WHY I AM RETIRING FROM MEDICINE AT 56

One word answers rapidly come to mind: because I "want" to, because I'm "exhausted". While there is much accuracy to both of them, the reality is of course much more complex, hence the interest in writing this essay. At the moment it is not clear who, if anyone, will ever read this, with more on that uncertainty to come. However, even if it is only myself, now, being just over a month after retiring, is the time to write.

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Broadly speaking the reasons can be split into positive and negative ones: why I want the time for something else, and why I don't want to practice medicine anymore, with time limitations being a connecting theme central to both. In order to end with more uplifting notions, I will start with the latter. I suppose the reasons for not wanting to continue can be further subdivided into the physical and psychological.

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Physically, at 56 years old, I am younger than most at retirement.  At first glance I also appear very healthy, and indeed my cardiovascular fitness [and, with the absence of any risk factors, hopefully also my vascular health] is well above average, still easily flying by most younger adults on uphill hikes. Similarly, I don't suffer from any classic diseases. However when viewed from a functionally comprehensive viewpoint, things that I joke about are actually very time consuming, and, as brutal honesty, especially when writing, is an ideal of mine, I must therefore admit to having to deal with two very significant health issues. Please don't take what follows as a sob-story [in many other ways my life is great], just the whole truth. Fatigue and the need for lots of sleep have been issues for me since my early teens. I have always needed to sleep in whenever possible, and have always needed a nap of up to an hour, first after school or classes, and then throughout all stages of my working career. I even generally will take a nap on weekends and vacation days, unless the day remains physically stimulating.

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Looking back, I am amazed that I made it through certain medical school rotations and a three-year internal medicine residency, both long before shift duration limitations were put into place. Some aspects of that time are worthy of a 2- paragraph detour. I recall getting home after long days with a pre-7am start in my surgical rotation at the, now-dismantled, Montreal General Hospital and [presumably after having rapidly eaten] hitting the bed and falling instantly asleep as if a switch had been turned off [otherwise falling asleep has always been delayed for me], not waking up until the alarm early the next morning. Studying in the evenings was not an option.

 

My residency was not quite as chronologically arduous, however most rotations consisted of 90-something hour weeks including a roughly 34 hour on-call shift every fourth night. I ended up at the University of Connecticut, having wanted to leave home for the first time but still be in driving distance. I had not considered any Ontario programs because I felt incapable of handling the 1 in 3 call at those programs back then, and actually ranked the well-designed UConn program as my first choice, above nearby Yale [so I never found out if I would have gotten in due to the match procedure-I suppose I probably would have, as a top 5 McGill grad], in part because the more confusingly-designed program did not give interns their first full weekend off until late October. Yet somehow I managed to not only thrive academically, but also maintain an acceptable quality of life, including, at long last, my first girlfriends.

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I still don't know how I survived those many nights of little to no sleep, and how I functioned intellectually in making countless important patient care decisions the next day. Certainly there was a very strong rationale for medical residencies to put in shift limits so that, as far as I know, no one ever still works the day after an on-call night. While there was an advantage to the continuity of patient care through eliminating the need for handover to a resident unfamiliar with the case until issues had been dealt with, it is hard to believe that such was not outweighed by the intellectually and emotionally compromised nature of the exhausted admitting resident.

 

Fortunately I don't recall any significant mistakes from these long shifts, although I do recall a possible needle-stick [during the pre-therapy hiv epidemic heyday]: glove pricked but no blood drawn, while doing a procedure post-call, which I chose to ignore. Only once was I so exhausted that I needed to ask to be allowed to go home the evening going into call when I found myself incapable of processing a patient's admission note. It was during a time when I was going through a phase of particularly bad exhaustion a couple of months after having had mononucleosis. Humourously, I had been worried about hiv due to an overly rapid clinical self-diagnosis of mono. I had woken up and felt lymph nodes on my neck, looked in the mirror and saw a red throat, and instantly thought to myself: several weeks into a relationship with very limited past sexual history = classic infectious mononucleosis!

