The Fourth Quarter
An essay delivered to the Kit Kat Club By Terry Davis May 18, 2010
"The Fourth Quarter"
"Are you still working full time?" The question grated on me, especially “still”. At 69 years of age, I hear the question more and more often. I am a recovering heart surgeon – a pediatric heart surgeon. Of course, I am also a husband, a father, a brother, and have many other roles which are equally, if not more important to me, but those other roles have evolved slowly over time. I had many years as a husband before I became a parent. I had decades to adjust to the role of a father before the first grandchild appeared. By that time, I was prepared to be a grandparent. But seven years ago, when I retired from surgery, that part of my self-identity went over a cliff. I remember the autumn I could no longer think of myself, or describe myself to others, as a heart surgeon. It was a casual conversation; no big deal. Three men were standing in a circle at a football tailgate party; each had an identity: a real estate developer; a franchisor for a rapidly developing business, and . . . me. Who was I? What did I do? I was no longer a heart surgeon. That show stopper was no longer available to me. Part of the problem was that I loved being a surgeon. For 35 years I had a great time. It was challenging, exhilarating, and, for the most part, fun. Of course, there were tough times: operations were not always successful. The hardest thing for me was leaving the operating room, knowing that I had to tell mom and dad that their baby died. But most of the time we were successful. It would have been great to have been a surgeon forever. Nonetheless, I was always aware that a surgeon, like a professional athlete, has a finite life span. As the clock ticked down on my surgical game clock, I knew it was time for retirement – time to move on. I had seen too many of my colleagues hang on too long – to the point they had to be encouraged by others, or the system, to put down the scalpel. I was determined not to let that happen to me. So I made the decision to retire from surgery. In the process I noticed a curious thing about myself: I had no problem giving up doing the surgery – I had been there, done that, got the tee shirt, and I was ready to do something different. On the other hand, it took me a while to understand I was having a real problem giving up being a surgeon. I had no clue how much of me was tied up in that professional identity. Increasingly, I found myself getting annoyed at little things."I almost backed into your little red car again today" my wife Barb said curtly one evening. Last summer I had bought a little red 1982 Fiat Spider convertible. I did it on a whim, because it just looked like fun. We had no room for it in the garage, so it sat out in the driveway, covered in the winter. Barb had always thought it frivolous, and took every opportunity to remind me when it was an inconvenience or when I had to pay for maintenance on it. "It's not that hard to see; I can't imagine you're not used to it by now" "It just seems so silly – hard to justify." "The only damn justification I need is that it strikes my fancy" I snapped back, and grabbed my jacket. “I'm taking a walk.” After several months I figured out what was really bothering me about how my world had changed. When I was an operating surgeon, if there was something that was not quite right – let’s say I didn’t quite like the feel of a particular hemostat in my hand (it was too stiff, or the ratchets didn’t release exactly the way I wanted) – a word to my team and that particular hemostat would be gone. No questions asked. A new one would be there for me to try the next case. I had control. I didn’t necessarily have control over the outcomes, but I was in control of my environment. Those days were gone, and apparently, I missed them.There was another, perhaps more existential reason why was I having so much trouble giving up that part of my identity. It has to do with how I chose surgery in the first place. I was never very good at sports. I went to Williams College, which is quite small. Short and squat as I am, one may wonder how I made the Track and Field Team as a pole vaulter. I got into pole vaulting because, until I joined the team, we only had two pole vaulters. At a track meet, in pole vaulting there are three places up for grabs: first, second, and third. And third place was worth a half point toward the team total. It turns out we played several other small colleges that had NO pole vaulters, so there was a third place to be had for anybody who could get over a bar at any height using a pole. I got my letter jumping heights with a pole that most of my classmates could get over without a pole. So, although I was on the team, and I got my letter, I never felt like I had really earned it by actually being good at the sport. So I always longed for more – to be a real athlete. Fast forward to the end of medical school, when I had to make a fundamental choice between going toward medical type specialties (e.g. internal medicine) vs. surgical type specialties (e.g. heart surgery). I couldn’t help notice that when I rotated on the surgical services, they all:1) wore