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EVERYONE ages. It’s a fact of life, a law of nature, and the great equaliser for all human beings. For eons, mankind has attempted to thwart mortality by searching for the fountain of youth, and through creams, injections and surgery, we have tried our best to retain our youth.
But time marches on, and we grow older no matter what.
Just as the general population is getting older, the Australian workforce is ageing as well. Between 2015 and 2055, there will be a 34% increase in the proportion of the workforce over the age of 65 years.
Doctors are no exception. The medical workforce is also getting older. In 2015, about one in four medical practitioners were aged 55 years or older (27.2%). And there are more doctors who continue to practise medicine beyond the usual retirement age. For example, four out of five Fellows of the Royal Australasian College of Surgeons (RACS) aged 65 years or older intend to continue in paid employment, with the primary reason being that they are doing work that they enjoy.
As George Burns, the great American comedian, actor and musician, once said: “You can’t help getting older, but you don’t have to get old.” Mark Twain also said, “Age is an issue of mind over matter. If you don’t mind, it doesn’t matter.” This clearly is true for a lot of doctors. We come into medicine as fresh, idealistic interns, and we grow into learned, experienced clinicians. Nothing replaces the skills and expertise a practitioner gains over time through practice.
Nevertheless, there is evidence that tells us that as doctors get older, their clinical outcomes may be affected. A recent study from the US in the BMJ concluded that within the same hospital, patients treated by older physicians had higher mortality rates than patients cared for by younger physicians. Closer to home, an Australian study found that older doctors were at higher risk for notifications relating to physical or cognitive impairment, records and reports, prescribing or supply of medicines, disruptive behaviour and treatment.
Even non-pathological ageing is associated with a notable decline in cognition. Multiple studies have found evidence of age-related functional deterioration including the dedifferentiation of ventral visual and motor areas (here, here and here), the decreased utilisation of medial temporal lobe regions in recalling memories (here and here), and the dysregulation of the default mode network (here and here).
The neurobiological changes that occur in the ageing brain are associated with a reduction in the efficacy of the working memory system, reasoning processes, executive function, attentional processing and decision making (here, here and here). Adept working memory is a prerequisite to inductive reasoning, a key function required for medical diagnostics and decision making. In addition, a number of physical skills are required for medical professions, in particular finger dexterity. When performing diagnostic, propaedeutic, therapeutic and rehabilitative procedures, practitioners must often use fine instruments which require precision.
Varying approaches to cognition deployed by older adults may also negatively affect executive functions. For example, Besedeš and colleagues found that older adults are more likely to rely on heuristics (mental shortcuts) when making decisions, resulting in judgements that are poorer than those of young adults.
It should be noted that getting older does not automatically equate to disability or clinical incompetence. Everyone experiences slight cognitive changes during ageing, which is very different to the mild cognitive impairment that occurs prior to the development of dementia. However, the risk of Alzheimer’s doubles every 5 years after the age of 65 years and 5% of all patients with Alzheimer’s will start showing symptoms before the age of 65 years.
The key here is to identify what is fluid intelligence, which is our global capacity to reason, our ability to learn new things and to think abstractly and solve problems, which may be affected with age, versus crystallised intelligence, which is based on prior learning and past experience, based on facts, and which increases with age.
The medical regulators have started to take notice of these findings, and the Medical Board of Australia has proposed a Professional Performance Framework, which requires medical practitioners who provide clinical care to have peer review and health checks at the age of 70 years and every 3 years thereafter.
As individual medical practitioners, we have a duty of care to our own patients, to ensure that we are able to provide our patients with the best care that we can possibly give. As hospitals and health care providers, we have a duty of care to our clinicians to ensure that they are safe to practise medicine. And as a health system, we have a duty to our community to put into place processes that identify and support clinicians in the transition from direct patient care to alternative career pathways that bring meaning to their professional identities and continues to allow them to serve the community, although in a different way.
However, we need to be aware of age discrimination laws. Age discrimination occurs when a person is treated less favourably, or not given the same opportunities as others in a similar situation, because he or she is considered to be too old (or too young), as outlined by the Age Discrimination Act 2004. In Australia, mandatory retirement only occurs in two contexts. Federal Australian judges must retire at the age of 70 years, as outlined in section 72 of the Australian Constitution. The Australian Defence Force has also maintained a mandatory retirement age of 60 for personnel and 65 for reservists, though this can be extended on a case-by-case basis.
