key: cord-0902969-e4ue8h01
authors: Beltran‐Bless, Ana‐Alicia; Vandermeer, Brent; Paterson, Alexander; Gunstone, Ian; Kaizer, Leonard; Arnaout, Angel; Vandermeer, Lisa; Clemons, Mark
title: Lost in Transition? Thoughts on Retirement, Part 2. “Should I Stay or Should I Go Now?”
date: 2021-05-18
journal: Oncologist
DOI: 10.1002/onco.13808
sha: 2f1a21407eaf27f9165ba2af3f4991c09a6d0ad7
doc_id: 902969
cord_uid: e4ue8h01

Although it is accepted that oncologists should plan for a future beyond full‐time oncology, there is little practical guidance for a successful transition into retirement. Previously, we provided strategies for various aspects of retirement planning. However, this became significantly more complicated as we face newer issues such as the COVID‐19 pandemic, the move to virtual patient care, greater awareness of burnout, and the increasing burden of regulatory issues such as the electronic medical record. It is evident that more prospective information is needed to guide oncologists in planning their retirement.

Just over 7 years ago we acknowledged Sir Paul McCartney, who, despite writing "will you still need me, will you still feed me, when I'm sixty-four" when he was 16, was still having to work well into his late seventies [1] . Possibly the result of poor financial planning? At that time, we tried to offer oncologists guidance on planning for their transition into retirement. Since our initial article, there have many advances both technologically and in the field of medical oncology, as well as a devastating COVID-19 pandemic, which has changed the way in which we live and work. This time we pay homage to The Clash and their song, "Should I Stay or Should I Go," again perhaps written with the subliminal message of retirement planning? Many of us who are near, at, or past retirement age are now begging the question, "should I stay or should I go now?" This article looks at how events both inside and out of oncology have impacted the decision to retire. In Table 1 we have summarized our previous publication and added some details on how we think these topics have evolved. In the text we expand on how some common themes have evolved but place greater emphasis on subjects that we could not have anticipated back then, such as COVID-19, the move to virtual patient care, the relentless progression of the electronic medical record (EMR) and regulatory challenges, and, quite simply, the question, is oncology advancing so fast that it is difficult for some of us "old timers" to keep up?

Although retirement remains a very personal decision, many of us will ask, when do most of our colleagues retire? In our original article, we talked about the "sea of grey" to describe the audience at most cancer conferences as possibly a reflection on the advancing average age of practicing oncologists [1] . We cited an American Society of Clinical Oncology (ASCO) survey of U.S. oncologists, which anticipated that 54% of practicing medical oncologists would be 65 or older by 2020. This survey also showed the expected retirement age for respondents was 64.3 years [2] . We know now that one in five U.S. oncologists is aged 64 years or older [3] .

It has now been a year since COVID-19 upended lives around the globe. This pandemic led to an abrupt, urgent, and unforeseen change in how we live our lives and practice medicine. The European Society for Medical Oncology (ESMO) Resilience Task Force study found that 78% of respondents had increased concern for their personal safety since the onset of the pandemic [4] . This is ever more important with an aging workforce at higher risk for complications from COVID-19 infection.

As work has possibly become less appealing, the current restrictions put in place due to COVID-19 have paradoxically also made retirement much less attractive. Retirees who spend lifetimes dreaming of travel, spending time with their grandkids, or simply enjoying their newfound freedom now have to accept their confinement. They might be leaving "normal" social interaction with colleagues at work to spend the majority of their days alone or with their spouses.

The Shift to Telemedicine "Virtual Care"