uniforms2) had teams that they led3) sweated4) had real lockers in real locker rooms! That is how I got into surgery. Some exciting role models early on were heart surgeons. At that time coronary artery surgery was emerging as the next best thing, so my initial training heavily emphasized adult cardiac surgery. But it was the loss of our middle child, Leah, to congenital heart disease at only five weeks of age that made the pediatric branch of heart surgery particularly compelling. We had no idea she was anything but completely normal. Her color seemed a little “off” from time to time, but it was the winter, so we thought maybe she was cold. Then one evening, while Barb was feeding her, she suddenly stopped breathing and went limp. Barb screamed for help, and I ripped our two-year-old son out of the bathtub and did CPR on Leah as we sped to the closest Emergency Room. Although we were able to resuscitate her, the news was very bad from the cardiac catheterization: she had a heart malformation called “hypoplastic left heart syndrome”. She was missing half of her heart. In those days there were no options. That disease was uniformly fatal. After her death, as was the routine in our family, we were heavily medicated and encouraged to move on. We did not have a funeral or any sort of recognition of the event, until over a year later. We now know that is not a reasonable approach. Some innovative surgical techniques for treating Leah’s problem had just begun emerging, and I felt that I had a little score to settle with “Mother Nature” if I ever got the chance. And so, I became a pediatric heart surgeon. Timing is everything. Thirty years later, as I was getting ready to retire, new ways of dealing with Leah’s defect, as well as other heart malformations were finally making a difference. My successor and the team that he has developed are now able to deal with these problems with considerable success. I left the field just as we were figuring out how to solve the very same problem that got me into the field in the first place. So, I lost my identity as a surgeon, at the same time I gave up my lifelong desire to be something like an athlete. I cast around for ways to understand what was happening to me – some framework that could provide me with guidance necessary to navigate these apparently treacherous shoals around and ahead of me. There are mountains of literature on the transition to retirement, but many are how-to books that may work for the particular author, but not for me. The dawn came slowly, as, bit by bit, a helpful metaphor emerged. Since at least part of how I ended up as a heart surgeon was rooted in my unrequited longing to be the athlete I never was, I began thinking of the stages of life in athletic terms. My favorite spectator sport is college football, so I have begun to view life as a football game with four 20-year quarters. The first quarter (age 0-20), we’re just figuring things out – who are we? What works? What doesn’t work? The second quarter (age 21-40) we are making things happen. We are settling into whatever roles we have chosen; making our case. The third quarter (age 41-60) we are positioning for the final push. This quarter is when we have established ourselves, and are making our reputation. Whether we are tied up in some kind of business or profession, or as a full-time parent, we are consumed with “making it happen”. Then comes the 4th Quarter: the best part of the game. If you could only view one quarter of a football game, which one would you choose? For me, it would be the 4th Quarter, where everything happens; the game won or lost. It’s where the action is. The clock is a factor, and, as time goes on, a bigger and bigger factor. There is always overtime, but for the sake of this essay, we’ll stick to regulation play. I have become a student of the 4th Quarter, because that’s where I am, and also because it’s the best part of the game. The following is a strategic analysis of life’s 4th Quarter: how to work with the clock, some penalties to avoid, and making sure you win the game. To begin with: what is the point of a game – any game? To Win! And how do we win? By scoring the most points! So, for this metaphor to make sense, we each have to know what those points mean for ourselves. What is most important to us? Money? Security? Longevity? Relationships? One way to answer this question is to ask yourself, in a quiet and private space and time: “What do I want out of life?” Take a moment to answer that, writing down the answer. Then ask yourself a follow-up question: “What do I really want out of life? Be honest. The answer will likely differ from your answer to the first question. Write that down. Now: one final question: What do you really, really, want out of life? There is no right or wrong answer. But, if you were honest with yourself, you just defined what the points mean in your game of life, what you are aiming for. I will discuss some of my thoughts about how to use the rules of the game to maximize your chances of making those points in life’s 4th quarter, however you have defined them. I will also discuss some penalties to avoid because they will keep you from getting to the goal line.
