Leonard Cohen's “Old Ideas” Tour stopped in Kingston this December and 5000 fans filled the K-Rock Center to hear 78-year old Cohen. He sang the entire repertoire, from So Long Marianne, and Suzanne to Hallelujah and I’m your Man. The audience, young and old, were captivated. As I watched him sing, rising lithely from bended knee, it was clear he had a youthful spirit. He was fully connected with the audience and we in turn were connected to him. He played for four hours. Leonard Cohen’s recently resurrected career is instructive for physicians as we try to decide how long to practice in an era with no mandatory retirement age. In this rumination I will forget young Leonard Cohen. It is the last five years of his career that I find instructive for retirement planning. In 2005 Leonard Cohen was reportedly swindled by his trusted manager, Kelley Lynch. He discovered that his retirement funds had been decimated. "I was devastated. You know, God gave me a strong inner core, so I wasn't shattered. But I was deeply concerned," said Cohen. Left with insufficient funds he returned to the road in 2008 after 15 years absence. Perhaps this was not the most artistically sound reason for a second act; however, at some point his muse returned and whatever financial motivation there may have been became irrelevant as his music soared. In Medicine, as in Art, many factors (finances, love of the profession etc) shape the retirement decision. Without a doubt, there are positive reasons to continue practice beyond an arbitrary retirement age, the best two being the pleasure of practice and the ongoing ability to make a positive difference in patient lives. However, financial imperatives are arguably one of the more common reasons to continue practice beyond the time when retirement would be both the graceful and prudent act. In some cases, the last years of practice (the physician equivalent of Cohen’s second act) are magical; often it is not. The senior physician can bring experience, gravitas to the bedside and offer wise counsel to the leadership of the Medical School. They may also be better positioned to selflessly mentor, focusing on the advancement of junior colleagues. However, like musical performance Medicine is a performing art that requires passion and skill. Neither passion nor skill automatically fades at a specific age, however few would argue that there is not some point in life where at least one of these wanes. Cohen has retained the passion and the skill to perform his craft at the highest level. He’s still got it…his love of the stage is visible, his passion for music palpable and his ability to entertain unequivocally persists. His voice, though deeper with a more limited range, remains a compelling instrument. So too, some older physicians retain the passion and facility for Medicine that they had in their youth and wrap it in the wisdom acquired over long years at the bedside. When this occurs all is good. Leonard Cohen can still rise from his knees as he rasps his Hallelujah to the crowd. Leonard Cohen can hold 5000 people in rapt bliss for four hours and three curtain calls and still dance whimsically off the stage at midnight. When he cannot do these things (or hopefully just before his abilities falter) he will stop touring. Can similar simple metrics guide our decision about when to retire from Medicine? According to Canadian Law, while retirement benefits begin at 65 years of age, one cannot be forced to retire. This acknowledges the new biological reality - that the average Canadian life expectancy has increased to almost 81 years. However, there are other biological realities: diminished visual and auditory acuity and lessened ability to maintain the pace and deal with sleep deprivation. There is also the challenge of remaining current with the rapidly expanding base of scientific and medical knowledge. The Royal College requires physicians demonstrate Maintenance of Certification. Medical practice is of course not just a series of “right answers” nor is quality ensured by time spent at CME events. The decision to continue practice should relate to real world ability to practice, the equivalent of Cohen’s ability to put on a great show. The lack of an applause meter in our offices and on the wards makes the quality of our performances harder to measure than in the world of music. Retirement is a process and need not be abrupt; rather changes in a career can be gradually implemented over years. Accommodations - changes in job description - can be made as we age in terms of hours worked, invasive skills performed and on call activities. However, as professionals, we should to put the patient’s needs first and be willing to have our skill set re-validated. We should restrict our activities to match our demonstrable competencies. Who knows better than physicians that ultimately retirement is inevitable? Yet, the conflation of being a physician with one sense of self worth causes many of us to struggle with the concept that retirement, or at least a restricted practice, might indeed be pleasurable. Leonard Cohen’s performance suggests to me a new retirement metric: a Retire or Remain score. The Retire or Remain score could be both self-determined and assessed by one’s supervising colleagues. I propose a simple 3-point system with 1 point each for: Passion, Energy and Ability. A score of 3 is required to Remain in practice. Note that financial need is not a component of the scale. Cohen may have started back on the road for the money, but that 5000 people stood and clapped, that he danced off the stage, and that he played until midnight gives him a 3/3. He should Remain. We as physicians would be well served to self-administer this metric with increasing frequency as we age and to discuss how others would score with trusted colleagues and our supervisors. It is a personal issue with public ramifications. Retirement is made more complex because we age in different ways and at different rates with very different impact on our ability and desire to practice Medicine. I will be checking my score form time to time. Ultimately, my decision to Remain or Retire may be guided by my ability to perform differential diagnosis, to win the trust of patients, to inspire students and to perform research that shapes the field. As we consider the timing of these changes in our careers we might reflect on Leonard Cohen’s poem, A Thousand Kisses Deep from his 2001 Album, Ten New Songs Excerpt: The ponies run, the girls are young, The odds are there to beat. You win a while, and then it’s done – Your little winning streak. And summoned now to deal With your invincible defeat, You live your life as if it’s real, A Thousand Kisses Deep. Take a listen to the whole piece. In December 2012 Leonard Cohen is a 3/3. He is on form, on the road and en route to New York for another performance. But in time his ‘little winning streak’ will end and he will retire. So too must we, as physicians, identify when our winning streak is nearing an end. The end of practice brings a chance to celebrate our careers. When we do not or cannot love the Practice of Medicine ‘a thousand kisses deep’ our race is run…and we begin the next great rotation.