Transcript

CARMELLE PEISAH: Joel Sadavoy, an old age psychiatrist from Canada, wrote about this mantle—this intrinsically entwined identity of being a doctor—that’s wrapped around us. And I always talk about that in papers because I can feel it myself. I can feel it wrapped around my nerves and my veins and my arteries—this mantle, this identity, of being a doctor.

MIC CAVAZZINI: Welcome to Pomegranate, podcast of the Royal Australasian College of Physicians. This month we're talking about one of the biggest steps in a physician’s career: retirement.

Some doctors avoid thinking about retirement altogether until they realise with a shock they can’t keep up anymore, or that their finances aren’t in order. But you're never too old to start planning, and imaging the identity you’ll have when you hang up the stethoscope.

Today’s episode was produced by, Zacha Rosen, who will introduce the rest of the story.

ZACHA ROSEN: Hello, I’m Zacha Rosen. In this episode we’ll hear from Carmelle Peisah and Chanaka Wijeratne, two of the authors of a recent study of doctors’ retirement intentions. We’ll also hear from John Dwyer, Emeritus Professor of Medicine at the Prince of Wales Hospital in Sydney, himself now retired. But first, paediatrician Jill Sewell—a former president of the College, who’s already thinking about her own retirement.

JILL SEWELL: I’m a paediatrician at the Royal Children’s Hospital in Melbourne and I’m getting closer to retirement. I’ve had a long history with the College of Physicians and was president about ten or twelve years ago.

I’ve been thinking about retirement, I would say, on and off over the last two or three years. I’m of an age when some of my contemporaries have already retired and I don’t have very specific plans as yet. I know that I’m getting closer to retirement, but not yet close.

So I’ve been thinking about whether to slow down, to stop completely, to stop clinical work but keep on going with other professional activities. And of course also thinking about the things that I might do with all of that spare time.

ZACHA ROSEN: Jill is also thinking about how to think about retiring. What should she do with such a big open future?

JILL SEWELL: I think the most important thing is to get to know yourself. If you haven’t had time to get to know yourself because you’ve been too busy working for a number of years , then take some time to get to know who you are as well as your medical professional persona. And different people will do that in different sorts of ways.

One of the things that many of my colleagues have never done is to take more than a week or two off for holidays. And so one of the pieces of advice I would give, you know, from around about that time is give yourself a long break. Go away for four or six weeks, or take some long service leave. And actually let go of a lot of things and think about yourself from a wider perspective and do that from time to time.

And I think that is a very good early thing to do as you’re sort of beginning on a potential path to thinking about retirement, because that’s what’s really going to give you the opportunities to have positive things in your future rather than just letting something go in the future.

Now I see far more people who’ve been very actively engaged in their medical speciality and profession who’ve gone much more gently into retirement and have really enjoyed becoming the person they’ve always wanted to be. And was always tucked away in a little corner of themselves for all those many working years.

Once upon a time I thought it would be an intimidating topic. But because I’ve been just allowing my mind to play over it gradually as I’m getting closer to the time, I’ve found it to be not such a frightening prospect after all. There’s plenty to do both continuing some professional interests and plenty to do with recreational interests. And plenty of people to spend time with.  So I’m now beginning to really look forward to it, rather than think about it with trepidation.

Freeing up time is going to be so enjoyable. Following up with things that you get interested in and you think, “Oh, wouldn’t that be good if…”or, “Wouldn’t it be fascinating if…”and having the time to follow those things up and spending more time with friends and family will very quickly reconcile me to retirement when it comes.

I think I would like to spend more time in my local community, being a member of my local community. I live in a suburb where there is a bit of a local community—I know that’s not true for all people. And there’s community organisations and associations and committees and it’s not that I want to start being on a hundred more committees. But I’d like to feel more part of the community by just being there, doing things with other people. Spending time in the park, chatting to other people, sitting on the park bench, doing those sorts of things is one thing I’d like to enjoy more as I have more time.

ZACHA ROSEN: One thing in particular made things easier for Jill.

JILL SEWELL: I think it was a realisation that you don’t have to make a specific choice that will sort of land you in one process or pathway or another. It was the realisation that I will continue to have choices. And I can change the way I do things. I might stop doing everything related to medicine for a year and then decide to take up some of the interesting professional things I’ve done in my life outside of clinical practice. So it was that gradual realisation of choice that made the difference to me.

CARMELLE PEISAH: I am University of New South Wales conjoint professor Carmelle Peisah. And I’m an old age psychiatrist.