Flag on the Field First, let us consider “a flag on the field”. The yellow flag is a part of the rules and regulations of football, and is an interesting concept. If a referee sees a violation of the rules while a play is in progress, he can throw a yellow flag on the field. This means the play can continue until its natural conclusion, and then he will sort out the penalties, if any. There was a flag on my field early in the 4th quarter. I wanted to stop doing cardiac surgery the day my replacement arrived, but I was struggling with what to do next. So, for a while, I continued doing non-heart chest surgery, and, while doing so, moved into a new career of hospital administration. Through the years, I had held some administrative posts (Surgeon-in-Chief, Administrative Surgical Director, and others). Our hospital needed someone with clinical experience to join their administrative team, and over time I have ended up working with a very talented group of people and having a great time. So far it is more of a re-wirement than a retirement. I still leave for work at 6:30AM and get home at 6PM, but the rhythm of the day is very different.Another unintended consequence of my decision to retire from surgery was the effect on my mission work. Many of my most significant rewards in life had come from mission work, helping heart surgical teams in third world countries become self-sufficient. But this avenue was not longer available, since I was no longer an active surgeon. This turned out to be a wonderful opportunity for me to get into a new area of mission work. But what? The invitation came without any searching on my part, and from an unlikely source. An Anglican priest from Kenya, John Nganga, was at our hospital being trained in Clinical Pastoral Care. He was passionate about helping AIDS orphans in his native Kenya. He stopped me one day in the elevator because he had heard about previous work I had done. He asked for advice about how to get started. What followed began a six-year journey which started on an empty field in Kenya, and has ended up with an orphanage and a working farm, which, despite ongoing struggles common to all such entities, is providing food, shelter, education, emotional and spiritual support to AIDS orphans in Kenya. Who knew where that serendipitous elevator conversation would lead? The flag on the field early in my 4th quarter allowed me to continue to re-define both my professional life and to allow me to find new focus for my mission energy in a way that did not involve surgery. It allowed play to continue while I sorted all this out. The flag has been picked up, and play has resumed. Time Out Another part of the rules and regulations is the Time Out. Anybody can call a Time Out, and it shuts down the whole game for everybody. Why are Time Outs called? It depends on when, in the game, it is called. For the most part, until late in the game, Time Outs are called to gain clarity (there are too many players on the field, the quarterback sees a defense he doesn’t recognize, or the coach is signaling a new play from the sidelines). Calling a Time Out allows the team to re-group, make a plan, and gather appropriate resources. My form of Time Out has been the Silent Retreat. This is a very specific exercise. Two to three days are spent just being silent, being with yourself: no radio, no TV, no talking, no Blackberry, no laptop, no email. The setting is pleasant, perhaps a hermitage or other type of Retreat Center. There are many to be found. You can listen to classical or meditative music if that helps to detach. Walking is encouraged, and, of course, journaling. I have found this to be a very useful way of gaining clarity as I have looked forward at various stages in life. At the age of 69 I am just about half way through my Fourth Quarter and just did a Silent Retreat during which time I was able to attain some clarity about what this time is all about for me. It took me a couple of days to put words around what I am facing: a fundamental shift in how I view myself. For most of my professional life I have viewed myself as being essential. I didn't think anyone could take my place. Of course that wasn't true, but I acted as if it was, and somewhere in the back of my mind I believed it. I reflected on days in recent weeks when I felt good, and days when I felt uncomfortable. As I looked at my schedule, it became clear that I felt best on days when I had lots to do—I was busy; engaged. The days that I was a little grumpy: they were empty with few commitments. Besides losing “control” I became aware that I need to come to grips with the fact that I am no longer essential. I need to settle for simply being relevant. This is a significant shift in how I view myself. On good days, I embrace it. But, from time to time, I find myself slipping into my old mindset. Returning to football: toward the end of the game, the Time Out is used for a very different purpose: to stop the clock if you’re behind. The Time Out does just that: it stops the clock to give you time to squeeze in more plays. The problem is that there are only a limited number of Time Outs. Once they are used up, there are no more. One reason for wanting to stop the clock in the 4th Quarter may be that 20% of men 55-64 are delaying retirement because of decreasing values of their houses. That is a good use of a Time Out. But remember, there are only a finite number available.Now, let’s talk about some of the penalties to avoid, particularly in the 4th Quarter. Unnecessary Roughness This penalty is called if, after a play is over, you unnecessarily crush your opponent – hurt them with a big tackle or twist their helmet. When called, you lose both yardage and a down, so your quest for points is really damaged. I have seen this penalty called on numerous occasions in my 35 years in academic medicine. All told, I have been through seven college presidents, eight deans, and ten department chairs in my career. In the fullness of time each of their