An Alternative to Traditional Retirement: Considerations for Physicians

Most physicians follow or supplement their clinical practice with physician leadership roles, and wind down their careers by scaling back to part time executives or clinical consultants before official retirement. Richard Afable, MD, MPH, FACP, suggests an alternative. After retiring from CEO and executive roles at several large health systems, Dr. Afable now advocates for community well-being and the development of others as the president and board chair of Be Well OC in Orange County. In this episode, we interview Dr. Afable about how physicians can (and should) plan for a type of “third career” - one that focuses on significance and service. He also shares concepts that physicians can consider as they work towards a retirement plan.

This transcript has been edited for clarity and length.

Cheryl Toth: Mike, we are covering a fairly new concept in today's episode. I talked with Dr. Richard Afable about a post-retirement option that is an alternative to part-time clinical work or consulting that you see physicians do.

The idea is the third career. There is the physician's first career phase, which is patient care, and then often there is a second career phase, which is often leadership roles. Then there is this third career phase that Dr. Afable describes, and it is advocacy focus where the physician follows a passion of his or hers and then becomes an advocate for the patient or for the community.

Mike Sacopulos: Very nice. Dr. Afable is really living that third career now after retiring as president and CEO of St. Joseph Hoag Health in Orange County, California.

Toth: Yes, and as the president and board chair of Be Well OC, which is where he is now, he is focused on improving mental health for all residents of Orange County, California.

Sacopulos: Our listeners are going to benefit from what Dr. Afable has to share.

Toth: We are talking today with Dr. Richard Afable, president and board chair of Be Well OC, a public-private partnership working to improve the mental health for all residents of Orange County, California. He is the recently retired president and CEO of St. Joseph's Hoag Health, an IDN based in Orange County and has more than 20 years of medical practice experience as a solo, group, and academic practitioner. Dr. Afable, thank you for being our guest today on SoundPractice.

Richard Afable, MD, MPH, FACP: Thank you for having me on.

Toth: Dr. Afable is a board-certified internist with an added qualification in geriatric medicine. In addition to his role at Be Well OC, he provides consulting services to many of the top health systems in the United States, focusing on strategy and innovation with CEOs and boards of trustees. I should also mention that Dr. Afable, you are currently an adjunct professor and lecturer at the University of California Irvine Mirage School of Business in Irvine. I am curious, what kind of courses do you teach?

Afable: I teach strategic management of healthcare, no surprise, at the business school. Having had a long and successful career as a physician executive, I am now doing that with MBA students at the Mirage University of California Irvine, Mirage Business School.

Toth: That is great. Well, for our conversation today, we are going sort of outside the typical leadership track, the topics that we cover here on the podcast, and we are going to talk about the possibilities of physician leaders to have a third career. Dr. Afable, this is something you have been giving some thought to and out there talking about. Give us an overview of this. I mean, what led you to focus on this idea of a third career for physicians?

Afable: Well, thank you, Cheryl, for the opportunity to discuss this idea with my colleagues with the American Association for Physician Leadership. The idea came to me as I observed myself. I observed myself transitioning from my second career as physician executive to the third element of my future, my career, which I thought was going to be some form of retirement. I was not sure what retirement was other than you stopped getting paid and you stopped being responsible for things. I knew I was going to remain busy; I knew I was going to do some things and had to have meaning in my life. I began to fall into, almost accidentally in many ways, activities that are of great substance and require a good deal of my time and a good deal of my talent and experiences.

It just came to me that I am in my third career. My first career was clinician. I spent almost 20 years practicing internal medicine in geriatrics and then teaching internal medicine in geriatrics at Wake Forest University as well as Northwestern University. Then by accident, and this is the case for many physician executives who are a little long in the tooth, like I am, I fell into executive work when somebody asked me to do some administrative activities while I was at Wake Forest University. Then I subsequently had an over 20-year career as a physician executive, chief executive of a hospital, chief medical officer of a large system on the east coast, and then chief executive of a medium-size at that time, large integrated delivery system here in Orange County, California made up of seven hospitals, over 10,000 physicians, almost 20,000 employees, over $3 billion of revenue. Here, I find myself as the chief executive officer of this large health system.