Having said all this, there is no suggestion that we should consider, let alone impose, a mandatory retirement age for doctors. One possibility for those older doctors who find the demands of a clinical workload increasingly challenging, is a transition to an alternative career, which may very well be in health, just not in direct patient care. This does not need to be a negative experience, but indeed, can, and should, be a positive, planned and rewarding move, and be seen as a natural progression of the expert clinician, moving from the role of a practitioner, to a mentor or leader.
The data tell us that doctors don’t retire easily. A recent study aptly titled Retirement patterns of Australian doctors aged 65 years and older found that retirement rates for doctors remained relatively low, at 4.1% (2009), 5.1% (2010), 4.2% (2011) and 10.4% (2012). Another study, published in the MJA, which looked at professional and psychosocial factors affecting the intention to retire of Australian doctors, found that delaying retirement by doctors may be related to the primacy of work compared with other life roles. In other words, being a doctor is important to doctors, and that loss of identity is a threat to any contemplation for retirement from clinical practice. As the RACS census puts it, the main reason why their Fellows aged 65 and older continue to be engaged in paid employment for the next 2 years is because “I am doing work that I enjoy”.
Ways to keep the older doctor engaged in the health system in an active way are being explored. A recent article in the BMJ “recommends that employers do more to support older doctors through flexible working arrangements and by removing barriers that discourage older doctors from continuing to work in the health service”.
The Medical Board of Australia itself, as part of its proposed Professional Performance Framework, recommends that continuing professional development (CPD) providers, indemnity insurers and employers should work closely and constructively with medical practitioners over the age of 70 years to raise awareness of risks that may affect performance. The Board also recommends improved support for safe clinical practice, and increased support for later career doctors considering and managing changes to their scope of practice or transition to retirement. This would include providing written guidance, CPD education activities and the use of “retirement ambassadors” to provide peer role models of successful retirement planning for doctors.
Essentially, when appropriate we want to help our older doctors leverage and maximise their experience in roles other than direct patient care, and this should happen in a proactive, planned and positive manner. The key here is to help the doctor themselves develop an ability to be self-aware, to self-reflect and, ultimately, to self-manage.
In this way, the doctor is able to work through some of the typical phases of the “transition into retirement curve”. In Stage 1 of this curve, as the doctor approaches retirement age, there is initial fear and confusion. In Stage 2, in the weeks before retirement, the doctor experiences sadness and worry. In Stage 3, as the doctor explores retirement, they experiment with different ideas and roles, and adapts. And lastly, in Stage 4, as the doctor actually retires, there are new beginnings, with acceptance, and finally, confidence. These four stages are necessary steps for each doctor to have to go through, and it is incumbent on all of us to support our colleagues through them.
In the end, there are many roles that exist that allow doctors to retain their professional identities as healers and clinicians. In fact, most older doctors move into these roles opportunistically and in an unplanned way. The older doctor traditionally transitions into a teaching role, and some become academics. Some move into research. Others transition from direct clinical care, into becoming medicolegal and forensic experts, offering opinions as expert witness and in legal reports.
Many older doctors enjoy rewarding careers as board members or non-executive directors, for hospitals, medical research institutes or other types of organisations. Many find themselves promoted into health management positions. All of these different roles combine to create a flexible portfolio career for the older doctor who is transitioning into retirement. And because most of them allow the doctor to continue to offer their expertise in health, they retain their identity as doctors.
As David Bowie said: “Aging is an extraordinary process where you become the person you always should have been”. A quote we once read on a mug sums it up perfectly: “You can retire, but you’ll always be a doctor”.
Professor Erwin Loh is Group Chief Medical Officer, St Vincent’s Health Australia and Clinical Professor, Monash University.
Amy Sarcevic is a science journalist.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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I was really astounded by the above comment: ‘A lot of my colleagues think that they can go part-time or locum when they no longer wish to do full-time work, not realising that the AHPRA and college demands for CPD not only remain the same but can be very difficult to either obtain or ‘validate.’ This is exactly the situation that most female doctors find themselves in when want to look after their own children rather than put them into full time child care. Medicine remains a very gendered profession. Its OK to be a female doctor with children as long as somebody looks after them.
Then to this article reinforces agism and cherry picks the evidence. While the Australian government is trying to increase the retirement age in general, medical academics are doing exactly the reverse.
