Beginning with the End in Mind

On Saturday, September 17^th my wife and I hosted somewhere in the range of 70 medical center colleagues, staff and their families at our place for a catered barbecue supper.  It reminded me of our wedding reception, as I did not have enough time to talk to everyone as much as I wanted to, and I almost forgot to eat.  Preparing for this event certainly filled the couple of days leading up to the party, as well as the day after, which included Sunday service and choir rehearsal. The Sunday congregation had a surprise lunch at coffee hour consisting of excellent ribs, chicken, mac & cheese, and salad.  As my wife said during the service, “you don’t know what will happen at church unless you show up”.

Despite instructions not to, my former pulmonary colleagues did present me with two very nice gifts, and others brought a number of fun and/or useful items.  A close friend, who also hired me 18 years ago, and the current chief of pulmonary each made very kind and thoughtful remarks such that I thought I was attending my own funeral.  Which was interesting as this is a thought experiment in some books that discuss life planning.  Thinking about what you would want people to say about you at your funeral identifies what you value most, and separates these from the urgent issues that often occupy our days. Once identified, it is these values that should inform how we plan and conduct our lives.

Remembering this advice has given me a lot more peace of mind the past week.  In an earlier post, I complained of the problem of not being busy or structured enough now that I didn’t have a beeper, clinic schedule, etc.  But I could be busy, and be neither effective nor productive, filling my time with the unimportant or inconsequential. I now realize that I have the gift of time to reflect, to give thought about how I would want to be remembered so that I can revisit my values and determine what is the right thing for me to do in this next stage of my life.  This takes time, but often is neglected because it is not urgent.  It is what Steven Covey in 7 Habits of Highly Effective People calls “Quadrant II activity” – planning, prevention, learning, and relationship building.  I probably should add that book to my references as it helped me 12 years ago when I redirected my pulmonary career from critical care to more public health activities in response to some burn-out I was experiencing.  Re-reading it now has been quite helpful.

Next week, I will be doing my backpacking Wilderness Medicine expedition for 7 days in the Galiuros mountains near Tucson AR to learn again how to do some basic medical assessment and care in a low resource environment – another Quadrant II activity.  While laying on the hard ground in my sleeping bag unable to sleep, I can reflect on my principles and values so that I can begin again with the end in mind.

Achievement versus Fulfillment

In my last post, I complained about the curse of having to be “productive”, as measured by that internalized judge of myself, which I will call my conscience.  As a working physician, I could look back on a week and count lives that may have been changed by my actions…well, more likely my billed RVUs: Relative Value Units – the accounting measure of a physician’s productivity, essentially how many patients I saw, procedures I did, consults I provided.  As a researcher, I could look at my grants, presentations, manuscripts, and data analyzed.  As an administrator, I could look at meetings run, memos created, policies altered.  What is the measure of my productivity – my worth – now? 

The retirement/reinvention books state that I need to change from focusing on “achievement” to pursuing “happiness and fulfillment”. 

According to the dictionary in Word, achievement is defined as “something that somebody has succeeded in doing, usually with effort; social status gained through personal merit”. 

In the free online dictionary, fulfillment is defined as “a feeling of satisfaction at having achieved your desires; the contentment one feels when one has fulfilled a desire, need, or expectation.” 

At first glance, it appears that you get fulfillment by having achieved something or lived up to expectations.  However, the construct meant by “fulfillment” in these books is that you are living up to your own expectations, not those of others.  And to do this, you first have to have knowledge about yourself, and the gumption to seek out those activities that “float your boat”, “put you in the flow”, that provide you with your own sense of self-approval and self-esteem.  

This is more difficult than you think.  Those of us successful enough to retire are very conditioned to judge ourselves according to the measures of our supervisor(s) or other external judges of our output.  That’s how we were successful in the first place.  We seek external confirmation of our worth.  To change to getting that only from within oneself is not straightforward or simple.  In addition to providing our own structure for the day, we also need to create our own internal measures by which we derive self-esteem.  I’m not there yet, but having articulated this problem, I have a start.

Today I did something that I would not have done two months ago.  I took a 5.6 mile walk through the rural roads near our home during a normal work day.  The farm land and hills of late summer were picturesque; people I have never met waved to me; a blue heron suddenly flew out of the rushes as I walked by; the Vermont Cookie Love owner greeted me with a smile of recognition.  I “achieved” practically nothing (except some additional training for backpacking – an excuse to do this), but I felt a sense of “fulfillment” in having taken the time to observe the beautiful surroundings and living creatures of Vermont.  Who knows how long one has to take in such beauty?  

The Rubber Hits the Road: the First Week

Time is a vacuum; it has to be filled.  What I learned this week is that I need to be busy, and the lack of structure formally provided by clinics, consults, bronchoscopies, pages, etc is a challenge.  Other than my wilderness medicine course, I had intentionally not scheduled much for this first month so that I could “recharge my batteries”.  I had forgotten that my favorite vacations are when I am busy – bareboat chartering in the BVI, organizing our family adventure in New Zealand.  I cannot sit around.  I still get up at 6AM, and I expect the day to be filled.  Now I have to fill it, or I feel at loose ends.

