Preparing for Retirement

Planning for Retirement.

Bill Nelems MD, FRCSC, MEd

Emeritus Professor of Surgery, University of British Columbia.

“You can't help getting older, but you don't have to get old.” George Burns.

Those of you who know me well will be surprised to learn that I developed a fascination for the ‘retirement planning’ process during my early surgical residency years.

While on call one weekend, I was both shocked and saddened as I watched an ambulance pull in to the Emergency ward carrying one of my most respected surgeon mentors as a patient. Just that morning, we had done ward rounds together, sipped our usual coffees and shared philosophies of life, as was our custom. It was a sunny Saturday morning and my mentor went off to enjoy a round of golf with his friends. On the first green, he suffered a grand mal seizure, collapsed and was brought to hospital. He was found to have brain metastases from a melanoma lesion removed some five years earlier. He didn’t return to work following his palliative radiation therapy, but he did maintain weekly contact with his residents. With a sense of urgency, he spoke to us about ‘life as a journey’, the need to plan ahead, how to deal with unexpected events, and most of all, the need to develop many concurrent interests outside of the realm of medicine. Within six months of his seizure he was dead.

With the passing of Mentor One, as I will call him, I began a quiet but critical examination of the lives and philosophies of my other teachers and colleagues.

Mentor Two served as a WWII surgeon. After the war, he returned to surgical practice in Canada and became one of the ’giants’ of our profession. He taught us how we were to develop our lives as workaholics, glued night and day to patient care. He was forced to retire at 65, long before that sensible Canadian Supreme Court Judgment abolished mandatory retirement. With no outside interests or hobbies, he lapsed into a state of depression and died an early death.

Mentor Three knew both Mentors One and Two very well. Mentor Two had also been his teacher whilst Mentor One was his contemporary. Mentor Three borrowed some pages from both of them. He did become a work addict, but he also developed a vast array of eclectic and outside interests. I have fished with Mentor Three on rivers, lakes and oceans. On one occasion I went moose hunting with him, got horribly rained out and returned home with only a purchased lake trout as booty. On another occasion, I slipped and broke one of Mr. Belsey’s prized fishing rods. Mr. Belsey’s magnanimity at the loss of his rod was matched in equal part by my personal embarrassment. It didn’t help that Mr. Belsey had been plying me with copious portions of Worthington E, a well-known British beer. These trips never had anything to do with fishing or hunting; they occurred only to serve as venues for the sharing of ideas and philosophies of life.

In retirement, Mentor Three has maintained a remarkable interest in nature, education, learning and collegiality. He was awarded the Order of Canada for his contributions to surgical education.

So what are the lessons that we glean from each of my mentors?

Mentor One reminds us of our humanity, our fragility, our need to develop empathy for others. His story also speaks to the notions of luck, chance and fate. “This is not how I planned to retire.” His illness was beyond his control. His death set the stage for my later interest in palliative care.

Mentor Two was a remarkable man. He came from modest means, served his country at a time of war, and lived a life of valour and dedication. His post retirement years, however, were barren. Without hobbies and interests, he had no purpose to live. The lessons from Mentor Two’s life are obvious.

Mentor Three has challenged me to seek definitions for work, retirement and engagement. Dictionaries tend to associate work with the generation of income, whereas retirement is described as that point at which one leaves the work force, earning no money. Definitions of engagement make no reference to money or income. They do not create an arbitrary boundary between work and the stoppage of work. When I speak of engagement, I am not speaking of that promise to marry, but rather the passionate commitment to life and all that it has to offer. I suspect that this commitment to life, this concept of engagement, is a learned phenomenon, and therefore teachable. I learned it from my parents, my life’s experiences and from some of my surgical mentors.

During our residency teaching sessions, Mentor One spoke of an engagement paradigm. He died while still relatively young, but all his life he had remained fully engaged.

Mentor Two lived and died in the paradigms of work/retirement, income/no income, busy/depressed, and alive/dead.

Mentor Three has had the good fortune of longevity, but his successes in life occurred only because he embraced engagement from an early age.

So perhaps this chapter should not be called ‘Planning for Retirement’ but rather, ‘Life long Engagement.’ Engaged citizens have higher levels of satisfaction that those who are unengaged (1). Participation in productive activities at older ages is associated with improved physical and mental health (2, 3, 4). Engagement is associated with lower mortality (3, 5). Fifty-eight percent of volunteers found that helping others made their own lives more satisfying (6, 7).

