The retiring surgeon

Welcome back to Dr Paul McCoubrie’s a 'view from the dark side' — a series looking at the world of surgery through the lens of a radiologist.

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“When you get to fifty-five, you either move sideways or slide into senescence”. These bons mots came from a slightly older surgical colleague. This was several years ago just prior to them moving to Australia. I merely queried the big move at that age.

Now having reached that age I look back and find their comment prescient. I chuckled at the time, but it has stayed with me as it has become progressively more real. It’s the kind of axiom that I wish I’d thought of; quirky and funny yet addresses an eternal truth. My immediate peers are indeed morphing or atrophying en masse. Well, their career pathway is. They aren’t physically transforming. That would be weird.

Only wine and cheese improve with age. The diminution of one’s powers is inevitable. Hence changing one’s working practices over time is only sensible. First to go is strength, then eyesight, then hearing, then dexterity and finally cognition. Not always the case, but that is the usual order of decrepitude.

Our physical peak is depressingly young, at around age twenty-eight. Physical decline is slow but accelerates after age fifty, whereafter we lose 1% of our muscle mass per year. With reducing strength comes less stamina and prolonged recovery time. You can operate into the late evening, even the wee small hours but, boy oh boy, you pay for it for several days afterwards. Staying fit, eating healthily and being slim all help but the toll of working long hours increasingly affects everyone after the age of fifty.

Our brain becomes less ‘fluid’ and more ‘crystallised’ with age. ‘Crystallised’ intelligence is the repertoire of knowledge and skills that accumulate throughout life. Whereas ‘fluid’ intelligence is more about abstract reasoning and information processing. Older surgeons accumulate crystallised intelligence but lose their fluidity. Ability to learn and understand new information peaks at around age fifty. Old dogs can learn new tricks; it just gets harder to do so.

Age forty-five to fifty is the deemed the time of peak performance for a doctor in the craft specialities. Growing experience and knowledge more than compensates for diminishing physical prowess. But at age fifty-five, you are still just about in your pomp but the slow downhill slide is already underway. The angle of the slope just gets steeper with age.

Some surgeons pretend that ageing hasn’t affected them. The more egomaniacal, the greater the self-delusion. For example, famed cardiothoracic surgeon Michael DeBakey performed major operations until he was ninety and was singularly bullish about practising at a great age. Which is quite preposterous. I personally value the wisdom of older surgeons; they’ve been there, seen it, done it, wished they’d not done it and never do it again. But would I let a seventy-plus-year-old surgeon operate on me? Let me put it this way: I’d rather do the splits on a barbed wire trampoline.

DeBakey and folk of his generation saw retirement as a cliff face they weren’t prepared to fall down. Waning of powers and physical decline were known but not discussed. Folk didn’t wind down; they worked hard until they retired. Retirement was bimodal: you were either still working full-time or you were retired. There was nothing in between. When the National Health Service (NHS) started in 1948, life expectancy was around sixty-six years old. Retirement was a hard stop at age 60. Career flexibility didn’t exist. You worked, you stopped and, in short order, you died.

But members of Generation X have very different attitudes to retirement. A 55-year-old surgeon can reasonably expect to live into their mid-late 80s. They want flexibility and control over their retirement. Ten years ago, this barely existed. Indeed, it was only in 2006 that the NHS abolished mandatory retirement at age sixty-five. Working less than time, annualising working hours and partial retirement existed but were difficult to achieve or came with financial disadvantages. Accordingly, most of the previous generation just retired at sixty. Gone. Poof. Disappeared from the workforce.

Which is plain daft. Many still had a lot to contribute and would have kept on working if it had been made easier. Although this varies from country to country, the rules are about retirement are relaxing. Fortunately those of us in the UK now have considerable flexibility. Those who have had enough can now retire without undue financial punishment and those who want to carry on working are encouraged to do so.

Modern British surgeons in their mid-late 50s have no pretence or shyness about winding down. The traditional reticence over being seen as anything other than all-capable and all-powerful is gone. Older surgeons happily seek different roles or changes to their existing role. When they talk about stepping back and working less than full time, a slight sparkle appears in the eyes. Coming off the on-call rota is a moment of proud transition rather than a sad diminution of professional duties.

Hence few see out their fifties in a similar manner as they entered them. Who would have guessed that, having spent twenty years building a clinical practice and a solid reputation, many surgeons in their fifties are quite happy to let it all go? Most of the defining motifs in the life of a young consultant are gladly relinquished in exchange for a fluid transition into retirement.

The decline in one’s powers normally coincides with domestic changes. An empty nest and a degree of financial comfort changes how you view the world. And at work, there is normally some, well, not professional boredom but more weariness or ennui. Add this weltschmerz to varying degrees of burnout and you get a cohort of surgeons ready for a change.

Moving sideways is varied and doesn’t have to entail emigration. Moving hospitals is reasonably common, seeking a different flavour of practice. Some leap sideways into a medical management role (aka “joining the dark side”). Some ascend to positions in a Royal College or Post-Grad Education. Non-operating surgeons are becoming more common, with a working week full of clinics, ward work, teaching, appraising and mentoring.

A lot of people ask me my late career plans. I think they mistake my cheery countenance and upbeat demeanour for someone who’ll pull a deBakey and never retire. Or imagine I’ll transform into a radiological butterfly after thirty years of caterpillar status. But the truth is that I will retire as soon as I’m financially able. Senescence aside, I’m looking forward to Stage III of my life - the Fun Stage. As Mark Twain wrote in The Adventures of Tom Sawyer, “Work consists of whatever a body is obliged to do, and that play consists of whatever a body is not obliged to do”. After forty years of working hard, I am definitely ready to play.