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by: Joseph DeLucia, DO

I never thought the day would come, but it has finally happened. I am the oldest member of my group.
 
The day arrived suddenly and without fanfare. The only older member left on medical leave, which quickly turned into total disability. He never returned, not even to say good-by. Was it all the years of nights, rotating shifts, and exposure to infectious disease that left his body ravaged and unable to go on? Some members of our group envied him; sleeping every night, never again cursed or spit at. Some of us feared; will this happen to us?
If you’ve had this thought, you are certainly not alone. The percentage of working doctors 65 and older climbed from 13 percent in 1975 to 18 percent in 2004 and is expected to rise even higher as the impending wave of baby boomers reach 65, according to the American Medical Association.

But who cares about age, you say. If I was a business person, I would be in my prime. They’d describe me using words like “distinguished” and “experienced”. But we all know that emergency medicine is a young man’s sport. You don’t see many 50-year-olds playing football, flying fighter jets, or chasing criminals. And it’s not just bout image; the numbers suggest that age can indeed affect performance. In the September 2006, Annals of Surgery, a study was published that found for three complicated surgeries, including heart bypasses, surgeons older than 60 had higher death rates. This was especially true if the surgeons did not do a large volume of cases, as many surgeons reduce their caseloads as they age.
A February 2005 study in the Annals of Internal Medicine suggested a similar correlation, albeit with a slightly different reasoning. The study stated that heart attack patients were 10 percent more likely to die in the care of a doctor 20 years out of medical school compared with a recent graduate. According to the study, mortality rates did not depend on the physicians’ age as much as on the number of years since medical school.

While the two aforementioned studies paint a rather bleak picture for aging in medicine, a recent Emergency Physicians Monthly survey found that EPs recognize an array of advantages to working with older physicians. Among the responses, readers credited their older colleagues with calmness, efficiency, fewer arguments, the ability to work with fewer resources and use fewer consultants, better technical skills, finesse and grace.

“Many older physicians were the pioneers in emergency medicine and propelled the specialty forward,” wrote one respondent. “This is a group of highly motivated individuals who did not just put in their shift and leave. The presence of the senior physician is often a deterrent to the on-call staff from eating the young emergency physician alive. It is the friction of the road that fine tunes the machine.”

As I look around, in my group and in others, I do not see many old emergency physicians. What happens to old EPs? In the current system, the rotating shifts, high stress, and life-and-death decisions eventually take their toll. Little by little, physicians lose the physical and mental ability required to make efficient and proper decisions under these stressors. Many then opt to leave the specialty. This cohort includes those physicians who started our specialty, the men and women who fought the battles and wrote the books and established our turf. Do we cast them aside or restrict them to urgent care centers and non-acute patients? Are they still capable of the full duties of any emergency medicine specialist? What are the options?

First of all, EPs have to acknowledge that emergency medicine is not like family practice. We cannot slow down, limit our practice, eliminate call and after-hours work and peter out some time in our 80s. Sure, some can become administrators, but for the rest of us, cutting back on shifts and numbers of procedures may deleteriously affect our abilities.

That said, according to the EPM poll, many physicians want to create more viable options for aging physicians. 93% of respondents said that emergency medicine groups should offer alternatives for aging physicians. 61% of respondents said that older physicians should be offered the alternative of doing fewer or no night shifts or working less hours overall. 87% agreed that these benefits should affect pay. This did not seem to be an issue with older physicians as most were more financially established. Only 13% and 8% respectively, said older physicians should be limited to less acuity or only work when accompanied by another physician. The age recommended for attaining these alternatives ranged from 52 to 70, median being 55.

Mandatory competency testing which is already required is a concern. Most of any age can answer questions correctly during a standard day time test. How does age affect the ability to answer questions correctly when being bombarded with multiple questions at a time, at 4 am, after changing your sleep cycle, in an uncontrolled noisy environment? How does age affect the ability to do procedures that require fine motor skills in this same environment?
Answers to these questions do not only rely on age but also on the individual’s motivation and health. Someone who exercises regularly, studies daily and without health problems is going to be more competent than a sedentary, 2 pack/day smoker with peripheral vascular disease, who only reads Marvel Comics.

