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March 30, 2020

Older Clinicians and the Surge in Novel Coronavirus Disease 2019 (COVID-19)

Author Affiliations
  • 1Center for Interdisciplinary Health Workforce Studies, Montana State University College of Nursing, Bozeman
  • 2Department of Economics, Dartmouth College, Hanover, New Hampshire
  • 3National Bureau of Economic Research, Cambridge, Massachusetts
JAMA. 2020;323(18):1777-1778. doi:10.1001/jama.2020.4978

The recent report of 2 critically ill emergency physicians infected by the novel coronavirus disease 2019 (COVID-19) is a sobering reminder of the vulnerability of the nation’s health care workforce.1 While all members of the health care workforce are vital as the health care system faces perhaps its greatest challenge in memory, physicians and nurses are the caregivers who typically have the most direct contact with patients, whether through advising, triaging, or treating those who require hospitalization.

Across the nation, people, and particularly those older than 60 years, are being asked to stay at home and practice social distancing to slow the spread of infection and help avoid overwhelming hospitals that are expected to encounter shortages of needed equipment and personnel. Recent estimates from the Centers for Disease Control and Prevention indicate that the rates of hospitalizations, intensive care unit admissions, and mortality among reported COVID-19 cases in the United States are substantially higher among patients older than 45 years compared with younger patients, with case-fatality rates exceeding 1.4% among patients aged 55 to 64 years and exceeding 2.7% among those aged 65 to 74 years.2

There are large numbers of older nurses and physicians, who, if they were not in the health care workforce, would be staying at home to minimize their risk of exposure. Instead, many older clinicians are reporting for work every day. These clinicians have decades of experience, knowledge, and decision-making skills that are crucially important to guide the wise use of scarce resources when treating patients, protecting coworkers, and ensuring the capabilities of health care delivery organizations. In this Viewpoint, to better understand the prevalence of older clinicians in the workforce, we briefly summarize the age distribution of physicians and nurses by employment setting and for the largest metropolitan areas in the United States, including areas particularly affected by COVID-19, including Seattle, Washington, and New York City.

A substantial portion of hospital-based registered nurses, non–hospital-based registered nurses, and physicians are 55 years of age or older (Figure). Among the nation’s nearly 2 million registered nurses employed in hospitals, an estimated 370 000 (19%) are aged 55 to 64 years, and an estimated 55 000 (3%) are aged 65 years or older and thus, at even greater risk of complications and mortality from COVID-19. Of the approximately 1.2 million registered nurses employed outside of hospital settings, who could be called in to assist as hospital needs increase, even higher percentages are aged 55 to 64 years (24%) or aged 65 years or older (5%). The physician workforce is older still; of the approximately 1.2 million physicians in the United States, an estimated 230 000 (20%) are aged 55 to 64 years and an estimated 106 000 (9%) are aged 65 years or older.

Figure.  Estimated Number of Full-time Equivalent Registered Nurses (RNs) and Physicians by Age Group
Estimated Number of Full-time Equivalent Registered Nurses (RNs) and Physicians by Age Group

Authors’ analysis of data is sourced from the US Census Bureau American Community Survey 2014-2018, which reports pooled data representing a combined 5-in-100 national random sample of the US population (1% of the US population in each year).3 The sample includes all individuals who reported working with an occupation of physician or surgeon (N = 48 538) or registered nurse (including nurse anesthetists and nurse practitioners [N = 168 801]). All estimates were weighted by sampling weights provided by the American Community Survey and represent full-time equivalent clinicians.

As the effects of COVID-19 are currently strongly regional, it is also important to consider how the ages of the nursing and physician workforces vary across the United States. There are considerable differences, and some of the areas with the most registered nurses and physicians aged 55 and older are among the most severely affected by the virus. The 25 largest US metropolitan areas, ranked by the percentage of the registered nurses and physicians in the workforce aged 55 years and older, is shown in the eTable in the Supplement.