The art of engagement is something that should be taught to all medical students and residents. At a time when I was the Director of the two-year Core Surgery Program at the University of British Columbia, I developed a ‘Principles of Life’ curriculum to accompany the requisite ‘Principles of Surgery’ course. The residents were obliged to read Viktor Frankl’s Man’s Search for Meaning (8). We staged role-plays designed to illustrate Edward de Bono’s Six Thinking Hats (9). We discovered Stephen Covey’s The Seven Habit’s of Highly Effective People (10). The residents loved it. They would sometimes skip out of the ‘Principles of Surgery’ classes, but they never missed out on my ‘Principles of Life’ series. At these sessions, I always maintained an element of surprise. When I left that Directorship job, my successor, coming from the work/retirement paradigm, refused to maintain my engagement courses. Weeds engulfed the promise of new life in a new pond. Ah well, there are always more ponds to create anew! Engagement will always trump work/retirement!

I would like now to extend the concept of engagement into a third dimension, one that includes autonomy, mastery, purpose, physical fitness, quality of life, life expectancy, personal finances, philanthropy and a desire to be part of a national reckoning in the development of Medicine in general and Thoracic Surgery in particular.

Daniel Pink, Al Gore’s former Chief of Staff, talking about personal motivation, describes the importance of autonomy, mastery and purpose in Drive (11). Autonomy, he claims, “is our desire to be self-directed”. Autonomy is key to full engagement. The more autonomous we are, the more we engage and embrace our world. As surgeons we enjoy high degrees of autonomy. As we age our level of autonomy increases, the children raised, the administration handed over to younger colleagues, our minds now fully focused on creative solutions. Mastery, Pink claims, is “the urge to get better at stuff”. That’s right, that’s why we learn to perform videoscopic surgery and endo-bronchial ultrasound, even as we age. But ‘getting better at stuff’ includes a whole lot more than technical procedures. ‘Stuff’ includes creative thinking, networking, giving away one’s talents for free and exercising one’s influence.

Purpose, work that’s meaningful, is the polar opposite of work for profit, work that creates money. Why does Linux give away its software platform for free? Why do people give away their ideas and their writing to Wikipedia? Why does Skype terrorize the telecommunication giants? Because millions the world over are driven by a sense of purpose. Most have paid jobs, but they give away the excess. Giving is meaningful.

Fully engaged surgeons, regardless of age, are primed to embrace these philosophies. They are fully autonomous, masters of their universe and driven by purpose and meaning.

Physical fitness is something that we can all embrace. Yes, some of us have health related challenges, but even then, everyone can expand the limits of their current activities to some extent. It takes mental toughness to push this through. The authors of Younger Next Year (12) talk about setting back one’s biological clock by exercising six days a week. They also offer dietary advice. They provide evidence that aging related mental and physical decay can be put off and that many illnesses can be eliminated.

For my part, I have embraced a sport with which I was very familiar as a child – cycling. In 2010, I rode 4500 kilometres through 5 different African countries in 6 weeks. On my 71^st birthday, I pedalled 207 kilometres in the rain and hail in Botswana.

My views on diet can be summed up quite simply – eat and drink in such a way as to always fly below the insulin radar. Do not dump large carbohydrate loads onto your system. You will only cause insulin to spike turning the excess calories into fat. Over time, repeated and unnecessary spikes only exhaust your pancreatic islet cells setting the stage for the onset of Type 2 Diabetes, and then of course, all of those diabetic related co-morbidities that we learned to manage so well during our surgical careers. How to keep below the insulin radar? – Fruit, rye bread not wheat, no potatoes, fresh veggies, a little meat and a lot of fish – small amounts at a time.

My thoughts on quality of life do not come up on a Google search. I equate quality of life’s experience to harmony with others. Engagement with others requires a pervasive sense of accord. The last thing one wants in retirement is social isolation. Daniel Siegel in Mindsight (13) explains that harmony and collegiality can be learned and enhanced at all ages, regardless of life’s experiences or co-morbid conditions.

Financial planning for retirement can be summed up in two words - assets and income. Each begets the other. The greater your asset base, the greater your income will be. The more you earn, the bigger your asset base becomes. Prior to 2006, retirement was eased by rising fixed investment income and by ever rising residential investment values (Figures 1 and 2). However, after 2006 the game changed. Investment income and residential values plunged. In retrospect, these changes presaged the financial crisis of late 2008, and the onset of the worst recession since the Great Depression of 1929.

For the ageing surgeon, life expectancy and personal finances have a curious link. The longer we live, the more money we will need on which to live. As a society we are all living longer, and as engaged surgeons we will live even longer still. As one retires, ones income shifts from professional income to fixed rate investments and pensions. Our principal asset will be residential. With low interest rates and falling real estate prices, retirement becomes a challenge.

