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© 1999 The Journal of Bone and Joint Surgery, Inc.
Current Concepts Review - Retirement from Orthopaedic Surgery* , MOORESVILLE , INDIANAPOLIS, MOORESVILLE, INDIANAPOLIS, INDIANA*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.
As the population continues to age, interest in late-life transitions has increased. Retirement is associated with many concerns, and the impact that it has on individuals' health and well-being is gaining considerable attention in the literature10. Findings from previous research regarding the impact of retirement on the general population have been inconsistent at best. Some studies have shown that retirees have poorer health, more depression and loneliness, less life satisfaction and happiness, a less positive view about retirement, and lower levels of activity than they did before retirement1,2,7,10,11,19,22,25, whereas others have documented retirement as having a positive impact on the life of older adults10. Retirees have reported looking forward to retirement and being satisfied with the outcome3,6,8,12,15,18,24; they have described beneficial effects of retirement on physical health and stress levels, with very few problems during the first year9,16,20; and they have found retirement to be a relatively benign event, with no apparent impact on well-being11,23. Despite the extensive literature concerning issues related to retirement in general, research on the retirement of physicians has been surprisingly limited. The few reported studies on this subject are predominantly based on descriptive surveys in which retired physicians or those nearing retirement are questioned about their plans for leaving practice and whether they will continue to engage in medical activity4,5,13,14,17,21,26. Few studies have examined physicians' perceived health status and changes in life satisfaction after retirement. Furthermore, there is very little information on the retirement of orthopaedic surgeons specifically. In one study in which specialties were identified, less than 3 percent of the physicians who were surveyed were orthopaedic surgeons13; in another study, less than 1 percent of the respondents were orthopaedic surgeons26. The primary purpose of the current study was to examine the impact of retirement on the physical health and the life satisfaction of orthopaedic surgeons after retirement. A secondary goal was to determine the predictors of life satisfaction after retirement from this specialty.
A questionnaire was mailed to all 1293 retired orthopaedic surgeons who were members of the American Academy of Orthopaedic Surgeons. Five of the retirees were women. The surgeons were identified with use of the computer files of the American Academy of Orthopaedic Surgeons. The study did not include any orthopaedic surgeons who had never been members of the Academy. The entire project was designed by us; the Academy helped to delineate the retired members, sent out the questionnaire, and tabulated the data. Seven hundred and eight surgeons (55 percent) responded by the time of the deadline given on the questionnaire; 643 were fully retired and sixty-five (9 percent) were semiretired, working an average (and standard deviation) of 12.7 ± 8.81 hours per week.
Survey Questionnaire Perceived physical health and changes in perceived health since retirement each were measured with use of a 5-point scale. Respondents rated their perceived physical health as excellent, very good, good, fair, or poor. With regard to changes in perceived health since retirement, respondents rated their health as much better, better, about the same, worse, or much worse. There were two items related to life satisfaction. The first life-satisfaction measure was derived with use of the 7-point delighted/terrible scale1. This item read: "Taking everything into account about what has happened in the last year and what you expect in the near future, how do you feel about your life in general?" The possible responses to this question included delighted, pleased, mostly satisfied, equally satisfied and dissatisfied, mostly dissatisfied, unhappy, and terrible. For this item, we included two other response categories: no feelings at all, and never thought about it. The second item, designed to measure changes in life satisfaction since retirement, read: "Have your feelings about your life in general changed since your decision to retire?" This item was scored with use of a 5-point scale; the possible responses were much better, better, the same, worse, and much worse. Qualitative data about the surgeons' experience of retirement were obtained with use of three questions: (1) "List up to three things that you have found the most enjoyable about retirement," (2) "List up to three things that were most difficult or challenging about retirement," and (3) "Based upon your experiences with retirement, what advice would you offer someone contemplating retirement?" The responses to these three questions were analyzed, and the most frequent responses were recorded.