Among registered nurses, the 25 areas range from nearly one-third (31.7%) aged 55 years and older in Boston, Massachusetts, to less than 1 in 5 (19.3%) in Miami, Florida. The top 3 ranked areas, in terms of having an older registered nurse workforce (including Camden, New Jersey, and East Long Island, New York), have had or are near sites of considerable COVID-19 infection (as of March 23, 2020). Regarding the physician workforce, there is even more variation between the area with the oldest physicians (Camden, New Jersey [38.9%]) and the youngest (Houston, Texas [19.4%]). Although areas with relatively older registered nurses do not necessarily have relatively older physicians, Camden, New Jersey, Fort Lauderdale, Florida, and Orange County, California, are among the top 5 areas with the oldest registered nurse and physician workforces.

It is reassuring that large numbers of older nurses and physicians are caring for patients today. These clinicians have decades worth of knowledge, experience, and relationships with coworkers that will be needed now more than ever when large numbers of patients are hospitalized with COVID-19. These clinician leaders are an essential and vitally important component of many organizations, especially because many of these older clinicians have experience with disasters, triaging, decision making, and managing staff and resources under times of great stress. Conversely, should these older nurses and physicians become infected and required to stay home, or if they become patients, the ramifications could be significant, not only in terms of the loss of their clinical expertise and presence when it is needed the most, but the loss of leadership, judgement, and maintaining morale.

Hospitals and other care delivery organizations, including state and local health departments, should carefully consider how best to protect and preserve their workforce, with careful consideration involving older physicians and nurses. Older clinicians are likely to have an even larger role in the months ahead as more regions address workforce shortages by requesting that retired physicians and nurses consider returning to the workforce during the COVID-19 outbreak, as has recently occurred in New York City, the state of Illinois, and Great Britain.4-6 While hospitals and other organizations ramp up their preparations, this is the time to determine whether there may be different roles for older clinicians that will ensure they are able to contribute over the long-term course of the pandemic. This is not to suggest that these older nurses and physicians should necessarily be precluded from providing clinical care or should be isolated, but rather to consider if their direct clinician duties can be shifted to emphasize roles with less risk of exposure. These roles may include various activities, such as consulting with younger staff, advising on the use of resources, being readily available for clinical and organizational problem solving, helping clinicians and managers make tough decisions, talking with families of patients, advising managers and executives, being public spokespersons, and liaising with public and community health organizations. In addition, hospitals will want to prepare for the effect that a severe illness or death of a colleague will have on their staff in terms of morale.

As the public, government, and the health care workforce prepare for what could be extraordinarily challenging weeks and months ahead, thought should be given on how to wisely use all health care resources, including the nation’s nurse and physician workforce—from students to the most seasoned.

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Article Information

Corresponding Author: Douglas O. Staiger, PhD, Department of Economics, Dartmouth College, Hanover, NH 03755 (doug.staiger@dartmouth.edu).

Published Online: March 30, 2020. doi:10.1001/jama.2020.4978

Conflict of Interest Disclosures: Dr Buerhaus reports receipt of grants from the Gordon and Betty Moore Foundation, serving as a member of the National Academy of Medicine Committee on the Future of Nursing 2020-2030, and serving as chair of the unfunded National Health Care Workforce Commission created by the Affordable Care Act. No additional disclosures were reported.

