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Issues of Concern to Emergency Physicians in Pre-Retirement Years: A Survey
The Journal of Emergency Medicine, Vol. 40, No. 6, pp. 706 –713, 2011 Copyright © 2011 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$–see front matter
doi:10.1016/j.jemermed.2009.08.020
Brief Reports
ISSUES OF CONCERN TO EMERGENCY PHYSICIANS IN PRE-RETIREMENT YEARS: A SURVEY Richard Goldberg,
MD,*
Harold Thomas,
MD,†
and Louis Penner,
PHD‡
*Department of Emergency Medicine, University of Southern California, Los Angeles, California, †Department of Emergency Medicine, Oregon Health Sciences University, Portland, Oregon, and ‡Department of Family Practice, Wayne State University, Detroit, Michigan Reprint Address: Richard Goldberg, MD, FACEP, Department of Emergency Medicine, LAC-USC Medical Center, 1200 N. State, Los Angeles, CA 90033
ability to practice, 28% reported memory somewhat or considerably worse, and 25% reported less ability to incorporate new modalities of diagnosis and treatment. With regard to retirement-related issues, 42% reported concerns about adequate financial preparations and 44% reported concerns regarding loss of identity upon retirement. The practice modifications most commonly reported to impact career longevity were the reduction or elimination of night shifts, a reduction in the number of hours per shift, and an increase in physician and support staffing. Conclusions: Respondents to this survey generally viewed themselves as competent, empathic practitioners. Yet a substantial percentage acknowledged at least some degree of cognitive or physical decline. The results suggest a role for the national organizations in emergency medicine in endorsing practice modifications that promote career longevity and clinical competence among its senior members. © 2011 Elsevier Inc.
e Abstract—Background: Many members of the American College of Emergency Physicians are now over the age of 50. Little is known regarding age-specific issues that may impact the careers of emergency physicians in the latter stages of their professional lives. Objectives: To determine issues of concern regarding aging and retirement among a cohort of emergency physicians in pre-retirement years. Methods: A survey of a randomized sample of 1000 American College of Emergency Physicians members over the age of 55 years was conducted with two separate mailings in the fall of 2006 and winter of 2007. The survey instrument consisted of 30 questions relating primarily to issues of health, finances, and the ability to practice emergency medicine. Four open-ended questions were included at the end of the survey, relating to means of promoting career longevity. Results: There were 802 usable responses received (response rate 80%). The average respondent was 57 years old and worked 30 clinical and 12 non-clinical h per week. The average estimated time to complete retirement was 7.8 years. Respondents generally viewed themselves as competent clinicians with improved ability to relate to patients and staff and little decline in procedural skills. However, a substantial proportion reported age-related concerns. Seventyfour percent reported less ability to recover from night shifts, 44% reported a higher level of emotional exhaustion at end of shift, 40% reported less ability to manage heavy patient volume, 36% reported less ability to handle stress of emergency medicine, 28% reported health limitations on
e Keywords—physician retirement; aging physician; physician wellness; physician impairment; career longevity; cognitive decline; clinical competence
INTRODUCTION A number of articles have appeared in the recent medical literature addressing issues of aging and retirement among physicians (1–14).
This work was funded by an American College of Emergency Physicians Section Grant.
RECEIVED: 12 March 2009; FINAL ACCEPTED: 29 August 2009
SUBMISSION RECEIVED:
8 July 2009; 706
Issues of Concern
707
Such issues would appear to have relevance to many members of the American College of Emergency Physicians (ACEP), 31% of whom are over the age of 50 years (personal communication, Karen Price, Member Services Representative, ACEP, June 6, 2007). Although it is assumed that certain life-stage issues are common to everyone in their pre-retirement years, little is known regarding issues that might be profession or specialty specific. Are older emergency physicians less able to tolerate shift work, heavy patient volume, difficult patients, or typical scheduling? Have they lost the dexterity to do certain procedures? Do they have concerns about cognitive decline? In September 2005, the Well-Being Committee of the ACEP formed a subcommittee to promote dialogue and research on the aging emergency physician. Among the activities of the subcommittee was the distribution of a randomized survey to ACEP members over the age of 55 years in an effort to identify issues of concern to this population. The survey results are summarized in this report.
