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JAMA Professionalism
April 18, 2017

Is It Time to Retire?

Author Affiliations
  • 1Department of Medicine, University of Toronto, Toronto, Ontario, Canada
  • 2Department of Medicine Research, St Michael’s Hospital, Toronto, Ontario, Canada
  • 3Wilson Centre for Research in Education, University of Toronto, Toronto, Ontario, Canada
JAMA. 2017;317(15):1570-1571. doi:10.1001/jama.2017.2230
Case Summary

Dr Bernard is a 70-year-old endocrinologist whose passion in life has been the practice of medicine and the care of patients with diabetes. He noticed that he was getting fewer referrals for new patients from other physicians in his group. On 2 occasions, other clinicians made passing comments to him about retirement. Although he has had a busy and productive career as a clinician, he had done little financial planning for retirement, resulting in his not having sufficient funds to fully retire. He loves working as a physician and never thought he would stop doing that. He wants to stay in practice but now feels insecure because he wonders if his colleagues believe he is getting too old and is not keeping current.

What Should Dr Bernard Do?

  1. Start planning his retirement now, which is sooner than expected, leaving him with less income than he had expected to have in retirement.

  2. Consider partially retiring so that he can still see patients with simple clinical problems.

  3. Talk with his medical director and ask for feedback on his performance to gain insight into whether there are problems with his clinical skills.

  4. Enroll in continuing medical education (CME) activities to gain new knowledge and test himself to determine if his clinical skills are current.

Consider the Options

Quiz Ref IDApproximately 1 in 4 physicians in the United States is older than 65 years.1 Physicians’ performance may decline with age, but a great deal of variation exists among individuals.1 For example, cognitive function typically declines with age, but the relationship of cognitive deficits and physician performance is complex and influenced by many factors.2,3 Maintaining clinical excellence and staying current with new advances is a persistent challenge for physicians, many of whom practice medicine for 3, 4, or even 5 decades after graduating from residency programs. As part of their professional responsibilities, all physicians must develop skills in reviewing their practice performance and obtaining feedback from various sources to inform their learning and improvement activities. Self-assessment alone without input from other sources is often inaccurate. Skills in self-assessment informed by feedback and measures of quality of care are essential to the professional commitment to providing excellent care.4

  1. Dr Bernard recognizes that there has been a great deal of research regarding diabetes care in recent years and that he hasn’t always kept current. He believes he has provided excellent care to his patients and doesn’t think he has caused any harm, although the thought of that potential disturbs him. Because of these concerns and what has been hinted at by his colleagues, he thinks it might be best to retire now, on his own terms.

    One downside is that he has a large practice with many long-term patients who like and trust him and who rely on his care. They would have to find new endocrinologists and develop new therapeutic relationships. He also might have significant financial difficulties that could put his family’s well-being at risk; indeed, he might have to forgo retirement activities that he had been looking forward to. Although patient welfare must always come first, it is reasonable to be concerned about his family’s well-being.

  2. Dr Bernard recognizes that it has been difficult to keep up with all the latest research in diabetes. However, in his experience, many diabetes cases are uncomplicated and the latest advances may not apply to them. He could consider limiting his practice by only treating “simple” cases while deferring more complicated cases to his colleagues.

    The potential downside to this is that it is not always possible to determine when a patient has more complex needs, which may put such patients at risk of complications. Furthermore, not providing care for complicated patients would create an imbalance in his group, with his partners having to absorb the responsibilities for more of the complex cases, which take more time and effort.

  3. Dr Bernard is not yet certain that there is a problem and, if so, how significant it is. Although the conversation may be difficult to initiate, he decides to ask his medical director for objective feedback on his performance. This approach would help him gauge whether he is overreacting, and if a problem really does exist, it would help him develop a solution in consultation with his medical director.

    Although this sounds reasonable, there is a risk that he might learn of concerns about his competence, and this awareness could be devastating to his sense of professional and personal identity. Another concern is that the medical director may not be able to provide the feedback he requires. Conceivably, there may be insufficient data on which to base an assessment, or the medical director may be unsure of how to constructively provide this sort of feedback.