Then it is time for me to move on because transition needed to happen within the organization. That is a reality. After the transition, I am moving on to what would be historically called retirement. I find myself today, I'm sure we're going to get into it a little bit, Cheryl, I find myself today as busy as ever doing work that I think has great meaning from not only me, but for the community that I'm in and the community that I'm serving. I like to call it, I have moved from a very successful clinical career and a very successful executive career to now what is a third career, and thus coining the phrase third career for physician leaders. A third career that is more about significance than it is about traditional success, which is oftentimes measured in monetary terms or in titles. This is measured more in significance and outcomes that are more beneficial to others than they would be to myself or those who I am specifically working with. That is the framing. I hope that makes some sense.

Toth: Yeah. Well, this idea about significance, tell us about where your projects are taking you and what you are doing now that is bringing this significance. I know you are doing some work in mental health. Is that part of it? Tell us about that.

Afable: Yeah, it is definitely part of it and it is, for me, it is the significant work that I am now engaged in. Oftentimes, when you are in your third career doing this significant work, you may not get paid. That is an important part of the third career is that you may not receive remuneration for the work that you are doing like you did your first or your second careers. We can get into that more deeply if you would like to. The good news is that when you are in this stage of a career, when you're in this third career phase, most times, and hopefully, you planned well, most times your monetary reward is not the reward you're looking for, and that's that success to significance piece. Back to your question, the area that I saw great need in my community, by the way, this is common in every community, was in taking a not very well-done, disorganized, disintegrated system of mental health services, both for mental illness as well as substance use disorders, and envisioning it as something very different.

Envisioning it as an ecosystem, as an organized system that provides for the needs, the caregiving needs, and the care receiving needs of every person in our community. We have three million people here in Orange County. Every person who needs mental health services deserves to get what they need when they need it, and from whom it could be best provided. Like most communities in the United States, ours is anything but that today. We started Be Well Orange County, it is a public-private partnership that is envisioning a better way to provide mental health services in our community. Emergency rooms are not the place for people to receive acute crisis mental health services, both for substance addiction as well as mental illness. The other place that absolutely should not be used for treatment of people with mental illness is jail.

By the way, the primary place in every city in this country where people with mental illness are treated when they have a crisis is emergency rooms or jail. We are changing that. I am involved in and am a primary mover of the leadership of that transition and that transformation from the current system, which does very well to a very new transformed system that will have outcomes of great significance, back to that word, to this entire community. I find myself now in a career moving that vision and moving that ball down the road, down the line, and it is my work now. It is what I do. It is my third career.

The one thing I found is that I was not prepared for this. I did not know what I would need to do. I did not know how I could prepare for it. By the way, I was not intentional as I was winding up my second career to move into my third career. I think it is really important. In hindsight, I wish I had trained or learned what I needed to learn to get ready to do this. I wish I had been very intentional about my third career, and that is one of the reasons I wanted to speak to you and to the AAPL members is let us be thoughtful and intentional about preparing for our third career. Because physician leaders, especially physician executives who have been very successful in their first and second careers are not going to do well just fading out into a retirement in which they are doing self-centered and self-directed activities. I just know my colleagues, that is not going to work for them, and that can lead to problems. I think being very intentional is a good way to go.

Toth: Good. Let us park that for a second because we are going to come back to that. I am curious though, you have talked about what you are doing in this third career, that it is not compensated. How did you get to this Be Well OC? I mean, what led you to this passion? Clearly, you are very passionate about this topic and there is a fire in your belly about making this change and having great outcomes around it. How did you get here? How does an internist with a geriatric’s focus end up in this mental health area?

Afable: It was more my second career that led me to the third career. My second career as the chief executive officer of a major hospital system in our community allowed me to see the need. What led me there was seeing the problem, which is what led me there, and I knew there was a problem there. We had fixed the need for cancer care, not that we fixed cancer, we just fixed the system so they work. We fixed stroke, we fixed heart disease, we fixed joint replacement. No one was paying attention to mental illness, no one was paying attention to substance use disorders. We were reacting to the need rather than leading our community down a better way to treat these problems. When I came out of my second career, I said, it was very clear to me somebody needs to pay attention to this, so I did, and I just spoke up.

