Several years ago, a good friend and colleague – the chairman of a psychiatry department – notified people about his retirement in a department newsletter. He wrote, “I sent out a letter to the alumni and adjunct faculty that I will retire on June 30 [2021]. I had decided five years ago that when I reached a certain age, I was going to retire. Such decisions have multiple determinants and are made with ambivalent feelings.”
My friend was on the faculty for 20 years and chairman for half that time. He further wrote, “It has been a wonderful journey. Watching many residents and faculty become outstanding clinicians, educators, and researchers has been an honor and joy. These wonderful relationships are part of the tapestry of my memory and will always remind me of my years at [the medical school]. I am leaving a vibrant, energetic, and young faculty.”
“Why retire,” I thought. It didn’t make sense that my friend would impose an age limit on himself to retire when he was 70 and cognitively intact. I know there are times when physicians begin to show signs of dementia and are singled out for neuropsychological evaluations. Similarly, some surgeons seem physically unfit to operate and are subjected to ophthalmological and neurological testing. In fact, this topic – the competency of older physicians to practice medicine – has become a raging controversy.
The issue concerns whether physicians should be forced to retire at a certain age like other professionals – judges, FBI agents, commercial pilots, air traffic controllers, military officers, national park rangers, and others. The argument for mandatory retirement almost always centers on public safety. Older physicians are believed to threaten patients’ safety because aging impacts vision, hearing, dexterity, stamina, cognition, and judgment. A 2005 article in the Annals of Internal Medicine kicked off a firestorm when the authors reviewed 62 studies and found that more than half (52 percent) showed a decline in patient outcomes with advanced practitioner age (only one study showed improvement).
A 2017 study in the British Medical Journal offered further proof that aging results in errors and poorer quality care. Among hospitalists in charge of Medicare patients, older physicians had higher 30-day mortality rates than those cared for by younger physicians, despite similar patient characteristics. The only variable that resulted in comparable mortality rates was high patient volume, in which case, young or old, it didn’t make a difference in patient mortality.
However, a recent analysis of 52 studies found quite the opposite, i.e., physicians’ clinical experience (a proxy for age) and quality tended to be positively correlated. Moreover, in a study of surgeons, age was not an important predictor of operative risk, including mortality, for most procedures. In yet another study, residents, and attendings were judged to be equal in their safety outcomes. A subsequent study of emergency medicine physicians found that older physicians fared better than younger ones in terms of committing fewer errors, prompting some to argue that training resources should be directed toward novice physicians instead of elderly ones.
Overall, the literature on this subject is complicated and conflicting, with marked variation in results and divided opinions about implementing mandatory competency testing or retirement for physicians, usually beginning at age 70.
Ageism is one significant factor that clouds findings and interpretations – the elephant in the room. The term “ageism” was coined in 1968 by psychiatrist Robert N. Butler (1927-2010), who became the first director of the National Institute on Aging. Butler, a fierce defender against discrimination and stereotypes of the elderly, compared ageism to racism, claiming it was “prejudice by one age group toward other age groups.” (Butler did not discuss “reverse ageism” coming from older workers toward younger professionals.)
In one of his seminal papers, “Age-Ism: Another Form of Bigotry,” Butler wrote: “Ageism reflects a deep-seated uneasiness on the part of the young and middle-aged – a personal revulsion to and distaste for growing old, disease, disability; fear of powerlessness, ‘usefulness,’ and death.” I do not doubt that much of the controversy surrounding the mandatory retirement of physicians is rooted in ageism.
Nowhere is this more evident than in institutions embarking on late-career practitioner screening programs, notably Yale New Haven Hospital, which is tied up in litigation with the U.S. Equal Employment Opportunity Commission over attempts to evaluate physicians simply because they are old. At Yale and other institutions, it is quite possible that policies may reflect ageist attitudes rather than genuine concerns about patient safety, and that implicit (unconscious) bias may be at work – a type of microaggression toward the elderly.
A recent study from Switzerland bears this out. There was a tendency among 234 human resource (HR) employees to see themselves as less biased than their HR peers or to be able to identify more cognitive biases in others than in themselves in their hiring decisions. The presence of a biased “blind spot” was thus confirmed. Furthermore, male HR employees showed a greater bias blind spot than female HR employees.
Age bias is one of the most common types of discrimination in the workplace today. This is very concerning for physicians, given that approximately 47 percent of active physicians in the U.S. in 2021 were 55 or older, and some plan to practice until they are in their 70s or 80s. An age mandate to deplete the physician workforce would wreak havoc on a system already facing dire shortages.
For sure, there are physicians advancing in age who should be removed from the workforce. There are also early-career physicians who should not be allowed to practice. The solution is to target the performance of individual physicians when their abilities are in question rather than target an entire class of physicians and begin collecting normative data for various age groups to prevent judgments from being made in isolation.
The AMA Principles of Medical Ethics also propose a way to solve the conundrum of mandatory retirement. It recognizes that physicians have a duty to monitor the quality of care they deliver as individual practitioners, e.g., through personal case review and critical self-reflection, peer review, and the use of other quality improvement tools. Physicians are responsible for maintaining their health and wellness. When practice issues arise, take measures to mitigate them, seek appropriate help as necessary and engage in an honest self-assessment of their ability to continue practicing.
For example, Richard Rothman, MD (1936-2018), was one of the nation’s most prominent and respected orthopedic surgeons. He was still doing surgery at age 80. However, he had his vision checked regularly and asked a senior partner to monitor the quality of his work for a day (he did fine). Rothman may have been a role model for the AMA, but how often can physicians be expected to follow his lead?
Let’s not forget that reasons other than ageism may explain the mandated screening of older physicians and fitness-for-duty evaluations in the absence of perceived deficits and that most physicians are ultimately in control of their retirement. In the case of my colleague, I discovered his retirement was not voluntarily planned. He became embroiled in conflict with the university, and his departure had nothing to do with his age, competence, or views about his age.
Finally, at the risk of digressing, I find it interesting that, according to a recent ABC news poll, the majority of U.S. citizens disapprove of the job done by President Biden, and one-third of citizens would feel “angry” if either Donald Trump or Joe Biden were elected president in 2024. Could it be their age, rather than their performance or party affiliation, that evoked such a strong public reaction?
Arthur Lazarus is a former Doximity Fellow, a member of the editorial board of the American Association for Physician Leadership, and an adjunct professor of psychiatry at the Lewis Katz School of Medicine at Temple University in Philadelphia, PA. His forthcoming book is titled Every Story Counts: Exploring Contemporary Practice Through Narrative Medicine.