Will this 2006 – 2011 trend continue downwards? Will it reverse and start to rise again? In times of recession and market volatility, prudence dictates that one needs to prepare for continuation to the down side. If by chance it does reverse, all will be well and good, but many physicians who retired at or near the 2006 zenith found that they had to return to work to pay their bills.

What strategies could be embraced to enhance asset base on the one hand whilst improving cash flow and income on the other?

Strategy number 1: Become informed about money matters. Pursue an understanding of economics with the same fervour you did when keeping up to date with medicine and surgery. Take charge of your accounts. Have financial advisors, but do not listen to all they have to say. After all, the fees and dues you pay them are looking after their asset bases and their incomes, not yours. A few years ago, I took the three month on-line Canadian Securities Course. This is internationally available at the Canadian Securities Institute web site (14). Enrol and become informed.

It’s one thing to know that investing can be reduced to equities, bonds, cash, currencies and commodities, but it is quite another to know in which of the vehicles to place your asset base. I now know the difference between the fundamentals and technical analysis. I have become a hobbyist market technician. On more than one occasion I have used these insights to instruct my advisor as to what to buy and when to sell.

Strategy number 2: Keep working, either as a surgeon or in some other gainful manner. By continuing to work, you accomplish both objectives with a single stroke – you continue to earn as you grow your asset base. For every year you work beyond 65, your retirement fund will increase by 9%. For every year you work beyond 65, regardless of how long you live, you will have one year less to finance.

Strategy number 3: Delay claiming retirement benefits for as long as possible. Since I am still working at 71, I have yet to activate my retirement pensions. When I eventually do claim them I can be assured that my monthly payment will be more than double those had I accessed the funds at 65. These monies are not lost even if one dies prematurely because they become part of a spousal estate roll over process.

If you are not yet extensively involved in the non-profit sector, then you can expect that to change. The non-profit sector is best defined as giving, volunteering or participating. To put the magnitude of this sector into perspective, consider the following: In 2008, in America, total giving exceeded $307 billion, volunteers contributed 14.4 billion hours of time, estimated to be worth $260 billion at average wages (15). In 2007, Canadians donated over $10 billion to charity and volunteered 2.1 billion hours of time or $38 billion in equivalent wages (16). It is hard to imagine how our societies would function without these contributions.

Bill Clinton, in Giving (17), says that everyone has something to give whether that may be money, time, things, skills, reconciliation, live animals or ideas.

For my part, I founded a non-governmental organization, The Okanagan Zambia Health Initiative to take educational curricula to nurses and physicians in Zambia (18). This work is at its infancy and yet we are already getting calls to extend what we are piloting in Western Province into a national program.

Give generously of your time, your ideas and your money. Support your favourite charities. By giving – you’ll live longer and happier. Give your children a little but not a lot. Whatever you do, do not deprive them of their need to work. It’s through work that they become fully engaged. It is through work that they passionately embrace life and all that it has to offer. You do not need to give them fish because you have already given them fishing rods.

As we retire, we join that large amorphous blob of boomers who have stopped earning, stopped paying taxes, and yet they demand their share of social benefits and health care. Their cravings and their costs are reaching exponential proportions. Brian Crowley in Fearful Symmetry (19) quotes that by 2020, in Canada alone, it will take 50 billion dollars to maintain the present quality of health care – moneys that are not yet budgeted for. He also states that the demographic bulge of the boomer phenomenon and the additional costs are proportionally similar throughout all of the other first world nations, especially in Europe and the United States of America. We are in the midst of, and part of, a boomer induced crisis in maintaining our status quo whilst relying on minority numbers of children and grandchildren to pay for it. Who better to participate in the needed health care reforms that must be found than retired surgeons? Join the public debate. Speak out. You are an expert.

People ask me “how will I know when it’s time to retire?” Our professional careers are not single entities. They are like good books, multi-chaptered, attention gripping, meaningful, informative and fascinating to the end.

As we age, fully engaged in life, there comes a time when some chapters of our professional lives can be permanently closed. At different times in my life, I was a divisional head, a cancer centre administrator, a training program director, an investigator, a founding member of the British Columbia Thoracic Surgery Program and an academic professor. These chapters of my life are over – they are complete. I feel that I made a contribution and they gave me satisfaction. I do not need to go back to them. I can retire now from those activities. This said, one chapter of my professional life remains incomplete, thereby precluding my full retirement. If you have any ‘unfinished professional business’, then you too are not ready to retire.

