When Should Physicians Retire?

When Should Physicians Retire?

It is no secret that certain abilities decline with age. Two studies showed the particular decline of sensorimotor skills, stamina, and cognitive functions such as inductive reasoning and verbal memory in people over the age of sixty-five.[1, 2] In many professions and industries, sixty-five is an acceptable retiring age for that very reason. However, as people have begun to remain healthier into their old age and live longer, many choose to work past sixty-five. Physicians are no outlier in this trend of an aging workforce. Almost a quarter of physicians are over the age of sixty-five, which is about a four-fold increase since 1975.[3] No one can stay fit forever, though, and the stakes are higher for professions with lives on the line. Physicians may be able to work into their old age, but there has to be a tipping point somewhere. The question then arises: how do we determine the proper time for a physician to retire? Furthermore, how should that be enforced? Answering these questions requires the consideration of several factors including the welfare of the patient, age discrimination, respect for senior professionals, and physician shortages.

On the matter of patient welfare, locating the tipping point for aging physicians has proven difficult. One study published in 2017 looked at the decline in cognitive abilities for physicians and found that the mean cognitive score declined by more than 20% from age forty to seventy-five.[3] However the same study noted that the variability in older physicians was drastic, meaning that some physicians remained fully competent while others were not. A different study published in 2006 showed that mortality rates for complex surgeries was higher in a population of surgeons over sixty than it was for younger surgeons. However, the same study showed that there was no significant difference in mortality or complications for routine procedures.[4] Both of these studies came to the same conclusion that the tipping point for physicians is not the same across the line and does not necessarily apply to every aspect of a physician’s job.

If the tipping point for physicians is not universal, then policy makers and hospital administrators must be wary of age discrimination when considering regulations for physician retirement. Currently there are no legal obligations for a physician to retire as a result of getting older. Although the Age Discrimination in Employment Act (ADEA) protects employees in the U.S. over the age of 40 from age-based discrimination,[5] many vocations employ age-related performance tests as well as mandatory retirement. For instance, commercial airline pilots have a mandatory retirement age of sixty-five as well as required annual flight review tests for older pilots. Similarly, many states have mandatory retirement ages for judges, law enforcement officers, and firefighters. Clearly, there is a precedent for regulating the age of individuals in demanding professions, so, from a legal standpoint, legislation is allowed in the case of physician retirement. In terms of a moral standpoint, age-based regulations for physicians seem to be justified only if a physician’s age causes issues for patients. As mentioned previously, it is difficult to determine just how much of an issue age is. Thus, regulations such as a universal retirement age seem unjustified while routine competency evaluations may warrant attention.

Physicians have avoided such a situation largely through concerted efforts by the AMA and other groups to oppose mandatory age-related policies. Currently, most programs for assessing age-related performance in medicine are entirely voluntary. This is compounded by the influence held by senior physicians in medicine. Whether or not legislation on physician retirement counts as age discrimination, it is worth considering whether it would be fair to force senior physicians to retire or submit to insulting cognitive evaluations. Many would argue that senior physicians deserve the dignity of voluntarily stepping away from clinical practice after devoting their lives to their profession. However, one problem with voluntary self-assessments or even peer assessments of competency is that it tends to not accomplish much. Few junior physicians would tell a senior physician to retire, and some older physicians have trouble realizing that they are slowing down. Thus, completely voluntary programs for competence in aging physicians creates far too many obstacles.[6]

One possible problem with mandatory age-based regulations is the burden it could place on underserved areas. Often times, rural areas cannot compete with the salary potential and benefits provided by urban hospitals. Consider a small rural clinic that operates with only two physicians, both of whom are over sixty. The burden of a mandatory retirement age or cognitive evaluation every few months could unnecessarily encumber these physicians who already must deal with limited resources and lower compensation. These burdens could frustrate these experienced physicians to the point where they retire early or move elsewhere for better compensation. Thus, that area could face an exacerbation of the already present physician shortage. This scenario highlights the necessity of creating region specific mandates for age-related evaluations. The same could be said for particular specialties since a rural primary care doctor may not require the same physical or cognitive ability as a spine surgeon.

In order to effectively regulate physician retirement with legislation, the best thing to do is look at already existing instances where hospitals have done so. One study mentioned previously examined the three hospital systems in the United States with mandatory age-based competence testing (University of Virginia Health System; Driscoll Children’s Hospital in Corpus Christi, Texas; and Stanford University Hospitals and Clinics).[3]  University of Virginia and Stanford University both have similar programs in which physicians must pass physical and mental examinations after a certain age and then retake them every few years. The authors recommended that hospitals institute similar mandatory evaluations across the country.

Regardless of any legislation, all doctors must acknowledge that they have an ethical obligation to mitigate risks for their patients. Every study on aging physicians has concluded that, at the very least, physicians should make more of an effort to assess themselves and their peers more regularly, whether legally mandated or not. At the same time, we cannot fault doctors for wanting to continue in their careers as long as possible. In fact, if they do not experience physical or cognitive decline, then they can continue to do the most good by working as long as they can. However, at a certain point every physician must retire from clinical practice before they contribute to unnecessary risks for their patients.

References

  1. Hartshorne JK, Germine LT. “When does cognitive functioning peak? The asynchronous rise and fall of different cognitive abilities across the lifespan.” Psychol Sci. 2015;26(4):433-443.

  2. Li H, Lv C, Zhang T, et al. “Trajectories of age-related cognitive decline and potential associated factors of cognitive function in senior citizens of Beijing.” Curr Alzheimer Res. 2014;11(8):806-816.

  3. E. Patchen Dellinger, MD; Carlos A. Pellegrini, MD; Thomas H. Gallagher, MD. “The Aging Physician and the Medical Profession A Review” Journal of the American Medical Association (2017). Accessed Oct. 3, 2017. http://jamanetwork.com/journals/jamasurgery/fullarticle/2644000

  4. Jennifer F. Waljee, MD, MPH, Lazar J. Greenfield, MD, Justin B. Dimick, MD, MPH, and John D. Birkmeyer, MD. “Surgeon Age and Operative Mortality in the United States” The Annals of Surgery (2006). Accessed Oct. 3, 2017. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1856535/?tool=pubmed

  5. United States Department of Labor. “Age Discrimination.” https://www.dol.gov/general/topic/discrimination/agedisc

  6. Peter Angelos, M.D., Ph.D. “How Should Colleagues Respond to Diminishing Capacities of an Aging Surgeon?” AMA Journal of Ethics 18, no. 10 (2016): 986-992.

Lost in Translation

Lost in Translation

Compatibility Testing and Organ Donation: Morals and Ethics

Compatibility Testing and Organ Donation: Morals and Ethics

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