METHODS A survey of a randomized sample of 1000 ACEP members over the age of 55 years was conducted with two separate mailings in the fall of 2006 and winter of 2007, the time interval between mailings being 7 weeks. It was funded by a section grant from the ACEP. Randomization was performed by staff within the Membership Division of the ACEP. The survey instrument (Figure 1) consisted of 30 questions, the first eight of which related to demographic data including age, marital status, number of years in practice, and number of hours currently working. Eighteen questions were designed to elicit self-reports related to issues of health, finances, and ability to practice emergency medicine. A four-point response format was used, with choices ranging from “strongly agree” to “strongly disagree.” Four open-ended questions were also included. The survey was pre-assessed by a sampling of 14 emergency physicians within the age cohort, but not participating in the formal study. A total of 802 responses were received (response rate 80%). Approval of the study was obtained by the Institutional Review Board of Oregon Health Sciences University.
Statistical Analysis The data were analyzed using the Statistical Package for the Social Sciences version 15 (SPSS 15; SPSS Inc., Chicago, IL). Questions about respondents’ demographic/personal/ professional characteristics, concerns about retirement, and current limitations were analyzed using the univariate de-
scriptive statistics features of SPSS 15. These provided means, standard deviations, range, and frequency distributions for the responses to each question. One-way univariate analyses of variance (ANOVAs) were used to compare the responses of different respondent subgroups (e.g., single, married, and divorced respondents). If the main effects analyses in the ANOVAS were significant, post hoc analyses of the three groups were conducted using Least Significant Difference post hoc tests. Pearson product moment correlations were used to examine the relationships among responses to different questions in the survey. For all analyses, the significance level was set at 0.05. However, in this report we do not discuss correlations of ⬍ 0.10 even if they were significant at this probability level. This is because the absolute size of such correlations was so small as to make them of little practical importance.
RESULTS The results are summarized in Tables 1-3. The data presented in Table 2 represent a collapse of responses “disagree/strongly disagree” into a negative response, and “agree/strongly agree” into a positive response.
Demographics Of the 802 responding physicians, the average age was 57.5 years, with a range of 23 years. Average length of practice was 26 years (range 41 years). Average clinical workload was 30 h per week (range 67 h), and nonclinical workload 12 h per week (range 60 h). The average estimated time to complete retirement was 7.8 years (range 25 years). The vast majority of respondents were married (84%), and were working full time (83%). The 3.7% of respondents that were fully retired were excluded from the analysis.
Issues of Concern A substantial proportion of respondents reported agerelated concerns. When asked to compare their current ability/status to ability/status 5 years previously, 74% reported less ability to recover from night shifts, 44% reported a higher level of emotional exhaustion at end of shift, 40% reported less ability to manage heavy patient volume, 36% reported less ability to handle stress of emergency medicine, 28% reported health limitations on ability to practice, 28% reported memory somewhat or considerably worse, and 25% reported less ability to incorporate new modalities of diagnosis and treatment. With regard to retirement-related issues, 58% reported
708
R. Goldberg et al.
Figure 1. Issues of concern to emergency physicians in pre-retirement years.
concerns about adequate financial preparations and 44% reported concerns regarding loss of identity upon retirement. In general, retirement-related concerns were significantly greater among single respondents than among married or divorced respondents. There were also a number of positive findings that appeared to be age or experience related, at least compared to ability/status 5 years previously. These include the ability to manage complicated clinical
problems (92% same or better); ability to perform common procedures (83% same or better); ability to empathize (49% better); and ability to handle difficult personalities (36% better). In response to the question, “Compared to earlier years in practice, the following aspects of my current practice are more enjoyable,” the most common responses, in order of frequency, were categorized as 1) relating to patients, 2) new technology, and 3) absence of night shift work. The
Issues of Concern
709
Figure 1. (Continued)
three most common responses to the question, “Compared to earlier years in practice, my skill as a practitioner has improved in the following ways,” were 1) relating better to patients and staff, 2) improved clinical and diagnostic skills, and 3) improved use of available technology. Regarding the question, “The following changes in my practice environment would enhance my career in emergency medicine,” the most common responses were 1) fewer or no night shifts; 2) fewer hours; and 3) more physician and support staff coverage. In response to the question, “What can the American College of Emergency Physicians do to help
members deal with issues regarding retirement and career longevity?,” the most common responses were 1) address the economics of retirement; 2) advocate for issues of concern to senior physicians; and 3) issue guidelines regarding fewer night shifts for senior physicians.
