Older Physicians Face Serious Boundary Issues

Older Physicians Face Serious Boundary Issues

March 2019

As the number of older physicians grows so do concerns about healthcare’s aging workforce. With researchers forecasting a serious shortage of physicians by 2030, some experts worry about the number of physicians considering retirement. Within a decade, they note, more than a third of today’s most experienced doctors will be 65 or older. More troubling still, a growing number say they are interested in retiring early. 

PBI Education Professional Boundaries, Inc

Others are equally concerned about the number of aging physicians who say they have no intention of retiring. Many will continue providing quality care for years, they admit, but no one can say how many will become dangerously impaired. 

A screening process, like the one under consideration by the Scripps Health system in San Diego, could solve the problem. If implemented, the new program will require screening for all physicians 70 and older. Competent clinicians would be cleared to continue working. Those with impairments would face restrictions. Some are likely to have their privileges revoked. 

Whether such programs catch on nationwide remains an open question. When Stanford Hospital and Clinics launched a similar program in 2013, it survived less than three years.

However these conflicting issues are resolved, both groups of aging physicians—those who remain in practice and those who retire—are likely to face significant boundary-related challenges.

With age, wisdom and experience comes heightened risk. When an accomplished sherpa fell to his death leading others up Mt. Everest, an experienced climber explained why guides sometimes fail to follow basic safety procedures. “They’re so fast and so efficient that sometimes they don’t bother to clip in. It takes a couple of seconds to clip in and a couple of extra seconds to unclip, and if you’ve done it a few hundred times, you can become a little complacent,” said veteran climber Peter Athans.

Something similar happens to senior physicians, says Stephen Schenthal, CEO and founder of PBI Education. “They know the risks intellectually, but they feel they’ve outgrown them. They unclip themselves from the safety line.”

A dangerous combination of ethical complacency and professional arrogance takes over. After decades of practice, these senior physicians believe their spotless record proves their innate goodness. Convinced that their morality has stood the test of time, they relax their vigilance. Less experienced doctors may need the discipline of rules and regulations, they imagine. They themselves are beyond that.

It’s this sense of invulnerability that trips up older and supposedly wiser clinicians. They start taking a more casual approach to patients, dismissing any complaints as par for the course. When staff and younger colleagues offer helpful suggestions, they ignore them. Even warnings from supervisors are brushed aside, until eventually they spark disciplinary action.

Distinguishing between beneficial self-confidence and destructive overconfidence is not easy. Experienced surgeons were humbled to learn some time ago that a simple checklist could help them avoid elementary mistakes, notes Schenthal. “The same kind of humility can help senior physicians avoid ethical and boundary-related missteps,” he noted.

Retiring with a License is Risky.  In a recent survey by CompHealth, a healthcare staffing company, more than half of the physician respondents said they hoped to continue working occasionally or part-time after hanging up their white coat. For them, retiring with a license seems an attractive option.

The American Medical Association apparently agrees. On its website, the AMA urges retiring physicians to ask themselves if they may one day want to return to practice. To avoid the sometimes lengthy and costly process of renewing an expired license, says the AMA, “Many physicians maintain their license for 2-5 years and stay current on their board certifications.”

Individual states offer retired physicians a range of options that fall in between an active and expired license. Texas has an “official retired status” that exempts physicians from the registration process, fee, and continuing education (CME) requirements. It also prohibits retired doctors from engaging in clinical activities and prescribing or administering drugs to anyone in any state.

Pennsylvania goes further, offering an “active-retired license,” which allows retired physicians to provide care to and write prescriptions for themselves and immediate family members only. A fee is required but active-retired licensees do not have to maintain liability insurance or meet most of the state’s CME requirements.

Connecticut views “older and retired physicians as a possible resource both in addressing the state’s physician workforce shortage” and in providing care “to those most disadvantaged by the current healthcare system.” To encourage such participation in retirement, the state waives the licensing fee, but reminds retirees that they are still obligated to meet CME requirements and adhere to professional standards.

Schenthal questions the wisdom of retiring with a license of any sort. “I have seen too many cases of retired physicians getting into serious trouble,” he says. 

The problem is analogous to the ethical complacency of senior practitioners. Those who retire with a license tend to relax their attention to professional obligations. Without the rigor of daily practice, they neglect continuing education and fail to keep up with the latest research. They generally let their insurance lapse. Yet when a friend or relative asks for medical help, they readily agree to write a prescription or take a look at a sore throat.

“They can’t help themselves,” explains Schenthal. “The reason they kept their license in the first place was because they couldn’t bear to let go of their professional identity. It’s too important to them, to their whole sense of identity and self-worth.” 

The problem is that any time a licensed physician treats or prescribes for someone, a doctor-patient relationship is created, with all that implies. But where the law sees a patient, retired physicians see a neighbor’s sick child. Instead of taking a history, maintaining proper records and scheduling follow-up treatment, they dash off a prescription or dispense some off-the-cuff medical advice. 

These casual consultations often go unreported—until something goes wrong. Once there is a problem, angry patients and patient families complain and board investigators quickly discover a pattern of violations. All too often the physician’s license is revoked, ending an otherwise exemplary career in disgrace.

In one case, after repeated requests, a retired orthopedic surgeon agreed to treat his adult son. He began by prescribing antibiotics for an infection and later added an opioid for severe pain. When the son began abusing the controlled substance, the surgeon’s distraught daughter-in-law reported the situation to the state board. The once respected physician lost his license and incurred significant legal fees. He no longer had any insurance. 

If you are thinking of retiring, don’t go cold turkey. Treating people is addictive. After the high of easing pain and curing illness, it’s hard for many physicians to contemplate, let alone embrace, a life without medical practice. Those who are not adequately prepared often go through a rough and lengthy adjustment period—a kind of withdrawal.

The only way to avoid such withdrawal is to gradually taper off. That’s why virtually all experts suggest that physicians plan ahead for retirement, not just financially but emotionally as well. 

  • First, look for ways to cut back without fully retiring.  Employers are often reluctant to make exceptions to demanding workloads, but there are signs this is changing. With retirements looming and patient populations surging, employers are beginning to see the value in accommodating older physicians’ desire to gradually ease up.
  • In his presentation on “The Aging Physician,” Glen Gabbard, MD spoke at length about the difficulties of successfully navigating the transition from active practice to retirement. One of his suggestions summarizes much of the advice offered elsewhere: 

“Retirement should not be about leaving something ̶ it should be about going to something.”