This seems to have been driven by the impression that older doctors are statistically more likely to receive complaints to the Medical Board or AHPRA. However the same can be said for male doctors, surgeons and rural doctors eg: http://hsla.org.au/wp-content/uploads/Bismark-2013.pdf. Is the answer then to encourage male rural doctors who are proceduralists to find a different profession? Clearly that would be absurd. However this is just the same as pushing all doctors over 65 to retire when many individuals will be just as competent as younger colleagues.
There are also obvious confounders in the complaints data, for example younger doctors are more highly supervised and often in supportive clinical settings, therefore complaints will be handled at a local level.
For every article about the aging brain there is evidence to show that older workers are just as competent as younger workers. There is a discrepancy between laboratory studies finding evidence of decrements in mental functioning by the sixties and studies finding no downward trend in work abilities and performance.
Much is made of a US study showing higher mortality in patients treated by older doctors and extrapolates from this that all older doctors are less competent due to age related brain changes, when the study showed no such data. However a study by public health researchers at Harvard in 2017 also found that elderly patients were less likely to die or be readmitted to the hospital within 30 days if treated by female doctors rather than male. Does this mean that all male doctors need to be encouraged to change careers? (Comparison of Hospital Mortality and Readmission Rates for Medicare Patients Treated by Male vs Female Physicians, Yusuke Tsugawa et al JAMA Intern Med. 2017;177(2):206-213.
Another concern is that this inference that older workers are less competent is transferred to middle age workers who then become victims of unconscious or deliberate but hidden discrimination in the workplace (http://theconversation.com/age-discrimination-in-the-workplace-happening-to-people-as-young-as-45-study-76095.) Medicine has been relatively immune to this trend due to the emphasis on seniority and experience however the increasingly youth obsessed AMA and the medical academia might just change this and not to the patient’s benefit.
I don’t often agree with almost every commenter but I am today! A lot of my colleagues think that they can go part-time or locum when they no longer wish to do full-time work, not realising that the AHPRA and college demands for CPD not only remain the same but can be very difficult to either obtain or ‘validate.’ A full-time person just gets his diary signed by the Dean/Director of his specialty education/DMS. I often do short term locums where I meet no other senior doctor and where there are no medical educators – and sometimes the DMS is area, and 200km away! Getting every single procedure/lecture attended/results check (QI- WTF?) signed off? really? Moreover, we often have no access to patient records once the locum ends, and certainly no leisure while working for QA activities.
I have been amused to note physicians sometimes think that they can be semi-retired by relocating to a rural hospital with a fraction of the inpatient beds, not realising that the absence of junior staff means that they are actually expected to provide routine care for them all. I am not sure what the answers are, but certainly casual and part time staff need some of the CPD entitlements afforded their full time colleagues. And rural hospitals now have the same LOS and bed shortages as the cities; patient safety demands increased ward staffing and middle grade staff – another not unreasonable job for physicians happy to step back from clinical governance and formal teaching.
As an older GP who has spent about 40 years working with distressed babies I find it hard to realise that I am unlikely to be able to retain my registration at the end of this CPD period as I will not have acquired the required number of points. This has been difficult because of having many health issues myself making obtaining points difficult despite still reading widely in my field of interest. There are few doctors who have the time or inclination [or perhaps experience] to deal with the difficulties of distressed infants as sorting them out is time consuming. I have found that a significant proportion have a combination of atopy and reflux and develop early Eustachian tube and middle ear problems. I have my own tympanometer so can measure ear pressures and ear drum movement where most doctors dont have access to a tymp. I have written a book about this relationship–but am unlikely to be able to continue this work [even in a limited capacity] because of the limitations of age and health added to the AHPRA restrictions.
Discrimination against older doctors is most visible at the level of Medical Council who magnifies even the most unjustified dissatisfaction reported by any patient to condemn the doctor. It is customary to assess the doctor on preconceived idea that a doctor above 70 years of age is dangerous. The regulating body can make it impossible to practice, demoralising and destroying the life long dedication and commitment of the doctor in the last phase of life despite no real decline in his/her performance outside the biased assessment process of the Council against the age.
“Physician, heal thyself”
While the reasons for this discrimination are multifactorial, I believe that the fact that doctors have allowed non medical people to run their affairs be it college, government, Medicare, big business , we are now paying the price of this abrogation of our responsibilities.
