Aging Physicians Put Off Retirement
Cover Story – June 2012
Tex Med. 2012;108(6):14-21.
By Crystal Conde
At 63, Charleta Guillory, MD, associate professor of pediatrics in the Texas Children's Hospital Newborn Center in Houston, is thinking about retirement, but she's not planning on leaving medicine anytime soon. The first African-American woman to attend Louisiana State University School of Medicine, Dr. Guillory, a 1974 graduate, has dedicated her life to serving others and can't imagine walking away now.
"I'm not thinking at all that I'm going to stop. I plan to practice until I can't physically or mentally practice anymore. With every fiber of my being, I feel I can give back and help someone every day," said Dr. Guillory, a member of the Texas Medical Association Committee on Maternal and Perinatal Health.
The neonatal-perinatal medicine specialist still works 80 hours per week.
TMA President Michael Speer, MD, who turns 70 this year, works similar hours in the same newborn intensive care unit. He says he has no plans to slow down but may "partially retire" in three years. Dr. Speer has envisioned life after medicine and says he may delve into wine making, do some traveling, and take or teach some college classes.
"I like what I do. I like caring for babies, being involved in organizational leadership, teaching, and keeping up with the practice of medicine. Also, in 2008, when the economy went south, I, like many Americans, couldn't retire," he said.
Drs. Guillory and Speer are part of a national workforce trend the American Medical Association is tracking. AMA data show a larger proportion of physicians than in the past are remaining in the medical field as they approach and even surpass the typical retirement age of 65. For Texas, the Association of American Medical Colleges (AAMC) 2011 State Physician Workforce Data Book shows 24 percent of Texas physicians are older than 60 (see chart).
Alice Gong, MD, professor of pediatrics at The University of Texas Health Science Center at San Antonio, has a theory why physicians remain in medical practice well beyond traditional retirement years.
"We are passionate about our work, and despite the negative parts of medicine, it boils down to us and the patients. We've been trained to alleviate suffering, and practicing medicine is a calling similar to that of a priest. For many of us, practicing medicine is an innate part of our being," she said.
Dr. Guillory adds that physicians who still practice in their 60s and beyond 65 have a wealth of knowledge to impart to the next generation of physicians.
"That type of invaluable mentorship is our legacy, and we hope to pass the baton to younger physicians who've benefitted from our experiences," Dr. Guillory said.
Retirement Wave Looming
As aging physicians begin planning for life in retirement, experts say the health care industry needs to brace itself for a substantial departure of seasoned professionals.
"The Future of Medical Practice: Creating Options for Practicing Physicians to Control Their Professional Destiny," a white paper for the Physicians Foundation by Jeff Goldsmith, PhD, examines the coming physician retirement wave.
Dr. Goldsmith, associate professor of public health sciences at the University of Virginia, describes the past five years as "a period of professional limbo for many older American physicians." The economic recession disrupted retirement plans for many of the more than 230,000 physicians older than 55 practicing in the United States. If the U.S. economy rebounds and property values recover, Dr. Goldsmith predicts, the U.S. health care system will witness a massive withdrawal of physicians from active practice, as many as 100,000 in the next five years. The potential exodus would occur simultaneously with 36 million baby boomers entering the Medicare program and perhaps 30 million more Americans receiving new health care benefits through health system reform if it survives legal challenges.
To access the white paper, visit the Physicians Foundation website. The Physicians Foundation formed in 2004 as part of a settlement in an antiracketeering class action lawsuit between physicians and medical societies and Aetna, Inc. Louis J. Goodman, PhD, CAE, executive vice president and chief executive officer of TMA, is president of the Physicians Foundation.
The AAMC Center for Workforce Studies estimates the United States will face a shortage of 124,000 to 159,000 physicians by 2025. AAMC says an acute physician shortage will profoundly impact health care access, quality, and costs. AAMC advocates boosting enrollment in U.S. medical schools by 30 percent, along with increased efficiency, better use of health care professionals, and new models of care to address projected physician shortages.
Older physicians haven't retired in droves yet, but Dr. Speer worries their eventual departure will affect primary care negatively and says the specialty is vulnerable. Pediatrics, internal medicine, and family medicine are ailing because fewer medical graduates are choosing careers in these specialties.
"Primary Care Specialty Choices of United States Medical Graduates, 1997–2006," published in the June 2010 issue of Academic Medicine, reports an overall decrease in the proportions of medical graduates selecting primary care specialties (see chart).
Dr. Guillory adds many students choose primary care subspecialties because they're more lucrative, making it possible for them to repay student loans more quickly. AAMC reports that the total average student debt has risen to $161,000. Once aging primary care physicians retire, Dr. Guillory says, the potential access-to-care implications for Texas patients are a grave concern.
"The shortages brought on by retirement coincide with an increasing demand for patient care. There is great difficulty in finding a replacement for retiring pediatricians, for example. The U.S. child population growth outpaces the demand for board-certified pediatricians. Combined with the aging pediatrician's inability to pass the baton to the next generation, a crisis is created," she said.