DISCUSSION Concerns have been expressed in the recent medical literature regarding the older medical practitioner. Pri-
710
Figure 1. (Continued)
R. Goldberg et al.
Issues of Concern
711
Table 1. Demographics Age (years)
Number of Years in Practice
Clinical Hours Worked/Month
Non-clinical Hours/Month
How Long Plan to Work As Now (Years)
How Long Plan to Work at All (Years)
57 ⫾ 2.74
26 ⫾ 5.01
121 ⫾ 47.35
48.14 ⫾ 54.1
5.5.44 ⫾ 3.3
7.88 ⫾ 3.89
mary areas of inquiry have included the impact of aging on the ability to practice medicine and the emotional sequelae of retirement (1–14). With regard to the latter, available evidence suggests that most physicians transition well into retirement, finding fulfillment in a multitude of non-professional activities (11–14). On the other hand, there is a growing body of evidence suggesting that, in addition to the physical concomitants of aging, substantial numbers of older physicians manifest age-related declines in their cognitive skills. Studies on the impact of aging on cognition, although allowing for substantial individual variation, suggest progressive deterioration in a number of spheres, including the ability to perform complex tasks rapidly, to adapt to new and changing conditions, to process incoming information and make complex decisions, and to perform effectively in a stressful environment (1–9). Additionally, increasing age is associated with decreased tolerance for shift work cycles, and a greater tendency toward late-night errors (15). Such findings have obvious relevance to physicians, given the intellectual and physical demands of the profession. Choudry et al., in a systematic review of studies relating medical knowledge and quality of care to years in practice and physician age, concluded that there is an inverse relationship between the number of years a physician has practiced and the quality of care provided (70% of studies reviewed demonstrated a negative association) (3). This relationship held for medical knowledge, adherence to nationally accepted guidelines and standards, and to patient outcomes. The findings were consistent across medical specialties. An accompanying editorial argues that medical practice must be accompanied by ongoing active effort to maintain competence and quality of care (4).
Table 2. Concerns Regarding Retirement Area of Concern Adequate financial preparation Loss of professional identity Adequate social contact Filling time Relationship with spouse
Disagree/Strongly Agree/Strongly Disagree Agree 42.4%
57.6%
56% 73% 79.9% 88.5%
44% 23% 20.1% 11.5%
The results of our survey of older emergency physicians are consistent in many ways with the established literature. Respondents generally viewed themselves as competent clinicians with improved ability to relate to patients and staff and little decline in procedural skills. However, a substantial percentage acknowledged at least some degree of cognitive decline (including the ability to acquire new knowledge) or physical limitation. Additionally, many senior physicians felt they would benefit from modifications of their workload with respect to hours, patient load, physician and support staffing, and, most particularly, night shifts. These findings pose challenges for the individual emergency physician, for physician groups, and for the ACEP. It would appear to be incumbent upon the older practitioner, in conjunction with colleagues, to be alert to the potential impact of aging on the quality of care delivered. Physician groups should be prepared to implement adjustments to hours, workload, and levels of acuity evaluated. Finally, efforts by the ACEP to address issues relating to older members (specifically, performance standards and practice modifications) may help to ensure professional competence, while at the same time prolonging careers in the specialty and easing the transition to retirement.
