Part 1: Deciding to Retire
In this three part series, Paul Valenstein, MD, FCAP, shares what he has learned on the other side of the microscope as a retired pathologist.
Sometime after I turned 60, I started thinking about when I should step aside from the practice of medicine and my leadership roles, and let others take my place.
Stepping aside doesn’t come naturally to men of my generation -- the baby boomers. Most of us who lead clinical practices or departments or organizations choose to hang on. Sometimes we hang on so long our situation becomes pathetic, but mostly we soldier on as weary caretakers instead of the change agents our tumultuous times require.
Why do we do this?
I imagine there are many reasons. We like the buzz that comes from being in the center of the hive. We are reluctant to confront the possibility that we have lost some of our energy or edge. We tell ourselves our younger colleagues aren’t ready yet -- they lack our wisdom and perspective. For many leadership junkies who have stayed with the same organization for many years, our network of friends is embedded within the practices and organizational units we help lead; we fear that stepping aside will result in social isolation, loss of respect, and an uncertain self-identity.
These concerns are powerful and not without basis. For me, the decision to retire was one I approached with ambivalence. I liked my work, at least most of the time. My roles gave me meaning and purpose. If I retired, would I be happy or bored? Fulfilled or unmoored? I could list a number of benefits to retiring, but also risks that were not to be trivialized.
My wife retired three months after me, but when I first started thinking about retirement she was an active professor of psychiatry at the University of Michigan, juggling a portfolio of research grants. My wife owned hundreds of psychiatry books that spilled over haphazardly from bookshelves located throughout our house. It was not difficult for me to locate several books with lengthy discussions about ambivalence, particularly within textbooks about a technique called "motivational interviewing." I read several avidly.
Rather than dismiss my concerns about retirement, I decided to give them the full weight they deserved, while also acknowledging retirement’s many benefits. I imagined I was both a therapist and a patient, interviewing myself about the possibility of retiring. My goal as a therapist was to help me (the patient) discuss my ambivalence thoughtfully and respectfully. The outcome of my treatment program with myself would be a new level of comfort with the decision I was facing and all of its implications. If it seemed as if retirement was right for me at this point in my life, I wanted to be sufficiently motivated to do it well. If, on balance, now was not the right time to retire, I wanted to understand why, to know when I should reconsider the question, and whether there was any preparatory work I ought to undertake.
When I worked as a pathologist, looking at tissue biopsies under the microscope, I used a variety of lenses to examine each specimen. The different lenses provided different levels of magnification, and each lens revealed part of what was going on in the biopsy. I decided to examine my thoughts about retirement using a set of psychological lenses, each designed to explore a different aspect of my decision. Readers contemplating retirement might examine their own thoughts and circumstances using these same lenses.
Friends and Social Life
This was clearly my biggest concern about retirement. What would my social life be after I left work? Work afforded me easy, regular, predictable access to friends. I had developed friendships with many of the people in my pathology practice, in the hospital laboratory, and among other leaders in my multispecialty group. How easy would it be to arrange meetings with friends after retirement, or to make new friends? The stereotype about all pathologists being introverts is an exaggeration, but not entirely without basis. Would I be willing to reach out, or would I end up trapped at home, lying on my sofa in a darkened living room, rewatching old movies, all alone?
I asked several retired professionals in my neighborhood whether maintaining contact with friends was a problem for them. None said that it was. Several said they thought it was easier after retiring to get together with friends, because time was less precious. But retired neighbors indicated that maintaining contact with friends who were still working was sometimes difficult.
Identity and Purpose
My work provided me with a sense of unity and meaning. When asked to describe myself, I, like many men, tended to talk about what I “did,” and, in particular, what I “did for a living.” My second biggest concern about retiring was that I would experience a loss of identity and diminished sense of purpose.
I am acquainted with the work of Dan McAdams and colleagues, who have developed a concept called “narrative identity.” Narrative identity is an internalized story we create about ourselves -- a personal myth about who we are, where we come from, how we got this way, and what it all means.
I wondered how my personal narrative might change after retirement -- would it continue to provide me with a satisfactory self-identify and sense of purpose? How would I answer the question “Tell me about yourself” after retirement?
Being “responsible” is an important theme in my personal narrative. Rightly or wrongly, I believe myself to be reasonably reliable, capable, and trustworthy. Retiring in an orderly way and at an appropriate time was part of being responsible.
If I stepped away from my paid jobs now, I wondered whether others would be ready to assume my leadership roles. Was it responsible to retire before equally capable successors had been identified and trained?
On the other hand, I was not sure that hanging on did right by the next generation. There are so many baby boomers in leadership roles that the next generation can’t fill all the roles at once. If everyone in my shoes waits too long and then walks away from all their jobs, the 40- and 50-year-olds will be overwhelmed. By stepping aside now, I could spend time as a mentor for new leaders and support them on the job.
Being paid for work provided me with external assurance that my efforts were valued. If an organization chose to pay me to work I believed that organization must find my work worthy, at least to the extent that the company was going to wind up with less money to hire other people or pursue some other aim once it had paid me. After retirement, any work I did would be unpaid, and as a result it might not be clear to me whether my work was important to recipients. I viewed this loss of feedback as a “con” to retirement.