careers have concluded. Some ended well, gracefully, and some ended incredibly poorly. Activity which could draw this penalty includes, but is not limited to, trashing one’s successor in an attempt to make him or her look bad, in order to make yourself look good by comparison. I have never seen this work, but have surely seen it backfire. Badly. I am not clear why I see this penalty called so often in medicine. I suspect it is common in other professions as well. Delay of Game When you are ahead in the game, it is tempting to use delaying tactics to keep the clock moving. In football, there are rules against excessive delay because this can make the game boring to spectators and sponsors. So, a team is allowed only 25 seconds from when the clock starts after the previous play to put another play in action. If the next play doesn’t begin by that time, the Delay of Game penalty will cost five yards. Efforts to artificially keep the game going in life’s 4th quarter surround us. Our society is heavily invested in our wanting to “delay the game”. We worship youth, and a youthful appearance. We are implored to color our graying hair, buy some side-by-side bathtubs for the backyard (I still haven’t figured that one out), and to fight any emerging wrinkles on our shopworn bodies. Some of things we try to do to “stay young” are, in fact, good for us and keep us healthy. Exercise, biking, and walking are activities which keep us in shape. If that is our motivation, we are winners. But if we are trying to preserve the illusion of youth in the 4th quarter, we could end up with a five-yard penalty for delay of game. I hasten to add that, as penalties go, five yards is not huge. If a little hair coloring makes you feel better about yourself, go ahead and do it, take the penalty, and move on. Two Minute Drill When you’re out of Time Outs, and there are just two minutes left in the football game, it is time for the two-minute drill in an attempt to get some last-minute points up on the board. This is a hurry-up offense, with no time for huddles, an immediate snap of the ball, and a number of tactics to squeeze the most plays possible into the last two minutes. The most remarkable two-minute drill I have ever witnessed in the game of life was executed by Lila Brewer, my mother-in-law. At the age of 96, she had all of her mental facilities, but her body was way into overtime, out of Time Outs, and she knew it. She summoned Barb to her bedside and asked for her help to complete her “to do” list in her last few days. They were able to do it all. She said goodbye in person to each member of the family, and gave away all of the modest amount of money she had to her family, so she had the joy of seeing them receive it. She had already planned her own funeral service. She was not the least morose. On the contrary, she was full of joy and hope for her future, when she would join her husband, Mel, who passed away the year before. In the end she drew her last breath peacefully, painlessly, and without anxiety or fear. Now that’s a Two Minute Drill to be proud of. It is a common observation in football, that when the two-minute drill succeeds in turning the game around, people always ask: “why didn’t they do that sooner”. Sometimes that’s a very valid question, but the reality is, the pace of the two-minute drill is so demanding that it couldn’t be sustained throughout the game. It is the same thing with the game of life.
I had a strange dream the other night. In my dream, I was watching Lila's game on TV. She had just completed her two-minute drill . . . and won. The commercials preceding the post-game interviews had begun to air. The Bud Lite ad featured sleek and beautiful young women surrounding a tub of ice chock full of Bud Lite being handed out by perfectly sculpted young men. Everyone was laughing. It was sunset on a tropical beach. As I switched the channel back from Lila's game to my own, I heard the whistle screech and realized I had drawn a penalty! What could it be? "Delay of Game" the referee shouted, to the roar of the crowd. "Delay of game?" I defiantly shouted back. "Wadayamean, Delay of Game? I retired from surgery gracefully seven years ago! Wadaya want?" "You're still workin’ – full time. When're you gonna slow down and start thinking' about winning the game? "I am winning! I'm gainfully employed, having fun, doing my thing!" Out of the corner of my eye I saw my coach draw his index finger across his neck indicating that I should knock off arguing with the referee. I was confused. I made the T sign with my hands, and called a Time Out. The whistle again screeched; the clock stopped. "Omigod! How many Time Outs do I have left?", I thought as they cut away to a Miller Lite spot. I woke up in a sweat thinking about how to win the game. It seems to me that the most important points in life, in the end, are about relationships: family and friends. Lila won because she was able to end up surrounded by both. Her two-minute drill did much to repair and embellish those relationships, which persist and continue to function well beyond the grave. So, I want to begin to make decisions and plans with that in mind. I Think I'm a long way from my two-minute drill, but I need to remind myself that my Time Outs are limited. Even though I'm not ready to quit my work yet, I probably need to emphasize more of the "life" part in the "work-life balance" equation. The time will surely come when it will be time to quit. It's hard for me to imagine life without the structure of work. That will be a whole new game. I will, indeed, move from being essential to simply being relevant whether I want to or not. And, if I'm lucky, and work at it, a new focus on "being" will replace my current emphasis on "doing". I wonder what that will feel like. I also wonder who might sponsor my game on TV; or if the ratings will be good enough to support network coverage. I don't imagine there would be much interest from the all-important 18–34-year-old demographic.
