Director’s Corner: Should there be a Mandatory Retirement Age in the ER?

Dear Director,

I have a couple of older docs on our team, and it’s got me thinking about whether there should be a mandatory retirement age in our field?

It’s a medical director’s job to make sure the emergency department is appropriately and safely staffed.  This means that doctors and advanced practice providers are qualified and trained to take care of the patients, are able to see the patients in a timely fashion and can safely take care of the patients that present to the ED while providing quality care.

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The medical director has the added responsibility of making sure that each individual provider can do the job. I’ve worked with many high-quality emergency physicians who worked into their mid to late 60s without losing a step.  But I’ve also had a couple of them tell me that “they no longer run into the critically ill rooms” like they did when they were younger and that I, as the medical director, need to let them know “when they can’t hit the fastball anymore and it’s time to hang up the white coat.”

Although we all age at different rates, the risk exists of cognitive and physical decline as we age. This isn’t a new issue. The AMA has studied this multiple times with a policy in place since 2021 (click here) and in 2024, released a paper outlining the principles in assessing physician competence. (click here)

However, there is not a standard mandatory retirement age in medicine across the country.

Why should there by a Mandatory Retirement Age for Emergency Physicians

Emergency Medicine is hard.  It’s fast paced and cognitively demanding. As we age, our reaction times and our cognitive abilities may decline. This can impact our decision making with critically ill patients and our ability to multitask. As you know, ER docs are constantly interrupted during their shifts and managing these interruptions and getting back on task can be more challenging as we age.

There is a high physical and emotional demand that comes with working in the ED. Each shift requires a certain amount of stamina as well, and our endurance can decline as we age. Shift work is hard and most of my 50+ year old colleagues will tell you that working nights and “bouncing back” becomes much more challenging as one ages.  Mandatory retirement ages ensure physicians don’t push beyond what’s physically and emotionally sustainable.

All of these things make it harder to work in the ED as we move past a certain age.

In 2023, Miyawaki et al. published “Association Between Emergency Physician’s Age and Mortality of Medicare Patients Aged 65 to 89 Years After Emergency Department Visit.” The authors found that “Medicare patients aged 65 to 89 years treated by emergency physicians aged under 40 years had lower 7-day mortality rates than those treated by physicians aged 50 to 59 years and 60 years or older within the same hospital.” The associations were more pronounced for patients with higher acuity.

I was in my 50s when this was published and found it hard to believe that I wasn’t providing the same high quality of care with the Medicare aged population than I did during my first decade in practice.  I knew I became a better doc during my first decade as an attending and because so much of emergency medicine is about pattern recognition, I have always felt my experience each year continued to help me.  Even when I compare my outcomes or quality of care with the younger docs in my group, the data says I do pretty well. But as we treat thousands and thousands of patients, that 0.04-0.07% increase in mortality for each decade our physicians age can have an impact on a national basis. Obviously, more research needs to be done to flush out the reasons why this happens (and then make interventions to reduce the gap).

I love hiring new docs out of residency.  They bring enthusiasm, energy, and often new skills and knowledge that I think elevates my group.  Potentially, if a group doesn’t have turnover in their workforce because the older docs aren’t retiring, the group could be at a disadvantage.  Having a mandatory retirement age opens opportunities for younger physicians, making space for new talent, ideas, and energy while helping manage workforce planning.

There is precedent in other high-stakes professions. Similar rules exist for pilots, air traffic controllers, foreign service employees, and some judges—roles where high performance under stress is critical, reinforcing a cultural norm of safety-first. At least for air traffic controllers, retirement comes with a full pension after 20 years of service at age 50, or after 25 years of service at any age, so they have a little more motivation to retire than ER docs.

Why there should be NO Mandatory Retirement Age

There are many reasons why there is no mandatory retirement age.  Let’s start with the obvious that laws are in place to prevent discrimination. Mandatory retirement policies may raise concern about age discrimination.  The US Equal Employment Opportunity Commission is responsible for investigating discrimination in the workplace. Title VII of the Civil Rights Act of 1964, a federal law, prohibits workplace harassment and discrimination, covers all private employers, state and local governments, and educational institutions with 15 or more employees.

It prohibits discrimination against workers based on race, creed color, national origin, religion, and sex.  Then in 1967, the Age Discrimination in Employment Act (ADEA) was enacted to protect individuals who are 40 years of age or older from employment discrimination based on age. This law directly prohibits employment action based on age and applies to mandatory retirement or testing based on age. The ADEA’s protections apply to both employees and job applicants. This one does make me laugh a little since almost everyone in medicine is 40 fairly early into our careers, but nonetheless, it does protect late career physicians as well.