Here is how I envisioned my life after leaving formal medicine (from my exercises done from “Your Retirement, Your Way” by A. Bernstein and J. Trauth):

“Five years after retiring, I will be choosing to expend effort on selected projects and tasks that make use of my skills in analyzing, planning, and working with others.  It will utilize my knowledge and experience in public health and medicine, perhaps focusing on tobacco control, but not necessarily.  I will also spend time on personal development in the areas of spirituality, personal health (exercise), and skills in a hobby that fit with my style and interests (possibly boat building or extending my skills in sailing).  I would like to contribute to my community in Vermont through continued work at the IRB, at the Red Cross in platelet donation, at the ALA of VT, and in tobacco control.”

Sounds good, but getting to specifics is harder.  I did spend about 4 hours Monday on IRB related meetings, but that is only 4 hours out of about the 100 hours of useable time in a week.  I also spent time on a sick cat, on grocery shopping, on making dinners and cleaning up, and on writing this blog (and editing it).  I have hiked, weight lifted, read my articles on wilderness medicine, reviewed a couple of protocols, done my wife’s powerpoint, sung in the choir, sailboat raced with a blind sailor at our helm on Wednesday, sailed another time with my wife and daughter, listened to the audio book “Omnivore’s Dilemma” by Michael Pollan in the car wondering if I can do the "local foods" thing, and tried to start a large tome by Karen Armstrong.   However, I am not as efficient or as “productive” as I was as a physician in the hospital.  What a curse to feel that way!

This is a challenge.  I remain convinced that I have no interest in going back to what I was, but I will need to work at providing myself structure in my day.  I suspect that those who know me are not surprised.

Developing a Plan

Finances are only a means to an end.  The real challenge is to figure out a plan for this stage in life that a) provides meaning and fulfillment, b) opportunities for learning, and c) connections with a vital social network.  “Retirement” is an outdated concept at a time when life expectancy for men approaches 80, and the possibility of being productive can extend well into our 70’s and beyond.  I did not leave pulmonary medicine just to sit around.  I left because I wanted to spend time and energy on a variety of different pursuits that may fit better with who I am and would like to become at this point in time.  Hence, the more appropriate terms I use when asked are “reinvention”, “rebooting”, or “renewal”.

Our financial situation opens up doors to “pursuits” that do not come with a paycheck.  However, with a multitude of doors available to open, there is a risk that I could enter many wrong doors, never finding the right one(s).  

For three years, I have tried to be somewhat systematic in approaching this challenge.  Several sources have been useful in provoking thoughts, offering examples, and providing approaches.  I have created an annotated list of references and citations as a separate “Page”, but again I am not giving an endorsement, and have no financial relationship to any of them.  Nonetheless, they have been helpful in my thinking about this.

In thinking through my portfolio of potential activities here are some of the possibilities, and the easiest, quickest answer to the question “What are you doing”:

1.    Chair the IRB Committee on Behavioral Research.  I have been doing this for several years, and there is no immediate successor (though someone who could do this very quickly if needed).  I have found this work intellectually stimulating and challenging, forcing me to learn new areas of research and research design, and often making me have to think through complex and competing concepts (essentially, when is the risk of the study justified by the benefits, how can the risks be minimized, what will make it possible to do the research).  I have contact with bright stimulating people, and I have to articulate myself well.  When I review a protocol, I get into the “flow” when time seems to stop.  My clinical duties have made this difficult to do “right”, so I welcome my greater time to expend on this.

2.    Support my wife in her full time position as the pastor of North Ferrisburgh UMC.  The decision to move to the parsonage was a step in this direction.  I have taken on the role of creating the Sunday morning powerpoint liturgy presentations (example of a slide attached).  I enjoy cooking, tolerate cleaning, and with cooking, would like to do more of the grocery shopping.  I have gone, and will go, on more mission trips such as our week long trip to Gulfport MS to work on houses damaged by Katrina.

3.    Consider other mission work.  I did a day long training to be an Early Response Team member in for United Methodists Committee on Relief and Volunteers in Mission.  These teams would go into areas hit by a disaster after the first responders had done their work for periods of up to 3 days doing mucking out, tarping roofs, and removing debris as well as listening to, and being a presence for survivors.

In 1986, I spent a month working at a hospital in Haiti.  It was exhausting work that I was not sure I was cut out for.  However, doing mission work in an area in which I have training (medicine) makes obvious sense.   Whether it would make a difference that I am now more experienced (I was still in training back then) is uncertain.  One thing I know, I need to regain skills in basic medicine.

4.    Public Health. I have training in public health (an MPH) and lots of experience now in working with Vermont’s Public Health Department.  Not sure what is available, even if unpaid.  I will continue to be chair of Vermont’s Tobacco Evaluation and Review Board’s evaluation committee, though I no longer on the board itself.  I’d love to help clinics set up systems to identify smoking status, but I am not sure I would have the credibility to do this now that I am not actively practicing. 