In the wake of COVID-19, clinicians took to telehealth to continue providing services to their patients via telemedicine. There is no doubt that telemedicine has many undisputed and proven benefits to the patient when it comes to improving convenience and access while reducing COVID-19 exposure risks and travel expenses for the patient. However, there could be some unintended negative consequences for the clinician [5]. Studies have documented increased clinician burnout due to screen fatigue, potential loss of information due to the limitations of the medium, difficulty discussing sensitive issues, and impacts on patient-clinician relationship, empathy, and compassion [6, 7] . An additional burden is witnessing increased emotional stress felt by sick inpatients due to current restrictions not allowing their family to be at their bedside often right up to the time of death. The need to manage patients with a life-threatening illness and/or advise on the adverse effects of treatment without the diagnostic accuracy and confidence of seeing the patient in person can make the interaction more mentally challenging for the clinician. Face-to-face communication by video is not really just faceto-face. As clinicians, we are trained to read nonverbal cues from the whole bodies of our patients to have a better understanding of their situation and what they are communicating to us [8] . Nonverbal cues also validate patients' understanding of what we convey to them. During a video visit, the frame is often limited to only a person's face, thereby eliminating access to many of these nonverbal cues [6]. In addition, consulting with patients is not simply exchanging information. Not being able to hold a patient's hand or hug them after delivering bad news hinders certain therapeutic elements associated with touch or interpersonal communication for both the patient and provider [8, 9] . The clinician's sense of job fulfillment is also related to the human-to-human connection embedded in trust and sincerity from our patients, and this is one of the main reasons most clinicians went into medicine in the first place [10]. As telemedicine visits will likely continue at higher than pre-COVID-19 levels after the pandemic, we need to be cognizant about their effect on clinician burnout and career fulfillment.

Possibly a double-edged consequence of COVID-19 has been the rapid demise of the multinational cancer megaconference in its usual format. The environmentally destructive impact of bringing thousands of oncologists from across the globe to a single city has often been ignored [11] . The focus was on increasingly exuberant meetings with pharmaceutical company funding at their core. Academic groups and pharmaceutical companies have found ways to work around the restrictions on travel induced by COVID-19. With improvements in technology and teaching techniques, can there really be any future for the global cancer mega-conference even if widespread COVID-19 vaccination is effective? We are all going to need to embrace online learning, and that can be challenging. However, reduced pharmaceutical company requirements for such conferences could hopefully lead to more "key opinion leaders" with less pharmaceutical company influence-we suspect sadly this is unlikely to happen. Although these conferences provided a welcome break from the stresses of cancer care and the opportunity to socialize with colleagues, the inefficiencies and cost of global travel (including quarantine processes), and the likelihood that the pandemic will continue globally for several years, will undoubtedly curtail conference related travel indefinitely.

With looming deficits exacerbated by the pandemic, more government involvement in the Canadian health care system is imminent as it searches for possible cost savings. With changes in EMRs in which more and more work is loaded onto the physician, many are laying off support staff. Physical examinations are already done less frequently-to the detriment of the diagnostic (and therapeutic) value of thorough examinations. An attempt to overhaul the fee system in Alberta in 2019 (put on hold because of the COVID-19 pandemic) led to 87% of Alberta doctors making changes to their practices, including layoffs, reduced hours, early retirement, and possibly leaving the province [12].

Since our original article, EMRs have been adopted widely and have added to the complexity of patient care. Although their intent is to increase efficiencies in quality of care, they are oftentimes less than intuitive and are often designed for inpatient work, making their adaptability to an outpatient practice less than ideal. EMRs have led to increased documentation requirements, computerized ordering with routing of prescriptions, and a never-ending inbox as what were formerly perceived as clerical tasks are now off-loaded to clinical staff-all leading to physicians spending more time on a computer than they do face-toface with patients [13] .

In a cross-sectional survey of 208 physicians and learners, 74.5% of those who reported burnout symptoms identified the EMR as a contributor [14] . It is therefore not a shock to hear that EMR implementation has an impact on retirement rates. Those at the cusp of retirement may see this as an unplanned opportunity to transition to the next phase of their life, rather than learn a new system. A retrospective study investigating medical provider attrition at a major academic center found a peak in provider attrition in the month prior to EMR implementation [15] . Indeed, at one of the authors' centers we still talk about a senior surgeon standing up in the middle of one of the many 

The pace of innovation of treatments in medical oncology is faster than ever before. It is now more difficult to stay abreast of the new research and maintain competency.

Oncologists need to dedicate even more time to stay up to date with current literature, and those at or near retirement age may be reprioritizing their life away from attending medical meetings and reading medical journals and more toward other obligations. The rapid evolution of immunotherapy (and its often perplexing toxicities) and precision oncology are two examples. Again, this feeds back to a need for us all to evolve to improved learning strategies. As oncologists, we have all had to learn to evolveindeed this was often one of the most satisfying parts of our job; quite simply learning about new treatments that enhanced the outcomes of our patients was pleasurable.