 

Later that morning, I was dismissed from my ER rotation after showing the attending a thermometer reading of 39.3c [he asked which patient that was, and when I responded "me", he quipped "you're out of here!"].  However my initial mono test came back negative, as the antibody-based test takes a week to convert [usually no one goes for the test until they start to wonder why this cold or flu isn't going away after a week or so], leading me to consider much scarier diagnostic alternatives. Fortunately the hiv test returned negative.

 

The advice which I found most helpful in getting through the time commitments of residency came from a friend's older brother, soon-to-be psychiatrist, the late Dr Michael Wainberg, who told me to think of my time in the hospital as my "normal life", and my time outside it as "the exception".

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To make matters worse, in more recent decades, the quality of my sleep has worsened. I am now usually up 2-3 times in the middle of the night due to bladder or bowel issues, more often in a bad night. And that is with either ativan or benadryl [I try to keep my neurons off-balance so they don't habituate to either, so far it has worked and effectiveness has been maintained, I will soon start trying to taper their use] often combined with melatonin. Needless to say this has often exacerbated my fatigue, and nap-dependency.

 

In March of 2020, ironically the very same weeks as covid exploded onto all of our lives, things got much worse for an unrelated reason.  A new couple with a young toddler moved into the hardwood-floored condo above ours, waking me with running noises and various other bangs and booms starting around 6am daily, and also preventing me from ever falling asleep during my post-work naps. Attempts at mitigation all failed and the next 2 years were daily misery [the exhaustion of raising a toddler without the reward of having a child!], until the situation changed.

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My other major problem is my bowels. I needed an anterior colonic resection for idiopathic [which means of unknown cause, or metaphorically, the doctor is an idiot and the patient looks pathetic] rectal prolapse when I was 26, and functionally, my bowels, which were always slow, have only worsened since without medical solution. Sparing you all the gory details, the functional issue is that it takes up about two hours of my day each day [which means that I meet the Canadian Revenue Agency's definition of disability for a tax credit, although I would never consider trying to claim it], most of that at night before I try to go to sleep. If I try to not move them, then I toss and turn awake [even if medicated] until I give in.

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So, in total, from the time I go to the bathroom for the night until I have had enough sleep to get up and be in decent shape for the next day [but still likely in need of a long afternoon nap] is generally about 11 hours. Yes, I can be quite "the joke". My days are literally short, and anything that I choose to do with them comes with considerable opportunity cost. I was always amazed at people who, like on the TV lawyer show "Ally McBeal", could regularly go out and socialize right after a long day's work, and maybe even do further work or reading after getting home. Maybe even have gotten up early that morning to exercise. Work hard and play hard. I was never one of those. Too bad.

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There are also several lesser, but contributory, psychological reasons why I don't want to practice medicine anymore, mainly related to the stress of it. To be clear, I have generally enjoyed the day-to-day patient interactions, and talking with my patients, especially about the non-medical aspects of their lives, is what I will miss most [I won't miss the work itself]. I have always considered it an honour and privilege not only to be able to ask someone I initially have barely met questions about their health, but also direct questions about their social and work situations and also ethnic/geographic origins, and be able to generally expect meaningful answers, potentially leading into tangential discussions, often of travel, but at times of controversial issues such as politics or religion. Survivors of the Khmer Rouge, Chernobyl clean-up, and Holocaust, as well as a modern-idealed female Bedouin refugee under threat from her own family, come to mind.

 

However medicine entails a lot of stress on multiple levels, from the unavoidable workload of very busy days, to the responsibility of patient care and running an office, to various issues of being part of a hospital and university division, participating in hospital clinics, to the stress of oversight from a governmental regulatory agency and the need, and time required, to maintain professional competency by keeping up with the literature.

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A couple of these deserve specific mention. Being on call as an endocrinologist is much lighter than many, and probably most, other medical subspecialties. Needing to go in after-hours was rare, as was being woken up in the middle of the night. However, due to that nature, we would be on call for seven days straight. The startling shock of my pager going off in the middle of the night, would be enough to prevent me from falling back asleep for at least an hour, if not more. Often the adrenaline of the shock would be combined with that of anger over the inappropriateness of the call itself [one, in retrospect, particularly funny recurrent issue was that for years obstetrics had a protocol whereby the covering endocrine attending was routinely paged following a delivery by a lady with gestational diabetes regardless of the time or her blood sugar level: "Dr Kreisman, I'm calling to inform you that Mrs Smith has delivered." "How is everybody doing?" "Just Fine." "What is her blood sugar?" "Perfectly normal." "So what do you want me to do at 3am? Congratulate her?"

