funeral, and thought “I've got to start enjoying today”. Unfortunately, but naturally, that sort of experience becomes more frequent the older we get. Those feelings of vulnerability and the weight of the passage of time all too often get lost in the background with the very next set of responsibilities to be faced; the next on-call night, or abstract deadline, or whatever. In an address to the medical students of the Albany Medical College in 1899, William Osler said: “Engrossed late and soon in professional cares, you may so lay waste that you may find, too late, with hearts given away, that there is no place in your habit stricken souls for those gentler influences which make life worth living”. Borrowing from the Talmud and Rabbi Hillel, regarding retirement, as we get a little older, we must ask, if not, why not? And, if not now, when? At the end of my second year of medical school at Tulane, our pathology professor gave us his traditional and locally famous lecture in preparation for entering our clinical years. We, as a class, were so moved by his sentiments, that we asked him to repeat the talk at our graduation. In closing I would like to quote Dr. Charles E. Dunlap because now, as I reflect on the end of my career and approach the end of my Presidency of this wonderful organization, his words resonate still, and again. With my apology for the dated context, he said: “… The love and respect and affection which you will so soon command as doctors of medicine–these are not things of your own making. These things have been earned for you by the decency and humanity of countless generations of good men, of all faiths, over the past 3,000 years. These men are dead, and for the next few years, you will hold in your hands this magnificent heritage. I hope that when it comes your turn to hand it on to your sons, not one of you will have cause to be ashamed”. I am, Dr. Dunlap, proud of my career and proud that I've had the opportunity to cap it by serving the WTA. I hope that those who follow me in this role will continue the magnificent heritage of the WTA.