Keywords

Scenario

Dr. B. is a 59-year-old internist working full-time in a group practice. She was diagnosed with cancer for which she underwent surgery and has recently returned to her clinical practice. New teaching responsibilities for medical students and residents in addition to adjustment to a new electronic medical record system have increased her workload considerably. Her older husband, a retired teacher, is to undergo hip replacement in a few months and she has elderly parents she assists. Although she has an adult son, he and his young family live abroad and cannot help with family needs. She is overwhelmed; she is emotionally exhausted, stressed, and does not feel she can accomplish all at hand. She is seriously considering her options.

Dr. B. is not unlike many senior career women who have responsibilities for family members and multiple stressors in the workplace. Early retirement may be a viable option, but careful considerations of the ramifications of this decision and exploration of alternative strategies to address her work–life situation are imperative. Options she might consider include part-time work, re-balancing her clinical and educational responsibilities if possible in her group practice, and investigating temporary solutions such as whether she is eligible for family medical leave.

As Dr. B. contemplates her decision, she must consider a number of factors. Is she happy with her clinical practice? Does she enjoy patient care and the camaraderie of the group practice? Does she look forward to the prospect of working with young people entering the profession of medicine? Should she more seriously consider her health as a factor in her decision given her recent diagnosis of cancer? Would retirement allow her the ability to better care for her parents? Is she physically able to care for them or should she explore services available to them? What is her financial status: can she afford to retire? If she participates in a pension plan, does retirement earlier than planned or reduction in hours of work negatively impact her distribution? Does she have interests other than medicine? What type of lifestyle does she envision in her retirement years? Does she have the means to support it?

Retirement presents a transitional zone, a proverbial yin and yang, that is, the receptive and active principles seen in all forms of change. When do physicians retire? Why do some retire early and some delay retirement? What considerations might facilitate continuing to practice or choose retirement? Are there factors that influence female physicians differently than their male counterparts when deciding how and when to retire?

When Do Physicians Retire?

This is a question addressed in a systematic review of 65 English-language studies which were mostly cross-sectional in design, methodologically strong, and with results deemed credible [1]. Retirement was defined as “fully retired”; primary care and specialty physicians were included. Most studies originated in the United States with others based in Australia, Canada, Finland, Israel, the Netherlands, New Zealand, and the United Kingdom. The average age for expected and actual retirement of physicians reported was 60 years and 69 years, respectively; retirement occurred later than planned. Studies analyzed were published from 1976 to March, 2016; thus, the socioeconomic and healthcare delivery environment varied greatly over the span of these decades.

In a more recent survey of late-career physicians defined as age 50 years and older in primary care or various specialties conducted by Hanover Research on behalf of CompHealth, an American healthcare staffing company found that respondents intended to retire at an average age of 66 years [2]. In a study based on data from the American Medical Association (AMA) Physician Masterfile which included 77,987 physicians age 55–80 years and with retirement defined as leaving clinical practice, the median retirement age of all physicians who left clinical activity from 2010 to 2014 was 64.9 years [3]. Retirement age was similar across primary care specialties. Female primary care physicians had a median age at retirement that was about 1 year earlier than males (0.5 year for female family physicians and 1.3 years for female general internists). If retirement was defined as retirement from any type of professional medical activity, median retirement age across all primary care specialties occurred about 1 year later for both males and females. Thus, physicians tend to retire in their mid- to late-60s. To put this in perspective, the average retirement age of the general employed population in the United States is 63 years; thus, as of 2014, physicians tend to work longer than the average American.

Why Do Some Physicians Retire Earlier Than Expected?