Limitations The study has several limitations. Our second mailing inadvertently went out to the entire cohort rather than the
Table 3. Five-Year Comparative Appraisal of Practice Skills
Ability to perform procedures Manage complicated clinical problems Empathize with patients Dexterity in performing procedures Deal with difficult personalities Incorporating new diagnostic/therapeutic modalities Memory Handle stress of emergency medicine Manage heavy patient volume Emotional exhaustion at end of shift Recover from night shifts
Better/Same
Worse/Much Worse
93.9% 91.5%
6.1% 8.5%
86.8 83.2 82.6 75.2
13.2 16.8 17.4 24.8
71.7 63.8
28.2 36.2
59.8 55.6
40.1 44.4
25.2
74.2
712
R. Goldberg et al.
initial non-responders. The possibility, though unlikely, does exist that some respondents completed the survey more than once. Second, the majority of questions involved selfreported responses that may or may not reflect enduring attitudes or stable assessments of current ability levels. Finally, whereas over 99% of the respondents answered the questions about their demographic characteristics, current practice, and concerns when they retire, only 84% of respondents completed the questions regarding specific physical and cognitive limitations in their practice. This raises the possibility that a substantial percentage of responders had limitations they were reluctant to disclose even in an anonymous survey.
CONCLUSION The survey results suggest that older emergency physicians generally view themselves as competent, empathic practitioners. Yet a substantial percentage acknowledges at least some degree of cognitive or physical decline. Additionally, the responses suggest that careers could potentially be prolonged by a number of practice modifications, including adjustment of work regimen with respect to hours, patient load, physician and support staffing, and, most particularly, night shifts. It would appear that national organizations in emergency medicine have an important role to play in promoting both
career longevity and clinical competence among senior members of the profession. REFERENCES 1. Eva KW. The aging physician: changes in cognitive processing and their impact on medical practice. Acad Med 2002;77:S1– 6. 2. Turnbull J, Carbotte R, Hanna E, et al. Cognitive difficulty in physicians. Acad Med 2000;75:177– 81. 3. Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care. Ann Intern Med 2005;142:260 –73. 4. Weinberger SE, Duffy FD. Editorial. “Practice makes perfect . . . or does it?” Ann Intern Med 2005;143:302–3. 5. Katz JD. Issues of concern for the aging anesthesiologist. Anesth Analg 2001;92:1487–92. 6. Budson AE, Price BH. Current concepts: memory dysfunction. N Engl J Med 2005;352:692–9. 7. Keefover RW. Aging and cognition. Neurol Clin 1998;16:635– 64. 8. Eva KW. Stemming the tide: cognitive aging theories and their implication for continuing education in the health professions. J Contin Educ Health Prof 2003;23:133– 40. 9. Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med 2004;79:570 – 81. 10. Katz JD. Challenges for the aging physician. Conn Med 2002;66: 539 – 42. 11. Virshup B, Coombs RH. Physicians’ adjustment to retirement. West J Med 1993;158:142– 4. 12. Lees E, Liss SE, Cohen IM, et al. Emotional impact of retirement on physicians. Tex Med 2001;97:66 –71. 13. Guerriero Austrom M, Perkins AJ, Damush TM, Hendrie HC. Predictors of life satisfaction in retired physicians and spouses. Soc Psychiatry Psychiatr Epidemiol 2003;38:134 – 41. 14. Anast GT. Benchmarking retirement: a best practices decision. Best Pract Benchmarking Healthc 1997;2:168 –73. 15. Mitler MM, Carskadon MA, Czeisler CA, et al. Catastrophe, sleep, and public policy: consensus report. Sleep 1988;11:100 –9.
Issues of Concern
713
ARTICLE SUMMARY 1. Why is this topic important? The membership of the American College of Emergency Physicians is aging. Approximately 31% of members are now over the age of 50. Little is known regarding the impact of aging on the ability to practice emergency medicine, or the practice modifications that might prolong and enhance the careers of our senior physicians. 2. What does this study attempt to show? The study attempts to identify issues of concern to older emergency physicians with regard to finances, health, preparedness for retirement, ability to continue in practice, and measures by which these concerns might be addressed. 3. What are the key findings? 1) While older emergency physicians generally view themselves as competent, empathic practitioners, a substantial percentage acknowledge at least some degree of cognitive or physical decline. 2) Respondents suggest that careers could be prolonged by a number of practice modifications, including adjustment of work regimen with respect to hours, patient load, physician and support staffing, and, most particularly, night shifts. 4. How is patient care impacted? 1) Survey responses suggest that physicians and physician groups should be mindful of the potential impact of aging on the quality of care delivered. 2) Physician groups should consider practice modifications for their senior members, including adjustments to hours, workload, and levels of acuity assigned. 3) Efforts by ACEP to address issues relating to older members (specifically performance standards and practice modifications), may help to ensure professional competence, while at the same time prolonging careers in the specialty.
