When are you going to retire? What will you do after you retire? Surgeons typically start getting these questions around the time of their 60th birthday. Because I felt that I had only become really good at my work in my 50s, I did not feel rushed to end the experience. My response was usually a shrug and an, “I haven’t given it much thought.”
As I approached the age of 65, however, it became apparent that I should give the matter some consideration. I was working with a group of three other general surgeons in a community hospital that was affiliated with a medical school, and the combination of teaching and patient care led to a very satisfying career. I was continuing to work a full schedule. Getting up at 3:00 am, even though it was only every fourth night, was losing its charm, and I found that my feet hurt after a long day in the operating room. I could not help noticing that it was taking me five minutes longer to do a routine hernia repair—not much of a change, but it caused me to wonder how long it would be before my performance would come under the scrutiny of those in power.
A substitute position
When I reached the age of 66, I decided that I should retire and pursue an entirely different line of work. I enrolled in the Pennsylvania Guest Teacher program and worked as an elementary school (kindergarten through fifth grade) substitute teacher for the next eight years. At first, I was called three or four days a week and found the challenge enjoyable most of the time.
In 2008, because of the economic crunch, a large number of certified teachers returned to the workforce, and I was called only once or twice a week. Being a clinical associate professor of surgery does not count as certification for teaching elementary school. As I sat around the house, reading the classics, playing the piano, and trying not to annoy my wife, I realized that I missed the physician-patient relationship, and that maybe I could return to a less physically demanding type of practice.
As a medical student at the University of Pennsylvania, PA, I wanted to be a family physician, but the surgeons lured me away. I.S. Ravdin, MD, FACS, was fond of telling his students that a surgeon is “an internist and something more,” and during my rotating internship I found the intelligence and commitment of the surgical residents impressive. Thus inspired, in the 1960s, I endured the physical and emotional trauma of a surgical residency in an academic institution, namely the University of Pennsylvania, where Jonathan E. Rhoads, MD, FACS, was Chairman. I anticipated that, when I emerged, I would be able to provide a special type of care to my patients.
Following residency, I joined two excellent general surgeons in Pottstown, PA, performing general surgery of the old-fashioned kind. No subspecialists practiced in this town, so the surgeons in my practice performed thoracic, vascular, and pediatric cases and also took care of all but the most complicated fractures. Practicing in this location was exciting, but it offered no academic opportunities or conferences, except for the occasional mortality and morbidity meeting. My only form of “education” at this time was the frantic reading before performing an internal fixation of a fracture, and of course on-the-job training with my excellent associates.
After two years, it was time for a change, and I accepted an offer in Allentown, PA, where I would be doing a more limited scope of surgery and could participate in a teaching program that had been around since 1934. I joined a busy private practice, and the change worked well for me. Medical school affiliations provided opportunities for teaching, and working with residents was a great source of satisfaction. This combination of teaching, learning, training, and patient care was ideal for me, and it was a way of life for 35 years.
When I retired, I converted my active Pennsylvania license to the “retired active” category, which requires the licensee to pay the same biennial fee as surgeons in active practice, but without the requirements for liability insurance or continuing medical education (CME) credits. With this license, I could prescribe medicine for myself and for my wife but could no longer provide services to other patients. To convert back to an active license, I would obtain liability insurance, do CME, and pay a $5 fee.
When I decided to return to medicine, however, the fact that I had been out of action for eight years was a problem, which was not made easier by the fact that I wanted to do primary care. I would need the help of a program provided by the Pennsylvania Medical Society to re-qualify. First, I needed a cognitive screen with a psychologist, which required an hour of testing to see if I had any cognitive impairment. After I passed this test, I was required to take a course in family practice. I completed this assignment with a 60-hour review course available on DVDs provided by Temple University, Philadelphia, PA, with a pretest and a posttest. Upon completion of these studies, I was required to take the National Board of Medical Examiners Module in Family Medicine, a two-hour test comprising 100 multiple-choice questions and given in a closed room with an outside monitor, to whom I had to surrender my iPhone.
After several weeks, I was informed that I had passed and was instructed to proceed with a four- to six-week preceptorship with a family practice group. An excellent group of family physicians, who, incidentally, had been some of my referring physicians, helped me out here, teaching me quite a bit, and I was finally ready for the last step, which was to spend a day with a teacher in the family practice residency. My evaluation was satisfactory, and I was deemed safe to get my active license back and go to work.
I had started this process in June, and it was the second week in December when I started waiting for the final ruling from the Pennsylvania State Board of Medicine. Fortunately, I was approved, and my new certificate arrived in the mail. The story does not end here. I needed a job, and I needed to be certified by the health insurance companies so that payment could be rendered for my services.
Reborn as primary care physician
A local internal medicine group offered me a part-time job to replace a retiring partner, and the process of getting insurance company approval began. I had to rejoin the active hospital staff, which meant making and submitting copies of all the certificates that had previously hung on my office walls, including evidence that I was board certified. Because I was certified in surgery, I came on staff as a nonoperating member of the department of surgery with special permission to do primary care.
Several more weeks went by before all the necessary approvals came through, and I was finally ready to start work on March 3, 2010. In all, it had taken 10 months to complete the process of getting back into the fold.
I am now working three days a week in a group with two other physicians and a physician’s assistant, doing adult internal medicine as a primary care physician. Because I am seeing only 10 to 12 patients a day, I have time to listen to them, and I have time to work with electronic health records, which takes about 10 extra minutes per visit.
Primary care physicians are expected to know everything about everything, and I still have a lot to learn. I find myself relying on reference sources, with my smartphone always at the ready with the appropriate applications. I explain to patients that, as a surgeon, I was familiar with about 14 drugs, and I am now expected to be knowledgeable in the use of 1,400. Patients actually seem to appreciate that I am looking up information, and I do not believe that I lose face by using an external source of wisdom in their presence.
Two-and-one-half years into this new career, I am happy with my choice to be reborn in another form. I am now 78 years old but feel much younger, probably because of the reactivation of neurons related to medicine that had been in a resting state for eight years. I hope to continue in this mode for another three or four years.
Is internal medicine as satisfying as general surgery? It is satisfying but in a different way. Relationships with patients are longer, and results are determined by many factors that are often out of my control. Genetic factors are out of my hands, and it can be difficult to get patients to cooperate in matters of weight loss, diet, smoking, alcohol, prescription medication use, and other lifestyle choices.
I feel that my original choice of general surgery was a good one for me, providing gratification of a kind that is inaccessible to me as a primary care physician. Based on my experience, I would continue to encourage any undecided young physician to take the path that leads to general surgery.
Advice for the retiring general surgeon
What advice would I give to a general surgeon who is about to retire? I would tell him or her that a license to practice medicine is more than a piece of paper, and the decision to let it lapse is an important one. In the words of Joni Mitchell, “You don’t know what you’ve got ’til it’s gone.” It is a good idea to find some way, through part-time work, volunteering, or teaching, to maintain active licensure until such time as ill health or old age dictate the end of the line.
Most of my difficulty in being restored to medical usefulness was caused by my eight years of pursuing activities that were not related to medicine. A surgeon who wants to move into primary care will need some re-education, but it is unlikely that it will be necessary to go through the 10-month exercise that I underwent. Anyone with the appropriate desire should be able to accomplish the new goal.