Modern Healthcare.  Two emergency physicians in critical condition after becoming infected with COVID-19. Published March 15, 2020. Accessed March 20, 2020. https://www.modernhealthcare.com/providers/two-emergency-physicians-critical-condition-after-becoming-infected-covid-19
Centers for Disease Control and Prevention; COVID-19 Response Team.  Severe outcomes among patients with coronavirus disease 2019 (COVID-19)—United States, February 12-March 16, 2020.   MMWR. 2020;69(12):343-346. doi:10.15585/mmwr.mm6912e2Google Scholar
Ruggles  S, Flood  S, Goeken  R,  et al. IPUMS USA: version 10.0 [data set]. IPUMS; 2020. doi:10.18128/D010.V10.0
WIFR TV.  Pritzker asks retired physicians, doctors and nurses to come back to work during the COVID-19 outbreak. Posted March 21, 2020. Accessed March 23, 2020. https://www.wifr.com/content/news/Pritzker-asks-retired-physicians-doctors-and-nurses-to-come-back-to-work-during-the-COVID-1o-oubreak-568997121.html
Norman  G. Fox News website.  Britain asking 65 000 retired nurses and doctors to return to work to help fight coronavirus. Posted March 20, 2020. Accessed March 23, 2020. https://www.foxnews.com/world/britain-coronavirus-retired-nurses-doctors
Marsh  J; New York Post.  In one day, 1000 NYC doctors and nurses enlist to battle coronavirus. Posted March 21, 2020. Accessed March 23, 2020. https://nypost.com/2020/03/18/in-one-day-1000-nyc-doctors-and-nurses-enlist-to-battle-coronavirus/
8 Comments for this article
Don't Overlook Respiratory Therapists!
Anne Kennedy, RRT, RCP | Retired
Nobody in the press is talking about Respiratory Therapists! Who do you think is managing the ventilator care? I know we have hospitalists, and pulmonary residents now that also can manage the vents, but when I worked nobody but RT's knew really how to run the vents.

But that's beside the point. The point is there is a third clinician that everyone overlooks and doesn't get "thank for your service" and is taking a huge risk!

So, please at least mention us in your comments and if you have the chance, mention us to the

Protecting Mentors - Protecting Patients
Peter Shah, BSc MA FRCOphth FRCP Edin | University Hospitals Birmingham NHS Foundation Trust
Peter Buerhaus and colleagues articulate the dilemmas faced in deploying older clinicians to help tackle the surge of Coronavirus Disease 2019 (COVID-19). Experience on the front-line is always invaluable, but so also is the ability to strategically evaluate the battle from a distance.

Older clinicians are in the crucial position of being able to mentor younger clinicians, both in the fight against COVID-19, and also, in due course, in rebuilding many of the shattered services that have been put on hold as staff and resources are deployed into the front-line.

The three pillars of mentoring: Support,
Challenge and Vision will be extremely important in the coming months and years. It is vital that we carefully assess the risks involved in deploying our most senior clinicians into high-risk areas of front-line practice - the knowledge loss if we get the balance wrong in many cases will be irreplaceable.

The challenge is to harness the technological advances of the 21st century and enable the transmission of critical information from the front-line - and in doing this, help to ensure that we benefit from the knowledge of our senior clinicians, but with acceptable risk as we reduce the contact time they need to spend directly on the front-line.
Where Are All the Nurse Practitioners?
Stan Sack, MD | Semi-retired, Independent Contracting Pediatrician
What I find fascinating: not only are older physicians providing much of the care, but many are being persuaded to come out of retirement to help out. I've yet to read anyone calling on nurse practitioners to go to bat. We've come off legislation implying that NPs are the future of medicine, are in many ways equivalent to physicians, and can direct their own practices. We've seen large numbers of physicians let go and replaced by NPs. I would guess that at least some chose to retire rather than seek other employment.

Now's really the chance for those
"equivalent" nurse practitioners to step up to the plate and show what they're made of. Looking forward to their help!
Jan Witkowski, PhD | Cold Spring Harbor
We should not forget the many other health professionals facing danger in the current situation. On Thursday last week, the ambulance service of the New York Fire Department answered over 7000 calls. While not on the same scale, the tens thousands of paramedics, EMTs and other healthcare professionals who answer emergency calls throughout the country are similarly exposed to potential COVID-19 cases. Many of these individuals are volunteers who perform this service from a sense of duty alone.
Losing The Best of the Best
Umbrine Fatima, MD, FACP | Kenmore Mercy Hospital, Buffalo, NY
The article is very timely and reflects the sentiments of thousands of physicians in the US and beyond. The sad news of Dr. James T. Goodrich losing his battle with COVID-19 is the latest loss for the nation. He was an asset to the physician community and the world alike. Many other physicians continue to fight this battle without appropriate PPE, whether under moral obligation to save lives over their own, or under threat and coercion from the health systems they work for. This pandemic will go down in the history books as the biggest nations being least prepared; where more than 90 days after the breakout politicians and health systems are still arguing (despite clear scientific evidence) whether the virus is airborne or not to justify lack of provision of N95 respirators to the front-liners, while sealing body bags shut without letting viewing by the families, as if the dead bodies are suddenly many times more contagious than when they were while alive a few seconds earlier. Physicians are being pushed in harms' way to provide care without appropriate tools or personal protection. Never before in my professional life have I seen doctors been thrown under the bus like the present time as healthcare organizations continue to deny us appropriate PPE.