Physicians Consider Retirement
Dr. Gong, a member of the TMA Committee on Maternal and Perinatal Health, started thinking about the future of her career last year while putting together a presentation, titled Aging in Practice, for the Texas Pediatric Society (TPS) annual meeting.
"In the process of examining aging in medical practice, I realized that I'm not alone; other physicians are grappling with the same concerns, such as what they'll do after they retire," she said.
At 57, she's not planning to retire in the near future. Dr. Gong says once she leaves practice she'd like to volunteer with an international organization to share her medical skills and knowledge with developing countries that have high infant mortality rates.
"U.S. physicians have a huge impact on society. I'd like to make a difference in developing countries by teaching others what I know," she said.
In creating the TPS presentation, Dr. Gong consulted with Drs. Speer and Guillory, as well as Stephen Welty, MD, chief of neonatology at Texas Children's Hospital.
One of the primary resources used in the presentation was a 2006 survey of 1,600 members of the American Academy of Pediatrics aged 50 and older. The organization received 1,114 responses to questions about patterns of work and retirement among older pediatricians, including the determinants of part-time work and retirement.
Survey results showed nearly 50 percent of respondents worked full-time past age 65, and 24 percent worked after age 70. It's common for pediatricians to work part-time and to gradually reduce their work hours before retirement, according to the survey. Factors that influence pediatricians to retire include burdensome on-call responsibilities, increased regulation of medicine, decreased autonomy, rising liability insurance costs, and stress of practice. (See "Top 10 Physician Stressors.") Factors influencing pediatricians to remain in active medical practice, the survey noted, include career satisfaction, financial obligations, good income, meeting patients' needs, and the need for health insurance.
"Physicians in many specialties can relate to these findings," Dr. Gong said.
Dr. Gong wanted to collect data on aging neonatologists for her portion of the TPS presentation, so she developed what she describes as a nonscientific, qualitative survey. She received 210 completed surveys that gave her a glimpse into neonatologists' thoughts and feelings about the last phase of medical practice.
"One of the most eye-opening findings from my survey was that 62 percent of respondents plan to practice after turning 65," she said. "I was also surprised to learn that only 35 percent of respondents feel they're financially prepared to retire."
Another finding that surprised Dr. Gong was that 76 percent said they hadn't thought about medical liability insurance coverage they may need after they retire. (See "How to Hang Up the Stethoscope.")
Dr. Speer stresses that competence, rather than mandatory retirement due to age, should be the deciding factor regarding whether physicians should be able to continue practicing.
Dr. Guillory agrees. She took the maintenance of certification exam for neonatology this year.
"What I realized immediately after I took the exam is experience compensates for any mild decrease in efficiency a physician may have. The exam gave me a concrete way to look at my capability as a physician. I'm glad I took the test. It proved to me that I'm up to date on what I've been teaching students," she said.
When a Gold Watch Isn't Enough
Physicians who do decide to retire may see their dreams of traveling, golfing, fishing, or just spending time with the grandchildren turn to nightmares. Many physicians may lose their professional identity, and their sense of self-worth may decline when they retire.
"For many physicians, their lives are wrapped around their careers. When they retire, the professional part of their lives is gone," said Lois Killewich, MD, PhD, a member of the TMA Committee on Physician Health and Rehabilitation (PHR). "If they don't recognize the potential emotional problems and have other interests to focus on after retirement, they could become stressed or depressed, which will take a negative toll on their lifestyle."
The PHR Committee helps ensure safe patient care by promoting the health and well-being of Texas physicians and offers live presentations on several topics to county medical societies, hospitals, and other groups upon request. Presentations provide physicians 1 AMA PRA Category 1 CreditTM in ethics and/or professional responsibility education.
Dr. Killewich, 60, a professor in the Division of Vascular Surgery at The University of Texas Medical Branch in Galveston, averages one PHR presentation per month throughout Texas. Some of her presentations address health problems that may affect physicians as they age and the importance of properly preparing for retirement.
"Addressing Impairment in the Aging Physician," a live presentation, discusses identification of common neurological, psychiatric, and other medical illnesses that may affect the aging physician and his or her medical practice. The presentation covers ethical obligations to address conditions of impairment in colleagues to ensure safe patient care and intervention to recognize illnesses in aging physicians.
"Physician Retirement: Personal and Ethical Issues" educates physicians on the importance of early planning for a successful and satisfying retirement. Highlights include identification of significant physician and patient care factors and ethical considerations in preparing for retirement and maintaining optimal patient care while planning for retirement.
The PHR Committee also educates the medical community through online and home study continuing medical education activities.
"Ethical Considerations in Physician Aging and Retirement," an online course, discusses how to recognize signs of and address impairment in the aging physician and encourages participants to become more aware of the personal and ethical considerations involved in planning for a successful retirement. Participants receive 2 AMA PRA Category 1 CreditsTM and 2 ethics and/or professional responsibility education credits.
Visit the TMA website for a complete list of live PHR Committee presentations, as well as online and home study courses.