This data was collated in the systematic review of physician retirement planning noted above. The list of reasons is unsurprisingly long given the span of years included in the report. Low job satisfaction, medical-legal issues, and health and financial concerns were common factors. Loss of autonomy, low morale, dissatisfaction with regulations, frustration with colleagues, feeling undervalued, and frank loss of interest in work were aspects of low job satisfaction notated. Excessive workloads and burnout were frequently cited reasons for early retirement, especially within the last decade. Lack of satisfaction with the regulation of medicine and bureaucracy and management viewed as oppressive gave rise to medical-legal issues. Poor health, cognitive decline, difficulty with sleeping, and psychological stress were other factors noted in more recent years. Some retired early to preserve health. Some viewed increasing costs of maintaining a practice including malpractice insurance fees and lower reimbursements as factors against continuing to practice; others had pension security.

In the CompHealth survey reported in 2017, doctors were not as satisfied with their careers as they had been; 59% of physicians noted their satisfaction had decreased since they began to practice. But they still had high overall career satisfaction: 82% were satisfied or completely satisfied with their careers. Concerns about staying competitive in the changing healthcare environment (38%), declining personal health (37%), providing quality patient care (26%), mastering technology (23%), and failing health of spouse/ partner were concerns about working past 65 years of age in this survey.

In a large national cohort survey of all United Kingdom-trained medical graduates of 1974 and of 1977, factors influencing the decision to retire or to continue to practice were collated [4]. The median age of the 1974 graduates was 64 years (men: 64 years; women: 63 years) and for the 1977 graduates 61 years (men: 61 years; women: 60 years). Forty-four percent of all respondents were retired (38% of men; 56% of women), 26% had retired but returned to practice (29% of men; 20% of women), and 29% continued to work in medicine (32% of men; 23% of women). For those retired, the reasons cited in decreasing order of importance were desire for more time for leisure or pursuit of other interests, increased pressure of practice (43%), retirement of spouse, family reasons, financial reasons (poor reimbursements, financial security), and on-call work. More men than women cited on-call work hours as a factor. Those retirees from the younger 1977 cohort were significantly more likely to retire due to pressure of work, reduced job satisfaction, or financial reasons, suggesting these factors are more relevant to earlier retirement. Of those retired, they did so earlier than planned due to changes in the work environment (14%) or due to personal circumstances (13.7%).

According to a recent large survey of pediatricians conducted by the American Academy of Pediatrics, 27% of those still working would retire if it were affordable [5]. Increased regulation in medicine, decreased clinical autonomy, and insufficient reimbursements were rated by >50%of respondents as the most important factors. For those pediatricians who had retired, nearly 27% rated the effort to keep up with clinical advances and changes in practice as important factors in deciding to retire.

Possible cognitive decline has become a factor receiving greater emphasis in recent years as a greater number of senior physicians continue to practice [6]. There has been an aging of the medical workforce with a 374% increase in the number of actively practicing physicians over the age of 65 years in the United States from 1975 to 2015. In 2015, 23% of practicing physicians were 65 years or older. For some professionals such as air pilots, air traffic controllers and firefighters, periodic testing is required or there is a mandatory retirement age. While there are not uniform requirements for physicians, some hospitals and institutions have introduced mandatory age-based assessments. Another assessment of competency is maintenance of certification requirements which have increasingly been implemented in the medical profession and have become another factor in early retirement considerations.

The situation of Dr. B. is not unusual. Common factors that favor an early retirement include personal health, family concerns, and the burden of practice including aspects of delivery of care. Data also confirms that retirement at age 59 years is earlier than average; her health and family concerns along with practice demands are well-recognized factors impacting this consideration.

Why Physicians Retire Later Than Planned

This is often due to career satisfaction, a desire to be active and focus on the social and stimulating intellectual aspects of the medical profession, a sense of responsibility to patients, ongoing financial obligations, and/or lack of interests outside of medicine [1]. In a survey of late-career physicians in the United States, age 50 years or older, the top three reasons for working beyond the age of 65 years were enjoyment of the practice of medicine, enjoyment of the social aspects of working and the desire to maintain current lifestyle [2]. Institutions can play a role in promoting physician satisfaction and practicing medicine for a longer period. Flexibility in work hours, emphasis on career development, and awareness of the value of some degree of personal autonomy over work are examples of ways the workplace can promote satisfaction and a longer period of time in practice [1].

