Is There Life After the Operating Room? Some Thoughts and Suggestions for Retirement.

"The one freedom that can never be taken away from us, that always remains, is the freedom to determine our attitude toward our circumstances." Viktor Frankl, "Man's Search for Meaning"

Even cardiothoracic surgeons, who are characteristically fearless in facing their patients' complex problems decisively, may sometimes find it hard to be equally resolute when confronting certain challenges in their personal lives. In particular, some surgeons are deeply apprehensive about the prospect of retirement, particularly as it involves making a transition to life outside the operating room.

Life in the operating room is, after all, a strange and unusual existence. The O.R. is a stage on which the surgeon performs in the spotlight, while exercising unquestioned authority, and marshalling the talents of many individuals who are dedicated to facilitating his (1) work. The O.R. is also a haven where the cares of the outside world don't intrude.

The transition from one phase of life to another is always smoother for those equipped in advance with relevant information and realistic expectations. We'll discuss below some of the underlying psychological reasons for the vague dread that often surrounds the word "retirement," and some practical measures for dealing with them. Though every surgeon's life and experiences are obviously different, and many surgeons and their spouses may feel that these problems do not affect them, it should be useful for everyone to understand some of these common psychological mechanisms, which often have unconscious effects. Each reader will hopefully find something useful for his own unique situation.

(1) The male gender is used intentionally. We write as a male surgeon and his wife, a psychologist. While we hope that female surgeons facing retirement may find many of the perspectives in this essay valid and useful, we acknowledge that we cannot speak to them with the expectation that these insights will be equally relevant. It is also true that female cardiothoracic surgeons have only become common recently, and few face imminent retirement.

THE CENTRALITY OF LOSS

It is crucial to recognize that every significant transition in life involves loss, or some kind of deprivation. Even though the meaning and extent of any intangible loss will differ for each person, and even if there is no tangible loss of person or property, major life transitions cause, at the very least, a loss of the status quo, the comfortable and familiar. So, in order to deal with feelings about the loss of a major part of one's life, it may be necessary to go through a process similar to grieving. This process should not come as a surprise, it may take time, and it should not lead to despair. Rather, for many it is a necessary phase before they can find contentment in a new phase of life. Just as "anticipatory grief" can be helpful in lessening the inevitable pain upon the death of a dear one who has been terminally ill, it is also useful in less dire circumstances. Retirement can arouse more disturbing emotions than other life transitions, because some of its losses are unique to that phase of life. To successfully adapt to this life change, it is essential to actively think about, to understand, and to prepare in advance for, the process of entry into a different everyday world.

Although no one is the same after retirement as before, it does matter why one is retiring. If difficult surgical procedures are no longer a challenge but have become tension-filled, tedious chores, if the hassles of malpractice and HMO's have become intolerable, if arguing with the Dean over his tax on the Cardiothoracic Surgery Department is no longer stimulating, but has become infuriating, then voluntary retirement will likely be a welcome change. But if involuntary retirement has been provoked by declining referrals, poor health, a new Dean, etc., one must first come to terms with those life issues. Otherwise, they will result in "misdirected anger" that perpetuates unhappiness and resentment. Those negative emotions will then be blamed on the presumed shortcomings of retirement, rather than on the conflicts that existed before retirement.

THE HUSBAND'S PROBLEMS:

1. Loss of Purpose: Surgeons are fortunate to have such purposeful work. Restoring patients to good health, teaching others, conducting research that adds to the sum total of human knowledge, and advancing the profession through local or national organizations, are all gratifying activities. After retirement, however, it may be difficult to find activities that are as gratifying and personally rewarding as surgery. This can easily lead to a revival of the youthful search for the meaning of life, with its associated emotional turmoil.

2. Loss of Status: When a surgeon retires, the spotlight turns elsewhere. The retired surgeon is no longer the center of attention in the hospital; he no longer has grateful patients, and the practice or department he developed is no longer under his direction. This inevitable loss of status can easily lead to a loss of self-esteem and to depression.