 

The worry over potentially being woken would lead to many nights of poor sleep, and when issues relating to call and needing to potentially [if no trainee was on with me] manage a difficult new hospital computer system [my office stayed paper-based to the end, actually allowing me much greater speed and efficiency for the most part] during it arose, that worry could begin weeks or months in advance. Getting out of doing call [although I had done it for more years than anyone else in the Division] was problematic.

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Dealing with, and even just the notion of potentially having to deal with, our regulatory college, was also unpleasantly stressful, a constant background threat. I have made many [generally small] mistakes in my career. However it was never these that led to any college [or hospital] complaints from patients. Those, probably averaging one every other year, would always seem to relate to something silly, often a small office issue. More recent ones included a complaint for not having noticed the lack of a response from a faxed-in Pharmacare special authority renewal request, and a complaint by a patient who had no-showed for a prompt telephone consultation over my secretary [with my knowledge] having refused an unneeded in-person consultation during the height of the omicron wave during COVID, rather than discuss the matter with me to learn my thinking initially by phone. Nevertheless regardless of the seeming impossibility of serious reprimand resulting, all would be, merit unassessed, forwarded by the college requiring a prompt and in depth response, provoking much stress. They then would often take at least half a year before themselves addressing the matter [meaning that one of these was hanging over my head for approximately half my career], generally dismissing it, unless further questions from the complainant led to another round.

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One of the funnier incidents occurred when we received a fax stating that one of our clinical letters had erroneously been faxed to their office from no less than the office of the provincial Privacy Commissioner! They additionally noted that my letter was not preceded by a cover-page [environmentally wasteful, we continued to omit them], and did not contain a disclaimer stating that if the fax were to be received in error, the recipient should destroy it. I always wondered who this bit of legal mumbo-jumbo was meant to sway- any reasonable person would already know that it should be destroyed, and I can't imagine anyone with criminal intent being scared off their good fortune by that silly postscript. Nevertheless my transcriptionist added a standardized one in small font from then on. But, I wondered, how were we so unlucky as to have randomly sent the letter to the fax number of the privacy commissioner of all possible digit errors? Was someone out to get me? After a bit of detective work it ended up that, as per standard practice, we had sent the fax to the number listed on the top of the patient's referral letter we had received. It so happened that this request had come on a page from an office shared by both a clinic and the privacy commissioner, as well as a third entity. Yet their common coverpage listed three numbers and failed to distinguish which one belonged to whom! Talk about a privacy error waiting to happen! My secretary had only made the mistake of sending it to the first number without investigating further. Unscheduled billing and practice audits [I survived a few] were similar, and the fear of such was compounded by a poorly designed and regulated referral system, only fixed in recent years. The fact that one of my predecessors was actually made to pay back a large sum despite having been fully compliant, because his practice was too close to the edge in terms of re-referral frequency, was always in the back of my head.

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Then, of course, there is the minority of patients that one would rather not have to deal with again. My former officemate once commented that for every insulting or difficult patient, it takes twenty nice ones to even things up emotionally. Very true, however I repeat, blatantly negative interactions were uncommon, although stressful ones constrained by time or medical circumstances were much more frequent and do wear on one as well.

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Despite the many negative issues listed above, the larger factor in my deciding to retire at 56 is wanting the time to do other things. Time is of course the setting that encompasses all the other factors, both positive and negative, and every decision to do or not do something bears opportunity costs which must be factored into any proper analysis. If I had endless time, or multiple lives, then I'd be more than happy to continue for another couple decades of practicing clinical endocrinology, but we only go around once.