Today despite anecdotes that more physicians are choosing to retire early, we were unable to identify whether or not this is true. This is important as an exodus of senior oncologists could present significant challenges to the health care workforce as medical oncology demand could exceed supply. Indeed, ASCO predicts a shortage of 2,393 oncologists by 2025 [16] . Such an exodus could present significant challenges for all involved in health care, and more investment should be put into workforce planning and resource management [16] . This could include incentives to oncologists pondering retirement, such as promoting a part-time transition, the increased use of nurse practitioners and advance practice nurses, and appropriate transitioning of patients back to their primary care providers [16] . More data are clearly needed. However, irrespective of when one chooses to retire, there are key steps that need to be put in place.

These issues were extensively discussed in our previous publication [1] , but some fundamentals remain the same ( Table 2 ). As always, proper retirement planning should start early and be ongoing throughout one's career, as the needs of the young newly qualified oncologist with young children vary greatly from those of the 60-year-old who has no mortgage but needs to provide for adult children and elderly parents. Savings should begin early for all physicians in order to retire with a good standard of living at a reasonable age. The first step is to try to determine a precise required retirement income. As we previously discussed, it is commonly recommended that one should save enough to draw 70% of pre-retirement annual earnings to maintain a similar lifestyle. Whether this 70% cutoff really applies when we are at the top of our earnings should probably be questioned. The next step is to understand the risks associated with different income sources, creating a road map for modeling and reviewing final retirement plans. This is all best done under the guidance of an experienced financial advisor to help you develop a personalized and comprehensive financial plan. All physicians should have an up-to-date will, advanced directive planning, and power of attorney documented. Estate planners are also being recommended earlier on to help bring family members into decisionmaking processes.

Although incentives to retire have changed amid COVID-19, so too has the financial environment. The current pandemic has led to a significant economic slowdown as lockdowns shut down many businesses and unemployment rose in certain sectors. In response, interest rates were lowered, which has a direct impact on those planning for retirement or currently in retirement. They are living off their savings (i.e., on a "fixed income") derived in large part from the interest generated from their savings and investments. Previous generations both were more inclined to save, as they lived through hard economic times more than once, and valued passing on an inheritance more than current generations think they will. As income generated from savings declines and life expectancies increase, the strain of low interest rate policy is placed squarely on the shoulders of the prudent saver and those dependent on their savings to fund their income. The low rates we are seeing today significantly decrease the sustainable income that can be received from one's savings, and they also create less incentive for savers to put more money aside as the reward of doing so has been decreased.

The TINA (There Is No Alternative) effect has been created by low interest rates and increased longevity. This has led to the demand and need for this generation to move funds from now lower-yielding fixed income instruments to riskier speculative investments in the stock market. This has shifted the risk spectrum away from a more conservative asset mix to a more aggressive approach. Unlike their younger counterparts, retirees do not have time on their side to recover from potential negative market fluctuations. This approach goes against the typical advice of reducing the risk of one's portfolio as one approaches retirement. Retirees are assuming more risk in doing so, but, as the moniker infers, they do not have any other choices. Furthermore, inflation and the prediction of increased federal taxes coupled with increased longevity will also exacerbate finances, leading to possible riskier investments.

Another "risk" retirees face today is the paradoxical risk of increased longevity. Rightly or wrongly many financial advisors assume that the retiree's life expectancy will increase to 95. In order to sustain an after-tax income of CAD $90,000 per year, retirees would now require nonregistered savings of CAD $2,324,000, an increase of CAD $802,000 or 53% more than if they live to age 85. When preparing for financial independence one needs to consider what additional savings would be required to be prepared for this increased longevity, including care in one's later years. These additional costs include caregivers, care programs, and private care residences. Should daily home visits be required for a loved one or yourself, this would set you back approximately CAD $45,000-$55,000 per year for 7 hours daily, and that is without the increase in price due to the current pandemic. Provincial care programs for patients with dementia, despite government coverage, still require CAD $25,000-$30,000 per year out of pocket.

Not only this, but current retirees are often seen as a sandwich generation, needing to provide for both their elderly parents and their adult children. This has been exacerbated by COVID-19, which has led to a disproportionate economic impact on young adults with the highest proportion of American children aged 18-29 living with their parents since the Great Depression [17] . There is also a question of how this economic slowdown will affect young adults achieving typical milestones such as completion of their education, buying a house amid higher housing costs, and beginning their own family. Navigating the economic reality of the past year has been a challenge even for those who are financially savvy and in tune with the market. As such, more than ever, a seasoned financial advisor is essential for achieving the desired lifestyle throughout retirement.