Some cannot imagine life without medical practice. A loss of identity and/ or sense of purpose with retirement from a demanding profession for which years of training were required are not an uncommon concern of many; little time may have been taken to develop or maintain interests outside of medicine. In a small but highly detailed study of academic Canadian physicians, manifestations of threats to personal identity included apprehensions about self-esteem after retirement, a loss of a sense of belonging, concerns about clinical competency, and continuity of patient care [7].Women physicians and other professional women may have a more difficult time than men adjusting to retirement. They are more likely to have a sense of loss with retirement compared to a sense of relief shared by non-professional women workers. And while the latter are more likely to base retirement decisions on family issues and responsibilities, professional women are more likely to base the decision on pension eligibility and health concerns [8].

Thus, among potential reasons for later retirement are the following:

  • Career satisfaction

  • Sense of responsibility for patients

  • Lack of interests outside of medicine

  • Concerns about loss of identity with leaving professional practice

  • Lack of financial ability to maintain desired lifestyle or pension eligibility

Pattern of Retirement

This is an important consideration, not only for the physician but also for the institution or group in which he/she practices. It impacts patients too. Institutional flexibility has been noted to be a positive driver of retaining physicians and facilitating retirement planning [1]. There is benefit to the institution to know retirement plans and, thus, better meet appropriate staffing demands. In a population-based retrospective cohort study of all physicians over 50 years of age in British Columbia, Canada, four retirement patterns for physicians were identified by payment data analysis: slow decline in practice activity by 10% to <25%, rapid decline by 25% to 90%, maintenance of practice with little change in activity until full retirement, or an increase in practice activity by 10% or more until retirement [9]. About 40% reduced their practice activity by at least 10% in the 3 years preceding retirement. Women physicians retired earlier as did those practicing in rural areas. Research is needed on why women physicians retire earlier [10]. In a study of pattern of retirement of academic physicians age 65 years or older, four potential retirement trajectories were identified: abrupt, progressive reduction in practice activity, some reduction such as half-time followed by abrupt retirement, and continued activity until serious illness or death [11].

Physicians prefer gradual retirement. In a small but highly detailed study, 89.5% of physicians surveyed preferred to retire gradually [12]. Flexible and fewer work hours, part-time employment, job-sharing, and decreased time on-call are among the possible options of gradually cutting back on clinical practice [1, 12, 13]. Sharing care between an incoming new physician and a late-career physician wanting to reduce hours can afford a smooth transition for the physicians, greater patient satisfaction, and also ease the impact of retirement on other members of a group practice. These approaches can be viewed as ways of keeping physicians in the workforce and improving work satisfaction. In some specialties greater part-time work before full retirement was noted among women compared to men [14, 15].There are caveats with part-time work: compensation might not be comparable to full-time work if pay is considered on an hourly basis of compensation; an individual may actually put in full-time effort and hours, yet be compensated an a part-time basis; the characteristics of one’s clinical practice might be impacted, such as limiting type of patient to be evaluated or procedures performed; one might be perceived as less dedicated; opportunities to engage in special projects may be viewed by others as an inconvenience [16]. Additionally, the aim is to reduce hours of work and care needs to be taken that the same number of patients are not scheduled in a reduced time frame! Impact on pension plan is a key consideration. Contemplation of any reduction in number of hours worked at any time in one’s career must be coupled with careful review of the impact on future pension distributions. One guide for part-time employment has been developed by the American College of Physicians [17].

Another consideration is full retirement followed by continued professional clinical activity in a locum tenens position or, for some specialties, telemedicine. Medical consulting such as for law firms, pharmaceutical industry, medical device company, insurance companies, or other entities are among other options for those retirees who wish to continue to participate in medicine professionally but without clinical patient activity [18].

In summary, most physicians prefer gradual retirement which permits a growth into the next phase of life.

  • Reduction in work hours might be accomplished by flexible and fewer hours of work, job-sharing, or decreasing on-call demands.