Ours is a physical as well as a mental specialty. Running from room to room, constantly changing sleep cycles, while performing procedures that require fine motor skills and rapid decision making is physical. Cognitive ability relies on adequate cerebral circulation.
Another option for aging physicians is the institution of a mandatory retirement age, such as is imposed on some pilots, police officers and firefighters around age 63. Age discrimination is not a concern when public safety is at risk. The rights and safety of the public outweigh individual rights. Should such a rule apply to emergency physicians? According to a recent Emergency Physicians Monthly poll, almost a quarter (23%) of respondents felt that “yes,” a mandatory retirement age for EPs would be appropriate. Not surprisingly, there was no consensus as to what that age should be.

Robert Bondurant, Program Director of the Missouri Physicians Health Program does not feel a mandatory retirement age is needed. Bondurant works with impaired physicians of all types, including drug and alcohol addiction, incompetence, and physical disabilities. Rarely, less than once a year, does he have an issue with age. Bondurant states when he approaches a physician about having impaired ability secondary to age, they are often eager to retire. Issues which arise, that leads to a physician being referred to Bondurant include poor charting, slow to dispose of patients, frequent arguments and defensiveness.
Interestingly, in the EPM poll, readers stated these same issues as difficulties with working with younger physicians. Readers responded that younger physicians have more ‘pissing contests’, are indecisive, slow, still trying to find their way, and only know one way of doing things. These comments were made by both older and younger physicians.
Older physicians should be required to work less hours with respective decreases in salary. The younger physicians should be given the extra pay and shifts as desired. For employers, offering these alternatives will attract and retain the more experienced and efficient physicians. Older physicians should teach their young the techniques, skills and art of medicine acquired with experience. All physicians need to practice the same health recommendations we ask of our patients. All physicians need to study and keep current.

Personal Recommendations from One “Old” Doc to Another
  1. Exercise regularly. Keep aerobically fit. Maintain cerebral circulation.
  2. Study and keep up to date on current modalities.
  3. Be financially prudent, so when the time comes you can retire.
  4. Don’t sweat the little things.
  5. Most things are little in the scheme of things.
  6. Enjoy every moment, for one thing the ER has taught me, it may be your last.
I plan on working in the trenches until I am too old to work any more. I am unsure at which chronological age ‘too old’ will occur. Hopefully a kind friend will tap me on the shoulder and tell me when, if I am unable to recognize it. 
 
next page: "You might be an old EP if you remember when..."
{mospagebreak title=You may be an 'old EP' if you remember when...}
 
 
 
You may be an “old EP” if you remember when...
  1. Patients had to knock on the door to get into the ER (or they arrived by hearse)
  2. Telemetry boxes were the size of refrigerators
  3. You had to crawl into the back of an ambulance
  4. Tagament was a wonder drug
  5. Nurses let you sleep from 2 a.m. to 6 a.m. and the patients were told to wait (and they understood).
  6. You admitted elderly patients because they needed “tests” when their family were going out of town
  7. Ultrasound was something submarines used
  8. Nurses stood up to let doctors sit down
  9. Bedpans were metal, cold and reusable
  10. You had to call the patient’s family doctor to see if they were going to come in to see the patient or if they wanted you to examine them
  11. Appendicitis was determined by clinical exam and not CT
  12. The coroner and funeral director was the same person
  13. Baby Aspirin was for babies
  14. IV solutions came in glass bottles
  15. Nurses and doctors wrote on the same single sheet of paper that was the entire chart  
Signs of the Times:
What are your recollections of days gone by in emergency medicine? Write in and we’ll publish your responses in the next issue. Send memories to This email address is being protected from spambots. You need JavaScript enabled to view it.
 

Comments   

# Hi, Dadandrew 2007-07-23 02:27
That was a very good paper and the "OLD EP" just made it even better!!!
Reply
# Hi, aging sonDorothy 2007-07-23 19:07
Enjoyed your article in the EP monthly on aging physicians. Now I know that writing is another talent you have. I did not believe that doctors thought about getting older, only that they got better with age. But as you say, they must keep up with the latest medicines and techniques in order to do their best. Mom
Reply
# your old secretaryHeather 2010-02-10 17:08
Great article Joe. I worried there for a minute it wasn't going to have your usual humor. Stick with it1 You are as good as any of those kids!
Reply

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