Statistical Analyses A proportional odds model was developed to control for confounding variables with use of a stepwise selection procedure. Variables that were shown to be significant in the initial analysis were used as the covariates in the model processing. The nominal variables were dummy-coded with a reference group, and the ordinal variables were coded in their natural order. When the response variable was life satisfaction in general, the score test for the proportional odds assumption held true (p = 0.3764), and the -2 log likelihood criterion indicated that the model fit well (p = 0.0001). At a significance level of 0.05, the fitted model contained significant effects for general health at the present time, current health status compared with that before retirement, relationship with spouse, travel or vacation activity, and reasons for retirement (Table I). For the response variable of life satisfaction after retirement, the score test for the proportional odds assumption held true (p = 0.1759), and the -2 log likelihood criterion indicated that the model fit well (p = 0.0001). The fitted model also contained significant ordinal effects for current health status compared with that before retirement, relationship with spouse, age, and level of participation in sports activities (Table II).
Demographic Data and Reasons for Retirement With regard to the reasons for retirement, 250 (37 percent) of 683 respondents cited personal or family reasons; 187 (27 percent), professional reasons; and 178 (26 percent), health concerns. One hundred and eighty-four respondents checked more than one category, and 302 (44 percent) indicated that they had had additional reasons for retirement, including the amount of stress produced by work (seventy; 10 percent), having reached the mandatory age for retirement (fifty-one; 7 percent), dismay about the changes that have taken place in health care (fifty-one; 7 percent), the threat of malpractice litigation (thirty-six; 5 percent), and wanting to have time to enjoy other pursuits (thirty-two; 5 percent).
Perceived Physical Health
Life Satisfaction and Predictors of Life Satisfaction The significant predictors of high life satisfaction in general were excellent general health at the present time (p = 0.0001), better health compared with that before retirement (p = 0.0019), a better relationship with one's spouse (p = 0.0007), an increase in travel or vacation activity (p = 0.0001), and having retired for personal or family reasons as opposed to health reasons (p = 0.0207) (Table I). Furthermore, better health compared with that before retirement (p = 0.0001), a better relationship with one's spouse (p = 0.0004), a younger age (p = 0.0001), and participation in sports activities (p = 0.0417) were significant predictors of improved life satisfaction after retirement (Table II). There was a significant positive relationship between the responses to the two life-satisfaction questions (p = 0.001). Overall, the logistic regression analyses indicated that current health status and the relationship with one's spouse had the most important effects on perceived life satisfaction and on changes in life satisfaction after retirement.
Rewards, Challenges, and Advice While freedom from their schedule was the most rewarding aspect of retirement for approximately one-third of this sample, 212 (33 percent) of 651 respondents also reported that the most challenging aspect of retirement was the loss of their role as an orthopaedic surgeon; 133 (20 percent), a lack of activities; and 115 (18 percent), poor physical health. An additional ninety-eight respondents (15 percent) reported financial concerns, and approximately sixty-five (10 percent) stated that increased interaction with family was difficult. When asked what three pieces of advice they would give to other surgeons contemplating retirement, the six most common responses given by the 647 surgeons who answered were that prospective retirees should have sufficient financial resources (168; 26 percent), have a plan for retirement (135; 21 percent), have hobbies and interests to occupy their free time (133; 21 percent), keep active and challenged (fifty-one; 8 percent), relax and enjoy retirement (twenty-four; 4 percent), and do it (that is, retire) (122; 19 percent).