For physicians, working past 65 is often seen as a good thing. We spend years of training to be fortunate enough to be able to care for others in a stimulating and exciting field. Those near, at, or beyond the age of retirement not only have years of experience but, more importantly, hold wisdom that can be passed on to the new generation of aspiring physicians. Their role as mentors is invaluable and should not be discounted. As such, implementing a gradual transition into retirement with de-escalating responsibilities can benefit both parties. Physicians working at institutions with flexibility leading to increased access to sabbaticals, flexibility of working hours, and control over career development are known to delay retirement [18] . De-escalation of clinical responsibilities over a period of time allows medical oncologists to extend their careers and provide the benefit of their experience to a system that will find specialist physician resources in short supply. For example, as noted above, the demand for medical oncologists is only going to grow [16] .

On the other hand, delaying retirement may lead to one's golden years passing by and can have two adverse consequences. First are excessive workload and burnout, which were frequently cited reasons for retirement and are more common with increasing age [18] [19] [20] . A study in 2013 showed that almost half of oncologists were burnt out, thus revealing that one must often take moments to introspect on one's work-life balance throughout practice and make necessary modifications [21] . This has been exacerbated by the current pandemic: a recent survey by ESMO of the global oncology workforce during the COVID-19 pandemic showed an increase in respondents experiencing burnout feelings from 38% in April/May 2020 to 49% in July/August 2020 [4] . Handling an excessive workload coupled with sleep deprivation, threats of litigation, and witnessing human suffering may become more challenging after 30 years in practice. The second consequence is that one is getting to an age at which one sees the health of colleagues and family members deteriorate, evoking much selfreflection on priorities and leaving many wondering, "why did I wait so long to retire?" TRANSITION Lack of clear retirement policies and recommendations for transition out of practice has led to less than seamless transitions, and many physicians feel that transitioning into retirement is not an easy process [22] . Many find it tough to go cold turkey after dedicating so many years to medicine, especially during a pandemic. It is possible to continue contributing by reducing hours, shifting from patient care to research, mentoring, or global oncology. Although parttime work is attractive, many practices do not accommodate it, as de-escalation leads to higher workload for other practice members [22] . Some physicians might move to less alluring work such as doing locum work in smaller centers, working in the pharmaceutical industry or with insurance companies or government agencies, chairing committees, or working in a poorly paid overseas job or medically underfunded areas. Although everyone seems to want to travel after retirement, in the post-COVID-19 world this may be neither possible nor plausible; therefore, the focus on recreational activities is even more important. A good hobby should be fostered prior to retirement.

With market demand expected to exceed supply of oncologists in the future, it is clear that retirement is not only affecting the retiree but will be leading to increased workload for their colleagues [16] . This is why strategies for a smooth transition of practice are necessary now more than ever: scaling back on-call hours, stopping new patient entry, and sharing patient care with the incoming practitioner are all policies that have been used. However, most centers do not have clear retirement policies [23] .

Most physicians struggle with their sense of self after retirement as they lose a part of their identity that made up so much of their life. This loss can also be felt as a separation from the health care system and a loss of the protection that it provides. Many stressors are non-financial, with up to 27% of retired physicians exhibiting some signs of depression [24] . Despite these factors, retirement is still seen as an overall positive experience and has been known to lead to improved overall health and improved quality of familial relationships [25] .

CONCLUSION incredibly rewarding, and despite our love of our work, we should all be planning for a future beyond full-time oncology. Amid the current pandemic, oncologists are not alone in taking a step back, looking at their life goals, and reprioritizing. COVID-19, technological advancements in patient care, and the shifting economic climate have likely changed people's retirement plans. The advice of a highly qualified financial planner has probably never been more important. Such a planner can help model the impact of lower investment yields and longer life expectancies so you can be prepared and adjust your plans well in advance. The prudent individual looks well into the future and makes plans based on the information at hand. When the situation and variables change, so does the plan.

There is a paucity of current literature and resources for retirement planning and transition. It is clear that prospective studies are needed, especially with the predicted growth of the field and shortage of oncologists in the future. We hope this paper will remind physicians that they will not live forever and that they should not ignore financial management. With proper planning and more than a little luck, let us hope we will all be able to make a successful transition, under our own terms.

A.H.P. is still dreaming of a happy retirement on his boat but, if he were to live to 90, can't quite afford it yet. M.J.C. would simply like to believe his children will one day leave home.

The authors indicated no financial relationships.

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