Never before have I witnessed politicians making healthcare decisions contrary to scientific evidence because isolation for 21 days or longer is fatal to the country's economy. Never before have I witnessed that a cheaper potential medicine be dismissed and put under threat of misuse by the "clinical guidelines" by the medical regulatory bodies because of the lost opportunity to the big pharma lobby. Never before have I witnessed the silliness of insisting on RCTs to confirm the benefit of interventions while denigrating reports of success of certain drugs in other countries as "anecdotal". Never before have I witnessed the ridiculousness of expending all healthcare resources towards attempting to save lives once they have triggered the cascade of no return while preventing early potential interventions of mild-moderate symptoms.

Never before have I witnessed non-evidence-based rules being imposed on the same physicians who are demanded to provide evidence-based care. Never before have I witnessed the excuse of necessity of a non-life saving drug for arthritis over the use of the same drug in a COVID-19 patient where it might be life saving. Never before have I witnessed a life saving drug disappear from the market the moment it is discovered that it may have life saving potential.

Never before have I felt like a puppet in the system created and run by lobbyists with economic interests over and above human interests. Never before have I felt so helpless as a physician.
Older Physicians should also be able to do Tele-Medicine Consultations
Hunasikatti Mahadevappa, MD FCCP | Fairfax Hospital, Falls Church , VA and Sleep and Lung Center, Fairfax, VA
INCREASED MORTALITY : The authors point to higher mortality in older patients. Oxford COVID-19 reports that patients aged 60-69 have a mortality of 3.6% and have a mortality of 8% in patients over the age of 70 years. Clearly they are at higher risk and should not be in close proximity with COVID-19 patients unless they are really well protected with N-95 masks, gowns, and protective glasses.

ETHICAL ISSUES: Older physicians should be able to be of help with younger staff, advising on the use of resources, talking with families of patients, advising managers and executives,
being public spokespersons, and liaising with public and community health organizations. They may be of help in difficult ethical issues like triage of ventilators when necessary.

TELE- MEDICINE: Hospitals should allow physicians to see patients via telemedicine. The Certified Nurse Assistant (CNA) can move the telemonitors around the medical and sub-acute nursing stations and physicians can talk to the patients over the monitor and see the patient. The patient also can see the physicians and make management decisions. This is additional help, not replacement of the hospitalist of the day, if possible. This also can be made available at night time-and this may increase the quality of patient care.

TELE-ICU: As COVID patients develop Acute Respiratory Distress Syndrome in about 2-8 days, intensivists may get burnt out if they work day and night. Older physicians should be able to help the ICU take care of patients at night in small and medium-sized community hospitals. This may help improve the quality of patient care in the long run.

HEALTH EDUCATION: Older physicians should actively educate the public via TV, newspapers and online about the need for Social Distancing. This is the most important thing you can do so that younger generations may follow the strict guidelines.

Let older physicians help you as much as they can without hurting themselves. Care of COVID-19 patient is going to be a marathon than a sprint. Time to plan for long haul.
Clinicians helping during the COVID-19 pandemic
Rosemary Perley Kwauk, CRNA | Hospital
Please don't forget nurse anesthesiologists who are permitted in many places to practice independently and are helping with the manpower shortage. That is how we got started in the beginning and are we capable of rising to the challenge. Thank you. Great article.
Nurse Practitioners
Stephen Luippold, MSN, Psychiatric NP | Nurse Practitioners
In response to Dr. Sack's question, "where are all the nurse practitioners," we are here on the front lines caring for COVID-19 patients alongside our physician and nurse colleagues. In the context of this article, I'm a 65 year old NP with 30 years experience and grateful to be in a position to help in this time of crises.


Stephen Luippold