AANS Neurosurgeon | Volume 26, Number 2, 2017

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Why Neurosurgeons Need to Prepare for Career Restructuring

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In a recent article published in the Wall Street Journal, Freedman notes that scientists are “pushing” to extend our lives and then questions if we are financially ready to “fill” those added days or not (6). In another article published in the Wall Street Journal, Clements states that one career in our lifetime may not be enough. He also noted that throughout the 20th century, life expectancy in the U.S. increased by just under 50 percent (5) and remarked that from a financial standpoint, adults have not prepared for the risk that living so long may run them out of savings (5). However, the authors point out that financial worries may be trumped by what we should actually do to make the most of that additional time (6).

In a survey of U.S. members of the American Association of Neurological Surgeons (AANS), McAbee et al documented that 52 percent believed that their professional lives would worsen in the future (9). Of significance was that the majority of survey responders were between 40 and 60 years of age. In the report, they noted that academic neurosurgeons who had practiced for over 20 years were least likely to be satisfied with their careers. They also documented that the burnout rate was highest among non-academic neurosurgeons when compared to academic neurosurgeons, and the overall burnout rate of those surveyed in the study was a staggering 56.7 percent (9).

Neurosurgeons will encounter the need for career “restructuring” when they no longer wish to perform operative neurosurgery due to age, health, burnout, career dissatisfaction or retirement. Life after neurosurgery is not addressed during resident training, post-residency subspecialty fellowships, national neurosurgical organizations or by the leadership. This may be due to the fact that the senior leaders and teachers of neurosurgery never considered living 20 years past retirement. Business persons and leaders in education outside neurosurgery are already aware and preparing for this “second stage” of life, and neurosurgeons can and should be actively pursuing these venues (5,6).

This article attempts to raise awareness of the various facets of career extension/restructuring, as well as the need for changing the cultural mindset of neurosurgeons, those that are teaching, as well as those that are in the leadership of national and state neurosurgical organizations.

Medical Literature
By reviewing business literature that addressed issues related to longer life spans, retirement, post-retirement plans, the physical and mental impact of lifestyle changes, financial needs, as well as “enthusiasm” for living, the recommendations for a second business career and/or extension of the original professional activity became evident.

The recent creation of “schools for the second half of life” at elite universities are addressed, in order to highlight the disparity with that of current neurosurgical literature. Medical literature that discusses issues related to physicians and/or neurosurgeons living longer was sparse. The available medical literature this report references primarily discusses physician career satisfaction, lifestyles and burnout. I could not find neurosurgical literature that addressed career longevity, extension and/or career restructuring.

The Finances of Living Longer
The Social Security Administration states that a 65-year-old woman today can expect to live until the age of 87, on average, and a 65-year-old male until an average age of 84 (5). Therefore, we need to measure our lives in decades, not years, and worry more about living longer, rather than dying (5). Freedman notes that too many are paying scant attention to how we should make the most of that additional time (6). Most importantly, how does one make the new chapter in life fulfilling enough for physical and mental health (6)?

Life extension without social innovation invokes images of a society loaded down by a population explosion of the “idle of old” (6). Freedman goes on to recommend devising new strategies for enhancing the whole range of experiences later in life; including education, faith, housing, work, finance and community (6). He also recommends planning early on for the transition so that you can prepare, navigate and meet your individual needs, essentially creating a “do-it-yourself process:”

“Individuals live their careers, know their interests, needs and what offers personal and professional satisfaction; consequently, any decision is very personal (6). Northwest University has introduced a two-part webinar for alumni to prepare for “second acts.” Harvard and Stanford Universities have created programs that permit the participants to explore options for a “next act” of purpose and productivity. Setting a template and exploring developing venues for the current candidates of a “second act” will benefit the younger ones, as they see senior ones involved in productive and creative ‘post professional years’ (6).”

Life After Neurosurgery
The risk, now, is living so long that you may run out of savings (5). There are important reasons to start saving as soon as you join the work force. If one does, there is the likelihood of financial flexibility in the event of career burnout or finding yourself in an unhappy job, so as to be able to move to another position or less lucrative career (5). If savings are indeed accumulated early and career satisfaction goals are met, there is a better guarantee for having the necessary funds for a lengthy retirement (5).