  4. Dr Bernard may have concerns about being out of date regarding latest advances in diabetes, but he’s not sure about this. To test himself, he engages in CME activities. He decides that if his knowledge base is indeed adequate, he will be reassured that there is not a problem and that he will not pursue reducing his clinical practice nor consider retiring for now.

    It is important to recognize that not all CME is comprehensive and current, and the effectiveness of CME as a means of maintaining professional competence is mixed.5 Outcomes are better for live media relative to print media, and multiple exposures to educational content are more effective than a single exposure. Simulation training may be effective for maintenance of procedural skills.6 Although online courses are convenient, physicians should choose their CME activities based on their learning objectives and the skills they wish to improve.

Discussion

Quiz Ref IDThe optimal time for senior physicians to retire is not known (Audio at time 1:30).7 Physician aging is associated with cognitive decline and decreases in manual dexterity and visuospatial ability. Quiz Ref IDA systematic review of 62 studies found that increasing years in practice is associated with decreased knowledge, lower adherence to evidence-based standards of care, and worse patient outcomes.8 Any individual physician may not experience these declines, and despite advancing age, he or she may be fully competent in practice. However, individual physicians may not be aware that they have diminished abilities that could affect patient care. Age-related reductions in clinical skills are subtle and may not be obvious to physicians, their colleagues, or their patients. On the other hand, some abilities or attributes, like compassion and resilience during stressful events, may increase with aging.2,3 Overall, it is important for physicians to possess insight and awareness of these potential changes and to be able to seek and accept feedback from their peers and patients.

Hospitals and health systems are increasingly required to assess physicians’ performance to ensure they meet standards for high-quality care. However, there is no agreed-on approach for testing aging physicians because assessment tools are not necessarily valid and there is no agreement on the best approach for ensuring that senior physicians can provide high-quality and safe care. Assessment of senior physicians’ clinical skills must be balanced to be fair to individual physicians and to not unfairly penalize older physicians, who may be forced out of the workforce unnecessarily, culminating in shortages of competent clinicians who are needed for the medical workforce. Most medical organizations do not support mandatory retirement ages for physicians but do support assessment of competency in clinical medical practice.

All of the approaches outlined above have some merit and are not mutually exclusive. They each recognize that the physician in question may not be up to date with the latest advances in his or her field, but the exact scope and seriousness of these potential knowledge gaps are in question. Option 3 (and, to a lesser extent, option 4) are appropriate approaches to start addressing the issue.

Resolution

Dr Bernard recognized that his colleagues kept mentioning retirement but was uncertain about the nature of their observation or concerns. Dr Bernard sought objective feedback on his performance from his medical director even though the potential existed that he would be told something he did not want to hear. It is a hallmark of a true professional to be open to honest feedback and to use that information to ensure continuation of high-quality care.4 Dr Bernard’s institution participated in a voluntary program to help physicians assess their knowledge and skills that included a peer assessment component. Using a standardized approach to case review,9 a colleague reviewed cases and chart notes from Dr Bernard’s practice and provided suggestions related to actual cases. The review identified some lack of knowledge about the appropriate use of some of the new oral hypoglycemic agents, but overall, the care of his patients was appropriate. Dr Bernard participated in a CME program that included a chart audit and developing a quality improvement plan on this topic. Dr Bernard also enrolled in the health system’s financial and personal retirement planning program to help him manage his financial position once he retired.

Audio and CME

Listen to the accompanying audio program for more information about physician aging and performance. Quiz Ref IDIn some instances, the answers to CME questions are in the audio and not the text of the article (Audio at times 13:48 and 17:00). Take the quiz at http://jamanetwork.com/learning/article-quiz/10.1001/jama.2017.2230.

Section Editor: Edward H. Livingston, MD, Deputy Editor, JAMA.
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Article Information

Corresponding Author: Wendy Levinson, MD, University of Toronto, St Michael’s Hospital, 30 Bond St, 250Y, Sixth Floor, Room 648, Toronto, ON M5B 1W8, Canada (wendy.levinson@utoronto.ca).

Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Ginsburg reports receipt of royalties for a book cited in the reference section of this article. No other disclosures were reported.

References
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