3. Loss of Routine: The driven surgeon is a justified stereotype, but in fact, mature surgeons with developed practices needn't be self directed or inwardly motivated. Few surgeons develop the "time management" skills of senior business executives, because surgeons are driven inexorably by the unavoidable routines of their practices. Patients and their problems continually confront surgeons, who cannot avoid the imposed orderliness and discipline of early rising, daily rounds, surgery, office appointments, correspondence, etc. Suddenly, in retirement, there are no externally imposed routines and obligations, and it can be challenging to fill 24 hours of the day. Without routines, it is easy to become slothful and indolent, and to succumb to a debilitating ennui due to a loss of motivation. Even those surgeons who have enjoyed golf, tennis, fishing, and similar recreations as brief respites from the cares of arduous but productive work, may find it entirely different to substitute them for the gratifications of being a surgeon.

4. Loss of "Busyness": The overly busy surgeon with no free time has often been able to avoid consideration of the nonprofessional problems in his life. ("Don't bother me about such relative trivia as the leaking roof, I'm about to start a redo triple valve replacement.") He may find it awkward or even uncomfortable to be confronted with the annoying details of everyday life that he habitually punted to his secretary or to his wife.

5. Loss of Health and Vitality: Major illnesses or simple physical indispositions, such as osteoarthritis of the hand or hip, may thwart lifelong plans to at last enjoy travel, or physically demanding recreations such as sports, gardening, etc. These problems can be particularly frustrating for surgeons who have never had the time or inclination to enjoy purely intellectual pursuits such as chess or reading, or the development of specific political or charitable interests. Also, though the mere act of retiring forces surgeons to acknowledge that they're not immortal and that they're getting older, illness really drives the point home. (Of course, there's a bright side to this problem: by the time one finishes counting out one's pills in the morning, reading the obituaries, getting to one's doctor's appointments, and recovering from a prostatectomy, there's no time to worry about how to fill the day!).

6. Loss of Companionship: The medical profession is an exclusive club in which surgeons have earned membership, and the hospital environment is their accustomed milieu. Their friends are predominantly physicians. The surgeons' lounge, as well as meetings of hospital committees, departments, and medical staffs, are all familiar "hangouts." Loss of these opportunities for social interaction with friends and colleagues in an informal and comfortable atmosphere can cause a substantial sense of loss of companionship.

THE WIFE'S PROBLEMS:

1. Loss of "Space": Surgeons are organizers. Husbands with more time at home may compulsively try to organize the house. Wives thus lose their privacy, and control of their space - the home.

2. Loss of "Freedom": Surgeons' wives are more accustomed than most wives to being alone at home, and they are accustomed to having daytime schedules they are free to arrange as they wish. They may be unhappy re-arranging their work or activity schedules to accommodate their husbands' new freedom.

3. Loss of Leisure: Husbands who rarely got home even for dinner, now eat most meals at home. In addition to having less time to call their own, wives may now have the burden of more meal preparation and cleaning up. Some wives will consider these nurturing responsibilities gratifying; their husbands are fortunate. Ideally, however, the husband and wife will share these responsibilities.

4. Loss of Job Satisfaction: The happily working wife may feel pressure to stop working in order to be part of her idled husband's recreational plans. Or, the homemaker who has been a longstanding nurturer, and a partner in supporting her husband's efforts to build a career, may lose the gratification of working with her spouse to help him achieve success. Ideally, a married couple can find new opportunities for shared ambition and collective effort, to replace the shared sense of accomplishment that resulted from the sacrifices both made to sustain the husband's career. Joint commitment to a charitable interest is one example of such activities.

PRACTICAL SOLUTIONS

A successful retirement doesn't just happen. Retirement isn't the end of the road, it is a fork in the road, and one must choose a course. Everyone must act on their own behalf by assessing their own needs and situation, by deciding what they want their retirement to be, and then by acting to make it possible. A person may have all the insight in the world, but if it doesn't affect their behavior, it won't help, because we are what we do. To evaluate one's flexibility or elasticity when coping with change, it is helpful to recall how one coped in the past with major life changes: moves to a new position, children's leaving home, death of a loved one, etc. Those who haven't done well in the past should not be embarrassed to seek professional counseling now. Retirement is one of the few major transitions in life for which there is usually ample time to prepare emotionally. After spending years in medical school and residency preparing for a surgical career, a surgeon shouldn't expect to have a successful career as a retiree without equally diligent preparation.