"Are you still working full time?" The question grated on me, especially “still”. At 69 years of age, I hear the question more and more often. I am a recovering heart surgeon – a pediatric heart surgeon. Of course, I am also a husband, a father, a brother, and have many other roles which are equally, if not more important to me, but those other roles have evolved slowly over time. I had many years as a husband before I became a parent. I had decades to adjust to the role of a father before the first grandchild appeared. By that time, I was prepared to be a grandparent. But seven years ago, when I retired from surgery, that part of my self-identity went over a cliff. I remember the autumn I could no longer think of myself, or describe myself to others, as a heart surgeon. It was a casual conversation; no big deal. Three men were standing in a circle at a football tailgate party; each had an identity: a real estate developer; a franchisor for a rapidly developing business, and . . . me. Who was I? What did I do? I was no longer a heart surgeon. That show stopper was no longer available to me. Part of the problem was that I loved being a surgeon. For 35 years I had a great time. It was challenging, exhilarating, and, for the most part, fun. Of course, there were tough times: operations were not always successful. The hardest thing for me was leaving the operating room, knowing that I had to tell mom and dad that their baby died. But most of the time we were successful. It would have been great to have been a surgeon forever. Nonetheless, I was always aware that a surgeon, like a professional athlete, has a finite life span. As the clock ticked down on my surgical game clock, I knew it was time for retirement – time to move on. I had seen too many of my colleagues hang on too long – to the point they had to be encouraged by others, or the system, to put down the scalpel. I was determined not to let that happen to me. So I made the decision to retire from surgery. In the process I noticed a curious thing about myself: I had no problem giving up doing the surgery – I had been there, done that, got the tee shirt, and I was ready to do something different. On the other hand, it took me a while to understand I was having a real problem giving up being a surgeon. I had no clue how much of me was tied up in that professional identity. Increasingly, I found myself getting annoyed at little things."I almost backed into your little red car again today" my wife Barb said curtly one evening. Last summer I had bought a little red 1982 Fiat Spider convertible. I did it on a whim, because it just looked like fun. We had no room for it in the garage, so it sat out in the driveway, covered in the winter. Barb had always thought it frivolous, and took every opportunity to remind me when it was an inconvenience or when I had to pay for maintenance on it. "It's not that hard to see; I can't imagine you're not used to it by now" "It just seems so silly – hard to justify." "The only damn justification I need is that it strikes my fancy" I snapped back, and grabbed my jacket. “I'm taking a walk.” After several months I figured out what was really bothering me about how my world had changed. When I was an operating surgeon, if there was something that was not quite right – let’s say I didn’t quite like the feel of a particular hemostat in my hand (it was too stiff, or the ratchets didn’t release exactly the way I wanted) – a word to my team and that particular hemostat would be gone. No questions asked. A new one would be there for me to try the next case. I had control. I didn’t necessarily have control over the outcomes, but I was in control of my environment. Those days were gone, and apparently, I missed them.There was another, perhaps more existential reason why was I having so much trouble giving up that part of my identity. It has to do with how I chose surgery in the first place. I was never very good at sports. I went to Williams College, which is quite small. Short and squat as I am, one may wonder how I made the Track and Field Team as a pole vaulter. I got into pole vaulting because, until I joined the team, we only had two pole vaulters. At a track meet, in pole vaulting there are three places up for grabs: first, second, and third. And third place was worth a half point toward the team total. It turns out we played several other small colleges that had NO pole vaulters, so there was a third place to be had for anybody who could get over a bar at any height using a pole. I got my letter jumping heights with a pole that most of my classmates could get over without a pole. So, although I was on the team, and I got my letter, I never felt like I had really earned it by actually being good at the sport. So I always longed for more – to be a real athlete. Fast forward to the end of medical school, when I had to make a fundamental choice between going toward medical type specialties (e.g. internal medicine) vs. surgical type specialties (e.g. heart surgery). I couldn’t help notice that when I rotated on the surgical services, they all:1) wore uniforms2) had teams that they led3) sweated4) had real