I met Dr. Harold Urschel in 1974, and ever since then, off the corner of my otherwise busy desk, I have been inundated with an endless stream of patients with Thoracic Outlet Syndrome. During my career, these patients have taught me more about life in general than any other category of patients. Collectively, they represent a population of patients who have fallen through a gap in our health care network. Even though we have published hard evidence showing the statistically significant objective presence of congenital thoracic anomalies in these patients (20), they still get written off as having a controversial diagnosis, a subjective conundrum, a ‘not to be trusted’ entity. Yes, the chronic pain phenomenon makes them difficult patients to understand and to treat. Thoracic surgeons are uncomfortable with managing the psycho-social aspects of chronic pain. It is time consuming to give these patients the attention they need. In Dr. Urschel’s environment, he has the support of an excellent team of Physiatrists who manage the co-morbidities associated with these patients, not a luxury enjoyed by most of us. They have precious few advocates within the system. And yet, more patients return to work following first rib resection than following open-heart surgery. A successfully treated patient writes me a note: “Thank you for giving me back the joy of swimming, camping, canoeing, playing in the snow and holding my children again.”

I have unfinished business for this population of patients, and for this, I cannot fully retire. Dr. Drew Bethune, a Halifax based Thoracic Surgeon, like myself, has had a similar experience to me. He is the only other Canadian Thoracic Surgeon to verify and validate my experiences. Together, we will form the Thoracic Outlet Syndrome Canada Foundation. We will institutionalize the condition. We will establish multiple centres of excellence across Canada. We will collect similar data for the condition. We will standardize treatment protocols. We will publish the data and close the health care gap that exists for this neglected but worthwhile population of patients.

Along with my volunteer work in Zambia, I still have much to accomplish. There are roads all over the world that need to be ridden – birds of all kinds that need to be photographed – wetlands that need to cultivated. I have grand children to raise, family and friends to enjoy. I will never fully retire, and neither should you.

Fishing with Mentor 3 in August 2011

References:

1. Butrica, Barbara A., and Schaner, G. 2006. The Retirement Project. “Perspectives on Productive Aging. The Urban Institute. Program on Retirement Policy. www.urban.org

2. Lum, Terry Y., and Elizabeth Lightfoot. 2005. “The Effects of Volunteering on the Physical and Mental Health of Older People.” Research on Aging 27(1): 31–55.

3. Luoh, Ming-Ching, and A. Regula Herzog. 2002. “Individual Consequences of Volunteer and Paid Work in Old Age: Health and Mortality.” Journal of Health and Social Behavior 43(4): 490–509.

4. Morrow-Howell, Nancy, Jim Hinterlone, Philip A. Rozario, and Fengyan Tang. 2003. “Effects of Volunteering on the Well-Being of Older Adults.” Journal of Gerontology: Social Sciences 55B(3): S137–45.

5. Musick, Marc A., A. Regula Herzog, and James S. House. 1999. “Volunteering and Mortality Among Older Adults: Findings from A National Sample.” Journal of Gerontology: Social Sciences 54B(3): S173–80.

6. Kutner, Gail, and Jeffrey Love. 2003. “Time and Money: An In-Depth Look at 45+ Volunteers and Donors.” Washington, DC: AARP.

7. Thoits, Peggy A., and Lyndi N. Hewitt. 2001. “Volunteer Work and Well-Being.” Journal of Health and Social Behavior 42(2): 115–31.

8. Viktor Frankl. Man's Search for Meaning, Beacon Press, 2006. First published in two parts in 1946.

9. de Bono, Edward. Six Thinking Hats: An Essential Approach to Business Management. Little, Brown, & Company. 1985

10. Stephen Covey. The Seven Habits of Highly Effective People. Free Press. 1989.

11. Daniel Pink. Drive: The Surprising Truth About What Motivates Us. Publisher: New York, NY: Riverhead Books, 2009.

12. Chris Crowley, Harry Lodge. Younger Next Year: Live Strong, Fit, and Sexy – Until You’re 80 and Beyond. Workman Publishing Co. 2007

13. Daniel Siegel. Mindsight: The new science of personal transformation. Bantam Books. 2010.

14. The Canadian Securities Institute http://www.csi.ca

15. U.S. Department of the Interior, 2009. http://www.nps.gov/partnerships/fundraising_individuals_statistics.htm

16. Statistics Canada, 2009. http://www.statcan.gc.ca/start-debut-eng.html

17. Bill Clinton. Giving: How each of us can change the world. Publisher Alfred A. Knopf. 2007.

18. The Okanagan Zambia Health Initiative. http://www.okazhi.org

19. Brian Crowley. Fearful Symmetry: The Fall and Rise of Canada’s Founding Values. Key Porter Books, 2009.

20 Redenbach DM, Nelems B. A comparative study of structures comprising the thoracic outlet in 250 human cadavers and 72 surgical cases of thoracic outlet syndrome. Eur J Cardiothorac Surg. 1998 Apr;13(4):353-60.