Secondary Logo

Journal Logo

The Graying of Emergency Medicine

SoRelle, Ruth MPH

Special Report
Figure

Figure

When Greg Henry, MD, asks an audience of emergency physicians how many have planned their next vacation with their spouses, at least 90 percent will raise their hands. When he asks how many have planned out their lives, he is lucky if two hands are raised.

That, said the former president of the American College of Emergency Physicians, is the problem. “We spend hours talking about skiing, and no time at all talking about how we want this thing called life to go and how to get to there from here. And how to get there from here is really important stuff.

“I call it Henry's law,” he said. “Good things happen only if they are planned. Bad things happen all by themselves.”

As the first wave of emergency physicians begins to contemplate their maturing careers, some hard truths emerged. The most obvious is that the population is aging, and the second most obvious is that emergency physicians need to prepare for what is to come.

“The latest figures from the American College of Emergency Physicians bear that out,” said Richard M. Goldberg, MD, a clinical professor of emergency medicine at Los Angeles County-University of Southern California Medical Center and the chairman of the ACEP Well-being Committee, which is charged with looking at aging issues in the profession. “Forty-one percent of members in the college is aged 46 or older and 28 percent is 50 or older,” he said.

“There are a number of concerns that aging raises,” he said, including:

  • ▪ The ability to absorb the hours that emergency physicians have to practice.
  • ▪ Quality of care issues that arise in an aging profession.
  • ▪ Economic concerns as physicians face reducing their practice hours or retiring.
  • ▪ Strategies for extending careers.
  • ▪ Changing career patterns as the profession shifts toward different demographics.
Back to Top | Article Outline

Aging and Emergency Medicine

As Dr. Henry said, emergency medicine is not dermatology. “It's not obstetrics-gynecology where the doctors age with their patient populations. We do not. Wrestling drunks at 2 a.m. is hard at 25 and 30. It's really hard at age 65. To think you can work 10 and 12 hours per day in your 60s is denial,” he said.

It's not something taught in residency, Dr. Henry said. That comes from the nature of the academic setting, in which teachers don't work four to six shifts a week, he said. “That's not a role model for what life will be like when you work in a group.”

Dr. Goldberg agreed that aging can present problems for the practicing emergency physician. “There have been several articles over the past two years about the issue of the older practitioner,” he said. “The few studies that are available indicate that they may deliver lower quality care and are less able or willing to keep up with new developments. Obviously, this is a concern in our specialty. The issue of declining competence will surface more and more.”

The special dynamics of emergency medicine may make aging a special problem, he said. “One is the fact that emergency physicians physically spend half of their careers working at night. The evidence seems to be that as you get older, you actually — starting around the age of 40 — adapt less well to circadian stress.”

Dr. Henry agreed. “The concept that everyone should work the same numbers of nights is stupid,” he said. “You should work more of those when you are younger and fewer as you get older. The smart groups say that when you hire on, you work about 40 percent midnights. Then, by the time you are 50, you work none. That's the way it should be. What we are doing is fundamentally denying the laws of aging and circadian rhythm variation. At age 30, you can do anything. I used to work the midnight to 8 a.m. shift and then start meetings at 9 a.m. Now, I can't do that anymore. We need to be more honest about the physiology of aging when we plan our scheduling and workload.”

Emergency medicine might take a lesson from other jobs where people work 24 hours a day, seven days a week. Police, for example, take age into account, he said. “By the time officers are 50, they are usually working the day shift and giving talks at schools,” Dr. Henry said. “The smartest groups with which I've worked recognized that you need to mature your career. The first thing you do as you get older is work shorter shifts. At the sixth or seventh hour of a shift, the things that leave first are your sense of humor. As you get older, you find yourself effective for fewer hours a day.”

The good news is that emergency medicine has a lot of variations that can enable physicians to tailor their jobs to the demands of their physiology, he said. Emergency physicians might consider urgent care, administration, occupational, or industrial medicine. “We can do all kinds of things which are not hard core, not taking care of overdoses in the department at 2 a.m. You can gradually shift our workload so that you are diong fewer shifts in one week, doing shorter shifts, and reducing stress,” he said. “In groups that staff a number of hospitals, you can move from larger hospitals to smaller ones. These are all protective strategies to give you longevity.”

Some groups allow doctors to job-share, Dr. Henry said. “Two guys turn 65, and say to the director, we will fill one slot, the two of us. All the group wants is someone in that slot. There is no doctor-patient relationship. Patients don't come in, and say I want to see Dr. Smith. The group needs that slot covered competently. There needs to be a different approach to work and staffing.”

