Speeding up the Countdown
In the 2016 Survey of America’s Physicians: Practice Patterns and Perspectives, a semiannual survey published by Merritt Hawkins for the Physicians Foundation, 17,236 doctors from different practice areas disclosed their plans for the next one to three years. Among specialists surveyed, 21.4 percent anticipated reducing their hours; 14.9 percent planned to retire; 11 percent planned to do locum tenens work; 7.2 percent planned to cut back the number of patients seen; 13.3 percent planned to seek non-clinical work; and 9.7 percent planned to transition to part-time practice. The doctors were questioned separately about whether changes in medicine and health care were hastening their exit from clinical practice. Half of all respondents aged 46 and older indicated that such changes were causing them to accelerate retirement plans. Physicians aged 45 and younger were not far behind, with 41.2 percent responding affirmatively. This sentiment was stronger among practice owners than employees (54.2 percent versus 42.1 percent) and specialists (48.2 percent) than PCPs (44.2 percent).
|Jack Holladay, MD, MSEE, says routine is key. He engages in research and writing from his home office several days a week. Dr. Holladay is also active with the AAO.|
Although it’s unclear how this data aligns with the retirement plans of ophthalmologists specifically, it’s fair to say that retiring from, winding down or drastically reducing clinical work is on the minds of many physicians.
A Humanistic Legacy
For Vincent P. de Luise, MD, the transition from a career as a fellowship-trained eye surgeon has afforded him time to build a legacy rooted in his lifelong passion for the arts. “I had been practicing for about 28 years,” he says. “ I elected to stop seeing patients and stop operating about five years ago, which was a very difficult decision.” An accomplished clarinetist for more than 50 years, Dr. de Luise has played recitals with talented patients as well as fellow ophthalmologist/musicians as one of the founders of the classical music concerts that flourished at the Academy and ARVO for many years. Dr. de Luise is a clinical professor of ophthalmology at Yale University and is also on the faculty at New York City’s Weill-Cornell Medical College. He serves on the Music and Medicine Initiative at Weill-Cornell. “I play clarinet in their medical school orchestra, and I’m the program annotator for their two annual concerts. I love both academic positions very much.”
Unsurprisingly, music informed Dr. de Luise’s surgical endeavors during his years in practice. “I would tell my patients that I believed playing the clarinet well helped me to be a better ambidextrous surgeon, and that being a good surgeon helped me be a better musician.” He also shared music’s beneficial effects with his patients, piping the orchestral music of Mozart, Handel or Vivaldi into the OR and waiting area. Not only did it calm the patients, but Dr. de Luise states that the music “helped me in surgery literally, psychologically and emotionally. It was part of what I looked forward to when I operated every Wednesday.”
The vibrant strands of Dr. de Luise’s medical and artistic careers have interwoven in his retirement. In 2012, he applied for an Advanced Leadership Initiative Fellowship at Harvard University. Of 300 to 400 applicants from around the world, Dr. deLuise was one of about 35 accepted. From January to December of 2013, he spent much of his time taking humanities courses, forming the concepts that have become the cornerstone of his second act.
“My proposal focused on exploring the possibility of nationalizing a humanities curriculum for medical schools,” says Dr. de Luise. He has divided humanities into six domains, each with separate mindfulness and motor components; for example, visual appreciation of art paired with sketching/drawing. “We really want to work both parts of the brain,” he says. “Perhaps some of this sounds a bit soft or New Age, but when you look at what I’m trying to do, it’s actually very scientific and neurologically based. There’s a whole neural network in the ventral striatum in the midbrain, the nucleus accumbens, the amygdala and the frontal cortex that is activated when we are involved in pleasurable activities.” He says that kind of whole-brain engagement leads to less anxious, more empathic doctors.
“I would often tell my patients, ‘I know you’re scared, but I can help you.’ The very act of stepping back and saying, ‘I can help you,’ is a kind of moment that is unfortunately becoming rare in medicine,” he says. “I believe strongly that it must be put back into the equation. Teaching students compassion and empathy through a humanities course is crucial. It’s the right thing to do for the next generation of doctors as a legacy to them. I’m convinced that these kinds of skills are just as important as the ability to make an excellent incision or to operate a laser or a phaco machine.”