  • Creative institutional flexibility in considering gradual retirement options can be a positive force.

  • Any reduction in hours of work must be preceded by careful review of the impact on current and future financial status including pension distributions.

  • Any contractual agreements between the physician and institution or group require careful review.

  • There are many options after retirement for continued participation in medicine professionally that do not include direct patient care.

For Dr. B. in the scenario, there is a sense of urgency as she contemplates her next step. She regrets that she has not spent time exploring these issues and strategically considering her late career options.

Planning

This is the key to successful retirement. The word “retire” connotes withdrawal, an exit, or departure, all rather negative descriptors. To this author “retread” is a more optimistic term to apply to this phase of life where freedom of personal and/or professional reinvention and continued growth can occur. There are what the author terms the Five F’s of Retirement Planning: Fitness, Family, Friends, and Fun, all of which cultivate a sense of personal well-being, and Finances. The goal should be transition “to” another phase in life not only “from” medicine. Ideally, retirement planning – so called “ exit strategies” – should receive as much enthusiastic attention as career planning and preferably early on in one’s career. It is better not to be like “the dog chasing the car,” that is, all in for the chase but not knowing what to do when it’s caught [19]. The success of this transition zone has a great deal to do with thoughtful, early planning and knowing one’s self. The plan should be adaptable to withstand unexpected situations such as some of those experienced by Dr. B. in the scenario, but flexible enough to permit ability to embrace new opportunities that might arise and offer further zest to life. This can be a time of reinvention: “I am the master of my fate/ I am the captain of my soul” [20].

A myriad of meaningful activities are possible after retirement that can include volunteer work inside or outside of medicine [21]. Many rewarding opportunities might be considered, such as mentoring, teaching, writing, donating time to free medical clinics locally or abroad, or speaking to the community about public health issues. Local medical societies, national and subspecialty medical associations, medical schools, and training programs as well as community non-medical volunteer networks such as the Corporation for National and Community Service (https://nationalservice.gov), family, and friends can all be resources to access. There is meaning in life after full-time clinical practice. Healthcare organizations and medical societies have an opportunity to educate late-career senior physicians about the possibilities.

Six significant practical insights about retirement were recently shared by survey technique of 1200 retired American physicians [22]. They underscore the need to take the time to truly consider options, to know one’s goals, wants, and needs. The first emphasis was the benefit of a gradual transition to retirement such that time could be taken to cultivate life outside of medicine, a so-called “growing into retirement” phase of 1–2 years, as has been outlined above. Defining and planning meaningful activities was stressed. Assessing goals before retirement and considering strategies to achieve them, taking care of one’s health, and making a commitment to enjoy retirement were other important insights shared by these retirees. The last two insights related to financial wellness: financial planning and priority spending. Financial planning with one’s spouse/ partner and a financial advisor was considered of utmost importance and, ideally, initiated early in one’s career. Re-assessment of wills, insurances, power of attorney, estate plan, and advanced directives should be done. The last insight shared by this group was the importance of prioritizing spending to live within one’s means. A clever way of thinking of finances over the years of retirement might be to consider three phases of this chapter: go go, go slow, no go!

The importance of early financial planning cannot be over emphasized as it can impact not only the timing of retirement but also the possibilities of what retirement will look like [23, 24]. Conversely, poor financial planning is a barrier to retirement [1, 12]. Planning for retirement should occur over one’s medical career [23,24,25,26,27]. Early considerations ideally include establishing a team of advisors including a financial expert, attorney, and accountant; obtaining life and disability insurances and considering insurance for long term care, too; and creating a will, developing advanced directives and establishing power of attorney. Mid-career actions might include paying off debts, maximizing retirement contributions, monitoring investments, re-assessing insurance needs, updating wills, and developing an estate plan. At age 50 years and older, updating financial goals, reviewing annual budgets especially expenses, and reviewing pension plans and other potential sources on income need to be the focus. Review of wills, advanced directives, and power of attorney should be done at every phase as with any major life transition such as having children. Insurance, especially health insurance, must be considered carefully, particularly if retirement occurs before the age of Medicare eligibility in the United States.

