Older Clinicians Face a Range of Boundary Issues

Older Clinicians Face a Range of Boundary Issues

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As the number of clinicians nearing retirement continues to grow, policymakers are confronting two very different concerns: what will happen to the quality of care if too many practitioners retire too soon, and what will happen if too few retire? Too many and the current shortage of clinicians will intensify to dangerous levels. Too few and patients may be put at risk by aging clinicians who no longer meet professional standards.

Canada and the U.S. are already facing clinician shortages, especially of nurses, and the situation is likely to worsen. According to a 2021 report by the Association of American Medical Colleges (AAMC), “A growing and aging population that will need more care, combined with an aging workforce of physicians nearing retirement, leaves the United States facing a severe shortage of doctors.”

The other concern, about the competency of aging clinicians, is controversial, to say the least. A 2021 MDLinx article reports that the number of U.S. physicians 65 years or older has grown dramatically in recent years, triggering concerns about patient safety. At what point does a clinician’s age affect their ability to practice medicine competently? There is no simple answer, notes the article, since “the effect of age on any individual [clinician’s] competence can be highly variable.”

The aviation industry takes a one-size-fits-all approach, requiring all pilots to retire when they reach a certain age. Healthcare administrators have followed a different route, looking for ways to assess aging practitioners that protects both the clinicians’ rights and the safety of their patients with limited success.

Yale-New Haven Hospital was one of the first to  implement a program to address the concerns of aging clinicians. Their “Late-Career Practitioner Program” launched in 2016, requiring all staff physicians aged 70 or older to take additional exams before recredentialing. The program faced opposition from the beginning. Then on February 11, 2020, the U.S. Equal Employment Opportunity Commission (EEOC) filed suit against Yale New Haven claiming, “There are many other non-discriminatory methods already in place to ensure the competence of all of its physicians and other health care providers, regardless of age.” According to a March 4, 2022 report by Bloomberg Law, the hospital has now admitted it has no evidence supporting its policy, a concession the EEOC says proves its point.

Regardless of the solutions policymakers eventually agree on, aging clinicians will continue to face other boundary-related challenges in the years ahead, both before and after retirement.

Before Retirement Overconfidence Poses the Greatest Risk

Mountaineers attempting to climb Mt. Everest rely on Sherpas, local guides who have made the climb numerous times. According to National Geographic, the Sherpas’ long history of success sometimes leads them to take risks they would never have taken earlier in their careers. After years of flawless climbs, the guides sometimes forego basic precautions, like clipping themselves to safety lines.

“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,” explained veteran climber Peter Athans. More than one Sherpa has plunged to their death as a result.

Something similar happens to senior clinicians, says Stephen Schenthal, founder of PBI Education.  “Senior clinicians who have never been accused of a violation begin to think they’re no longer at risk, that they no longer need ‘to clip in,’ taking shortcuts and skipping simple protocols that they’ve done ‘hundreds of times’.”

When these clinicians suddenly find themselves facing regulatory discipline near the end of long, unblemished careers, they are often incredulous. “They come to our courses convinced there’s been a mistake or misunderstanding, unable to wrap their heads around their own culpability,” says Schenthal.

All clinicians need a degree of self-confidence to do their jobs, but many have learned the hard way that they also need to guard against overconfidence. Surgeons balked at first when asked to use a simple checklist, says Atul Gawande, MD, author of The Checklist Manifesto: How to Get Things Right. Most quickly came around, but 20% remained strongly opposed to the use of checklists. “They said, ‘This is a waste of my time, I don’t think it makes any difference,’” Gawande told NPR, “And then we asked them, ‘If you were to have an operation, would you want the checklist?’ Ninety-four percent wanted the checklist.”

Senior clinicians can learn from these surgeons, says Schenthal. “No matter how experienced they are, clinicians who value their own and their patients’ safety still need to understand and follow rules, regulations, and policies.”

After Retirement, a Clinician’s License is Itself a Liability

According to a 2021 MedPageToday article, many physicians maintain their license after they retire. Most say they may want to return to active practice some time and want to keep the door open. But the reality, says Schenthal, is that many clinicians just can’t bear to give up their license. “Their professional identity is too important to them, to their whole sense of identity and self-worth,” he explains.

When a licensed, retired clinician treats or prescribes for someone, they are still held accountable as if they are licensed to practice full-time. All too often retirees fail to keep up with their professional obligations. They may neglect the continuing education or malpractice insurance their state requires. They may even ignore basic standards of care they never would have neglected earlier in their careers. When a friend or neighbor asks for medical help, the still-licensed clinician doesn’t bother taking a full history or adequately updating the patient’s medical record. These clinicians can face discipline for failure to meet these standards, potentially ending their otherwise exemplary career in disgrace. 

Some states have created special licensing options for retirees who don’t want to give up their licenses.

Physicians in Texas who take advantage of the state’s “official retired status,” can keep their license and avoid registration and CME requirements. But they are not allowed to engage in clinical activities or prescribe drugs. In Pennsylvania, MDs who maintain an “active-retired license,” must complete the biennial application and submit the required fee, but they are not required to have medical professional liability insurance or meet the state’s CME requirement.

In Connecticut, retired dentists pay a reduced fee for a “retired-status license,” but must maintain liability insurance and meet CME requirements, even though they are not allowed to own or operate a dental practice. Retired nurses in the state also get a break on license fees if they do not intend to practice for monetary compensation. 

Schenthal still advises caution, noting that retirees are just as likely to violate the terms of these specialized licenses as they are their regular licenses. And regulators are just as likely to take action. 

A Few Suggestions for Clinicians Planning for Retirement

1. Maintain a robust personal life throughout your career. 

Treating people is addictive. After the high of easing pain and curing illness it’s hard for many clinicians to contemplate, let alone embrace, a life without medical practice. Those who are not adequately prepared for this change often go through a rough and protracted adjustment period, a kind of withdrawal. “The richer your life is outside of work,” says Schenthal, “the more you have to look forward to in retirement.” 

2. Create a glide path to retirement. 

As with any addictive substance, the only way to avoid painful withdrawal from medicine is to gradually taper off. That’s why virtually all experts suggest clinicians ease into retirement gradually and why employers are offering programs to help. Senior registered nurses in Ontario, Canada can make use of Late Career Initiative, a program that allows them to spend 20% of their time on less strenuous activities, such as mentorship, preceptorship, patient safety and research initiatives. Veteran doctors and nurses in Minneapolis can take advantage of a phased-retirement program and flexible work arrangements offered by Allina Health.

3. Find meaning outside of medicine. 

After devoting so much of your life to caring for others, take some time to enjoy yourself.  In a presentation to the American Medical Association, The Aging Physician: Possibilities and Perils, noted psychiatrist and author Glen Gabbard, MD, stressed the importance of finding meaningful pursuits outside of medicine. “Retirement,” he said, “should not be about leaving something — it should be about going to something.”

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