lockers in real locker rooms! That is how I got into surgery. Some exciting role models early on were heart surgeons. At that time coronary artery surgery was emerging as the next best thing, so my initial training heavily emphasized adult cardiac surgery. But it was the loss of our middle child, Leah, to congenital heart disease at only five weeks of age that made the pediatric branch of heart surgery particularly compelling. We had no idea she was anything but completely normal. Her color seemed a little “off” from time to time, but it was the winter, so we thought maybe she was cold. Then one evening, while Barb was feeding her, she suddenly stopped breathing and went limp. Barb screamed for help, and I ripped our two-year-old son out of the bathtub and did CPR on Leah as we sped to the closest Emergency Room. Although we were able to resuscitate her, the news was very bad from the cardiac catheterization: she had a heart malformation called “hypoplastic left heart syndrome”. She was missing half of her heart. In those days there were no options. That disease was uniformly fatal. After her death, as was the routine in our family, we were heavily medicated and encouraged to move on. We did not have a funeral or any sort of recognition of the event, until over a year later. We now know that is not a reasonable approach. Some innovative surgical techniques for treating Leah’s problem had just begun emerging, and I felt that I had a little score to settle with “Mother Nature” if I ever got the chance. And so, I became a pediatric heart surgeon. Timing is everything. Thirty years later, as I was getting ready to retire, new ways of dealing with Leah’s defect, as well as other heart malformations were finally making a difference. My successor and the team that he has developed are now able to deal with these problems with considerable success. I left the field just as we were figuring out how to solve the very same problem that got me into the field in the first place. So, I lost my identity as a surgeon, at the same time I gave up my lifelong desire to be something like an athlete. I cast around for ways to understand what was happening to me – some framework that could provide me with guidance necessary to navigate these apparently treacherous shoals around and ahead of me. There are mountains of literature on the transition to retirement, but many are how-to books that may work for the particular author, but not for me. The dawn came slowly, as, bit by bit, a helpful metaphor emerged. Since at least part of how I ended up as a heart surgeon was rooted in my unrequited longing to be the athlete I never was, I began thinking of the stages of life in athletic terms. My favorite spectator sport is college football, so I have begun to view life as a football game with four 20-year quarters. The first quarter (age 0-20), we’re just figuring things out – who are we? What works? What doesn’t work? The second quarter (age 21-40) we are making things happen. We are settling into whatever roles we have chosen; making our case. The third quarter (age 41-60) we are positioning for the final push. This quarter is when we have established ourselves, and are making our reputation. Whether we are tied up in some kind of business or profession, or as a full-time parent, we are consumed with “making it happen”. Then comes the 4th Quarter: the best part of the game. If you could only view one quarter of a football game, which one would you choose? For me, it would be the 4th Quarter, where everything happens; the game won or lost. It’s where the action is. The clock is a factor, and, as time goes on, a bigger and bigger factor. There is always overtime, but for the sake of this essay, we’ll stick to regulation play. I have become a student of the 4th Quarter, because that’s where I am, and also because it’s the best part of the game. The following is a strategic analysis of life’s 4th Quarter: how to work with the clock, some penalties to avoid, and making sure you win the game. To begin with: what is the point of a game – any game? To Win! And how do we win? By scoring the most points! So, for this metaphor to make sense, we each have to know what those points mean for ourselves. What is most important to us? Money? Security? Longevity? Relationships? One way to answer this question is to ask yourself, in a quiet and private space and time: “What do I want out of life?” Take a moment to answer that, writing down the answer. Then ask yourself a follow-up question: “What do I really want out of life? Be honest. The answer will likely differ from your answer to the first question. Write that down. Now: one final question: What do you really, really, want out of life? There is no right or wrong answer. But, if you were honest with yourself, you just defined what the points mean in your game of life, what you are aiming for. I will discuss some of my thoughts about how to use the rules of the game to maximize your chances of making those points in life’s 4th quarter, however you have defined them. I will also discuss some penalties to avoid because they will keep you from getting to the goal line.