Our questionnaire, which was designed to examine the impact that retirement had on perceived physical health and life satisfaction and to determine the predictors of life satisfaction, revealed that the sample of 708 retired orthopaedic surgeons had retired for various reasons, including wanting to spend more time with family, wanting to reduce stress, concerns about health, and dismay about the current health-care climate. These data are consistent with those reported in previous studies. A recent survey from the American College of Surgeons17 revealed that physicians had retired because of concerns related to how malpractice is governed, health-care reform, the high cost of practice, frustration about third-party reimbursement for services rendered, a desire to undertake other activities, having reached the mandatory age for retirement, and diminishing satisfaction with work. In a survey of physicians from Minnesota (only 2 percent of whom were orthopaedic surgeons), the high cost of malpractice insurance also was cited as a reason for retirement13. In a survey of psychiatrists from Texas, major reasons for retirement included having reached the mandatory age for retirement, having led a so-called full life and being ready for a change of pace, physical illness, and emotional illness4. The results of the current study indicate that most of the surgeons found retirement to be beneficial to both their physical health and their life satisfaction. Indeed, more than half of our sample reported that their life in general was better or much better since retirement. Predictors of life satisfaction included good health, a good relationship with one's spouse, an increase in travel or vacation activity, and having retired for personal or family reasons as opposed to health reasons. These results are, for the most part, consistent with data from other studies on retirement, in which predictors of success have included a perception of good health, a comfortable income, and increased family ties21,26. The current survey did not include any questions about income level; however, in written comments, many surgeons expressed the need for careful financial planning before retirement and 15 percent indicated that financial management was a challenging aspect of retirement. One-third of the surgeons responded that they found certain aspects of retirement to be challenging. It is noteworthy that the aspects that some surgeons found challenging were the same ones that others found rewarding, probably indicating the importance of these issues. The most difficult aspect of retirement was the loss of the role of orthopaedic surgeon (33 percent). In contrast, an almost equal number of surgeons (32 percent) reported that freedom from their schedule was the most rewarding aspect of retirement. The loss of role was described rather poignantly in some of the surgeons' written comments. For example, a seventy-five-year-old surgeon who had been retired for three years reported "being a stranger in the hospital" and being "unable to look at radiographs and write prescriptions." Another surgeon, who was seventy-one years old and had been retired for seven years, reported that the "satisfaction of professional accomplishments [is] no longer there." A third respondent, who was seventy-two years old and also had been retired for seven years, stated that the "loss of prestige and loss of medical fraternity" were especially difficult. While many surgeons (203 [30 percent] of 677) reported that having time for other pursuits was a positive change, a considerable number (133 [20 percent] of 651) stated that keeping busy or finding activities to occupy their time was a challenge. Although the structure of the questionnaire did not allow us to explore the antecedents of this concern, the written comments suggested that the surgeons who expressed it were more preoccupied with their professional role and had not developed any major nonprofessional interests before their retirement. In addition to concerns about health and finances, another area of adjustment after retirement was the surgeon's relationship with spouse and family. While 167 (25 percent) of 677 surgeons reported that having more time to spend with spouse and family after retirement was rewarding, sixty-five (10 percent) of 651 found these interactions to be challenging. Again, it was difficult for us to make associations between this concern and its preretirement antecedents, but the written responses indicated that surgeons who had had a less satisfactory relationship with their spouse before retirement were, as might be expected, more likely to find this relationship more challenging after retirement. The response rate for a questionnaire of this type was very high, with 708 (55 percent) of the 1293 retired surgeons responding by the time of the deadline. An additional 100 surgeons returned the questionnaire after the deadline, increasing the response rate to 62 percent (808 of 1293); there were no appreciable differences between the responses on these additional questionnaires and those that were analyzed in the current study. It is important to note, however, that 485 (38 percent) of the surgeons to whom the questionnaire was mailed did not respond. It is possible that the nonrespondents included a larger proportion of subjects who were less satisfied with retirement and life in general and that they may also have had poorer perceived physical health. The purpose of the questionnaire was to provide information that would allow us to prepare a seminar on psychological issues related to retirement, with the hope of being able to offer preretirement counseling. The experience of the retired surgeons was generally positive. The most enjoyable aspects of retirement that were reported were the ability to spend more time with family, the ability to travel, and freedom from schedules and time constraints. However, there were areas in which counseling might be helpful. These included the need to anticipate feelings of loss after surgical practice is discontinued; the need to explore new professional interests before retirement; and, especially, the need to be sensitive to the interests and concerns of one's spouse and family both before and after retirement. Perhaps the wisest advice is encapsulated in the comment of a sixty-four-year-old surgeon who had been retired for three years. He wrote: "One needs three things for successful retirement: (1) enough money, (2) outside interests [other than medicine], and (3) knowing in one's heart that one's self-worth is not dependent upon being a doctor. When one has these three characteristics, one can retire at any time, regardless of age or how long one has worked."
The Center for Hip and Knee Surgery, Kendrick Memorial Hospital, 1199 Hadley Road, Mooresville, Indiana 46158.
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