It’s never too early to think about planning for the future. And it also I think offsets this anxiety and fear. So you’ve got to confront it. I’m doing some research with Associate Professor Chanaka Wijeratne, Joe Earl and Georgina Luscombe where we just looked at intention to retire. And what was so striking in this research was that about 11 per cent of doctors had no intention of retiring at all. And about 27 per cent were unsure.

I’m gobsmacked the thought that you’d think you’d never retire, or that you are uncertain that you are going to retire—you want to be carried out in a box? And in fact, I do think of an example of a distant relative who saw patients in the morning, had a headache, lay down and died in the afternoon, in their late eighties. And I think while that’s lovely for them and I think that’s probably a lovely way to go, what concerns me is that many doctors see medicine as a right. I think medicine is a privilege.

ZACHA ROSEN: Chanaka Wijeratne.

CHANAKA WIJERATNE: My name is Chanaka Wijeratne, psychiatrist at Prince of Wales Hospital and Conjoint Associate Professor at University of Notre Dame Australia. I’ve a special interest in the health of older doctors.

ZACHA ROSEN: If you had a colleague who was say, 58, and they were thinking about retirement and they came to you for advice. What advice would you give them?

CHANAKA WIJERATNE: I’d congratulate them on thinking about it, because they’re well ahead of most of their colleagues. That’s the first thing I would say. And the second point is that it’s never too early to start retiring. Some of this sounds simplistic, but it’s amazing how infrequently doctors think about it.

A couple of things that came out from the study were that doctors were more likely to retire if they had adequate financial resources—which seems obvious and of course makes sense. And certainly I’ve seen a number of doctors where they’re still working because there might be a mortgage on their home, on their practice, they might be a supporting a second family, they might be supporting grandkids’ school fees. That’s not uncommon. They might have lost money in the global financial crisis.

Having a good financial plan really is important. I’ve come across so many doctors who might have lost money in a poor investment or just haven’t got a good grasp of their finances. I saw a doctor the other day who had no idea of what his mortgage or tax bill was. So I think it’s important that everyone has knowledge of that. And has some financial planning with either a planner or an accountant.

ZACHA ROSEN: Carmelle Peisah.

CARMELLE PEISAH: Finances are a big thing in determining retirement timing, and indeed post retirement satisfaction across the board of all human beings. So if we look at some of the research, Joe Earl—who’s one of the co-authors in our research—has done, finance is a big thing. But for doctors yes.

ZACHA ROSEN: As well as finance, retirement needs to be approached by taking stock of all of your reserves.

CARMELLE PEISAH: In my recent publication for Australasian Psychiatry, although it was ostensibly focused on psychiatry, I think the general principles apply—and that for each individual, retirement and ageing needs to be confronted on the basis of what reserves you have—i.e. biological reserves, psychological reserves, social reserves. And indeed all the burdens you have: biological burdens, psychological burdens and social burdens, matched with the tasks, the demands of the job.

And for each person that’s individual. And so if you take stock of yourself using the kind of questions that I talked about in Australasian Psychiatry: Is it time for me? Have I achieved enough? Is pain bothering me? Have I got sensory problems? Have I got physical problems? Are my family needing me? Am I doing all the things I want to do? It’s a whole bunch of questions that you can do for self-reflection.

If you retire by taking stock of those issues, and at a time that suits you based on honest reflection of those questions—I mean self-insight—that’s a good retirement.

ZACHA ROSEN: It’s important not to let retirement take you by surprise.

CARMELLE PEISAH: In the later 1990s I was approached by the then New South Wales Medical Board Impairment Committee to start doing assessments of impaired doctors. And I became what was then called an independent board-nominated practitioner assessing both students and doctors.

I found it really distressing—I’d see doctors, particularly ageing doctors, who came to see me and needed assessment. And I’d be feeding back to them that they were impaired, that they were facing some issues of ageing, sometimes cognitive impairment, issues related to retirement. And they’d sort of look shocked or they’d be more often in denial. And there was a real sense of the rug being pulled from underneath them.

My distress at seeing the distress on these doctors faces when they were shocked to say, “Look, it’s time to give up.” And the grief having to confront it in that way, when it’s a shock, rather than dealing with it and addressing it early. This is the whole thing about planning, in the sense that the rug could be pulled out from underneath you at any time. And that can be not only in regards to your own illness, but illness of your spouse or your family member.

Joel Sadavoy, an old age psychiatrist from Canada, wrote about this mantle—this intrinsically entwined identity of being a doctor—that’s wrapped around us. And I always talk about that in papers because I can feel it myself. I can feel it wrapped around my nerves and my veins and my arteries—this mantle, this identity, of being a doctor.

ZACHA ROSEN: This sounds like it’s one of the biggest things.