Flag on the Field First, let us consider “a flag on the field”. The yellow flag is a part of the rules and regulations of football, and is an interesting concept. If a referee sees a violation of the rules while a play is in progress, he can throw a yellow flag on the field. This means the play can continue until its natural conclusion, and then he will sort out the penalties, if any. There was a flag on my field early in the 4th quarter. I wanted to stop doing cardiac surgery the day my replacement arrived, but I was struggling with what to do next. So, for a while, I continued doing non-heart chest surgery, and, while doing so, moved into a new career of hospital administration. Through the years, I had held some administrative posts (Surgeon-in-Chief, Administrative Surgical Director, and others). Our hospital needed someone with clinical experience to join their administrative team, and over time I have ended up working with a very talented group of people and having a great time. So far it is more of a re-wirement than a retirement. I still leave for work at 6:30AM and get home at 6PM, but the rhythm of the day is very different.Another unintended consequence of my decision to retire from surgery was the effect on my mission work. Many of my most significant rewards in life had come from mission work, helping heart surgical teams in third world countries become self-sufficient. But this avenue was not longer available, since I was no longer an active surgeon. This turned out to be a wonderful opportunity for me to get into a new area of mission work. But what? The invitation came without any searching on my part, and from an unlikely source. An Anglican priest from Kenya, John Nganga, was at our hospital being trained in Clinical Pastoral Care. He was passionate about helping AIDS orphans in his native Kenya. He stopped me one day in the elevator because he had heard about previous work I had done. He asked for advice about how to get started. What followed began a six-year journey which started on an empty field in Kenya, and has ended up with an orphanage and a working farm, which, despite ongoing struggles common to all such entities, is providing food, shelter, education, emotional and spiritual support to AIDS orphans in Kenya. Who knew where that serendipitous elevator conversation would lead? The flag on the field early in my 4th quarter allowed me to continue to re-define both my professional life and to allow me to find new focus for my mission energy in a way that did not involve surgery. It allowed play to continue while I sorted all this out. The flag has been picked up, and play has resumed. Time Out Another part of the rules and regulations is the Time Out. Anybody can call a Time Out, and it shuts down the whole game for everybody. Why are Time Outs called? It depends on when, in the game, it is called. For the most part, until late in the game, Time Outs are called to gain clarity (there are too many players on the field, the quarterback sees a defense he doesn’t recognize, or the coach is signaling a new play from the sidelines). Calling a Time Out allows the team to re-group, make a plan, and gather appropriate resources. My form of Time Out has been the Silent Retreat. This is a very specific exercise. Two to three days are spent just being silent, being with yourself: no radio, no TV, no talking, no Blackberry, no laptop, no email. The setting is pleasant, perhaps a hermitage or other type of Retreat Center. There are many to be found. You can listen to classical or meditative music if that helps to detach. Walking is encouraged, and, of course, journaling. I have found this to be a very useful way of gaining clarity as I have looked forward at various stages in life. At the age of 69 I am just about half way through my Fourth Quarter and just did a Silent Retreat during which time I was able to attain some clarity about what this time is all about for me. It took me a couple of days to put words around what I am facing: a fundamental shift in how I view myself. For most of my professional life I have viewed myself as being essential. I didn't think anyone could take my place. Of course that wasn't true, but I acted as if it was, and somewhere in the back of my mind I believed it. I reflected on days in recent weeks when I felt good, and days when I felt uncomfortable. As I looked at my schedule, it became clear that I felt best on days when I had lots to do—I was busy; engaged. The days that I was a little grumpy: they were empty with few commitments. Besides losing “control” I became aware that I need to come to grips with the fact that I am no longer essential. I need to settle for simply being relevant. This is a significant shift in how I view myself. On good days, I embrace it. But, from time to time, I find myself slipping into my old mindset. Returning to football: toward the end of the game, the Time Out is used for a very different purpose: to stop the clock if you’re behind. The Time Out does just that: it stops the clock to give you time to squeeze in more plays. The problem is that there are only a limited number of Time Outs. Once they are used up, there are no more. One reason for wanting to stop the clock in the 4th Quarter may be that 20% of men 55-64 are delaying retirement because of decreasing values of their houses. That is a good use of a Time Out. But remember, there are only a finite number available.Now, let’s talk about some of the penalties to avoid, particularly in the 4th Quarter. Unnecessary Roughness This penalty is called if, after a play is over, you unnecessarily crush your opponent – hurt them with a big tackle or twist their helmet. When called, you lose both yardage and a down, so your quest for points is really damaged. I have seen this penalty called on numerous occasions in my 35 years in academic medicine. All told, I have been through seven college presidents, eight deans, and ten department chairs in my career. In the fullness of time each of their