Should older family physicians retire?

This month in Canadian Family Physician, we attempt to answer the question, “Should older family physicians retire?” Racine puts forward many good reasons why he thinks they should (page 22).1 Dickie thinks the opposite, emphasizing their contribution and their experience (page 23).2 Even before responding to this question, we should first understand what is meant by older physicians and by retirement. If at first it seems easier to define retirement as being simply the fact of no longer practising medicine, it is important to remember that all family physicians, regardless of their age, are invariably in the process of retirement, as most of them are progressively withdrawing from practice. In fact, a great many family physicians, if not most of them, are not practising in the way they started out—no longer doing obstetrics, visiting patients in hospital, or taking shifts in emergency, preferring to devote themselves to more focused and circumscribed areas. Consequently, most family physicians are undeniably in the process of progressive retirement. As for defining older physicians, it is pretty clear at this point that it is all relative. If I say to you that I’m 59 years old (no way I am 60!), many young readers would say to themselves, “He’s no spring chicken.” But older readers would think that I’m in the prime of my life, even that I do not look my age. We all know physicians of 45 or 50 who are already out-of-date to such an extent that their practice, their attitudes, and their way of thinking are outdated, while there are some “youngsters” of 70 who are remarkably vivacious and young at heart. So the definition of an older physician is certainly open to discussion. Heavens, don’t ask me what to say of a doctor who is 65! Nevertheless, the real issue around physicians’ age and the need to take retirement or not is linked to the question of professional competence rather than to age, strictly speaking. Most of us who remember the good Dr Welby, that illustrious doctor whose miracle cures were shown on television—I should mention that he treated but 1 patient each week—have to realize that in getting older we lose everything, including our ability to practise medicine. It is generally recognized that aging is a handicap. A great deal of data suggest a lowering of professional competence related to age.3,4 This affirmation, however, is not as definite as all that. In fact, in an exhaustive review of the literature5 published in 2002, Eva arrived at the following conclusion: “Analytic processing tends to decline with age whereas nonanalytic processing remains stable.” In reality, according to Ericsson and colleagues, it seems that the decline in performance that is observed with age is more associated with a reduction in regular practice than it is with age itself.6,7 And so, paradoxically, it seems that older physicians are just as good as younger ones if it is a question of making a diagnosis when all the contextual data are available.8,9 Without doubt, it is what we call clinical flair that many older physicians seem to demonstrate. Consequently, while the need for health services never ceases to increase, forcing older family physicians to take retirement or putting such pressure on them that they have no other choice would surely be an error. On the other hand, no one wants to be treated by an incompetent family physician, even if he is Dr Welby. The solution rests, no doubt, with a more focused practice. At a time when it is unusual for family physicians to practise in all the areas of family medicine, the choice to do so seems less reasonable for older physicians. As it is impossible in our lives to excel in absolutely everything, older family physicians should, with good reason, limit their practices to those fields in which they excel. As for those who do not make this choice, they should be prepared to be the object of more rigorous surveillance by the regulatory authorities that monitor quality of care. As Socrates said, the older I get, the more “I know that I do not know.”