One advice that seems to make sense right now is to “recharge my batteries” first.  It’s too early to make too many decisions, and I need to put some space between actively working and taking up this “3^rd stage”.  To that end, I am taking a week to go backpacking in Arizona to learn wilderness medicine skills.  Perhaps this would be good for me if I do some sort of medical missionary work, but it really sounds like just a good time doing something completely different.  Besides, it has been the easy answer to all the questions about “What are you going to do?”

Finances

I suspect everyone daydreams about what they would do if they didn’t have to worry about a paycheck.  You may be asking, “How do you, Ted, get to live this daydream?”  Four reasons: the first we had no control over, the other three we did.

No control

1.     Both my wife and I had prosperous and generous parents.  No question, this has been a major reason I have this opportunity. Still, we could have squandered this advantage had we not done the following three things as well.

Under our control

2.     We lived below our means.  When we got married (in 1977 while in graduate school), my wife had some money left over from that saved by her parents for her college expenses.  We put these funds into a money market account (relatively new in the 1980s) and called it our “rainy day” fund.  We did not touch this except for emergencies or investments (eg, a house down payment).  In doing this, we learned a valuable lesson – just because you have money doesn’t mean you have to spend it.  

Physicians are unfortunately prone to errors in this regard, as discussed in this recent NYT article by Ron Leiber.

YOUR MONEY   | August 27, 2011

Your Money: Investment Advice for Doctors: First, Do No Harm

By RON LIEBER

They take eight or so years off from the world to do nothing but learn how to be doctors, then receive a six-figure annual paycheck with no real idea of what to do with it.

3.     We minimized our debt.  This is related to #2.  If we could not afford it, we did not buy it.  We paid off our credit cards in full at the end of the month.  A little over a year ago, we sold our home to move to the parsonage of the church my wife leads (North Ferrisburgh United Methodist Church).  We needed to be near the church community for her work, and our youngest son was about to graduate from high school.  And it is a neat old house with a lovely porch. This eliminated our one remaining debt – the mortgage.

4.     We started saving as soon as possible.   We started our first retirement savings when I was an intern in 1981, and rarely has a year gone by that we did not contribute to our retirement accounts. We have experienced the “miracle of compound interest”.  Our investments were in mutual funds with an eye towards diversification, while minimizing costs.  

I made one major move in 2007 that was providential in hindsight. I switched half of our 403b accounts from equities to bonds.  However, I wasn’t trying to time the market, rather I knew I needed greater diversity at my age.  In 2008-09 when the market crashed, I didn’t sell anything or change my distribution plan. Instead I kept investing in both equities and bonds with the dollar cost averaging approach implicit in bi-monthly contributions to 403b accounts.  I also made additional investments in equities through IRAs in early 2009. We’ve done fine, and I don’t let the daily ups and downs of the market (more exaggerated recently) concern me much.

General approach to finances from here

Our approach from here uses a “bucket system” to smooth out our spending over a projected life span of 99 years.   We have “non-retirement” assets that generate some income, but which I intend to gradually deplete over time. Within this bucket (as in our retirement accounts) we are diversified in cash, bonds, and equities.  Our next bucket is our retirement assets. We will only tap our social security when we reach the maximum age to start distributions, which will ensure the largest per month amount of payment.  What if neither of us lives much longer than 70?  So what?  We won’t care – we'll be dead.  The biggest risk in retirement is to outlive one’s financial assets, not failure to maximize social security returns if you happen to die early.  Therefore, unless you have a terminal disease, its best to plan on living a long time.

My guides for this approach have been many, but the primary teacher has been my father-in-law, Jed Hornung.  It’s interesting to read written sources, but I am always somewhat skeptical.  We only take advice from people who are paid by the hour and who are not on commission or have something to sell.  The two books that I would recommend, with some reservations, are the following.  No, I am not paid to recommend them – I am not trying to make money by blogging.

I Will Teach You To Be Rich by Ramit Sethi (Mar 23, 2009) A book written in an engaging style for “20 somethings”, but with a number of wise points about saving and spending money.  It’s more about starting out than retiring, but for those who are trying to work on the approaches of 2, 3, and 4 listed above it is pretty good, and fun to read.

Spend 'Til the End: Raising Your Living Standard in Today's Economy and When You Retire by Laurence J. Kotlikoff and Scott Burns (Jan 5, 2010)  This is more to the point for those considering “reinvention” and reduced incomes.  Written by a Boston University economist and a columnist, they have a program (which I’ve used) to figure out how you could smooth out your consumption of funds over a projected (long) life span with a given amount of assets taking into account inflation, interest, dividends, taxes, planned costs, etc.  I don’t buy the very conservative suggested approach of having only TIPS (Treasury Inflation Protected Securities), but there are other very interesting concepts and strategies, particularly regarding social security and just the concept of “consumption smoothing”.

So, that is why I think I can do this.  If you start to see ads on this blog, you’ll know I was wrong.