I think the article is discriminatory and ageist, reflecting wider community views of older people. Witness the recent rejection of an elderly privately insured woman by the private hospital in Hobart. As an older part time GP, I have often experienced difficulty in referring similar patients with multiple comorbidities to the private system, unless able to negotiate a direct admission via a specialist. Very time consuming and would not be a viable proposition in the corporate GP environment. where 70% of GPs now work.
GPs often work beyond retiring age as they are not well set up financially.to retire, thanks to problems with the Medicare rebate and escalating practice costs. There are few mentoring roles for GP retirees. I have had professional GP colleagues well into their in their 70s who have provided invaluable rural locum relief.
In my view, this article is just another attempt to discriminate against older doctors. The authors reference texts that suggest that brain structure and function changes with age. Well, nothing new there. But they provide no reference that any of these possibly age-related changes affect physician performance in any capacity. We are not talking about disease-related pathology like Alzheimer’s disease here.
In two articles that they use to raise concerns about older doctors’ performance, the authors do not mention that the conclusions of these articles go against their claims of age-related poor performance. In one (1) the conclusion noted that among doctors who treated a large number of patients there were no differences between younger and older doctors. In the second (2) the conclusion noted that older doctors were at lower risk of notifications about mental illness and substance abuse.
Having tried (unsuccessfully I believe) to question the capacity of older doctors, the authors then go on to suggest that these doctors should take up alternate medical careers as mentors, leaders, administrators, directors, academics, teachers and researchers in hospitals and medical institutions! I find it strange that having besmirched the reputation of older doctors the authors now want this group of physicians to undertake critical roles in the profession of medicine.
Discrimination is defined as “the unjust or prejudicial treatment of different categories of people, especially on the grounds of race, age, or sex.” I doubt whether the authors would be so insensitive as to tar an individual from a racial, ethnic, religious or gender group with purported (correct or incorrect) characteristics of the group. Yet this is what is implied from their article with regard to age discrimination. Surely we have learned that each person (in this case an older doctor) should be treated on his or her merits, not on presumptions about the characteristics of their group?
I find it concerning that an article with the limitations of this one managed to get through the critical eye of the editor of MJA InSight.
1. Physician age and outcomes in elderly patients in hospital in the US: observational study. Tsugawa Y et al. British Medical Journal 2017;357:j1797
2. Health, performance and conduct concerns among older doctors: A retrospective study of notifications received by medical regulators in Australia. Thomas LA et al. Journal of Patient Safety and Risk Management March 21, 2018.
Unfortunately our system of medical education is not attuned to make use of the retired doctor and the practical experience he can pass on. I teach medical students practical ENT which I believe to be important particularly in general practice. The teaching involves no patient contact. For this service I am required by the university to have medical registration, ma;practice insurance and College of Surgeons accreditation (requiring Fellowship subscription and the obtaining of CPD standards). As I am purely honorary and do no paid medical work of any sort I cannot claim any of these significant expenses as tax deductions.
In addition the new requirement for medical registration of 152 hours annually of “recency of practice” may make it impossible for me to continue to provide this tuition.
Our splendid but ageing family Surgeon used his (gloved) osteoarthritically fused index finger as a blunt dissector in surgery. He was a legend!
Management and mentoring is fine, if you have already been doing it successfully. But if not, it is probably too late to have an epiphany and start doing so. We need to remain self-aware and not old farts hanging around for too long. A careful transition is the key and finding fulfilling pursuits outside medicine can be a challenge for many.
I retired last year aged 82. I did not go through the first 3 ‘ stages of retirement ‘, I went straight to stage 4. The two main reasons I retired were: that my wife did not want to return to a remote area where I had a 49 year association and could have been useful as a half time GP and half time administrator ( I realised I was no longer comfortable with night work or emergency medicine) , and I was no longer prepared to put up with the old and the newly proposed ‘ageist’ and stifling bureaucracy that has almost destroyed the 58 years of joy that I got from the practise of various branches of medicine.
In response to Anonymous, it is not sensible to set an arbitrary retirement age for surgeons, and the RACS certainly does not . Some might need to stop at 60, others remain fit, well with cognitive/motor skills intact well into their 70s.
The current crop of potential surgeon retirees are the first largely non-smoking generation of doctors and are fitter and healthier than their surgical teachers and mentors were at the same age.
