An intensivist’s view of the issue of ageing practitioners.
The medical profession is ageing in parallel with the wider community. About one-quarter of Australia’s medical workforce is at least 55 years old and, if US data is applicable, it is likely that more doctors will choose to continue working into their late 60s or 70s than previously.
Although ageing has been discussed by medical boards and colleges in Australia and overseas, almost none have developed policies or position statements recommending practice changes for the older practitioner.1 Partly this has been because of concerns regarding age discrimination and also because of government objectives supporting increased workforce participation by older people.
Ageing is likely to affect some aspects of medical practice more than others and different medical specialties in different ways. Intensivists, like obstetricians, have a working lifestyle that includes irregular hours, late-night calls and call-backs and the stress of unexpected, potentially life-threatening emergencies. In addition to the intellectual demands, both specialties involve some procedural work, requiring dexterity and good visual acuity. These are all factors that would need to be considered in developing recommendations specific to these specialties.
What kinds of health issues are faced by older doctors?
Doctors generally enjoy above-average health and are less likely than the general community to suffer lifestyle-related illnesses such as smoking-related illnesses and ischaemic heart disease. However, depression is more common and the suicide rate is higher among some subgroups, such as anaesthetists. Anaesthetists and emergency physicians also have the highest rates of substance abuse.2
There is also evidence that poorer health is seen among rural and remote practitioners, and those working excessive hours or shift work. Some doctors are also vulnerable to stress and burnout, which have been shown to be particularly problematic for intensivists. However, other data suggest that the current generation of ageing doctors has improved work-life balance and lower levels of psychological distress compared with their predecessors.3
Like the rest of the community, doctors have increasing rates of chronic illness as they age, including, importantly for proceduralists, osteoarthritis and declining visual acuity. Older doctors have been said to be at risk of the ‘four Ds’ – depression, drink, drugs and dementia. Of 41 doctors over 60 referred to the NSW Medical Board, 22 per cent had depression, 29 per cent substance abuse, 54 per cent had cognitive impairment and, alarmingly, 12 per cent were found to be demented.4
What age-related neurocognitive changes are relevant to medical practice? Verbal skills and semantic memory (facts, words and meanings) are typically well preserved in ageing, which means that doctors with significant impairment may ‘present well’ and conventional mental state testing may miss significant problems. Adaptive and critical thinking and processing speed are most affected – very relevant to dealing with emergencies, along with hearing, visual acuity, depth perception, colour discrimination and manual dexterity.5
There is some evidence that older doctors are better than their younger colleagues at tasks that rely on non-analytic strategies or pattern recognition, such as formulating initial diagnoses. What we recognise as ‘experience’ therefore has some scientific validity. However, most studies (though not all) suggest that older doctors perform worse than their younger colleagues in many other areas. Surgeons aged over 60 have higher operative mortalities, especially for procedures with low volume or high complexity, such as pancreatectomy or cardiac bypass surgery, and older doctors are also more likely to be investigated and disciplined by licensing bodies.6 Cognitive decline is frequently accompanied by a loss of insight, which potentially limits the role of self-regulation.
How to age well
Doctors identified by their peers as ageing well adopt practice changes intuitively. They take longer with consultations, avoid professional isolation and areas of unfamiliar practice, and reduce procedural work. They show insight into the effects of ageing on their practice and the need to adapt their working hours and choice of work.7
Long-term planning for retirement, including financial planning, a transitional phase of semi-retirement and the need to cultivate a variety of non-medical interests and relationships early in one’s career are all important.
Proper personal healthcare is essential. Self-treatment and corridor consultations should be scrupulously avoided and every doctor beyond middle age should see a general practitioner annually, at least.
Mandatory retirement: should we jump before we are pushed?
In Australia, retirement for judges currently is mandatory, at age 72, and for pilots, at age 65. Pilots also undergo physical and mental examinations every six months beyond 40 years of age. Few authorities support such a draconian approach for doctors. It does not fit with our contemporary understanding of cognitive ageing, which is highly variable in onset and severity, nor with government objectives that promote continuing workforce participation by older people.
Nevertheless, there are arguments for set retirement, including the reluctance of many doctors to relinquish their medical identity and the loss of insight that often accompanies cognitive decline.
In Ontario and British Columbia, peer assessments are now mandatory every five years for practising physicians over 70.8 Competency assessment for older doctors has been widely discussed, but there is a lack of consensus about how this should be done. Universal continuing education requirements may not be adequate to detect subtly impaired practitioners and there are obvious difficulties in approaching a senior colleague who may previously have been a mentor, supervisor or examiner.
Australian intensivists virtually all work in group environments where ‘incidental’ peer review occurs more or less continuously, but solo practice is more common among obstetricians and gynaecologists, who may therefore be more vulnerable to undetected impairment.
Adaptive practice Transitional activities such as teaching, mentoring, tribunal, medico-legal and college work can provide opportunities to capitalise on the strengths of senior doctors, while allowing them to avoid potential areas of weakness. The American College of Emergency Physicians, one of very few such organisations to have published a policy on ageing practitioners, recommends the abolition of night work (substituting some weekend cover), consistent shifts at set times rather than variable shift arrangements and the substitution of some high-acuity work with an increased role in teaching or administration.9
There have been discussions at various times in the Australian and New Zealand College of Anaesthetists, including a detailed review by Prof Barry Baker in 2001, who recommended no night calls from 60 years of age and mandatory retirement at 65.10 Prof Baker retired soon after, true to his word, but his proposals were never adopted.
The Australasian College of Intensive Care Medicine is in the advanced stages of developing a position statement that also recommends consideration of reduced night call for older intensivists, reduced ‘front line’ exposure to major resuscitation and ‘buddying’ with senior trainees to assist with emergency procedures.
While such measures are feasible in the public hospital sector, there is a trend for older intensivists, like many other specialist groups, to retreat into private practice,11 where opportunities for continuing education, peer review and peer support are often more limited.
With the general trend towards a longer working life for doctors and the community at large, issues faced by ageing practitioners need to be addressed by the profession. A more supportive, understanding and adaptive medical culture needs to develop in relation to older doctors, and the professional colleges should take a lead in this process. Insight into the vicissitudes of ageing and planning for retirement should play more of a role in college continuing education programs, which perhaps need to be tailored for older practitioners. As we enter an era of increasing demand for healthcare services, we need to develop strategies that will allow us to retain the wisdom and expertise of our most senior colleagues, while ensuring that they can continue to practise confidently and safely.