doi:10.1016/j.jemermed.2009.08.020
Brief Reports
ISSUES OF CONCERN TO EMERGENCY PHYSICIANS IN PRE-RETIREMENT YEARS: A SURVEY Richard Goldberg,
MD,*
Harold Thomas,
MD,†
and Louis Penner,
PHD‡
*Department of Emergency Medicine, University of Southern California, Los Angeles, California, †Department of Emergency Medicine, Oregon Health Sciences University, Portland, Oregon, and ‡Department of Family Practice, Wayne State University, Detroit, Michigan Reprint Address: Richard Goldberg, MD, FACEP, Department of Emergency Medicine, LAC-USC Medical Center, 1200 N. State, Los Angeles, CA 90033
ability to practice, 28% reported memory somewhat or considerably worse, and 25% reported less ability to incorporate new modalities of diagnosis and treatment. With regard to retirement-related issues, 42% reported concerns about adequate financial preparations and 44% reported concerns regarding loss of identity upon retirement. The practice modifications most commonly reported to impact career longevity were the reduction or elimination of night shifts, a reduction in the number of hours per shift, and an increase in physician and support staffing. Conclusions: Respondents to this survey generally viewed themselves as competent, empathic practitioners. Yet a substantial percentage acknowledged at least some degree of cognitive or physical decline. The results suggest a role for the national organizations in emergency medicine in endorsing practice modifications that promote career longevity and clinical competence among its senior members. © 2011 Elsevier Inc.
e Abstract—Background: Many members of the American College of Emergency Physicians are now over the age of 50. Little is known regarding age-specific issues that may impact the careers of emergency physicians in the latter stages of their professional lives. Objectives: To determine issues of concern regarding aging and retirement among a cohort of emergency physicians in pre-retirement years. Methods: A survey of a randomized sample of 1000 American College of Emergency Physicians members over the age of 55 years was conducted with two separate mailings in the fall of 2006 and winter of 2007. The survey instrument consisted of 30 questions relating primarily to issues of health, finances, and the ability to practice emergency medicine. Four open-ended questions were included at the end of the survey, relating to means of promoting career longevity. Results: There were 802 usable responses received (response rate 80%). The average respondent was 57 years old and worked 30 clinical and 12 non-clinical h per week. The average estimated time to complete retirement was 7.8 years. Respondents generally viewed themselves as competent clinicians with improved ability to relate to patients and staff and little decline in procedural skills. However, a substantial proportion reported age-related concerns. Seventyfour percent reported less ability to recover from night shifts, 44% reported a higher level of emotional exhaustion at end of shift, 40% reported less ability to manage heavy patient volume, 36% reported less ability to handle stress of emergency medicine, 28% reported health limitations on
e Keywords—physician retirement; aging physician; physician wellness; physician impairment; career longevity; cognitive decline; clinical competence
INTRODUCTION A number of articles have appeared in the recent medical literature addressing issues of aging and retirement among physicians (1–14).
This work was funded by an American College of Emergency Physicians Section Grant.
RECEIVED: 12 March 2009; FINAL ACCEPTED: 29 August 2009
SUBMISSION RECEIVED:
8 July 2009; 706
Issues of Concern
707
Such issues would appear to have relevance to many members of the American College of Emergency Physicians (ACEP), 31% of whom are over the age of 50 years (personal communication, Karen Price, Member Services Representative, ACEP, June 6, 2007). Although it is assumed that certain life-stage issues are common to everyone in their pre-retirement years, little is known regarding issues that might be profession or specialty specific. Are older emergency physicians less able to tolerate shift work, heavy patient volume, difficult patients, or typical scheduling? Have they lost the dexterity to do certain procedures? Do they have concerns about cognitive decline? In September 2005, the Well-Being Committee of the ACEP formed a subcommittee to promote dialogue and research on the aging emergency physician. Among the activities of the subcommittee was the distribution of a randomized survey to ACEP members over the age of 55 years in an effort to identify issues of concern to this population. The survey results are summarized in this report.