CARMELLE PEISAH: It is. It’s really hard to give up. Certainly in the eighties, when I was in undergraduate medical school, the expectation was that medicine should and is going to be your whole life and studying should be all your life.

I actually like to say to students, I make a lot of jokes about watching crappy television about shopping to sort of model the fact that medicine isn’t everything.

ZACHA ROSEN: In fact, this work centrality can be a problem.

CHANAKA WIJERATNE: One of the other findings from our study was that work centrality reduced the odds of retiring. The primacy of your work over other aspects of your life. So leisure time, family time and so on. And the other side of the coin is the sense of strong self-identification with medicine. The other thing I found is that a lot of doctors just have not developed other interests. Really, work has been their whole life.

ZACHA ROSEN: It’s not only this mantle which is hard to let go of. While doctors need to stay healthy enough to practice, they are still allowed to age.

CARMELLE PEISAH: How is it that doctors who feel that they’re ageing feel that they’re not successful? How is it doctors only perceive themselves as successful if they’re super doctors—that they can see for a kilometre and hear through walls?

ZACHA ROSEN: Can you still be a good doctor and have, say, hearing problems?

CARMELLE PEISAH: Of course you can—as long as you know you’ve got hearing problems, and you go and get your ears tested and you put in a hearing aid. We seem to think that you have to be completely pristine in regards to mental and physical illness with not a glimpse of sensory change or a glimpse of fatigue—still handle on-call perfectly, still deal with our families. All the problems that we face and our vessels have to have no plaques and that our blood pressure has to be pristine. And that we have to make no adaptations and that’s what’s success is.

That’s just nonsense.

ZACHA ROSEN: This is one of two important things that a doctor should be aware of about ageing. The signs of ageing aren’t necessarily prohibitive from continuing to practice. But the accumulated experience of age doesn’t necessarily lead to improved outcomes either.

CHANAKA WIJERATNE: We know that and this is data from a meta-analysis so it’s actually a review of, I think something over 60 studies. And what this showed was that, the majority of the study is, about three quarters suggested that there was an inverse relationship between patient outcomes and the age of the doctor or the experience of the doctor.

So what that means is that the older you are or the more experience you have, the poorer the patient outcomes tend to be. And that’s been shown for both surgical and medical outcomes. And of course the question is, “But why is that so? And is that knowledge and accumulated experience over many years, is that sufficient to overcome some of the other age related changes?”

It may have something to do with knowledge. So we know that again if you look at older doctors, that their knowledge of medical information that’s static is as good as a younger doctors. And by static I mean the sort of information that was pertinent when that doctor was a junior medical officer or trainee specialist. But again if you look at older doctors, their knowledge of new information is not as good as that of younger doctors.

ZACHA ROSEN: So this is a consideration to keep in mind. But there is no mandatory retirement age for doctors.

CHANAKA WIJERATNE: Australians are generally eligible for an old age pension at the age of 65. And my view is always been that that’s probably a little bit too young for doctors to retire, because at that age they still have a lot to give to the profession, as they were.

In our current climate there are obviously shortages in the medical workforce which older doctors are able to fill. We know that younger doctors, junior doctors, very much respect older doctors for their wisdom, experience and knowledge. So older doctors provide a lot for not only the community but for the profession. And at 65, we’re talking about people with good brains.

Ageing in the medical context I guess is somewhat different to what we might see it in the usual context. So there are probably three broad areas of ageing to look at: physical, psychological and cognitive. So if you take the physical, we know that doctors essentially have a better health than the rest of the community. Although we’re obviously not immune from any physical impairment.

Secondly if you take the psychological factors, there was data from the Beyond Blue National Mental Health Survey of Doctors and Medical Students and this showed that the rates of psychological distress are actually lowest in doctors aged over 60.

The third aspect of ageing is cognitive ageing. And again it’s a little bit like physical ageing. But being a doctor your risk of developing dementia is actually about 50 per cent lower than the rest of the population. But that doesn’t mean that doctors would be free of any cognitive changes.

There are a number of suggestions that have been made in the literature. And I guess it kind of recognises some of those other difficulties I mentioned earlier. You know, physical, cognitive challenges that we all inevitably will face with ageing. And this can be quite simple things like doctors opting out of on-call work, so you’re not kept up through the night. Clearly, the better you sleep the better your cognition would be during the working day.

ZACHA ROSEN: And while doctors need to look after themselves at work they also need to be careful about their own health away from work.

Former Director of Medicine at the Prince of Wales Hospital, John Dwyer.

JOHN DWYER: I know so many people whose retirement was a disaster for them—literally seeing them die early, I think because they simply weren’t occupying their brain and their body appropriately and were feeling they had nothing to do or nothing to offer.