It should also be obvious that since retirement isn't a solo act, any forthcoming change in the surgeon's life style should fit in with the routines and needs of his spouse or companion. It is important that both partners have some private time, and some separate interests, because either spouse's dissatisfaction will eventually disturb the other's contentment. In addition, new joint interests may flourish. For example, since the surgeon now eats more meals at home, but also has more time to cooperate in meal preparation, both husband and wife may enjoy cooking classes, which can open up a new world of activities such as travel programs in Europe that include classes in regional cooking.

APPENDIX

A PARTIAL LIST OF SUGGESTED ACTIVITIES FOR A RETIRED SURGEON:

(Many of these may seem obvious to some readers, though it is hoped not to all. In any case, they are based on psychological principles that should be applicable to many circumstances).

1. If you're uncomfortable with ad-libbing your way through life, make a routine schedule and keep to it. This will help maintain your sense of order, and the feeling that you control your life, rather than it controlling you.

2. Arrange to retain your old office and access to a secretary; if this is unrealistic, consider renting one. This will get you out of the house, will provide a reassuring and useful link to your habitual routines, will sustain your self-esteem, and will facilitate other useful activities, such as expert testimony in malpractice defense, editorial reviews etc.

3. Seek appointment to committees in your hospital, and in our national professional organizations. Become active in local community organizations that you never had time for.

4. Identify a form of exercise that can be enjoyed with your spouse or companion.

5. Become computer and Internet competent. This will not only fill many enjoyable hours browsing the web, but e-mail will enable you to keep in touch with your children, grandchildren, and friends in faraway places. You can play bridge or chess on the web up to tournament levels (Plus, you'll occasionally encounter such extreme frustration and aggravation with your computer that your other troubles in life will seem insignificant).

6. Keep a sense of humor, and laugh as often as possible (See item 5 above).

7. Tell your friends how much you appreciate and enjoy their friendship; they will reciprocate. Don't lose touch with friends who are geographically distant; you will now have the chance to travel to see them.

8. Of course, you'll want to read all those books you were always going to read "if you only had the time," but don't ignore professional journals. It's not only enjoyable to stay up-to-date when you don't have to, but your lay friends will still seek your opinion about general medical matters, as they always did. If you're well informed, it will boost your self-esteem.

9. If associated with a teaching hospital, try to continue to make teaching rounds. If nothing else, teach physical diagnosis to medical students.

10. Audit college courses that interest you.

11. Take a course in writing. Human beings have a need to express themselves and to be heard. (That's why graffiti have been around since the dawn of civilization.) At the least, you'll have the time to write Letters to the Editor on subjects that concern you, or book reviews on Amazon.com. Many syndicated columnists in the lay press post their e-mail addresses and personally answer thoughtful correspondence. Teach yourself to touch-type; despite the absurdity of the QWERTY keyboard, touch-typing will make writing more pleasurable.

12. Write your autobiography for your descendants. Don't you wish your ancestors had written theirs for you? Research your family history on the Web. If you're descended from late 19th or 20th century immigrants, you can usually find their names on ships' manifests.

13. Identify a political organization or candidate for whom you can work enthusiastically.

14. Identify some charitable interests. In addition to the inherent satisfaction that charitable giving provides, it can be an interest and activity you share with your wife. After you contribute money, your interest in becoming involved in an organization's activities will be taken very seriously.

No list of such suggestions could be complete since the lists of possibilities are virtually endless. In particular, this list pays no attention to the financial aspects of retirement, such as managing one's investments, etc., which alone can approach a full time job. The point is that retirement can be the best time of life, but it requires thoughtful planning so that one can see the limitless possibilities as being exciting rather than daunting. The importance of this phase of our careers was recognized by Mark Orringer in his Presidential Address to The Society of Thoracic Surgeons (Ref. 1). It will also be one of the major subjects to be addressed by The Society's new Workforce on Aging.

References

Orringer M.B. Unity and Participation: Embracing Counterintuitive Survival Skills. Ann Thorac Surg 2002;74:3-12.