METHODS A survey of a randomized sample of 1000 ACEP members over the age of 55 years was conducted with two separate mailings in the fall of 2006 and winter of 2007, the time interval between mailings being 7 weeks. It was funded by a section grant from the ACEP. Randomization was performed by staff within the Membership Division of the ACEP. The survey instrument (Figure 1) consisted of 30 questions, the first eight of which related to demographic data including age, marital status, number of years in practice, and number of hours currently working. Eighteen questions were designed to elicit self-reports related to issues of health, finances, and ability to practice emergency medicine. A four-point response format was used, with choices ranging from “strongly agree” to “strongly disagree.” Four open-ended questions were also included. The survey was pre-assessed by a sampling of 14 emergency physicians within the age cohort, but not participating in the formal study. A total of 802 responses were received (response rate 80%). Approval of the study was obtained by the Institutional Review Board of Oregon Health Sciences University.
Statistical Analysis The data were analyzed using the Statistical Package for the Social Sciences version 15 (SPSS 15; SPSS Inc., Chicago, IL). Questions about respondents’ demographic/personal/ professional characteristics, concerns about retirement, and current limitations were analyzed using the univariate de-
scriptive statistics features of SPSS 15. These provided means, standard deviations, range, and frequency distributions for the responses to each question. One-way univariate analyses of variance (ANOVAs) were used to compare the responses of different respondent subgroups (e.g., single, married, and divorced respondents). If the main effects analyses in the ANOVAS were significant, post hoc analyses of the three groups were conducted using Least Significant Difference post hoc tests. Pearson product moment correlations were used to examine the relationships among responses to different questions in the survey. For all analyses, the significance level was set at 0.05. However, in this report we do not discuss correlations of ⬍ 0.10 even if they were significant at this probability level. This is because the absolute size of such correlations was so small as to make them of little practical importance.
RESULTS The results are summarized in Tables 1-3. The data presented in Table 2 represent a collapse of responses “disagree/strongly disagree” into a negative response, and “agree/strongly agree” into a positive response.
Demographics Of the 802 responding physicians, the average age was 57.5 years, with a range of 23 years. Average length of practice was 26 years (range 41 years). Average clinical workload was 30 h per week (range 67 h), and nonclinical workload 12 h per week (range 60 h). The average estimated time to complete retirement was 7.8 years (range 25 years). The vast majority of respondents were married (84%), and were working full time (83%). The 3.7% of respondents that were fully retired were excluded from the analysis.
Issues of Concern A substantial proportion of respondents reported agerelated concerns. When asked to compare their current ability/status to ability/status 5 years previously, 74% reported less ability to recover from night shifts, 44% reported a higher level of emotional exhaustion at end of shift, 40% reported less ability to manage heavy patient volume, 36% reported less ability to handle stress of emergency medicine, 28% reported health limitations on ability to practice, 28% reported memory somewhat or considerably worse, and 25% reported less ability to incorporate new modalities of diagnosis and treatment. With regard to retirement-related issues, 58% reported
708
R. Goldberg et al.
Figure 1. Issues of concern to emergency physicians in pre-retirement years.
concerns about adequate financial preparations and 44% reported concerns regarding loss of identity upon retirement. In general, retirement-related concerns were significantly greater among single respondents than among married or divorced respondents. There were also a number of positive findings that appeared to be age or experience related, at least compared to ability/status 5 years previously. These include the ability to manage complicated clinical
problems (92% same or better); ability to perform common procedures (83% same or better); ability to empathize (49% better); and ability to handle difficult personalities (36% better). In response to the question, “Compared to earlier years in practice, the following aspects of my current practice are more enjoyable,” the most common responses, in order of frequency, were categorized as 1) relating to patients, 2) new technology, and 3) absence of night shift work. The
Issues of Concern
709
Figure 1. (Continued)
three most common responses to the question, “Compared to earlier years in practice, my skill as a practitioner has improved in the following ways,” were 1) relating better to patients and staff, 2) improved clinical and diagnostic skills, and 3) improved use of available technology. Regarding the question, “The following changes in my practice environment would enhance my career in emergency medicine,” the most common responses were 1) fewer or no night shifts; 2) fewer hours; and 3) more physician and support staff coverage. In response to the question, “What can the American College of Emergency Physicians do to help
members deal with issues regarding retirement and career longevity?,” the most common responses were 1) address the economics of retirement; 2) advocate for issues of concern to senior physicians; and 3) issue guidelines regarding fewer night shifts for senior physicians.