Back to Top | Article Outline

Economics

Dr. Henry, a clinical professor of emergency medicine at the University of Michigan, warned that the physicians who anticipate retiring at 62 or 63 are not being realistic about the future of Social Security or other retirement systems. “You are going to need to do things past that age,” he said. Yet he fears that people are burying their heads in the sand. “We never talk about money in residency programs,” he said. “You are going to get old or sick or something else. Yet [residency programs] concentrate on disease entities you might see twice in your lifetime.

“It is predictable that in 20 years, you will be 20 years older or dead. If you are 20 years older and you haven't planned, you are in trouble. You can't be old without money,” he said.

As physicians age and reduce the number of hours they work, they need to understand the economics of that practice. “Half time equals half benefits,” he said, but “at age 65, you are covered by Medicare.” Yet working between ages 65 and 70 can result in tremendous productivity if channeled in the right way, he said. “Just taking care of follow-up clinics can be important. There are lots of jobs that could be very functional and very important.”

Figure. D

Figure. D

The issue of declining competence will surface more and more.”

Dr. Richard Goldberg

Deciding how to allocate money also is important, he said. “Take the question of investment planning. What do you do with your money each month? How do you plan to fund your children's educations? What is the intelligent way to get the assets out of your estate so that it is not penetrable by lawsuits?” Dr. Henry said financial planning for young physicians should start early in their careers as a part of their training. “You should understand how to look at money and your life,” he said.

Back to Top | Article Outline

Adjusting Psychologically

“Going into retirement is a rite of passage that carries emotional baggage,” said Dr. Goldberg. For physicians, this is particularly true because so much of their personal identities are caught up in their profession, he said.

Dr. Henry added that a maturing career gives an emergency physician time to grow emotionally, psychologically, and in terms of society. “It's rarely discussed, but doctors are not great societal members,” he said. “They are not great contributors of their time. This is the time when you as a senior person have some degree of perspective and intelligence. You need to shift to make sure you have made your imprint on society. I believe in that. One should be ashamed of dying until you have made an imprint on society. This is when you make that shift.”

Figure. D

Figure. D

“Good things happen only if they are planned. Bad things happen all by themselves.”

Dr. Gregory Henry

Retirement means that emergency physicians can do different things, not that they do nothing at all, he said. “It doesn't mean that those activities are not valid. There are lots of activities we can do which are absolutely purposeful and valid that may not be remunerated in the same way. I lecture at residencies all the time, and the amount of money involved is very small. I do it for the love of the profession and because I feel I have something to say.”

Back to Top | Article Outline

The Future of the Profession

As the first wave of emergency physicians approaches retirement, Dr. Henry said he worries that the profession is not training enough replacement physicians. “Now that 40 percent of our residents are women, we can't make the same work assumptions we did in the old days based on the current gender shift.” He said studies indicate that when women take out time for childbearing and childrearing, they are less willing to work the kinds of hours and shifts common in emergency medicine. He said ACGME estimates that the shift to women indicates that as many as one-third more residency slots will be needed in coming years to turn out enough emergency physicians to cover the emergency departments of the future.

“Then there's the generational shift away from Baby Boomers, who were raised by people who fought in World War II and lived through the Great Depression,” said Dr. Henry. “We were mean. We worked hard. Many of the younger generation don't work like that.”

With the younger generation wanting to spend more time on their lifestyles and less on their occupations, he said, “they will get paid less and need more people. We haven't made the adjustments in the system to accommodate them. We haven't increased the output of our residency program to take this into account.”

Dr. Goldberg said his well-being committee has formed a task force to look at the problems of the aging physician and the aging physician population to look at issues facing emergency physicians in their pre-retirement years. It is an important issue that has had little exposure so far, he said.

“Specifically, we would like to identify the issues involved, and to see if we can identify ways to enhance or prolong the careers of emergency physicians who are in the latter stages of their careers. For those physicians who are soon to be in pre-retirement, can we identify the areas of concern for which they might be preparing?”

He said the committee is currently putting together a survey of the membership to help determine areas of concern to them. They also are putting together an annotated bibliography on the topics of aging physicians as well as retirement issues such as financial planning and emotional adjustment. Dr. Henry said discussing the issues can only improve the matter for future physicians. “We need candor on these problems,” he said.

Back to Top | Article Outline

Issues for Physicians as They Age

  • ▪ The ability to absorb the hours that emergency physicians have to practice.
  • ▪ Quality of care issues that arise in an aging profession.
  • ▪ Economic concerns as physicians face reducing their practice hours or retiring.
  • ▪ Strategies for extending careers.
  • ▪ Changing career patterns as the profession shifts toward different demographics.

Source: Gregory Henry, MD, (interview), October 2005.

© 2005 Lippincott Williams & Wilkins, Inc.