Private hospitals normally require annual re accreditation after 70, and the RACS requires CPD and personal work audits. Most older surgeons limit the scope and amount of work they do, staying in their comfort zone.
In terms of transitioning to retirement as a surgical assistant, a surgeon will still need a steady hand and reasonable physical stamina. It is not for everyone, just those that have the capacity and the desire to remain involved in surgery.
The public system is unforgiving. There are very few optIons to slow down from senior positions and continue to contribute.
It is too late and probably not appropriate to start a new medical career outside.
As a relatively junior physician in his fellowship year, this hews both ways. Yes, older doctors do have a wealth of clinical experience and knowledge to pass on.
But at the same time, older doctors are also in my experience the most likely to:
– adhere to outdated practice through inertia (vs EBM) – it’s almost a rite of passage for most physician trainees to be at some stage a shield against the older consultant’s clinical decisions
– have ingrained in them unhealthy working attitudes, mostly arising from ingrained gender perceptions
– be the most entitled: how many of us have a HOU or senior consultant who tacks his name on to the end of registrar publications in which they have nil/minimal input? How many of us have consultants who expect (and exploit) the public system to subsidise their private practice?
I think a medical education should be the province of a separate, motivated professional cadre of clinician-educators. I do not think it should be a fallback plan for the senior consultant unable to mentally adjust to their aging process.
Also, my orthopaedic/genreral surgeon mentor from 1976 is still doing minor ops at 81yrs. He and I go push bike riding together nearly every week.
Once retired they need to move on. Mentoring for some ,albeit too many, is an excuse to hang on too long after retirement. Surgeons should stop operating at 65 ears of age.
That is rubbish. It all depends on your biological versus your chronological age. My GP is 83+ and is still as sharp as a tack.
Successful ageing requires functional adaptation. If a doctor is able to function properly within their scope of practice they should not be stopped just because of advancing chronological age.
The countries of the free world are run by elected officials over the age of 70 .
The public servants and secretaries of State are over 70.
Perhaps the minimum age for Medical Board should be 70 – the rest do not have the experience or wisdom to oversee the profession.
The article lists a pot – pourrie of reasons to try to justify the article and ends by a quote authoritatively written on a mug- so much for evidence based article.
Enough of a grab bag to justify discrimination. The symptoms are universal in discrimination E.g. I know some jews are bad but my neighbour whom I have known for years is not one of them – so send them to a concentration camp but not him
It’s harder for older doctors to stay up to date with clinical practice. CPD is too easy and a performance review which is standard for other professions would be a good idea.
This is all very positive and encouraging stuff for ageing doctors in transition to managing and mentoring roles that “allow the doctor to continue to offer their expertise in health, they retain their identity as doctors.”
They should however, carefully read the Medical Board’s ageing and un-amended “definition of practice” and advice on who needs to maintain registration, a somewhat onerous and expensive process in retirement.
The broad scope of this definition suggests to me that doctors in advisory or mentoring roles must maintain full registration or, to be effective must skate perilously close to the limits of the law. The Medical Board could solve this dilemma with a few strokes of a pen, AHPRA and politicians permitting.
I agree with Randal. G.P.s also may continue well after 65, but still need to continue with CME. However the Caveat placed on them (and others) by AHPRA, that they must do a certain number of hours in a practice per yea, can be stifling. If you are intending actually to continue with your previous work – unchanged but for a reduction in hours, then it is obviously not a problem for most people. However, if you are intending to do other work (e.g. assisting with a surgeon when needed, perhaps in a country area, or working in a special interest area that involves patients, but with few numbers each year) then it can make it impossible to fulfil the requirements and so lead to a reluctant full retirement and possible disadvantage to a previous service.
Prepare to retire to some activity rather than just mourning retiring from something.
Acknowledge you may be just as fulfilled working part time at a limited “easier” field of practice than usual.
I am dubious about confident ‘know it all in retrospect’ retired doctors pontificating in the medico legal system.
Once retired they need to move on. Mentoring for some ,albeit too many, is an excuse to hang on too long after retirement. Surgeons should stop operating at 65 ears of age.
Surgeons can transition to retirement by assisting colleagues in theatre in private hospitals This maintains professional contacts ,provides some income and can include some teaching and mentoring of younger colleagues. I retired from surgical practice at 69 Years of age and have been assisting for three years I rally enjoy it and it keeps me mentally and physically active