To schedule a live presentation, email TMA PHR Administrative Assistant Sharon Chicano, or call (800) 880-1300, ext. 1343, or (512) 370-1343.
Dr. Killewich says making presentations about aging and retirement across the state gave her information she can apply to her life. After 20 years in the medical field, Dr. Killewich will retire in February.
"I'm retiring partly because I'm tired, but the main reason is so that my husband and I can pursue our dream of sailing around the world," she said.
She's not too worried about adjusting to retired life.
"I think I have enough interests that I probably won't have problems. I might work again at some point in the future in a part-time capacity in medicine or in another industry," she said.
For more information about the PHR Committee's services, email Linda Kuhn, TMA PHR program manager, or call (800) 880-1300, ext. 1342, or (512) 370-1342.
How to Hang Up the Stethoscope
Retirement can be a lot of work. The responsibilities associated with closing or selling a medical practice make the process a complex transaction.
To guide physicians in the right direction, TMA offers Closing or Selling Your Medical Practice. The publication, available in hard copy for $99 or as a PDF for $89, features chapters on selling a medical practice, notifying patients and employees, medical records management, and important decisions for retiring physicians. It also includes a helpful practice-closure checklist. To purchase Closing or Selling Your Medical Practice, visit the TMA website.
Austin attorney Michael Stern, JD, CPA, has experience in business formation and representation, contracts, and health law. He says physicians closing or leaving a practice have a duty to notify their patients of their decision and to offer them a chance to get a copy of their medical records. He adds that it's a good idea for physicians to seek advice from a lawyer and an accountant when selling or closing a medical practice.
Under Texas law, physicians must give patients adequate notice and opportunity to seek another physician or face patient abandonment charges.
Texas Medical Board (TMB) spokesperson Leigh Hopper says physicians whom the board determines have abandoned a patient face potential penalties ranging from a remedial plan with a $500 fee to sanctions that could include continuing medical education requirements and an administrative penalty. She says some cases of patient abandonment, depending on the facts, could cause the board to revoke a physician's medical license.
TMB rules outline the procedures retiring physicians must follow when leaving a medical practice. It says physicians must:
- Publish notice in the newspaper of greatest general circulation in each county in which the physician practices and in a local newspaper serving the immediate practice area;
- Place written notice in the physician's office at least 30 days before the date of termination, sale, or relocation of the practice;
- Send letters to patients seen in the previous two years, notifying them of discontinuance of practice; and
- Submit a copy of the notice to TMB within 30 days of the date of termination, sale, or relocation of the practice.
TMB rules also cover medical records management, release, and charges; patient access to diagnostic imaging studies; and appointment of a custodian for a physician's records.
The rules say physicians must maintain adequate medical records for at least seven years from the date of last treatment by the physician. For patients younger than 18 when last treated, the physician must maintain the medical records until the patient reaches 21 or for seven years from the date of last treatment, whichever is longer.
Closing or Selling Your Medical Practice lists retention guidelines for medical records of deceased patients, drug records, hospital records, mammography images, managed care contracts, Medicaid and Medicare records, and more. The book also features a sample medical records release authorization form and sample letters for physicians who are discontinuing or closing their practices.
Lawsuits Still Possible
Retirement doesn't mean you can stop worrying about getting sued. Patients can sue for alleged medical malpractice after you leave practice.
John Alexander, senior vice president of underwriting services for the Texas Medical Liability Trust (TMLT), says Texas law doesn't require retiring physicians to purchase "tail coverage" but it's a good idea for them to examine any contractual agreements they have with employers or partners. The documents may require them to secure the coverage when they cancel their insurance policies.
Tail coverage continues insurance protection for future claims stemming from when a physician's insurance policy was in force. Tail coverage is free if a doctor has had claims-made policy with TMLT for the five years before retirement and is 50 or older. TMLT policyholders who don't qualify for free coverage pay a one-time charge for the endorsement.
"Tail coverage continues until the limits provided are exhausted by claim payments. Until the endorsement limits have been consumed, TMLT pays all legal costs related to defending covered claims," Mr. Alexander said.
TMLT's standard tail endorsement is valid indefinitely.
Mr. Alexander acknowledges that physicians' practice and financial circumstances differ and that their coverage needs vary. TMLT underwriting staff can assist policyholders who are retiring or who are thinking of altering their practices. For more information, call TMLT underwriting services at (512) 425-5800.
For a summary of the statute of limitations for medical professional liability in Texas, visit the TMA website.
TMLT is the only medical professional liability insurance provider created and exclusively endorsed by TMA.
Crystal Conde can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by email.
Top 10 Physician Stressors
The TMA Committee on Physician Health and Rehabilitation identified these top 10 physician stressors:
- Time constraints;
- Problems with patients and their families;
- Financial issues;
- Overwork or too much work;
- Fear of lawsuits and malpractice;
- Insurance issues and third-party intrusions;
- Problems with hospital administrators or hospital and office staff;
- Family concerns;
- Paperwork; and
- Governmental regulations, including Medicare and Medicaid.
Source: TMA Coping With Stress in the Practice of Medicine, 2009 and 2010 course evaluations
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