ZACHA ROSEN: Jill Sewell.

JILL SEWELL: When I first came to work here at the Children’s Hospital, there were a number of very senior paediatricians and paediatric surgeons who were wonderful people, who’d really set up the specialty of paediatrics in Melbourne and had worked very long and very hard to develop the speciality and to develop the Royal Children’s Hospital in the early days. And I saw them as they started to retire, and several of them retired and in what seemed to be weeks or months had their heart attack or their whatever and died. And I was really shocked by that. And subsequently, the people that I’ve seen retire—that hasn’t happened very often. I think there was a run of them when I was still quite a young paediatrician. And I can remember thinking then, “That’s not going to happen to me.”

ZACHA ROSEN: Chanaka Wijeratne.

CHANAKA WIJERATNE: Physical health in turn translates into cognitive health and psychological health, because chronic physical disease like diabetes mellitus, hypertension, dyslipidaemia and so on—they’re all risk factors for both cognitive impairment, especially in terms of vascular risk factors and vascular cognitive impairment, but also for depression.

We know from good robust research that only about roughly half of doctors have a GP, would you believe. Even when you have a GP, it’s important that it’s someone who is independent. So the GP or specialist that you’re consulting, shouldn’t be someone that you’ve gone through medical school or that you train with or who’s a mate.

ZACHA ROSEN: Carmelle Peisah.

CARMELLE PEISAH: The position statements of all the colleges are very much insistent upon getting your own GP, avoiding corridor consultations—you know, “My buddy,” “I’ve got this friend and they’re depressed,” that kind of stuff. We’re increasingly making statements that that’s not to happen, and ensuring that there’s regular review to ensure that you have your screening done. So your cardiovascular screening, your breast screening and all the other things that happen as part of good healthy lifestyle.

ZACHA ROSEN: And while it can worry some doctors that their cognition might not be able to keep up without being a doctor, others are worried about what happens to their cognition without it. There is the worry that life outside of medicine simply might not be as engaging.

CARMELLE PEISAH: In some of my research and particularly interviewing some older doctors, they often justify practicing perhaps into their 90s or late 80s by saying that patients kept them stimulated or kept them busy and active. And I find that distressing because I don’t see patients as crossword puzzles.

I think we owe it to our patients to recognise our own limitations and our lack of omnipotence that we will get old just like them. That we will indeed suffer from some of the similar vicissitudes of ageing that our patients suffer from. And that really, we can’t go on forever, although we spent many, many years training to become doctors, refining our skills, trying to get better and better.

ZACHA ROSEN: So how do you move on to something that challenges you as much as that?

CHANAKA WIJERATNE: Exactly, exactly. And that’s the $64,000 question. Is going to the “university of third age,” is that going to cut it in place of medicine? Perhaps it does for some people, perhaps it doesn’t for others.

We talk about “encore careers.” So, encore careers are careers which are different to your primary career. But where you’re still paid, and you get some satisfaction from, and which you can use the skills you’ve learnt in your primary career. I know of a colleague who has become a life coach. And he actually specialises in helping older doctors adapting to ageing and transitioning to retirement: How do you know when is the right time to retire? How do you know when you should be starting to transition down to retirement?

What a lot of doctors tell me is that they will depend on their family or colleagues to tell them when the time is right to retire.

ZACHA ROSEN: Is this the old idea of the tap on the shoulder?

CHANAKA WIJERATNE: Yeah and I think that’s a difficult area, because I think by and large your colleagues will not tell you that—unless there’s a very obvious sign of impairment in yourself or there’s been a very poor clinical outcome. So I think it’d be unusual to have that tap on the shoulder.

ZACHA ROSEN: So if you’re waiting for the tap on the shoulder, you might be waiting for a very long time.

CHANAKA WIJERATNE: Yeah, yeah to the point where you kind of overstay your welcome. That’s probably not the best way to determine the timing of your retirement.

And the ongoing maintenance of your physical health is important and just having a very concrete plan where you would nominate a retirement age. And that may vary with personal circumstances, such as when children might finish university education—or a lot of people follow their spouse into retirement.

But I think have a concrete period or date in mind and work towards that. Work backwards as it were. So have a time at which you decide to cut down from full time hours to part time hours, where you might take on some more teaching, some tutoring of medical students and so on.

Look, the few people I’ve spoken to I think are surprised by how well they’ve adjusted to retirement. I’m obviously not there yet so I don’t know what a good retirement looks like. But my sense is that as much as we all fear it that when we get there, I think we’d all be pleasantly surprised that the extra time of smelling the roses really is pleasant.