DISCUSSION Concerns have been expressed in the recent medical literature regarding the older medical practitioner. Pri-
710
Figure 1. (Continued)
R. Goldberg et al.
Issues of Concern
711
Table 1. Demographics Age (years)
Number of Years in Practice
Clinical Hours Worked/Month
Non-clinical Hours/Month
How Long Plan to Work As Now (Years)
How Long Plan to Work at All (Years)
57 ⫾ 2.74
26 ⫾ 5.01
121 ⫾ 47.35
48.14 ⫾ 54.1
5.5.44 ⫾ 3.3
7.88 ⫾ 3.89
mary areas of inquiry have included the impact of aging on the ability to practice medicine and the emotional sequelae of retirement (1–14). With regard to the latter, available evidence suggests that most physicians transition well into retirement, finding fulfillment in a multitude of non-professional activities (11–14). On the other hand, there is a growing body of evidence suggesting that, in addition to the physical concomitants of aging, substantial numbers of older physicians manifest age-related declines in their cognitive skills. Studies on the impact of aging on cognition, although allowing for substantial individual variation, suggest progressive deterioration in a number of spheres, including the ability to perform complex tasks rapidly, to adapt to new and changing conditions, to process incoming information and make complex decisions, and to perform effectively in a stressful environment (1–9). Additionally, increasing age is associated with decreased tolerance for shift work cycles, and a greater tendency toward late-night errors (15). Such findings have obvious relevance to physicians, given the intellectual and physical demands of the profession. Choudry et al., in a systematic review of studies relating medical knowledge and quality of care to years in practice and physician age, concluded that there is an inverse relationship between the number of years a physician has practiced and the quality of care provided (70% of studies reviewed demonstrated a negative association) (3). This relationship held for medical knowledge, adherence to nationally accepted guidelines and standards, and to patient outcomes. The findings were consistent across medical specialties. An accompanying editorial argues that medical practice must be accompanied by ongoing active effort to maintain competence and quality of care (4).
Table 2. Concerns Regarding Retirement Area of Concern Adequate financial preparation Loss of professional identity Adequate social contact Filling time Relationship with spouse
Disagree/Strongly Agree/Strongly Disagree Agree 42.4%
57.6%
56% 73% 79.9% 88.5%
44% 23% 20.1% 11.5%
The results of our survey of older emergency physicians are consistent in many ways with the established literature. Respondents generally viewed themselves as competent clinicians with improved ability to relate to patients and staff and little decline in procedural skills. However, a substantial percentage acknowledged at least some degree of cognitive decline (including the ability to acquire new knowledge) or physical limitation. Additionally, many senior physicians felt they would benefit from modifications of their workload with respect to hours, patient load, physician and support staffing, and, most particularly, night shifts. These findings pose challenges for the individual emergency physician, for physician groups, and for the ACEP. It would appear to be incumbent upon the older practitioner, in conjunction with colleagues, to be alert to the potential impact of aging on the quality of care delivered. Physician groups should be prepared to implement adjustments to hours, workload, and levels of acuity evaluated. Finally, efforts by the ACEP to address issues relating to older members (specifically, performance standards and practice modifications) may help to ensure professional competence, while at the same time prolonging careers in the specialty and easing the transition to retirement.
Limitations The study has several limitations. Our second mailing inadvertently went out to the entire cohort rather than the
Table 3. Five-Year Comparative Appraisal of Practice Skills
Ability to perform procedures Manage complicated clinical problems Empathize with patients Dexterity in performing procedures Deal with difficult personalities Incorporating new diagnostic/therapeutic modalities Memory Handle stress of emergency medicine Manage heavy patient volume Emotional exhaustion at end of shift Recover from night shifts
Better/Same
Worse/Much Worse
93.9% 91.5%
6.1% 8.5%
86.8 83.2 82.6 75.2
13.2 16.8 17.4 24.8
71.7 63.8
28.2 36.2
59.8 55.6
40.1 44.4
25.2
74.2
712
R. Goldberg et al.
initial non-responders. The possibility, though unlikely, does exist that some respondents completed the survey more than once. Second, the majority of questions involved selfreported responses that may or may not reflect enduring attitudes or stable assessments of current ability levels. Finally, whereas over 99% of the respondents answered the questions about their demographic characteristics, current practice, and concerns when they retire, only 84% of respondents completed the questions regarding specific physical and cognitive limitations in their practice. This raises the possibility that a substantial percentage of responders had limitations they were reluctant to disclose even in an anonymous survey.