That is all I did was I showed up and I spoke up and I said, "We could do this better." I gathered some people around me who had similar passion and believed what I believed. Today, we have over 200 organizations, public and private, that are part of Be Well Orange County. We are into our third year now moving down the path of creating an incredible ecosystem of care and doing some things like capital investments in new facilities, being a system of digital health that allows for us taking to scale the ability to get to every person who needs it, including the homeless, for example. Including people who do not normally have access to care, we are building a way for that to occur. Like I said, everybody deserves to get the care that they need, and we are building a way to do that. What happened is I saw it, Cheryl, that is how it happened. I saw the need and I stepped into it.

Toth: Also, I find this really interesting because in thinking about how to be intentional, which we'll get to in just a second, you're really saying that this kind of bubbled up for you in that second career and you saw it as a need, and it was something that you were passionate about. Any reason that it spoke to you as a passion?

Afable: I think physicians are innately drawn to unmet needs and open opportunities to make something better. We are naturally drawn to that. In that innate sense of where is the need, whether it be for an individual patient or whether it be for a group of patients or for a community, we need to do that. My training as an internist and as a clinician drew me to a natural attraction to fix a problem. That is what happened, I saw the problem, and I saw it in a way that maybe others could not see it. I also could see solutions because in my work as a physician executive, and this is work that the AAPL does on an educational basis, on a pretty regular basis, is it teaches to learn how to be a solution, to create solutions for problems that occur and to do it in a very organized way that leads to resolutions of those problems. It was easy for me; I fell right into it.

Toth: If we think about being intentional, as you pointed out earlier, what does that mean for physicians who are maybe at the midpoint of their career looking already saying, hey, that third career is coming, and how can they be more intentional?

Afable: Sure. I think we have a good prototype for that, which is the AAPL, which is helping physicians who want to move from a mostly clinical role to a not necessarily typical physician executive or leadership role, but the reason are attracted to and participate in the AAPL is because they want to move and be intentional about moving from purely clinical work to a lead role. Leadership means affecting others and affecting the environment that we work and live in. That is what they do. Our members already know what intentionality means. That is why we learn quality, we get a master's of quality from Jefferson to AAPL et cetera, et cetera, so that's intentionality. What I am suggesting is that as we tend towards the end of our physician leadership career, which may still include clinician work, by the way, and probably commonly does, that we should begin to plan for that transition and there are things that we can learn.

For example, how do we define significance? Let us have a definition of that for us personally. What will cause us to have meaning in our life as we move from that set to our third career? That transition is going to happen whether we plan for it or not. Let us just plan for it and let us make sure that we have understood how we can transition. For example, you need to have finances in order. You need to work until the end of your life. If you need to work until the end of your life because you have not planned your finances well, you cannot go into your third career. You are going to have to stay in your second career, which is working for a living and doing something to support yourself. Nothing wrong with that, it is fine. That is an example of what I mean to be intentional.

Defining significance, having your economic life in order, and understanding how you can go about this significant work. Examples, you could be in governance, you could move to roles of governance within higher education, within medical training, within community organizations. You could also get into mentorships. You could organize yourself around them. When I may be intentional, do not just say, do not just put the word out there that if anybody needs a mentor, I am willing to mentor you. That is not being intentional, that is called luck or hope. By the way, luck and hope are not strategies. Have a strategy as to how you are going to transition into your third career. I felt it, but I could have been much more strategic about it. Yes, I was fairly strategic about it, but I did not really package it or make it into an intentional action, and I could have been more organized in my thought process. That is what I mean by the intentionality of it.

Toth: One of the things I really picked out from your comments is an action step that any physician could do right now is to really start thinking about what does significance mean to them? What now are they going to think? Then, the second action step, I guess, is making sure you have things in order or can get things in order to bring about that significance later in their career. You were talking about having a strategy for thinking about this third career and that you really did not have the opportunity to do that. Give us some lessons learned here and how would you suggest physicians thinking about this or who are intrigued by this third career go about putting together a strategy?