Dr. de Luise continues to work on the pedagogy he conceptualized at Harvard, presenting to peers as well as future doctors. At the AAO national conference in October, he taught a course called “With an Artistic Vision: Perception, the Arts and the Eye,” having been invited back to do so a second time. “That’s a part of who I am right now. I didn’t give a course on phacoemulsification or LASIK: I gave a talk on perception and the arts.”
To thrive professionally and beyond, Dr. de Luise recommends that colleagues nurture their non-clinical talents: “Never lose sight of who you were,” he advises. “Always continue to have a passion or skill that you can continue, whether you’re an artist or photographer, kayaker or mountain climber. Keep doing those things. They will make you better as a physician. Then when the day comes—and it will come to all of us—when you’re not in medicine anymore, you’ll have a wonderful passion that you can continue to do for the rest of your life.”
A New Routine
Sometimes, retirement arrives unbidden, as it did for Jack T. Holladay, MD, MSEE. He feels fortunate, nonetheless. In February of 2010, Dr. Holladay underwent surgical repair of an ascending aortic aneurysm with dissection—a dire emergency with a survival rate of approximately one in 350,000. “To have lasted after that repair, and to hold the longevity record at about six-and-a-half years, I feel pretty lucky,” he says.
Although he exceeded expectations, achieving what his doctors deemed a full recovery, Dr. Holladay took stock of some residual effects at one month postop. “I recognized that I wasn’t fully 100 percent,” he says. “I would say maybe 95 percent, but not 100. I had had a stroke in the auditory nerve and the vestibular nerve, so my balance was a little off, and the hearing in my right ear was totally gone. The scrub nurse stands on the right. So I thought, ‘Gee, at 95-percent performance and not being able to hear out of that right ear, I don’t feel comfortable doing surgery anymore.’ ”
|Planning ahead helped Amir Arbisser, MD, and Lisa Brothers Arbisser, MD, make time for travel and the pursuit of other interests.|
Consulting and writing is Dr. Holladay’s new focus. “I do get a great deal of satisfaction out of the work I do now,” he says. In addition to continuing as a clinical professor at Baylor College of Medicine, he has pivoted to his background as an engineer versed in optics. “I work with manufacturers to develop new intraocular lenses and to modify their lasers for better performance,” he says. He continues to publish, most recently on IOL implantation after-effects and toric IOL calculations. “Those research areas are great!” he enthuses. “The other thing that’s really exciting and fun is working with the AAO task force to develop consensus statements for accommodating intraocular lenses and extended depth of focus lenses. We’re also just now working with the RAND Corporation to develop a metric that will allow us to determine patient-reported outcomes with a validated measure that all lens manufacturers can use to get consistent results across the board,” he adds. Dr. Holladay reports that the task force met with RAND and FDA representatives prior to the official opening of October’s AAO meeting in Chicago.
In addition to the Academy’s national meetings, Dr. Holladay continues to attend ASCRS and other major ophthalmic meetings, with the recent exception of ESCRS, as extended air travel is contraindicated.
When he’s not traveling, Dr. Holladay structures his days to maximize productivity. “I usually get up at about six o’clock,” he explains.“Then I have a cup of coffee and work for about four hours on Monday, Wednesday and Friday. On Tuesday, Thursday and Saturday, I have that cup of coffee and go play a round of golf. Sunday’s my day off. I sometimes have to give up golf if I’m working on a project that requires more, but that seven-day schedule works out pretty well. Routine is something I’ve always found helpful in making sure I’m productive.”
A 30-Year Plan
“We were literally thinking about retirement from the first day we saw patients,” says Amir Arbisser, MD, of the practice he built with his wife, Lisa Brothers Arbisser, MD. “We had what I would call a 30-year plan. Although we didn’t know exactly what the exit strategy would look like, we made some decisions from the outset with an eventual endpoint in mind.”
