How old is too old to practice?

When is a physician too old to practice competently and safely? Should it be whenever the physician decides to retire, or should there be a mandatory retirement age for all physicians?

It’s a timely question as physicians are getting older. More than 2 of every 5 active physicians in the US will be 65 or older within the next decade, with a large portion nearing traditional retirement age, according to data from a 2021 report published by the Association of American Medical Colleges.

The average American retires at age 63, according to an analysis of US Census data. Physicians tend to work a few years longer, with an expected retirement age of 66 for the average physician, a 2016 survey reported. One quarter of physicians anticipate retiring even older, at age 70, while 9% plan to call it quits at age 75 or older.

Age and performance

A few years ago, an article in BMJ set off a controversy when it concluded that, “Patients treated by older physicians had higher mortality than patients cared for by younger physicians.

“[F]or every 77 patients treated by doctors aged ≥60, one fewer patient would die within 30 days of admission if those patients were cared for by physicians aged <40,” the authors wrote.

The implication of the article (whether the authors intended it or not) was that older doctors are less competent than younger ones. An exception to this finding: physicians who treated a high volume of patients—their age showed no association with higher mortality.

A paper by authorities at the American Medical Association bolstered the notion that with age comes decline: “Comprehensive assessment approaches show that increasing physician age and longer time since graduation predict overall poorer performance.”

The authors cited studies showing that, “increasing years in practice [are] associated with decreasing knowledge; lower adherence to evidence-based standards of care for diagnosis, prevention, and treatment; and worse patient outcomes.”

As physicians age, they tend to make more decisions based on experiences instead of analytic cognitive thinking, the authors explained. Although “domain-specific, experientially based knowledge” remains stable, “fluid intelligence”—the capacity to process information to analyze and solve novel or complex problems—decreases with age, they wrote.

Manual dexterity and visuospatial ability also diminish, which has obvious implications for surgeons and their patients. The authors noted that aging in surgeons is associated with increased patient morbidity and/or mortality in a variety of procedures.

Aging vs competence

But with age comes wisdom, the authors acknowledged. Although cognitive function may decline as we get older, “Some attributes needed to deliver quality health care—such as wisdom, resilience, compassion, and tolerance of stress—may increase with aging,” they wrote.

Also, age is not the only factor that affects competence, and it might not even be the most important one. “Solo practice, international training, lack of board certification, general practice, and incongruence between training and scope of practice predict an increased likelihood of poor outcomes on performance assessments,” the AMA authors noted.

This may underpin why high-volume physicians, by contrast, don’t show an association between their age and higher patient mortality.

The authors of the controversial BMJ study pointed out that poorer patient outcomes might be a result of the way that older physicians practice, as opposed to a mental decline due to aging. “It is possible that physicians further from training are less likely to adhere to evidence based guidelines, might use newly proved treatments less often, and might more often rely on clinical evidence that is not up to date.”

What now?

“The public expects and deserves the medical profession to undertake a more vigorous examination of the issue of the aging physician, which may include mandatory testing and wellness evaluations as physicians age,” wrote E. Patchen Dellinger, MD, Department of Surgery, University of Washington, Seattle, and coauthors in a recent article in JAMA Surgery.

Mandatory evaluations—though not exactly popular among older physicians—should be instigated by the medical profession before regulators and legislators impose “more draconian measures,” Dr. Dellinger and colleagues warned.

“Pilots undergo routine physical examinations and testing beginning at 40 years and accept it as a routine part of their work,” they wrote. “Embracing mandatory age-based testing of physicians for wellness and competence could mark the first step in a much-needed evolution of the culture of medicine toward more regular assessments of physicians throughout their career[s].”