Afable: As I had mentioned, I fell into my second career almost by accident some 25 years ago and moved from a hundred percent clinical to half-time clinical and half-time administrative and then moved a very successful time in administrative career as a physician executive. That was fortunate, and as I had mentioned, it is not a strategy. I should have gone through a process, a process that the AAPL provides physicians who are interested in that sector and are moving. As you know, many hundreds, if not thousands of physicians are moving in that direction today and doing so very, very successfully. The AAPL, previously the ACPE, gave us a way by which we could do that and take that action. Today there is no way to move from that second career to the third career. It is all up to the individual then, it is up to the individual physician leader and executive to be intentional.

What I would say is rather than just hope that something good happens to me as I retire from my second career, what I would say is be very intentional, strategic, about moving to a set of actions that we'll call a third career that will take you to that significant work. What that means is you have to sit down and define significance for yourself, what has meaning for you. Just like you did for your first career, you wanted to be a doctor. For your second career, you wanted to be a leader. Your third career, you want to advocate and provide for predominantly those things that will be meaningful to you, which most times for us, just to be clear, will be in helping others and doing some things that you couldn't do in your first or your second career. For me, transforming how mental health care is provided in a community.

Being very intentional, sitting down, and then you have to ask the question, what do you need in order to make that transition? It might need to be education on governance. It might need to be education on influencing others. It might be learning emotional intelligence, for example, that EQ stuff that maybe you did not really do very well in your first career and maybe you picked it up in your second, but maybe you need to know more. Because what's interesting, Cheryl, is that I am in my third career. I am not in charge of anything. I am not the responsible party or in charge of anything, but yet, in my third career, the work that I am doing is influencing an entire community of three million people. How do you influence without power? How do you influence without title? Those are things that need to be learned. You do not just pick that up naturally.

Toth: Now let me stop you right there, because we know that there is not a lot written out there. You have mentioned AAPL and some coursework perhaps out there, but what are some resources, books or things that maybe are not specifically about the third career, but learning about EQ and understanding how to lead without a title. Any thoughts about resources for doctors who are listening, what they could use themselves?

Afable: I cannot be specific at this point, but there is a curriculum that is necessary to be successful in this third career, just like there was for the second career, and there is no doubt there was one for the first career, also known as medical school and residency. It needs to be a curriculum for getting physicians to a level of success in this third career. I have ideas of what that curriculum should be and can be. I think the AAPL is giving that some thought as well right now. Rather than being specific, let us just say there is a curriculum, and it depends upon how you define significance, what direction you think you are going to be going.

I gave some few examples, mentorship, governance, organizational development, community benefit creation. Those would be examples of significant direction. Then understanding what the curriculum would be to get you to a level of great influence and competency in that third career going forward. Maybe the curriculum is going to be different for every physician going into this third career. However, I think there is a core, and you used an example, so did I, of influence and the emotional intelligence piece. That is a really important part of it. I think that curriculum will be consistent. The nuances around your individual decisions and your individual direction will decide what additional curriculum elements would be included there.

Toth: Have you read any books that you think have helped you? Let us call it outside of healthcare, outside of academic curriculum, any books you would suggest that have been beneficial for you as you have moved into your third career?

Afable: Well, it is interesting that you ask that because I just finished reading a book about Thomas Jefferson. My reading on this book of Thomas Jefferson is why we hold the third president of the United States up in great high regard as if he were greater than most, if not greater than all in leading our country. He was much maligned. By the way, Aaron Burr was just as likely to be the third president of the United States as he was. What made him great was not his title and not his background, but rather in hindsight, what he did as a leader for our country. I think reading about other great leaders and understanding how they got to where they are and the path that took them there. How they developed their plan to lead.

Jefferson was not looking for the title of president. Jefferson was looking to make the greatest country that this world has ever known. That was his vision and that is what he did. As opposed to George Washington who did not want to do any of this. They forced him into doing it. Jefferson had the vision and then understood how to make that happen. That is the kind of reading that I think is important for physician executives and leaders as they move into their third career is that is a form of mentorship, is reading about others who have done this and done it because of their intentional directionality and vision of making something better. That would be an example of what I would build into a curriculum as we talk about planning for the third career.