The Arbissers retired at the end of 2013, having taken multiple steps to ease the transition. They had purposely never held their practice too closely, bringing new partners aboard who shared equally in the ownership, overhead and direction of the business, which grew to eight locations in the Quad Cities region of Illinois and Iowa. By the time the Arbissers retired, they were able to sell exactly two equal shares out of twelve total. That buyout was facilitated by their earlier decision to valuate the practice using “a businesslike model based on a small multiple of the annual profitability that allowed for a very simple calculation of the buy-in and buy-out price,” explains Dr. Arbisser.
He also says that the couple managed their lifestyle so that retirement was a transition instead of a jumping-off point. “Most physicians really don’t have a lot of experience taking time off. They’ve been in a production mode for three or four decades since leaving med school.” Dr. Arbisser adds that this can lead to burnout—and the premature end of careers that could have been sustainable longer with just a change of pace. “I’m concerned that a lot of people are reactive when they hit that retirement button. Six months later, they may wake up and say, ‘What do I do? I’ve taken all the trips, done all the fishing, or maybe made model planes or run marathons. Now what?’ ”
He says this has societal as well as personal implications in an era of growing demand for health care. “Most dcotors in their sixties or even their seventies are really good physicians with great capabilities and a lot of experience. It’s a hell of a resource to take off the playing field.”
Dr. Arbisser and his wife bridged this gap by inviting another ophthalmology couple who was also trying to downshift to job-share in their practice. For four years, the Arbissers practiced one month on and then one off, alternating with the other couple. This meant that their overhead was covered year-round, and their full-time equivalent units actually came out ahead of their partners’, as their shares of the practice had constant coverage.
In addition to benefitting their practice, job-sharing also afforded the Arbissers time to fully develop their interests so that they could hit the ground running—at their pace—once they did hit the full-time retirement button. Dr. Lisa Arbisser remains active with an adjunct professorship at the University of Utah Moran Eye Center, and Dr. Amir Arbisser is managing a growing chain of private sleeping areas inside airport TSA security checkpoints. “It really allows me to be creative and to have a diversion,” he says of the business.
The couple also does a lot of family-oriented activities. The parents of four and grandparents of three are self-described “groupie parents” who enjoy seeing performances by their children who are in the arts. They also spend time with Dr. Arbisser’s parents. “We have a lot of things going on,” says Dr. Arbisser, “and we feel blessed to have time for them.”
Making it Work
The above accounts of retirement would come as no surprise to Lawrence B. Keller, CFP, of founder of Physician Financial Services in Woodbury, N.Y. He says that for many of his clients, retirement from medicine is not the end of work. “The idea of retirement is nice, but for these people, sitting around a campfire or fishing gets old pretty quickly,” he observes.
Vicki Rackner, MD, a consultant and coach who is the creator of thrivingdoctor.com and author of the forthcoming book The Myth of the Rich Doctor, notes, “I don’t like to think of retirement planning so much as I like to think about the freedom to do what you want down the road. I think it’s important to consider how you want to serve once you can’t or don’t want to practice clinically anymore. There are a lot of ways to do it.”
If retirement is really about the freedom to forge a new phase of life on your terms, you can take a few measures now to maximize your odds of getting there.
• Start early. “The AMA is researching methods of evaluating the skills of older practitioners because the inability to retire is so widespread,” says Dr. Rackner. To avoid having to operate and treat long after they’d prefer to stop, Mr. Keller says young ophthalmologists need to pay down student debt and start saving ASAP. Consider applying for a public-service loan-forgiveness program if you’re going to work for a non-profit facility or a government agency. If you’re going into private practice, look into refinancing your student loan through a private bank.
One change Mr. Keller has noted in recent years is that younger doctors crave financial education. “The golden-age practitioner didn’t really care so much about financial education. If things went awry, they would just see more patients,” he explains. “I think that today’s younger practitioner knows there is a ceiling as to what their potential earnings are. They know that there are a limited number of hours in the day, and that reimbursements are declining. What I see among the newer doctors is that they’re starving for financial education.” Mr. Keller cites a proliferation of financial blogs geared to doctors, such as whitecoatinvestor.com and its companion book, The White Coat Investor: A Doctor’s Guide to Personal Finance and Investing, both by James M. Dahle, MD. “If someone reads those, they will be very well set for a meeting with a financial planner, to know whether what’s being recommended is in the financial planner’s best interest, or in theirs,” he says.
