Am I Too Old to Practice?
In the cover story from the summer 2018 edition of Today's Christian Doctor, Dr. Al Weir discusses an important question for all healthcare professionals: when is the right time to retire from practicing?
by Al Weir, MD
Lucette Lagnado penned an article in the Wall Street Journal on June 25, 2017 entitled “When Are Doctors Too Old to Practice?”1 The central character in that article was a 71-year-old pediatrician who was facing a new rule at his New Jersey Hospital that required mental and physical testing for all physicians at the age of 72 in order to maintain their hospital privileges. He chose to retire instead. Age is becoming our issue as physicians.
The master surgeon and educator, Sir William Osler, once wrote: “The [physician] teacher’s life should have three periods, study until age twenty-five, investigation until forty, profession until sixty, at which age I would have him retired on a double allowance.”
Well, I’m past there now and no one is offering me a double allowance to quit. That’s the way my father was as well. He and I were playing tennis when he reached 90 after retiring at 81. He loved his practice of internal medicine and left it with a sharp mind and good health because he had no buddies left to share night call with him. He fell into a funk for six months before he discovered that life in retirement could be wonderful.
On the other hand, when a senior member of my practice group was only 73, I walked into his office and told him, “You asked me to tell you if I ever thought you were losing your ability to take care of patients safely. I am so sorry, but I think you are there.” He suffered from early onset dementia, and I had been watching an escalation of minor mistakes in his patient care for several months. He thanked me for being honest and left practice within a month.
Thinking about the right time to hang it up is a fascinating process. When I was younger, I thought I might retire at 55 and enter a second career for the Lord, in international missions preferably. The Lord did allow me to take a break from practice at about that age for three years and serve full-time with CMDA, but my passion for patient care overwhelmed me and I returned to the occupation for which God created me, expecting to work well into my 70s if the Lord chooses.
In ever increasing numbers, physicians are choosing to work in practice after the age of 65. In fact, 23 percent of all physicians are over the age of 65, and 40 percent of those are actively practicing. We have all thought about those Golden Years when we no longer must hop out of bed at 5 a.m. and deal with time-pressured decision making throughout our 10 to 12 hour days. But fewer of us are taking advantage of such opportunity. Why are more and more doctors not leaving the profession at 65 and enjoying the life we have built our nest eggs for? And, for that matter, why should our society allow us to continue very complex decision making and high agility procedures when the skills for such clearly diminish with advanced age?
To address the latter first, there is fairly good evidence that, in general, our cognitive and physical functions as physicians decline as we age past 60. Declining knowledge, failure to acquire new knowledge, decreased dexterity, increased surgical morbidity, failure to incorporate new modalities of therapy, slower reaction time and fatigue have all been documented to increase as physicians age in general (though wisdom, resilience, compassion and tolerance of stress may increase with aging).2,3 Because of this decline in function in some physicians, the American Medical Association has recommended and is spearheading efforts to develop competency guidelines for older physicians. Some hospitals and medical staffs are moving ahead on their own, as described in the Wall Street Journal article.
This means that the future for many of us will be required testing after the age of 65 or 70 in order to remain in practice.
There will certainly be problems in developing such a system of testing for many reasons. Most physicians who choose to practice after the age of 65 are highly competent and produce excellent result for their patients. The data presently used to suggest the need for such testing is of poor quality and relies to some degree on those physicians referred for testing based on observed concerns, a selection bias. There is presently no functional target to shoot for in deciding who is incapable of good practice. There is also presently no validated testing to measure deviation from that unknown target.4
Choosing whom to treat is also problematic. Relying on self-reporting of competency has been shown to be ineffective. Reporting by colleagues is limited by conflicts of interest and a desire to avoid harm to those reported. Referral for testing based on incidents of patient harm are clearly too late in many circumstances. Mandated testing by age is egalitarian but has no proven outcomes benefit. Much like reducing work hours in house staff training, the testing of elderly physicians will make theoreticians happy but may provide no improvement in overall healthcare. Nevertheless, we are moving toward a future in which some testing based on age will be mandated; and we, as Christian physicians, must accept the need to place the wellbeing of our patients over our own self-interests. Some doctors do become functionally inadequate before we choose to leave practice and our patients deserve better. We should leave practice if we cannot provide good care for our patients. Primum non nocere. Competence issues must be addressed in our personal practice decisions for our patients’ sake.