At some point in their careers, neurosurgeons face the reality that they no longer wish, or are unable, to perform operative interventions. Most of the neurosurgeons I have been in contact with seemed to perceive that moment will be at end of their neurosurgical careers. Several have gone on to non-medical careers, such as acquiring wineries, farming, business ventures and others. Some expressed desire to no longer have any contact with medicine. A few have gone on to academic administrative work or hospital administration. I personally know of two neurosurgeons who are assisting other neurosurgeons in patient care by participating in clinics dedicated to screening new patient referrals.

Burnout and career dissatisfaction are pervasive problems in medicine that can negatively affect a physician’s personal, physical and mental well-being (2). Physicians attempting to positively impact the lives of others become overwhelmed and frustrated by unforeseen stressors related to their jobs (3,8). The combination of the above has been associated with the desire for early retirement, interpersonal relationship dysfunction and suicidal ideation, and the patients under their treatment are often dissatisfied with the level of care they receive (1).

Previous studies revealed that surgical specialists have a high degree of professional burnout (1). It would be reasonable to presume that neurosurgeons who practice a field of high intensity would have a high incidence of burnout, and thus, a desire for an early career exit. In a survey taken by 750 U.S. neurosurgeons, 52 percent indicated that they believed that their professional lives would worsen in the future, 59.2 percent believed that they had too much on-call time and 44.6 percent were dissatisfied with time allowed for personal development (9). Academic neurosurgeons who had been in practice for over 20 years expressed a high rate of career dissatisfaction (9), and the survey revealed that among all neurosurgeons, 35.1 percent reported high emotional exhaustion, depersonalization (31.3 percent), a low sense of personal accomplishment (28.4 percent) and an overall burnout rate of 56.7 percent. Nonacademic neurosurgeons had a higher rate of burnout compared to academic neurosurgeons at 62.9 percent versus 47.7 percent (9).

McAbee et al., concluded that there is a need to address and diminish the impact of career dissatisfaction and burnout among neurosurgeons, so as to provide safe and reliable care to the increasing U.S. patient population (9). To that end, they recommend personal and organizational interventions. The authors did not address the need for career restructuring programs and/or preparation for a “second act” for those that are retiring from operative neurosurgery.

Societal Responsibility
Access to neurosurgical care is not uniform in the continental U.S. and its territories. The population growth in and of itself is predicted to further limit access to neurosurgery, since there is no proportional increase in the number of neurosurgeons in training. There is already documented disparity in neurosurgical outcomes in the care of patients in “low volume” centers, when compared to those cared for in “high volume” centers (4).

Neurosurgeons are dedicated to their profession and are hardworking, and in the process, they sacrifice personal and family time. They contribute much and are certainly entitled to look forward to their retirement as a compensation for the many years of long, stressful work days and the accompanied physical and emotional fatigue. At the same time, the wealth of experience and knowledge acquired through the years will no longer be available for the benefit of the community and the younger neurosurgeons. It is estimated that it now costs society approximately 1.2 million dollars to educate and train a neurosurgeon, and that figure does not include medical school education (10).

From the standpoint of societal investment, it is very worthwhile, and I am certain that all neurosurgeons agree that the community receives a very dedicated and labor-intensive reward.

Discussion
Neurosurgery leadership needs to create the necessary interventions in order to maximize the return to the community, and these interventions should begin before a neurosurgeon stops performing surgery and/or retires. Those neurosurgeons that have become so dissatisfied with the value of their careers may not wish to extend it, but they could respond well to a meaningful career “restructuring.”

Some neurosurgeons may desire to work part time in education, research or medical administrative roles. Physician shortage in other specialties are providing services to geographically undeserved patient populations in the continental U.S. and its territories via tele-health initiatives. Neurosurgical centers or university-based programs could employ neurosurgeons who are no longer performing operative procedures, allowing them to consult patients through structured tele-medicine clinics and provide community education through tele-health venues. This way, the “retirement experience” could potentially employ neurosurgeons in clinical care, clinical research projects or neurosurgical patient follow-up.

Whatever interventions are explored, they should create an atmosphere for enthusiasm and a positive experience so that neurosurgeons can look forward to the “second step” in their lives; one that is a continuum of career satisfaction, devoid of emotional and physical stress. The need for change was emphasized by Benjamin Franklin many years ago, as he said “When you are finished changing, you are finished altogether” (7).