Barriers to retirement planning can include poor personal financial management including simply a lack of personal interest, rigid institutional policies that favor full retirement over gradual, and a professional culture that favors work over other aspects of life [1, 28]. Facilitators of physician retirement include financial planning resources offered to physicians at multiple times throughout their careers, opportunities for gradual transition toward retirement, and the introduction of the concept of career mentorship by supporting collaborations between younger and older physicians [12]. There is an opportunity for organizations to provide easily accessible support [29]. Areas of support could include retirement planning, basic income tax services, college planning for children, short- or long-term disability planning, or other areas of financial counseling such as life insurance, long-term care insurance, basic estate planning. But also organizations can provide support for professional issues such as burnout, time management, and work-life integration, as well as for personal issues such as those facing Dr. B. in the scenario above. Professional medical associations such as the American Medical Association, the American College of Physicians, and many specialty societies also offer guidance, resources, and support.

If a physician decides to retire, any contractual agreements must be carefully reviewed. Any employment contracts with a group should be assessed, especially with respect to advanced notification of retirement [27]. In a group practice, responsibility for patient records and patient transition would be assumed by the group. For those in private practice, state requirements for record storage, retention, and accessibility need to be reviewed and arrangements made for this as well as smooth transition of patients to other providers. Requirements of malpractice carriers and state medical licensure need to be reviewed thoroughly.

With her recent surgery for cancer, Dr. B. has reviewed her will and advanced directives, but she did not review her long-term financial plan including her group’s pension plan in which she has participated, details of her contractual arrangement with her group, nor her insurance policies. She regrets not having taken full advantage of financial counseling services offered by her group early on in her career; she let demands of the practice and of her family supersede time spent on long-term planning. Only now does she fully appreciate how important planning throughout her career should have been. Her inclination is to retire from full-time practice, but she is uncertain what impact early retirement will have on her future. Planning in advance for the expected and unexpected would have placed her in the “driver’s seat” instead of circumstances driving her.

In summary, a retirement plan should

  • Begin early in one’s career and be re-assessed throughout the span of a career

  • Be based on realistic goals with thoughtful strategies to achieve them

  • Be flexible enough to adapt to unexpected circumstances

  • Be developed by a team with expertise in finance, law, insurance, and accounting

  • Be financially sound with attention to a realistic budget

  • Be attentive to contractual arrangements with the workplace and to whether the employer supports late career transitions to retirement

  • Take advantage of any planning services offered by the employer

  • Embrace a healthy lifestyle and a commitment to enjoy this phase of life and late career

  • Be open to new opportunities

Healthcare institutions would be wise to offer comprehensive retirement planning that includes but is not limited to financial planning and is triggered at key times throughout the course of a physician’s career. Such programs could prevent sudden unexpected departures, decrease burnout, and increase fulfillment by tapping the wisdom of senior physicians. These early-, mid-, and late-career discussions either within one’s specialty department, HR, or other office geared toward support of the clinicians could include:

  • Assistance with financial planning, wills, advanced directives, and adequate insurance health and malpractice coverage

  • Surveys of “what is important to me” to clarify interests inside and outside of medicine

  • Strategies for gradually scaling back over time and increasing attention to other pursuits or family focused activities

  • Wellness coaching

  • Opportunities to be mentored by retired or late-career physicians

  • Opportunities for mentoring students, trainees, and early career physicians

  • Opportunities to refine and tailor one’s practice over time to take advantage of an individual’s expertise and interests

How physicians adjust to retirement

This has been the subject of a systematic review of peer-reviewed English-language literature published with quantitative and/or qualitative analysis [30]. Generally, retirement was viewed as positive. Financial security, good health, engagement in meaningful activities, and improvement in quality of time spent with family including spouse and relatives correlated with adjusting well to retirement. Having a plan enhanced adjustment. Poor health of a spouse had a negative impact and correlated with depression in the retiree; some retirees suffer depression with leaving active medical practice [31].