My personal approach to this concern has been to empower three colleagues to inform me if I become functionally deficient, at which time I will undergo the necessary testing to decide my future practice plans based on best patient care. By empowering them in the front end, it removes from them much of the guilt that might inhibit an honest assessment otherwise. By choosing three, I assume at least one will be honest, regardless of my feelings.
Assuming we have a system in place to ensure our competence, what personal factors come into play when we make our retirement decisions? Certainly, many physicians, just like other folk, are happy to retire and move on to other interests when they have the desire and the circumstances that allow a change. But others of us might have one or numerous incentives to continue working when we reach 65 to 70.
Often, we just love our work so much that we don’t want to let go of what we love. We have been blessed by God to be part of a profession that helps others and also fills our hearts with satisfaction.
Sometimes, we are confident God has clearly called us to continue our medical work. We are on mission. His will, as we understand it, overcomes any emotional or physical concerns that might lead us to retire.
Sometimes we have financial reasons, usually based on dependent family members or possibly the result of poor planning prior to age 65. Our required expenditures remain greater than our expected income if practice were discontinued, so the work goes on.
Sometimes there is just no one to take our place. There are people we serve and we have established no adequate succession plan to continue their care. We may want to decrease our workload, but the need is greater than our fatigue. This is particularly true of solo practitioners and physicians in rural practices.
Sometimes, the anxiety of the unknown, life without healthcare, causes us to hesitate when the fork in the road appears ahead.
A common thread in many analyses of physicians facing retirement is the concern over losing their identity, which has been so wrapped up in practicing. We are uncertain there will be value to our lives once we are no longer practicing.
In a review regarding academic physicians, Onyura, et al.5 divide this identity concern into six distinctive and important needs:
- Self-esteem: Need to maintain a positive conception of one’s worth
- Self-efficacy: Need to maintain and enhance feelings of competence at a desired task
- Continuity: Need to maintain a sense of consistency across time and situation
- Distinctiveness: Need to establish and maintain a sense of differentiation from others
- Belonging: Need to maintain feelings of closeness to and acceptance by other people
- Meaning: Need to find significance and purpose in one’s existence
Any of these identity issues might make it difficult for us to hang up our stethoscopes, even though we might otherwise choose to do so. Onyura quotes one physician interviewed, “It’s hard to stop being a doctor, ever…All of us have a concern about the fact that leaving what has been the main focus of our lives, may leave us somewhat rootless. We worked so hard to get here, and I think, in many ways that’s our identity, that’s who we are.”
So, how do we decide if we are too old to work?
We should support and help develop a just and effective system to ensure competency of physicians at all ages. If we are physically or mentally unable to provide good care for our patients, we should stop.
But then, if our physical and neurocognitive status has been cleared, age is not the issue. Moses did perfectly well as an older gentleman leading the people of Israel, and Absalom failed miserably with the same nation as a younger man. If our mental and physical faculties are intact, we must address the personal considerations listed above in our decision to continue or to leave practice.
For Christian healthcare professionals, the primary issue is God’s will. Our determination of His will for our medical practice is wrapped up in all that we have been discussing. Wanting His will with all our hearts, and following His will when we can see it, become the first steps toward making the right decision. This determination requires prayer, community, a greater desire for His glory rather than for our own satisfaction, and it requires trust. We must realize that His mission for our lives overrules fatigue, finances, pride and all identity issues. Perhaps His mission requires us to continue practice, or perhaps His mission is taking us in a totally new direction of service—international or local healthcare for the underserved, comforting of the widows and homebound in our churches, teaching God’s Word, mentoring a young generation of Christian healthcare professionals to take the baton from our hands and run, spending time with a family that needs us badly, etc.
When making retirement decisions, we need to consider those around us, those who are dependent on us emotionally or financially. God has ordained that family takes care of family. Sometimes that requires more money. Sometimes that requires more time at home. Financial support for others always requires wisdom. We are capable of being caught up emotionally in ways that prevent our dependents from finding their own wings or finding the wings that God would provide to help them fly. Sometimes those we think most need our financial help would be much better served with the gift of time that might come from cutting back our occupational load.
Of course, we must consider our patients. If we are all they have, we should not desert them without providing alternative avenues for patient care. I remember the weight of this obligation when I left practice for the mission field. God provided then, and He will provide for all of us as we leave practice, but we must plan and be deliberate and do our best to develop a succession plan.
