Retirement: A Primer for Plastic Surgeons

Some may remember an aging colleague who, we believed, stayed in practice far too long. We wondered whether their patients obtained optimal care in the twilight of their (surgeons’) careers. Imagine, also that, your Division wanted to hire a new recruit. This individual would introduce modern skills. Due to limited hospital resources, the aging surgeon would need to vacate their position for the new recruit. The timing of retirement for some surgeons has been impacted by the unemployment or underemployment of recent graduates in Canada. ¹

This editorial addresses the sensitive topic of retirement. It is usually discussed behind closed doors at the Heads of surgical services committee meetings.

Discussion on retirement should not be a sensitive topic; it affects us all, and we have a collective responsibility to address it. By being proactive, plastic surgeons can avoid the consequences of a haphazard transition (Box 1). I will tackle the topic using a two-pronged fashion. First, I will summarize what the literature and law say about retirement for surgeons. Second, I will share my experience with transitioning to retirement. Hopefully, you will take something from this editorial that will be of use to you.

What Does the Literature Say About Retirement?

Not all surgeons are alike; some cannot wait to retire, whereas others will continue to be productive beyond their 70s. Some continue to work past their prime due to the heightened sense of value experienced during active clinical practice, loss of identity, livelihood, and status.^2-4

There are no formal guidelines in medicine regarding when one should retire, and societal bodies currently have no restrictions on practicing age.^5-7 The College of Physicians and Surgeons of Ontario (CPSO) initiates a peer assessment process at the age of 70, and then every 5 years thereafter. ⁸ In 2019, nearly half of active physicians practicing in the United States were 55 years or older ⁹ and so the question arises, does age matter? More importantly, is there a risk for older plastic surgeons to continue working? Do older surgeons perform less well than their younger colleagues?

A recent review ¹⁰ listed the physiological changes that occur with aging (Table 1). Regardless of profession, pronounced decline is seen after the age of 65. Researchers have urged for reliable, long-term testing in cognition, and manual dexterity to help quantify deficits associated with increasing age. ¹¹ The introduction of MicroCog®, a self-administered questionnaire designed to measure mental skills (e.g. memory, attention, and reasoning), was commissioned by insurance carriers to measure the risk posed by the aging physician almost two decades ago.^12,13 Research using the MicroCog® found, that at all ages, physicians performed better than nonphysicians. ¹³ There was an overall decline in older physicians, working or retired, with retired physicians scoring lower than those working. ¹³ No correlations were found between MicroCog® scores performance, incompetency, or lack of skill. ¹³ Despite the potential usefulness of such tests, to my knowledge, these are not used to examine plastic surgeons’ neurocognitive competence.

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Table 1.

Physiological Effects of Aging on Surgeons. ¹⁰

Vision a

Physicality (movements become less integrated with cognitive thinking)

Deterioration of hand dexterity

Fatigue interferes with work

Increased effects of physical and psychological stress

Musculoskeletal complaints with long surgeries

Burnout

^a

Visual acuity, depth and motion perception, peripheral visual field and temporal sensitivity, and color discrimination, cataract formation.

In addition to the effects of aging, older surgeons may be less willing to adopt new techniques (e.g. robotic surgery, endoscopic techniques). ¹⁰ Do the physiological changes make older surgeons less proficient than younger surgeons? The evidence is inconclusive. Some studies show an increased risk of morbidity or mortality in procedures performed by surgeons between the ages of 60 and 80. ¹⁴ Others report lower rates of mortality and complications in older surgeons, ¹⁵ and others state that volume of surgeries performed, rather than age, is a better predictor of complication rates in older surgeons. ¹⁶

What Does the Law and Professional Organizations Say About Retirement?

There are numerous laws that prevent discrimination on the basis of age. The Canadian Medical Association's Code of Ethics ¹⁷ states that the practice of the art and science of medicine must be performed competently with integrity, and without impairment. Our practices as surgeons are also protected, in part, by the Canadian Human Rights Act, ¹⁸ the Canadian Charter of Rights and Freedoms ¹⁹ and provincially by different Human Rights Codes. On the other side of the coin, the Public Hospitals Act through its annual credentialling protects the public. ²⁰

How Should One Transition to Retirement?

As previously mentioned, the CPSO initiates a peer assessment process at age 70 ⁸ so those of you close to this age may keep this in mind. Those surgeons, who work in academic institutions, may find the University of Toronto Department of Surgery Guidelines for Late Career Transitions ²¹ helpful. This resource provides suggestions on how surgeons and their departments should approach the subject of transitioning to retirement and recommends ways to contribute (e.g. teaching and mentoring) after retirement. ²¹

Figure 1 ²² outlines the key challenges of retirement for surgeons. First, one should ensure that their finances are in order; there are unexpected events in life, and you need to make provisions for these. Employ a financial advisor and start planning from day 1 so you can retire comfortably (the Canadian Medical Association provides a pension plan for physicians). Second, the timing of retirement may be impacted by your health. Try to live a healthy life so that you are not forced to retire earlier than desired. Lastly, your psychological well-being, including relationships with yourself and your family, should be considered at the time of retirement. You will need the support of your friends and family throughout your practice and during your transition to retirement. In retirement, you may decide to maintain some connection to surgery (e.g. volunteer work, scientific writing) or take a more epicurean approach (e.g. pursue hobbies, traveling).

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Figure 1.

Challenges Faced by Retiring Surgeons. ²²

Personal Experience With Transitioning to Retirement

My transition to retirement started 3 years ago. In 2018, my Division allowed me, after 37 years in practice, to get off the on-call schedule. In return I was to give up, gradually, over a 3-year period, one-third of my hospital resources/year (i.e. operating room and clinic time) to a new recruit in our division. I was asked to mentor this new recruit until my retirement. As there was no office space for the new recruit at the time, I shared my office. This was beneficial to both of us, he learned a few tricks on how to manage an office and I acted as a sounding board for some difficult cases he encountered. My transition period to retirement has been enjoyable. With the extra free time I did things I really enjoy, such as writing, conducting research, and mentoring various types of learners (Table 2). On April 15, 2021 a CPSO assessor reviewed my practice as I reached the threshold age of 70 (mandated by the CPSO). I think the assessment went relatively well, however, as I was neither observed doing surgery nor took a neurocognitive test, I doubt very much the CPSO will really know how safe a surgeon I am!

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Table 2.

Activities During the Transition to Retirement.

42 Peer-reviewed publications

Publication of text book 23

Supervision of many residents and medical students in their research projects

Member of Master's and PhD committees

Reviewer for peer-reviewed surgery journals

In referring to Figure 1, here is how I dealt with the “Challenges of Retirement.” I am fine with my financial situation, I still feel healthy, I am stable psychologically (I think), I have improved my relationships with my family as I have more time for them, and I accomplished some writing and mentoring. The big question is can I go a bit further?