I reminded myself, however, that the sort of market-based validation I enjoyed in my paid job was absent from all the volunteer work I did, and was also absent from my personal relationships (my marriage being a particularly noteworthy example). I was not paid to put work into my marriage, but still found the work intrinsically worthwhile. If I retired, I would need to seek other signals that my efforts were appreciated.
I often found it difficult to be fully “engaged” -- attentive to the moment -- because I had so many administrative responsibilities that involved advanced planning. I took a mindfulness-based stress reduction (MBSR) class several years before I retired, and learned to meditate. The MBSR class helped me become aware of when my mind was in “planning” mode rather than “in the moment” (a great deal of the day, as it turned out) and when I had what some call “monkey mind” -- scattered, unrelated thoughts that popped into my head in no particular order. Yet, sometimes, when I was working, I enjoyed what the psychologist Mihály Csíkszentmihályi calls “flow” -- being completely immersed in my work. I suspected I would spend more of my day fully “present” and engaged if I were retired. But I was not sure.
Time with Family
As far as time with family went, retirement seemed to be all “pro” and no “con.”
My parents were in their 90s, and lived down the street. I believed retirement would give me more time to spend with my parents while they were still alive. I have two daughters who were both married and of childbearing age. Retirement would allow me to spend time with grandchildren, should they arrive. And retirement would certainly allow me to spend more time with my wife, helping her live a fulfilled life, especially if she retired around the same time as me.
I thought carefully about whether I had enough money to retire, but tried not to overthink my finances because there were bound to be significant unknowns I could not anticipate. I had confidence in my ability to develop a financial model and didn’t use a professional planner (but suspect most readers would be wise to do so). Instead, I made a number of conservative assumptions – including a 30% downturn in the stock market -- and then ran the numbers to see if my wife’s and my savings, supplemented with social security, were sufficient to carry us through a reasonably long life. They seemed to be.
I wasn't bothered by the fact that my assumptions could be wrong. My model was reasonably cautious, and the only way to be absolutely sure one has enough money for retirement is never to retire. The practice of medicine taught me that the pursuit of certainty comes at a steep price. If events didn’t go according to plan, I felt my wife and I could adjust.
Missing the Buzz
I have a friend who ran a large organization. After he retired, he found himself missing the “buzz” of work, and this caused him considerable distress for several years. He enjoyed being one of the first to know about a new development, and liked being involved in initiatives the public would only learn about months later. I acknowledged that for myself, having early access to privileged information was also an occasional rush -- I liked receiving special briefings from the College of American Pathologists’ advocacy office in Washington about legislative developments that might affect pathology practices. Others wanted to know about these developments, and my access to “inside” information increased my social cachet. Yet the flip side of enjoying early access to information is fear of missing out -- of not being one of the first to know. How much better, I thought, if I didn’t have to worry at all about when I learned something. I suspected I would remain an interesting person even if I didn’t possess the latest news. The “buzz” can be a big distraction.
Loss of Status
I didn’t spend much time worrying about loss of stature after retirement, although I recognize some do. When I was younger, status and respect were more important to me, but over the years I have come to see respect as something awarded (or withheld) by others and not under my control. Nowadays, I try to concentrate on the quality of my own thoughts and behaviors, and not worry about whether I am respected.
Many professionals worry they will have nothing to do when they retire. I didn’t. For me, the world has always offered more possibilities than time to explore them. There are more good books to read than I will ever have time to read; more lectures to attend than I could ever attend; more movies to see, clubs to join, places to travel, people to meet, volunteer activities, etc. It helped that I lived in a college town full of interesting things to do and people from whom I could learn.
In my experience, when somebody says he is worried about being bored he isn’t really worried about having nothing to do. He is worried about not engaging with the world around him. Boredom is a problem of motivation, not opportunity.
The medical community uses the term “burnout” for a form of work-induced depression related to chronic stress. Burnout is characterized by emotional exhaustion, depersonalization (disengagement from people and surroundings), and a diminished sense of accomplishment.
Many jobs are stressful, but medical practitioners have double the prevalence of burnout as the general working public (about 55% vs 25%, respectively). The reason for the increased prevalence of burnout in medical providers is not well understood. Clinical practice is a high-stakes endeavor and probably involves more stress than typical employment. Also, the long hours worked by most practitioners afford less time to recover from work-related stress before returning to work. Burnout is as common among young physicians as elderly practitioners; it does not seem to result from the diminished capacity that accompanies aging.
For me, personally, burnout was not an issue. I mostly liked my work. Occasionally, on individual days, I felt overwhelmed, but I have been fortunate to be able to titrate my workload to keep it manageable. Over the years I have cultivated a number of self-care habits that kept me, like Shakespeare's Beatrice, “on the windy side of care.” I probably also benefited from the fact that physicians in medical specialties that are not patient-facing, such as pathology, have a slightly lower prevalence of burnout than the average physician (about 5-10% lower).