Toth: I think that's a terrific idea because when you look outside of your immediate, where you're headed for that significance, in this case politics and a president's life and leadership, I think you glean all kinds of ideas that you just may not have even thought of. That is great advice. Other advice for those young physicians who are listening who have maybe in the first five years of their first career, what can they be doing now? Anything to be thinking about that third career or do you think it is just too far off for them to put any thought toward this or put things in place for themselves?

Afable: Well, thank you for that question. I have been thinking about the young physicians, especially those who are transitioning from a clinical career to an executive career. We will call it more of a leadership standard related career, is mostly if not purely clinical physician move. Do they need to move to a third career or is a third career available to them? The answer of course, is yes, but I think it'll be much more difficult to move from a purely clinical career to a third career that is more about advocacy and significance and less about success because it's in the role as physician executive, that second career that most of our AAPL members are either in or striving for, that you begin to learn more of an organizational-based level of measures of success and understanding what success means in a broader sense for a larger group of people.

That understanding and that experience, that experience allows for the third career, which is moving fast to significance and influencing large groups of people in a significant way that allows one to do that. I think physicians, if you are going to stay in a pure clinical role, I would say understand your measures of success well. Those measures of success are predominantly going to be around you and an individual patient. Nothing wrong with that. In fact, that is what we do and that is how we do it. That is our primary way of using our medical degrees. For those young physicians and who have chosen to move into physician leadership/executive work, there will be a time in which, probably 20 or 30 years down the line, they are going to be in a position and a place where they can begin to think about that third career.

Remind themselves when they are younger that they are going to be making that transition and to begin to understand that is what that transition is going to be. Knowing it 20 years ahead of time will help you greatly to know when the timing is right. A lot of this is timing, by the way. I am not suggesting that everybody should retire and move into their third career. Maybe some people should just stay in their second career for as long as they possibly can. Nothing wrong with that. In fact, that is very admirable, to be sure.

Toth: Well, and I think there is a nice pearl in what you just said for those physicians who do want to stay in the clinical side of things. That's okay, but maybe they don't have to take on a physician executive role, but perhaps they serve on a committee, or they do something in the local community that's a service, work on a board or something that gives you the perspective that's a non-clinical one, which can then also lead you to that third career and provide some context and skill.

Afable: It definitely can. Those are individuals who are mostly clinical and are more than part-time or more than supplementary time in physician executive work. There are gradations of that second career, are there not? The great thing about being a physician is that it gives us that kind of freedom that it is not all or none. We do that very well because I know most of my colleagues are some pretty smart women and men, and they are very capable of doing these sorts of things.

Toth: Well, this has been a fantastic conversation, Dr. Afable. Last couple of minutes here, what are your final thoughts for physicians out there who have had their interest piqued by this conversation? What is your advice?

Afable: Well, thank you again for the opportunity to speak to my colleagues in the field of physician leadership, to be sure. The opportunities that exist now for physician leadership and physician influence are greater than ever. The timing of this interview in the middle of a pandemic just brings out the great opportunity that we have as a profession to lead and to have significant impact on the health and well-being of our entire communities, which is really what we do innately as doctors. Embrace this time, embrace the change, understand that this is the best of times for physician leaders, not the worst of times, and also, a time of great responsibility. That includes those who are ending their second career, those who are approaching the time when maybe they were expected to retire and fade away, this would not be the time. This would be the time to embrace it fully, to embrace that third career that can really maintain their significance in the lives and well-being of people and their entire communities.

Toth: Well said, Dr. Richard Afable from internist to physician executive in large health systems and IDNs to now working to solve the mental health crisis in Orange County and do that for providing a framework for the rest of the country. I love your passion around this topic, and we are so glad that you joined us today and took some time to talk with us. Thank you.

Afable: It has been my pleasure. Thank you so much.

Listen to this episode of SoundPractice.