Older age does not equate to incompetence. In fact, many physicians remain sharp and effective well into their 70s.  We’ve probably all known physicians who worked into their 80s, including my grandfather who still volunteered a couple of days a week at a medical school derm clinic into his 80s.  Renowned cardiac surgeon Dr William Debakey operated until he was 90.  Senior emergency physicians bring decades of clinical wisdom and calm-under-fire leadership that are hard to replace. They often serve as mentors and role models for younger doctors as well. They add tremendous benefit to the group dynamic within the ED and the hospital.

Although it wasn’t many years ago that ACEP predicted we would have an abundance of emergency physicians, physician shortages certainly exist now and are likely to exist for some time into the future. Many emergency physicians are finding alternatives to working in the ER and leaving emergency medicine at younger ages than previous generations. Forced retirement could create staffing issues and access to care, particularly in rural and underserved areas.

Options for assessing aging physicians

Stanford University School of Medicine was one of the first to implement a Late Career Practitioner (LCP) Policy and currently there are approximately 30 US Healthcare institutions who take a similar approach. While the starting age varies, it’s typically between 65-70 years old. The purpose of these kinds of policies are to design assessments to help ensure quality of care, depersonalize the issues and processes around aging, and remain compliant with the law by standardizing the competency evaluation process. The assessments can vary from peer evaluation, neurocognitive assessments, and/or annual physician exam by a primary care provider. Having a LCP Policy in place can decrease the risk of the institution facing a discrimination lawsuit.  However, it may also be overly inclusive, subjecting too many people to mandatory testing who do not need it.  It can also be difficult to interpret the tests, which can lead to appeals or other legal processes.

There are alternative, and perhaps better, tools that we have as medical directors that should work well to evaluate competency if they’re working properly. These include peer review, quality improvement initiatives, and Ongoing Professional Practice Evaluations (OPPE). In addition to OPPE, Joint Commission requires all hospitals to have a practitioner health policy which is separate from any disciplinary process.  If there is a concern, you can order a fitness for practice evaluation. This can be used for anything ranging from mental health and substance abuse to cognitive or motor deficits that could impact the physician’s performance.

Each department and hospital need an effective peer review process that impartially reviews cases and trends results.  72 hour returns for admission can provide data and insight into what patients are coming back to the ED and rates can be compared from provider to provider. Individual case review can evaluate medical decision making.  Unexpected outcomes such as rapid upgrades to the ICU from a non-ICU bed, unexpected deaths or criticisms from other departments should also be reviewed at the department level.  Some of these will warrant a hospital committee peer review which should also be tracked and trended.  Even our routine quality initiatives such as thrombolytics for stroke, STEMI management, and SEP-1 cases should be reviewed and tracked to look for outliers.

All of these things then roll up into the OPPE process, which should also include productivity, utilization, and length of stay data.  Historically, OPPE was required every 6 months, but the Joint Commission relaxed their standards a few years ago.  It’s currently only required annually though many hospitals still do it semi-annually. Reviewing your OPPE and comparing providers to each other will allow you to identify outliers.  Whether it’s an LCP or a younger doc, a discussion as to the etiology of the issue and whether correction or improvement is possible, is the process to evaluate any physician. This can be a very effective and fair way to evaluate an LCP.

Finally, I think there are things that medical directors can control to make it a little easier to keep good docs working later into their career.  This could mean having an age threshold where docs can opt out of nights, offering reduced hours, and/or helping docs find an ED where the pace and acuity allow them to slow down a bit. Of course, having an age threshold on reducing or eliminating night shifts is still dependent on-site factors, such as number of older docs at the site, availability of nocturnists, etc.

Conclusions

I feel fortunate to have had the opportunity to work with many docs who brought decades of experience to our ER.  In general, I am supportive of trying to find a way to keep people working so they can retire on their own terms. A one size fits all retirement age is controversial and fortunately, there are better ways to manage aging in emergency medicine.  These include having effective peer review and OPPE processes to identify docs who may be missing their own signs that their abilities are declining and also working with docs to find a schedule or an environment that best fits their health and abilities.  The added bonus is that these same evaluation strategies help us identify any provider who may be having issues and allow us a standardized approach to investigate.

References

1. https://councilreports.ama-assn.org/councilreports/downloadreport?uri=/councilreports/n21_cme_01_annotated.pdf
2. https://www.ama-assn.org/delivering-care/health-equity/9-principles-guide-physician-competence-assessment-all-ages
3. https://doi.org/10.1016/j.annemergmed.2023.02.010

Photo Credit: Tima Miroshnichenko