Burnout should not, in my opinion, be a cause for retirement. Better to reduce one’s workload, restructure the nature of one's work by delegating some tasks to others, or find a new job that offers a more balanced work environment. Unfortunately, this is not always possible; employers are only beginning to confront the problem. For a practitioner experiencing burnout who is in a financial position to retire, it is often easier to throw in the towel than to find a new job or reinvent the job she holds.
Some aging physicians find themselves physically too tired to keep up, even though they are not psychologically burned out. I know a physician with rheumatoid arthritis who was not depressed and was clinically quite capable, but who found that her disease required her to get more rest than her job allowed. She retired.
Many physicians have reported to me that they decided to retire rather than learn to use a new electronic health record (EHR) system that their practice was installing. I suspect this phenomenon is more widespread than generally appreciated. In all cases, the arrival of the new EHR was the final weight that tipped the scales, not the only reason for retirement. Aging may have made these physicians less able to adapt to changing technology, but mostly the new EHR was seen as requiring the physician to perform more low-value tasks that were not gratifying or consistent with what the practitioner considered to be “physician work” (such as talking with patients about their health). Regardless of the cause, it seems unfortunate that an electronic tool with the potential to make work easier was instead doing the exact opposite -- driving out highly trained and capable providers who might otherwise have continued to practice.
Loss of Clinical Abilities
As medical practitioners grow older, we periodically ask ourselves whether we are losing our clinical skill. Since I was contemplating retirement at a fairly young age -- in my early 60s -- a critical loss of abilities didn’t concern me. Nevertheless, we have an obligation to our patients to be reasonably capable. As every physician knows, we can’t trust the “system” to tell us when we are no longer fit to practice. And we have all sorts of psychological incentives to convince ourselves we remain capable. Practice partners can sometimes identify when we are slipping, because they have an opportunity to observe our work at close quarters. But it is difficult even for colleagues to know when we have crossed the line, and it is painful for partners to share their concerns with us. In my own case, I felt that some of my abilities (such as judgement) were continuing to improve as I aged, while others (such as an ability to maintain sustained focus) were clearly diminishing.
Making the Decision to Retire
After reflection and discussion with my wife, I decided to retire. My circumstances didn’t point overwhelmingly in favor of retirement; retirement simply won out on balance. I set a date 18 months in the future, to give myself, my colleagues, and the organizations with which I worked a chance to adjust.
It is easy to postpone thinking about retirement. The irony is that the act of retiring -- even thinking about retirement -- takes work.
One of the factors that motivated me to make a decision, rather than put the decision off, was not wanting to become one of the people I have seen who waited too long. In my world, the physician who has lost his clinical skills is the most salient example of the person who waited too long, but there are others. The weary leader who is all caretaker and no longer a catalyst for change is another archetype I didn’t want to become. I felt the seeds of complacency beginning to sprout within me, even if they had yet to grow roots.
I have also seen some aging leaders lurch in the opposite direction -- becoming impatient and agitated, almost drastic. Perhaps sensing their tenure drawing to a close, these leaders seek to right all wrongs and pursue great (but often ill-conceived) ends on their final watch. A sense of desperation edges out concern for coworkers’ capacity for change or the time required to evolve an organization’s culture. These unsettled souls look like leaders on the surface, but are a nuisance at best and sometimes dangerous. When I saw such a person, I thought: you are overcompensating at others’ expense.
In addition to not wanting to become someone who waited too long to retire, I experienced what a colleague called “a sense of ending.” In my administrative life, I tended to work on projects with a 3-5 year duration. Two of my active projects happened to be drawing to a close at the same time. Either I would need to look for new projects and commit to working another 3-5 years, or be left with too little work to do.
Making a decision to retire was also made less difficult for me because I had developed an understanding about what retiring meant: Retirement, to me, meant not taking money in exchange for work, nothing more. That was how I defined “retirement” operationally. I still planned to do “work” after retirement -- to do some sort of disciplined activity for the benefit of others -- but I would work as a volunteer, and not be financially compensated.
There are millions of “jobs” in the United States, but only some of them pay money. Paying jobs come with a set of opportunities and responsibilities -- the opportunity to earn a living, advance a career, to harness parts (or all) of an organization to make some difference, and the responsibility to work certain hours, in specified locations, to follow reasonable direction, and to adhere to policies and other expectations appropriate for a paid employee or contractor. Non-paying jobs (such as volunteering, or being a husband or father) generally come with a different set of opportunities and responsibilities.
I conceptualized retirement as moving from paying jobs to non-paying jobs. I would be leaving paid work, but I would also be arriving at a new place -- a place in life where I had the time and energy and opportunity to do more unpaid work. I would be entering what some have called the “encore” period of my life.
Paul Valenstein, MD, FCAP, practiced pathology for 33 years before retiring. At the CAP, he served on many committees and councils, chaired the Council on Scientific Affairs, authored a book on Quality Management, and served on the Board of Governors and as the CAP Secretary/Treasurer. He held major administrative roles leading a group of more than 500 physicians and a consortium of more than 80 non-profit laboratories. He currently divides his time between Ann Arbor, MI and Berkeley, CA.