• Do you need a financial planner? “A lot of people say to me, ‘I don’t have any money. I have a ton of debt. Do I really need a financial advisor to tell me what to do with money I don’t have?’ ” says Mr. Keller. “You really want someone to navigate ideas and thoughts with you,” he explains. “I give people a list of things to do or ways to do things in a certain order, and then make them aware of the pros and cons.” Mr. Keller emphasizes that participation is key. “Financial planners are great; but don’t just blindly allow them to do whatever they want without questioning anything. I tell my clients that you don’t have to be an expert, but you do have to be involved.”
• Target 20 percent. “Almost from your first day of residency, start putting 20 percent of your gross income into retirement savings,” Mr. Keller recommends. “Some might say 20 percent is really high. True, but if you put away too much, that means you get to retire sooner or wealthier.” If the market goes down, or if the rate of return on your investments is lower than you expected, Mr. Keller points out that putting away 20 percent is going to give you a good cushion from the vicissitudes of life.
It is also worth noting that “enough” savings for retirement is relative to the post-practice lifestyle you want, and is also partially unknowable: Do you know with certainty how long you’ll live after retirement, for example? When you consider all the factors you can’t control, that 20-percent cushion makes sense.
• Think about taxes. “The biggest expense any doctor will have is taxes,” says Dr. Rackner. “It’s important to look not so much at what wealth you’ve accumulated, but how much you will actually be able to access, so there are tax strategies that are crucial to getting ahead.”
One strategy is to pay taxes on retirement savings sooner rather than later. “If my tax bracket today is low, I know that it is only going to go up as I become a more senior physician,” says Mr. Keller. “Unless I’m getting a match from my employer to put money into a pre-tax retirement plan, I really don’t want to be doing it, because that’s almost like reverse tax planning. I’d be better off using what’s known as the Roth 403b plan, and paying the tax today, rather than in the future when my income is higher.”
• Insure your future. “Ophthalmologists should all have disability insurance in case they become unable to perform their medical duties,” says Mr. Keller. Practice owners who shoulder some or all of the associated fixed expenses should also have disability overhead expense insurance. “This type of disability insurance covers the fixed expenses, so doctors can either sell, or know that they have a practice to come back to that’s financially sound,” he says.
• Avoid emotional investments. Dr. Rackner urges physicians to avoid “DDDs” (“dumb doctor deals”). “Doctors today do not have the ability to recover from bad investments the way they once did,” she says.
Mr. Keller says that his clients tend to be “emotional investors” who assume the best in others and dislike confrontation. “They are way too trusting, and they believe that the ethical bar of every other profession is the same as theirs,” he notes. “As a result, they are poised to be taken advantage of on many levels.” Any investment can disappoint, but trying to make a financial plan work with far less money than anticipated can lead panicked doctors to take still more unwise risks in a last-ditch effort to maximize returns.
• If you’re an owner, plan for succession. Mr. Keller tells physicians to plan ahead whenever possible, “ideally, probably 10 years before you get out,” he recommends. “While you’re still active, find a younger ophthalmologist who is a surgeon with great clinical skills and bedside manner. Start making the introductions so that the relationships are built with the new doctor, then go ahead and have him or her buy the practice. The transition is made, and you’ve maximized your value.”
“As physicians, service is in our DNA, but we don’t always take such good care of our financial outlook,” notes Dr. Rackner. A solid retirement plan can make a bravura second act possible when the time comes to hang up your gloves. As the post-practice lives of Dr. de Luise, Dr. Holladay and Dr. Arbisser amply demonstrate, there can still be a lot to do.
“Those Mondays, Wednesdays and Fridays, after I’ve had a cup of coffee to get going, I’ve found that I can work on papers and do the calculations that I need to do,” observes Dr. Holladay. “When I sit down, I’m ready to go. I’m really ready.” REVIEW