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  • The Aging Physician: Challenges and Opportunities

    For more than a decade we have experienced external influences on clinical medical practice with the intended goal of improving the quality and efficiency of care.

    These changes have been foisted upon us, in large measure, by governmental agencies and insurance companies. And while we can question whether the goal of better healthcare has been achieved by any of these actions there is little question that they have become an imposition on our lives, have created emotional stress and have altered the traditional physician-patient relationship.

    The COVID-19 pandemic severely altered clinical practice patterns, influenced employment relationships and negatively impacted the outlook of many physicians with respect to the long-term prospects of medical practice. We now face additional challenges. Among the issues we are encountering are aging of both the patient and physician populations; physician burnout; the projected deficit in the physician workforce; mandated physician retirement and physician self-regulation.

    Stephen Obstbaum, MD

    Currently, 43% of the Academy’s membership of is 60 years of age and older, which is an increase of 10% from the survey performed a decade earlier. This trend parallels the aging physician population in general. Projected estimates over the next 15 years are that two of every five physicians will be 65 years old or more. At the same time the senior patient population age is also destined to increase by 42% for those over 65, while the proportion of those over 75 is anticipated to grow by 74%. Although we need a viable workforce to provide the requisite health care to an aging society, many physicians intend to retire, some of whom are still mid-career, largely related to physician burnout.

    A multitude of factors have contributed to physician burnout. An article in Forbes cited “long-term, job-related stress” as the over-riding cause of physician burnout. The Medscape survey cited in the Forbes article ranked ophthalmology at a 40% burnout rate, which was somewhere in the middle of the pack. The drivers of physician dissatisfaction and burnout are endemic, but the practice imperatives of some specialties make them more likely to experience the stresses of the current health care delivery environment. The drivers of physician burnout include emotional exhaustion from excessive workloads, the inability to spend adequate time with each patient, administrative tasks and clerical burdens often associated with the electronic health record entries required for billing purposes. Using scribes to enter clinical data has addressed one of the pressing issues, but the pressures of patient volumes, obtaining prior authorization and the demanding pace of practice continues to take its toll. Physicians simply desire the opportunity to care for their patients without external interference as had existed when physicians enjoyed a greater degree of autonomy.

    In a recent guest essay in The New York Times, Sandeep Jauhar, MD, questioned whether we would choose to be cared for by a 100-year-old physician. The article poses the ethical quandary surrounding the cognitive and physical decline of aging physicians and their ability to function competently. It further pits an individual physician’s decision to continue in medical practice against the societal need for patient safety and raises the question of chronological age versus functional age with respect to the ability to safely continue clinical practice.

    Although there are mandated age requirements for some professions, there is no such mandate for physicians. Because of the variability in functional performance associated with aging, mandated retirement does not seem justified. But as a profession we have an ethical and societal obligation to ensure that the health care we render satisfies the standards of safe, effective and efficient practices. Dr. Jauhar proposes that periodic competency assessments be performed after a certain age, perhaps 65 or 70 years old. This concept is not novel or original. It has been proposed by several surgical organizations and more recently by the American Medical Association. But as might be anticipated, any proposal advocating compulsory testing has encountered resistance and legal push-back specifically related to ageism.

    An approach that recognizes the sensitivities of aging physicians while preserving their societal and ethical obligations should be accepted as a basic tenet of a periodic assessment initiative. Other surgical groups have advocated for an active program to educate physicians about preparedness for the eventual decline in physical and cognitive performance, as well as, of their duty to self-regulate. Physicians are reluctant to plan for retirement for a variety of reasons. Lack of self-esteem and resistance to change are important factors in the perception of becoming a lesser physician. 

    Rather than being an impediment, periodic assessment of neurophysiological performance preserves the dignity of the individual by encouraging participation in a modified clinical practice model while respecting the realities of an altered physical and cognitive status. The Academy has previously addressed transitioning out of practice and will continue to serve as a resource in the future.

    A more sensitive issue is the lack of physician self-regulation. By the nature of our educational process, we have evolved a culture of deferential treatment of our mentors. This often produces a hesitancy to report the functional decline of a senior colleague. As individual physicians we generally fail to recognize our own deficiencies and only become aware of our waning skills with the occurrence of poor clinical outcomes.

    In addition, although physicians understand an ethical responsibility to report a colleague whose performance is suspect because of aging, there is often a reluctance to become involved. In each of these instances, a periodic assessment model that tests objective neuro-physical and cognitive measures could obviate the pervasive arbitrary reporting status. It is reasonable to consider the initiation of testing even earlier than has been proposed. A decline in test results from a baseline value, derived when the expectation for an ophthalmologist’s performance has not been influenced by increasing age, could alert the physician to the benefit of considering a transitioning of professional activities.

    Self-regulation also reinforces the concept of variability — that there are members of the medical community who can effectively function far beyond what their chronological age might suggest. Metrics generated by valid assessment instruments can guide our planning strategies for the healthcare workforce of the future. And it is in our best interest to be active participants in determining how a testing program is developed and how it will be administered. 

    The Academy has a tradition of creating opportunities from challenges. Each of the issues that has been cited requires an objective examination and a frank discussion so that the development of recommendations is on a firm footing. We, as a profession, are obligated to provide an open forum to educate our members and to actively engage in a conversation about the emerging issues that will potentially affect all active practitioners. We encourage all attendees at AAO 2023 in San Francisco to join us for the symposium titled “Professional Longevity.” It is in our best interest to become enlightened managers of our professional lives.

    (SYM56) Professional Longevity:  What are the Essential Elements in Our Approach to this Emerging Challenge?

    Mon. Nov. 6
    8:00am – 9:15am PST

    Chairs:  Stephen A. Obstbaum, MD and Samuel Masket, MD
    Presentations by: George Bartley, MD; Tamara Fountain, MD; John Irvine, MD; Paul Lee, MD; Flora Lum, MD; and Alfredo Sadun, MD, PhD