CARMELLE PEISAH: A good retirement is a retirement tailored to that specific doctor. So what is a good retirement for a 60-year-old whose wife suddenly had a stroke is going to be different from a 90-year-old who’s cognitively extremely with it, still providing great contributions, perhaps in a different area than they previously did. Different again from a 50-year- old who themselves had suddenly to have a bypass and having to slow down as a result of that. I think a retirement is a retirement tailor-made. I’m very against mandatory retirement. But that requires us being responsible and realising what are our individual needs.

ZACHA ROSEN: And those needs really do vary from doctor to doctor. To be clear, there is no mandatory retirement age for doctors. But even so, John Dwyer thought about when he wanted to retire well in advance.

JOHN DWYER: Well my name is John Dwyer. I’m Emeritus Professor of Medicine these days, still affiliated with the University of New South Wales. And I retired from my position of Head of the School of Medicine of the Prince of Wales Hospital for the University and Director of Medicine at the Prince of Wales Hospital 11 years ago now. And enjoying that retirement.

ZACHA ROSEN: John not only had plans to retire, but he told the people around him those plans well in advance—his work and his family.

JOHN DWYER: I told both the area health service and the university 18 months before my retirement that I was going to take that step. I think that the family are all very interested in this—and of course, your wife in particular. The subject came up over a number of years as to when I might retire. So we talked about it a lot, but there was a general agreement certainly between my wife and myself that I should retire.

It was 2006 that I retired. I had recently turned 65 and I had told my staff for many years that I wanted them to retire at 65 to make way for new young talent to come through. So I felt I had to live up to the standard I’d set and retire.

But I was actually ready to retire at 65. I can remember it vividly. I mean there were the usual rounds of last minute farewells and slaps on the back and a few drinks here and there. But I can remember being excited and scared at the same time. Many times, the thought went through my head of whether I was making a mistake. I was still physically well and involved in a heck of a lot of things. But I soon realised that I’d made the right decision.

ZACHA ROSEN: Do you remember how you felt the day after you retired when you woke up the next morning?

JOHN DWYER: Yes, I did really know that I was retired. And it was a very nice feeling to think that I didn’t have to be at A or B at eleven o’clock or seven o’clock. But those first few days after retirement are very strange.

I’ve always had two passions besides medicine. One was classical music, collecting music, listening to music. And of course since I’ve retired I’ve had the chance to do more of that. I was always also a very keen tennis player and I’ve played a lot of tennis over the years and really enjoyed it. Tennis has been a big part of my life. Thank God I’ve been well enough to continue to play tennis a couple of times a week. So I carried those over into retirement only more so.

And then after I retired I was able with some colleagues to set up the Friends of Science in Medicine, which is now a twelve hundred strong group of scientists and clinicians championing the need for evidence-based medicine. Probably professionally, my time now in retirement is mostly consumed with the Friends of Science and Medicine. I couldn’t have begun to spend the amount of time I’m spending now on consumer protection and healthcare reform when I was actually working.

You know, you realise things like—I probably spend more quality time with my grandchildren than I did with my own children when they were five and six and seven, because I was so busy at that stage of my career. Talking to people that have retired, they all pretty much say the same thing. Then there’s the never-ending barrage of emails; there will be 20 emails that I didn’t have at the time that we started this interview—and of course I don’t necessarily have to reply to all of them this afternoon, but it is a balancing act. And come five o’clock I’ll be sitting down having a glass of wine with my wife. And she’ll be wanting to know all about this interview and how it went!

It takes a bit of getting used to. It’s probably one of the great transitions in life. Retirement is an equally important phase of your life, as was your professional career. It’s a transition, it gives you all sorts of opportunities. If there’s one message that I could give to people it’s to think of retirement as a very positive phase in your life, where you’re actually able to indulge yourself more—but at the same time be a useful citizen and continue to try and make this a better place that we all live in.

MIC CAVAZZINI: That was John Dwyer ending this episode of Pomegranate. Thanks also to Jill Sewell, Carmelle Peisah and Chanaka Wijeratne for their contribution. The views expressed are their own, and may not represent those of the Royal Australasian College of Physicians.

This episode of Pomegranate was produced by Zacha Rosen. For literature mentioned in the podcast, or to claim CPD credits for listening, visit the website at racp.edu.au/pomcast.

The College is developing further resources to support members who are considering retirement, so send us an email if you’d like to provide your input. The address is pomcast@racp.edu.au, and please share the story around using the hashtag #RACPpod.

I’m Mic Cavazzini, and I hope you can join us next time, with a story from the emergency room on how to manage distressed autistic children.