Education venues, such as those established by the AANS and Congress of Neurological Surgeons (CNS), offer post-graduate education courses related to neurosurgical coding, practice management, career opportunities for young neurosurgeons and more. Aside from the innate educational value, leadership could foster a cultural mindset within the neurosurgical community, facilitating “professional value” for those considering retirement, and/or ending the operative neurosurgery component of their career.

Conclusion
Leaders in neurosurgical education, national organizations and residency and fellowship training programs need to work together in order to shift the cultural mindset regarding the “end of career years.” Using the field of business as an example, neurosurgical leaders can generate a “professional fit” in order to create venues for neurosurgeons that would allow them to look forward to emotional and personal satisfaction in the second stage of their lives. In turn, the community as a whole can benefit from the addition of a new venue of health care.

I wish to acknowledge the excellent support in the preparation and electronic submission of this article provided by Jennifer Santarone and the support provided by the trustees of the Lucy B. Gooding Charitable Foundation Trust, as well as the Baptist Health Foundation of Northeast Florida for facilitating my career restructuring and extension, which has allowed for a personally and professionally rewarding beginning to a “second stage” of life. I also want to extend my appreciation to Andre E. James JD, MBA, and Marc N. James ExMBA, for guidance and direction on the information from the world of business, referring to second careers, career extension and related materials.

References
1. Balch CM, Shanafelt TD, Sloan JA, Satele DV, Freischlag JA: Distress and career satisfaction among 14 surgical specialties, comparing academic and private practice settings. Ann Surg 254:558-568, 2011.

2. Bittner JG IV, Khan Z, Babu M, Hamed O: Stress, burnout, and maladaptive coping: strategies for surgeon well-being. Bull Am Coll Surg 96:17-22, 2011.

3. Bressi C, Porcellana M, Gambini O, Madia L, Muffatti R, Peirone A, et al: Burnout amongst psychiatrists in Milan: a multicenter survey. Psychiatr Serv 60: 985-988, 2009.

4. Clement RC, Carr BG, Kallan MJ, Wolff C, Reilly PM, Malhotra NR: Volume0outcome relationship in neurotrauma care. J Neurosurg 118:687-693, 2013.

5. Clements J. What Long Life Spans Mean for Your Money and Career, The Wall Street Journal, April 25-26, B7, 2015.

6. Freedman M. How to Make the Most of Longer Lives, The Wall Street Journal, June 1, R1, 2015.

7. Malone J: When You’re Finished Changing, You’re Finished. Houston, TX. Malone Media Group, 2012 (http://malonemediagroup.com/When-youre-finished-changing-youre-finished) [Accessed October 27, 2015]

8. Maslach C, Jackson SE, Leiter MP (eds): Maslach Burnout Inventory Manual, ed 3. Palo Alto, CA. Consulting Psychologists Press, 1996.

9.McAbee JH, Ragel BT, McCartney S, Jones GM, Michael LM, DeCuypere M, Chen JS, Boop FS, Klimo P. Factors associated with career satisfaction and burnout among US neurosurgeons: results of a nationwide survey. J Neurosurg 123:161-173, 2015.

10. Statement of the American Association of Neurological Surgeons, American Board of Neurological Surgery, Congress of Neurosurgeons, Society of Neurological Surgeons before the Institute of Medicine, on the subject of: Ensuring an Adequate Neurosurgical Workforce for the 21st Century. December 19, 2012. 

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Jack Kushner | April 19, 2016 at 6:29 am

In 1995 I retired from Neurosurgery. I earned a Master’s Degree in Finance. I started a medical transcription business in India and a telemedicine company in Israel. I have been lecturing at Oxford, Cambridge, Edinburgh, Cork, Prague, Israel, and Hanoi, Vietnam in addition to 16 medical centers in the USA. Am now building a Genomic Medical Center in Hanoi, VIetnam. I have published “Preparing to Tack; When Physicians Change Careers” and “Coping Successfully with Changing Tides and Winds”. So I have been working a second career for some time. Was recently honored as “Honorary Professor of Medicine and Healthcare” at Cambridge. Jack Kushner MD Annapolis, jkaoportal@comcast.net, 410-7573754

Jack Kushner | April 19, 2016 at 6:31 am

Reference is made to “Preparing to Tack; When Physicians Chance Careers” and “Coping Successfully with Changing Tides and Winds” Jack Kushner H. Prof Med, BA, MD, MGA, FACS, FICS, FAANS, HDG (Oxford)
Annapolis, Maryland