AMA Insurance has reported on the financial preparedness of retired physicians in the United States and retirement satisfaction [32]. The survey included 1202 physicians representing the broad spectrum of medical and surgical specialties; 13% were female and 85% of respondents were married. Twelve percent had retired at less than 60 years of age; 14% retired at age 75 years or greater. Eighty percent of respondents were either satisfied or very satisfied with retirement, while 9% were either dissatisfied or very dissatisfied with retirement. Eleven percent of respondents were neutral. Most retired physicians were leading full, active lives with over 80% spending time with friends and family, as well as leisure activities (76%) and travel (60%). A significant percent (41%) engaged in volunteer work, taught (16%), worked part-time (17%), consulted (15%), or started a new business (4%). No details were given about the amount of time devoted to past profession.

The top 5 factors that impacted satisfaction in this survey were age at retirement, financial knowledge and status, initiation of savings early in career, and use of a financial planner. Those who retired under age 60 years were more likely dissatisfied or very dissatisfied; those who retired between the ages of 60 and 65 years were most satisfied. Nearly 30% of those who retired before the age of 60 years viewed their financial status as behind where they would like to be. Seventy-one percent of the respondents who judged themselves financially savvy and understood their personal finances were more satisfied with retirement compared to those who rated themselves as not very knowledgeable. Nearly 3 out of 4 retired physicians worked with a professional financial advisor and they were more likely to be satisfied with their retirement than those who did not. Forty-seven percent of those who did not use a financial advisor preferred to handle their own finances.

Satisfaction in retirement also depends on being confident that financial fitness extends throughout retirement, and this confidence depends on a number of facets including at what age one retires, health, and longevity. Overall, in the AMA Insurance survey, respondents were confident that their retirement funds would last. Living within one’s means, wise investment decisions, generous savings, and having a financial advisor who shared that view bolstered confidence. Conversely, market volatility and less savings lowered confidence that retirement funds would last. Major health issues, unexpected costs that rapidly reduced savings, supporting other family members, or having spent too much early in retirement years reduced confidence.

Returning to Dr. B. in the scenario, if she had made retirement readiness a part of her overall career planning, she could deliberate more confidently on a broader range of options leading to a satisfying retirement – even at age 59 years. Greater satisfaction in retirement is more likely achieved if the following factors are considered:

  • Be enthusiastic about retirement planning and begin it early in the course of a career; be attentive, reassess, and adjust the plan over time.

  • Be knowledgeable about finances, work with a professional financial advisor, and save early.

  • Be aware of contractual arrangements and insurance coverages – including that for health.

  • Be open to opportunities along the course of a career trajectory; in particular, be aware of potential possibilities permitting a gradual retirement that do not impact pension distribution.

  • Be engaged in meaningful activities; know your interests and what gives you satisfaction.

  • Be healthy!

Gaps and Opportunities

The limited data currently available indicates that there is substantial overlap but also key differences between male and female physicians in terms of when and why they retire, the patterns of retirement, reasons for retirement, and how they adjust to retirement. As greater numbers of women approach retirement age, there is an opportunity and a need to investigate in detail all aspects of their retirement including planning and to develop more tools to support this phase of career and life. Among opportunities are the following:

  • Study ongoing demographic trends among male and female physicians including age at retirement, pattern of retirement, reasons for retirement, perceived key stressors that might have impacted time of retirement, and details of degree of financial planning undertaken and when it was initiated. Such data can inform future workforce needs and needs of female physicians in particular.

  • There is no data to the author’s knowledge of minority female physicians and aspects of their retirement.

  • Develop educational tools about retirement that are geared to female physicians.

  • Gather data about activities undertaken by female physicians in retirement, in particular volunteerism, care for family members or friends, and professional versus non-professional activities.

  • Assess satisfaction of retired female physicians and factors that positively or negatively impact it.