 

In addition to, as discussed above, my having less daily time than many, I also feel that many in society have incorrect notions about time left, and I also have, what I suppose could be considered atypical views on what I want from life and how I would like to spend my time. All the standard clichés are true. None of us know how much time we have left, and I think many overestimate their chances of both living a long life, and of being in good enough condition to do all one wants after retirement.

 

Shortly after I started my practice, a physician who I was covering for took a turn for the worse and passed away at 46. That has always stayed with me. More recently a mentor died at 65. To whatever degree possible, the time to live is now.  Those who work 12-hour days, six days a week, 50 weeks a year, are, to be blunt, fooling themselves, fueling an uncaring machine. There is no afterworldly reward for having been a good cog in its wheels.  As Mark Twain stated, work is a necessary evil, to be avoided. Obviously this soundbite shouldn't be taken to extremes, and there is a lot to be said for doing one's part through work in order to contribute to the betterment of human society. The ultra-independent ideal of being a "free man on the land", feeling justified in giving nothing back to society because one is taking nothing at all from it, is pure bullshit. We are all products of human civilization and modern society, and even the most reclusive of us use, and depend on, countless inventions and frameworks of it. We all owe society an awful lot. However that doesn't mean we owe it everything. The question is where to draw the line.

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Before further discussing where I have drawn the line, there is one other very practical necessary evil whereby I must acknowledge my good fortune; money. Obviously, I can only debate these theoretical aspects of when to retire, because [Trump's current tariff-induced market slump-derived anxieties ignored] I am fortunate to have earned enough money [and, through no doing of my own, to have been born into a family, country, and society that allowed for such possibility] to expect to be able to live a comfortable lifestyle [although not what I would consider a rich one- we always travel economy class, and avoid expensive accommodations]. My wealth is very likely to outlast my health, even if hoped for future endeavours do not lead to any financial compensations.

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So where to draw that line? Of course, this will differ for everyone, and extremes [and financial barriers] aside, there are no wrong answers. I have always been somewhat atypical in my views and actions, and never really fit in with the crowd. But what fun is there in being completely normal? I took a year off between residency and fellowship [very easy to do, as application for fellowships are generally done in year 2 of a 3-year residency- I just waited until year three, and had a years' vacation built in], and flew around the world.

 

I have generally taken longish vacations with several summers off completely, and have been fortunate enough that my wife was able to structure her schedule to correspond [she retired a year ago, another factor in my decision making]. But I suppose the most impactful atypical decision we made was not to have children [I've often told patients of mine struggling with fertility that the world needs more parents, not more children. As an aside, I believe first children should be financially rewarded, second neutral, third and on progressively penalized by governments]. Our reasons were in a sense "selfish", although I could turn that around and say that those intentionally procreating are the ones being selfish in today's world- one's personal decisions [on anything] are made on the margin, not the average.

 

Plans for early retirement were always linked in our minds lifeplans to not having children, thus allowing for more time and freedom for other pursuits. I must also admit to having somehow been vaguely influenced by insurance commercials touting "Freedom 55" decades ago, as some form of a measure of success in life [admittedly, a more common one is the biological imperative of having children, at which we are failing miserably. Though, from a purely evolutionary perspective, memes- harder to develop or contribute to, although I will try, may be outstripping genes in their importance for the future]. So retiring around now has long been under serious consideration. I did try a sort of semi-retirement, only working about half of the weeks since my 55th birthday. For many I think that is an excellent solution to the work-life balance, however for me it just meant more vacation time. When I was working, the load, as well as the stress and fatigue, were full, and it was not any sort of more relaxed workstyle, while more vacation just meant more travel [not so terrible...], but not really the opportunity to explore or experience anything new or different. Nevertheless, it is important for me to feel that I've paid back my "debt" [albeit one not of my choosing or doing] to society, and while my medical career may be far from the longest, when I started in Vancouver [as a single man], I set 20 years of core practice as my minimum in order to feel that I had accomplished such. Now, after 25 years of core clinical practice, and a prior additional ten of being possibly even more useful to society as a trainee working insane hours in the hospitals, I feel that I have accomplished such to my satisfaction.