CONCLUSION The survey results suggest that older emergency physicians generally view themselves as competent, empathic practitioners. Yet a substantial percentage acknowledges at least some degree of cognitive or physical decline. Additionally, the responses suggest that careers could potentially be prolonged by a number of practice modifications, including adjustment of work regimen with respect to hours, patient load, physician and support staffing, and, most particularly, night shifts. It would appear that national organizations in emergency medicine have an important role to play in promoting both
career longevity and clinical competence among senior members of the profession. REFERENCES 1. Eva KW. The aging physician: changes in cognitive processing and their impact on medical practice. Acad Med 2002;77:S1– 6. 2. Turnbull J, Carbotte R, Hanna E, et al. Cognitive difficulty in physicians. Acad Med 2000;75:177– 81. 3. Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care. Ann Intern Med 2005;142:260 –73. 4. Weinberger SE, Duffy FD. Editorial. “Practice makes perfect . . . or does it?” Ann Intern Med 2005;143:302–3. 5. Katz JD. Issues of concern for the aging anesthesiologist. Anesth Analg 2001;92:1487–92. 6. Budson AE, Price BH. Current concepts: memory dysfunction. N Engl J Med 2005;352:692–9. 7. Keefover RW. Aging and cognition. Neurol Clin 1998;16:635– 64. 8. Eva KW. Stemming the tide: cognitive aging theories and their implication for continuing education in the health professions. J Contin Educ Health Prof 2003;23:133– 40. 9. Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med 2004;79:570 – 81. 10. Katz JD. Challenges for the aging physician. Conn Med 2002;66: 539 – 42. 11. Virshup B, Coombs RH. Physicians’ adjustment to retirement. West J Med 1993;158:142– 4. 12. Lees E, Liss SE, Cohen IM, et al. Emotional impact of retirement on physicians. Tex Med 2001;97:66 –71. 13. Guerriero Austrom M, Perkins AJ, Damush TM, Hendrie HC. Predictors of life satisfaction in retired physicians and spouses. Soc Psychiatry Psychiatr Epidemiol 2003;38:134 – 41. 14. Anast GT. Benchmarking retirement: a best practices decision. Best Pract Benchmarking Healthc 1997;2:168 –73. 15. Mitler MM, Carskadon MA, Czeisler CA, et al. Catastrophe, sleep, and public policy: consensus report. Sleep 1988;11:100 –9.
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ARTICLE SUMMARY 1. Why is this topic important? The membership of the American College of Emergency Physicians is aging. Approximately 31% of members are now over the age of 50. Little is known regarding the impact of aging on the ability to practice emergency medicine, or the practice modifications that might prolong and enhance the careers of our senior physicians. 2. What does this study attempt to show? The study attempts to identify issues of concern to older emergency physicians with regard to finances, health, preparedness for retirement, ability to continue in practice, and measures by which these concerns might be addressed. 3. What are the key findings? 1) While older emergency physicians generally view themselves as competent, empathic practitioners, a substantial percentage acknowledge at least some degree of cognitive or physical decline. 2) Respondents suggest that careers could be prolonged by a number of practice modifications, including adjustment of work regimen with respect to hours, patient load, physician and support staffing, and, most particularly, night shifts. 4. How is patient care impacted? 1) Survey responses suggest that physicians and physician groups should be mindful of the potential impact of aging on the quality of care delivered. 2) Physician groups should consider practice modifications for their senior members, including adjustments to hours, workload, and levels of acuity assigned. 3) Efforts by ACEP to address issues relating to older members (specifically performance standards and practice modifications), may help to ensure professional competence, while at the same time prolonging careers in the specialty.