careers have concluded. Some ended well, gracefully, and some ended incredibly poorly. Activity which could draw this penalty includes, but is not limited to, trashing one’s successor in an attempt to make him or her look bad, in order to make yourself look good by comparison. I have never seen this work, but have surely seen it backfire. Badly. I am not clear why I see this penalty called so often in medicine. I suspect it is common in other professions as well. Delay of Game When you are ahead in the game, it is tempting to use delaying tactics to keep the clock moving. In football, there are rules against excessive delay because this can make the game boring to spectators and sponsors. So, a team is allowed only 25 seconds from when the clock starts after the previous play to put another play in action. If the next play doesn’t begin by that time, the Delay of Game penalty will cost five yards. Efforts to artificially keep the game going in life’s 4th quarter surround us. Our society is heavily invested in our wanting to “delay the game”. We worship youth, and a youthful appearance. We are implored to color our graying hair, buy some side-by-side bathtubs for the backyard (I still haven’t figured that one out), and to fight any emerging wrinkles on our shopworn bodies. Some of things we try to do to “stay young” are, in fact, good for us and keep us healthy. Exercise, biking, and walking are activities which keep us in shape. If that is our motivation, we are winners. But if we are trying to preserve the illusion of youth in the 4th quarter, we could end up with a five-yard penalty for delay of game. I hasten to add that, as penalties go, five yards is not huge. If a little hair coloring makes you feel better about yourself, go ahead and do it, take the penalty, and move on. Two Minute Drill When you’re out of Time Outs, and there are just two minutes left in the football game, it is time for the two-minute drill in an attempt to get some last-minute points up on the board. This is a hurry-up offense, with no time for huddles, an immediate snap of the ball, and a number of tactics to squeeze the most plays possible into the last two minutes. The most remarkable two-minute drill I have ever witnessed in the game of life was executed by Lila Brewer, my mother-in-law. At the age of 96, she had all of her mental facilities, but her body was way into overtime, out of Time Outs, and she knew it. She summoned Barb to her bedside and asked for her help to complete her “to do” list in her last few days. They were able to do it all. She said goodbye in person to each member of the family, and gave away all of the modest amount of money she had to her family, so she had the joy of seeing them receive it. She had already planned her own funeral service. She was not the least morose. On the contrary, she was full of joy and hope for her future, when she would join her husband, Mel, who passed away the year before. In the end she drew her last breath peacefully, painlessly, and without anxiety or fear. Now that’s a Two Minute Drill to be proud of. It is a common observation in football, that when the two-minute drill succeeds in turning the game around, people always ask: “why didn’t they do that sooner”. Sometimes that’s a very valid question, but the reality is, the pace of the two-minute drill is so demanding that it couldn’t be sustained throughout the game. It is the same thing with the game of life.
I had a strange dream the other night. In my dream, I was watching Lila's game on TV. She had just completed her two-minute drill . . . and won. The commercials preceding the post-game interviews had begun to air. The Bud Lite ad featured sleek and beautiful young women surrounding a tub of ice chock full of Bud Lite being handed out by perfectly sculpted young men. Everyone was laughing. It was sunset on a tropical beach. As I switched the channel back from Lila's game to my own, I heard the whistle screech and realized I had drawn a penalty! What could it be? "Delay of Game" the referee shouted, to the roar of the crowd. "Delay of game?" I defiantly shouted back. "Wadayamean, Delay of Game? I retired from surgery gracefully seven years ago! Wadaya want?" "You're still workin’ – full time. When're you gonna slow down and start thinking' about winning the game? "I am winning! I'm gainfully employed, having fun, doing my thing!" Out of the corner of my eye I saw my coach draw his index finger across his neck indicating that I should knock off arguing with the referee. I was confused. I made the T sign with my hands, and called a Time Out. The whistle again screeched; the clock stopped. "Omigod! How many Time Outs do I have left?", I thought as they cut away to a Miller Lite spot. I woke up in a sweat thinking about how to win the game. It seems to me that the most important points in life, in the end, are about relationships: family and friends. Lila won because she was able to end up surrounded by both. Her two-minute drill did much to repair and embellish those relationships, which persist and continue to function well beyond the grave. So, I want to begin to make decisions and plans with that in mind. I Think I'm a long way from my two-minute drill, but I need to remind myself that my Time Outs are limited. Even though I'm not ready to quit my work yet, I probably need to emphasize more of the "life" part in the "work-life balance" equation. The time will surely come when it will be time to quit. It's hard for me to imagine life without the structure of work. That will be a whole new game. I will, indeed, move from being essential to simply being relevant whether I want to or not. And, if I'm lucky, and work at it, a new focus on "being" will replace my current emphasis on "doing". I wonder what that will feel like. I also wonder who might sponsor my game on TV; or if the ratings will be good enough to support network coverage. I don't imagine there would be much interest from the all-important 18–34-year-old demographic.