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So, beyond just relaxing, inordinate sleeping and other vegetative functions, and daily exercise [after which I'm a much nicer person- my wife told me she would only show up at our wedding ceremony if I'd already exercised] , what are my plans for "part two"? Obviously, being away is a major part of the answer. We have been fortunate enough to, in recent years, have come into two additional "functional homes" where we hope to spend a lot of time for the foreseeable future. One in the tricultural gourmet city-island of Penang, where we stay at a condo with a morningtime-quiet coconut tree-lined large swimming pool, and my wife has countless family [including her aging parents] and friends. The second is a moderately remote architectural gem of a house on one of BC's islands, where we have been spending several weeks a year enjoying the coastal life including kayaking and hiking and a free [beyond the annual BC Fisheries license] seafood buffet, and have also developed a social circle. Once the trials of packing and arrival are over, neither of those feel like travel to us, and we are generally fairly sedentary while there, other than often a side trip from/in Malaysia.

 

So true travel, therefore, becomes the next part of my answer. However, I have already been to over one hundred countries, and must admit, likely in part due to my secondhand smoke-adverse, childlessness-enhanced, dislike of large noisy crowds, to having much less interest in seeing the next big city or top-tier tourist attraction than when I was younger. What I do greatly enjoy seeing, and, if possible, driving, are the countrysides of new places [in Canada included- I'm still yet to go to Newfoundland, although I'm married to a Newfie]. We will still hit some new exotic places, but more common will be exploring secondary destinations within the more standard countries. Time spent lying on the couch in Vancouver, watching movies and other stuff on the television, is likely to take up too large a portion of our shrinking pie of remaining time to fail to acknowledge it just because of its pedestrian nature.

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Yet, none of the above would really count as worthy of writing about, or what I would consider "following my dreams". In part I want the time to be open to new possibilities, to have the time to figure out what I want to do, what else there is out there to do, to experience or explore. Would I consider a second career, some sort of "work"? Some manner of being of benefit to society? Yes. I don't like the thought of never again being useful to anyone other than my wife. However anything that requires "scheduling" on a regular basis is definitely out. I've had problems with the world's externally imposed schedules ever since my early teens, and the relief of getting away from such is fundamental to my retiring [unfortunately our planet's astronomically-imposed 24-hour schedules of sunrise, sunset, and how my co-inhabitants on the planet react to such, is much harder to escape-stay off my seawall!!]. The sort of work that I can do at my own time and pace, picking up on, and leaving off of, at a whim, does appeal to me. And you are looking at one version of such work that appeals to me greatly: writing. I've always felt that I have something to say on many topics, from medicine [I've had a handful of OpEds related to my anti-tobacco advocacy published over the years, and may continue that line of work], to travel, to the nature of life, and existence. Starting from a bunch of letters to my grandmother describing a school trip summer in Israel at fifteen, I have always written when I have been traveling. This continued through a work-abroad summer in London as a young adult, to the following summer of classic Europe travel, the around the world year before fellowship, and my many vacations since, which have in more recent years generated a mass-email to my family, friends and colleagues. Hopefully they agree that I have had something interesting to say, and have not just been humouring me...

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Many of you know what I really want to write a book about, and have fantasized about doing for decades,- my distaste for belief and religion. Parts of "my book", possibly to be titled "The Logical Impossibility of a God", have already been intermittently written over the years. I do intend on finishing it. What happens from there I have no idea. Will it get published? Will it make waves, or sit, unseen, in some corner of the internet? Either way, I feel it is something I need to do. It will allow me to make my own peace with the nature of life & existence, and feel that I've at least tried to nudge human society towards being a more rational and better place. Should it take off, I've wanted to be young enough to see it through, wherever that leads. Either way, I do have some other writing-based projects in mind, possibly including a biography of an anti-tobacco colleague of mine titled "Adventures of a Serial Activist".

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So there you have it; why I retired from medicine at age 56. The long answer explaining the "I want to" and "I'm exhausted". We will see what happens. Queue up Jean-Luc Picard's introductory prelude to "Star Trek, The 2nd Generation" - to boldly go where no man has gone before. Play the music. I'm off!

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-Stuart