Knowing the right time to retire

Article first published in vicdoc July 2010

With the average age of Victorian doctors well over 50 and the state’s medical workforce shortage set to continue for several years, modern doctors are expected to have longer working lives than previous generations. But physical and cognitive decline can creep up on older doctors. When is the right time to retire from clinical practise? In the absence of clear guidelines the decision can be difficult, writes AMA Victoria Media and Public Affairs Officer Fronscesca Jackson-Webb.

The medical profession is often compared with commercial aviation in doctors’ battle for safer working conditions. Both professions require many years of education and have significant responsibilities to protect public safety. But while pilots are required to undergo annual health and performance assessments to determine their competency, doctors are not.

Doctors are able to practise medicine as long as it is safe to do so, but often this relies on self-assessment, which may not always be accurate. Age restrictions on employment in Victoria are rare: judges must retire from full-time duties at the age of 70, and under the Canon law parish priests are required to offer their resignation when they reach 75.

Internationally, mandatory retirement for older doctors has been trialled without much success. Germany, for instance, recently lifted a 16-year requirement for doctors in the public system to retire at 68 years of age. The cut-off was initially introduced to contain an expected over-supply of doctors. Thousands of clinicians relocated to the UK and one third of the workforce abandoned clinical practise – far from an over-supply, the restrictions left Germany with a significant medical workforce shortage.

Locally, poor government planning in the 1990s has left Victoria with the worst doctor shortage the state has ever seen, with a current shortfall of almost 1,000 doctors. International medical graduates play an important role in filling the gaps and recent increases in medical graduate numbers mean a new generation of doctors will be available in the future to meet the increased demand of the state’s growing and ageing population in the future.

Pressures are particularly great in rural and regional Victoria where the GP-to-population ratio is the lowest. Reluctant to leave their community without a doctor, many country Victorian GPs work well into their seventies as solo GPs or in small clinics, planning to retire only when a replacement can be found.  

The relief that the new wave GPs and specialists will bring to the medical profession is still several years away. The number of medical graduates will have doubled in the seven years to 2014, with around 768 doctors a year, but training these junior doctors to become GPs and specialists will take another six to eight years. The pressures on senior doctors to remain in the workforce to teach and train these new doctors will inevitably increase over the next decade.

Professional considerations aside, doctors are not immune to financial difficulties and this can play a role in decisions to postpone retirement. “There’s the perception in the community that doctors earn a lot of money and therefore they will be fine, but they spend a lot of money too,” says Dr Kevin Macdonald, chairman of AMA Victoria’s retired doctors group.

Planning is the key to being able to retire and maintain the same lifestyle, according to Dr Macdonald. “Quite a long way out, you have to establish an alternative income source to support one’s lifestyle,” he says. “And that doesn’t come overnight. Planning for income substitution could easily take ten years to get a suitable series of investments in place.”

In the wider community, one third of Australians cite reaching retirement age/being eligible for the pension and superannuation as the primary reason for retiring, followed by declining health. Most Australians plan to retire at some stage in their 60s, though this may rise as pension eligibility creeps up to 67 by 2017.

Dr Macdonald sees retirement is an opportunity for doctors to reinvent themselves, to try new things, and meet new people, but says breaking ties from an all-consuming medical career can be incredibly difficult. “In medicine you’ve got doctors who are associated with the profession for up to 50 years and to a large extent, it defines who they are.”

He says doctors would never deliberately put their patients at risk by continuing to practise when they are no longer competent, but cognitive and physical decline can happen gradually. “I don’t think some people can actually recognise when their skills and their competencies have dropped away sufficiently to put themselves and their patients at risk. We’ve probably all seen examples of someone not being so good as they get older,” he says.

While there are more checks and balances in public hospitals, doctors working in private practice would have less opportunity for problems to be flagged. In the case of serious issues, doctors would be morally obliged to have a quiet word, says Dr Macdonald, but deciding whether to intervene is a very tough call.

Notifications to the Medical Practitioners Board of Victoria (MPBV) relating to possible cognitive and other health problems have increased in recent years, with half of all notifications between 2004 and 2006 falling into this category. The proportion of older doctors known to the Medical Board remains low, however, with 0.94 per cent of doctors over 60 being known to the Board and 0.85 per cent for all age groups.

It is the Medical Board’s responsibility to protect the public from unsafe medical practice, but in the absence of guidelines to determine what level of cognitive or physical impairment may put a patient at risk, its role must be reactive. Unsatisfactory performance is only picked up after a patient’s safety has been put at risk and the Medical Board notified about an incident. 

The Medical Board deals with doctors’ potential declining health discreetly. Rather than encouraging the doctor to participate in what could be a humiliating hearing resulting in suspension, the Board encourages doctors to consider voluntarily resigning instead.  

In November last year the UK’s General Medical Council (GMC) introduced a controversial medical licensing and revalidation program. Doctors must now hold a license to practise medicine and are required to undergo annual performance evaluations to assess whether they meet national standards set by the GMC.

Unlike Australian Medical Boards, which respond to safety issues after they occur, the UK scheme aims to give patients regular assurances that UK doctors are fit to practise. Under the scheme, a senior doctor, known as a Responsible Officer, oversees the annual evaluations and makes a recommendation every five years about whether the doctor meets acceptable standards.

The GMC concluded its public consultations on the licensing and revalidation program last month and British doctors remain unconvinced of the benefits. The British Medical Association has suggested the GMC go right back to the drawing board. “The BMA is concerned that the proposed system will do very little to weed out underperforming doctors but will add yet another layer of bureaucracy to the doctor’s role,” says BMA Chairman Dr Hamish Meldrum.

“This does not make sense at a time when doctors are facing increasing pressure to spend more time with their patients. With the NHS facing cuts, this is not the time to spend invaluable resources on forcing doctors to dedicate time to box-ticking and form-filling exercises,” he says.

No proposals have been flagged locally to mimic the UK’s licensing and validation process or local aviation performance checks but the National Registration and Accreditation System’s mandatory reporting requirements, which come into effect this month, may prompt a cultural shift for doctors to be more aware of their colleagues’ competence.

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