Loving our work is certainly a reason to continue it. But we must not make our work our idol. Considerations of God’s plan and the needs of our families may outweigh the joy of self-fulfillment. If God leads us away from practice, we can trust Him to replace that joy with something better. In When Your Doctor Has Bad News, I told the story of Jennifer Hanks and her children.6 Jennifer, who gave me permission to share, had suffered many months under my chemotherapy for her lymphoma. Her children suffered as well without a healthy mom and with little time dedicated to childhood fun. Finally, the treatment was completed and Jennifer’s family had planned a week away at nearby Pickwick Lake. Her young son prayed daily that this outing would actually happen, after many disappointed promises. The week came for
the vacation and they were rained out. Jennifer’s son came to her in tears, “I asked God to let us go. Why didn’t He answer?” Jennifer answered her son, “God did answer. His answer was ‘no,’ but God said ‘no’ to Pickwick so He could say ‘yes’ to something better.” Jennifer did not know at the time, but her friends had entered their names in the Make-a-Wish Foundation and presented them soon after with a fully paid family trip to Disney World. Jennifer was able to go to her son and announce, “Don’t you see? God said ‘no’ to Pickwick so that He could say ‘yes’ to Disney World.” It will be the same for some of us with quitting our practices. We cannot imagine leaving that which has provided so much joy and meaning. But, if God wishes us to leave it behind, He will replace Pickwick with Disney World, both in joy and usefulness. It took six months for my father to discover Disney World when he retired, but his joy resurfaced and he was a dedicated and happy servant for the Lord until he left us for heaven.
Questions surrounding anxiety over the unknown are simply a matter of trust. We take the step He chooses and trust Him to catch us.
Questions of identity, as listed by Onyura above, have been clearly settled by the apostle Paul. “For you are dead, and your life is hid with Christ in God” (Colossians 3:3, King James 2000). “...You are not your own, for you were bought with a price...” (1 Corinthians 6:19-20, ESV).
Our self-esteem is based on the value the Creator has placed on us. He values us enough to die for us. And our belonging is assured forever. “Come to Me, all who are weak and heavy-laden, and I will give you rest” (Matthew 11:28, NASB). “...I go and prepare a place for you... that where I am you may be also” (John 14:3, ESV).
Our self-efficacy requires competency in whatever venue the Lord places us, whether right where we are in practice or in the new mission to which He sends us. Our continuity is in Him and in our church and will last forever.
Our distinctiveness is guaranteed if we follow the most distinctive man who ever lived. Matthew 5 is our path. Very few others will follow. Our meaning is the meaning of the cross. “And I, if I be lifted up from the earth, will draw all men unto me” (John 12:32, King James 2000).
So, what are the takeaways? How do I decide if I am too old to practice?
- Remember that God has a mission for your life as long as you live, whatever your occupation.
- God’s will wins. Seek it and follow the best you can. What do you want me to do with the rest of my life, Lord?
- Remain competent and up to date in knowledge and skills. It takes more energy to do so as we age.
- Develop a system around you that will inform you if you are falling short of good patient care.
- If you have physical or cognitive deficiencies that limit your capabilities, and you wish to remain in healthcare, consider changing your job description. Many choose fewer hours, volunteer work or administrative positions.
- Decide what is best for your family, best for your patients and best for your Christian service.
- Trust God to provide the joy and meaning for your life, whatever your decision.
- Remember that your identity is in Christ, not in your occupation.
I have just turned 67. Someday, not yet, it will be my turn to set aside the work that has so blessed me. I hope to do so in the same way I started this beautiful journey into healthcare, as an offering to my Lord.
1 Lagnado, L. (2017, June 25). When Are Doctors Too Old to Practice? Retrieved February 13, 2018, from https://www.msn.com/en-us/money/healthcare/when-are-doctors-too-old-to-practice/ar-BBD9gIF?li=AA4Zjn
2 Hawkins R, et al. Ensuring competent care by senior physicians. JCEHP. 2016; 36(3):226-231.
3 Grace E, et al. Predictors of physical performance on competence assessment. Acad Med. 2014; 89:912-919.
4 Kupfer J. The graying of US physicians. JAMA. 2016; 315(4):341-342.
5 Onyura B, et al. Reimagining the self at later career transitions. Acad Med. 2015; 90:794-801.
6 Weir A. When your doctor has bad news. Zondervan. Grand Rapids. 2003.