The logical result of successful physician retention is that physicians become senior physicians. Should ED employers provide special consideration for them? This is the question posed by Pamela P. Bensen, MD, after reading part one of this series. Dr. Bensen was the founder and principal of Emergency Medicine Associates, a group in Maine, from 1984 to 1997, and the first female board member for ACEP.
At 63, Dr. Bensen is finding great difficulty securing part-time employment in the specialty she has served with great distinction since 1973. Her story led me to examine the policies and procedures in place across the country addressing the needs of senior physicians. The truth is, for the most part, there aren't any. On the other hand, most of the physicians, directors, and heads of groups with whom I spoke said it's time to look at the question.
I surveyed more than 80 physicians ranging in age from 36 to 66, and asked if they believed physicians 55 and older should receive special consideration when it comes to night shifts. More than 90 percent of responders said senior doctors should be allowed to cut back on or eliminate night shifts. Eighty-two percent said seniors should be able to cut back monthly hours if desired, and more than 70 percent thought shorter shifts should be available for them. Most, however, said senior physicians should have the same responsibility for patient per hour statistics, and remain equally accountable for quality patient care and satisfaction.
Andrew Cole, MD, the president of Peninsula Emergency Physicians at the Sentara CarePlex Hospital in Hampton, VA, said his group, which has been in existence for more than 30 years, has given senior physicians the option to work exclusively in the minor care area, going from partner to employee. They retain the benefits they enjoyed as partners except for the annual profit share. According to Dr. Cole, “The total equality of the group members is actually more important to us than protecting senior partners, and the senior docs are cool with that.” He went on to emphasize that he wouldn't shy away from hiring a 50+ doctor because “older physicians know what they want, and that is a plus.”
Ellis Weeker, MD, the regional director of the CEP America South and East Bay/Northern California Region and an emergency physician at Good Samaritan Hospital in San Jose, agreed; the group recently hired a physician in his 60s. Dr. Weeker pointed out that while they are working on creating a senior physician policy, their partnership track “was created to recognize the needs of individual physicians. The key word is flexibility.” Partners with more than 10 years of service can choose to work fewer hours, take a sabbatical, and have greater flexibility for compensated nonclinical hours including teaching, committees, wound care, and community-oriented activities such as EMS.
“We recognize that physicians have different needs at different points in their careers and accommodating them is important to us,” Dr. Weeker said. “Consequently, we don't require specific policies for issues like age. We have built our group in a manner that allows us to maximize the value from the individual's wisdom and experience, and recognize that value outside of just the clinical. I believe senior physicians will be contributors long after their clinical services are finished.”
Also demonstrating a keen understanding of the values provided by senior physicians is Gar LaSalle, MD, the chief medical officer for TeamHealth and the medical director of one of Northwest Emergency Physicians' emergency departments. “Elders should be venerated,” said Dr. LaSalle. “They bring perspective and institutional memory, especially if they have longevity with a department, and they know both the community and the community medical providers, which is hugely beneficial and can't be undervalued.”
The TeamHealth leadership course, which all directors must attend every two years, teaches how to observe staff physicians for health and wellness issues and how to intervene when a doctor needs help. “Suppose an older doc has a health problem,” Dr. LaSalle said. “If the group is acting responsibly with good citizenship, they take care of each other, they cover for each other, and they work like a family.”
The Northwest Emergency Physicians' division of TeamHealth actually has one of the only senior physician policies in place that I found. They hire “nocturnists,” physicians who work the night shift exclusively for a significant differential. As physicians gain seniority, they are given higher priority for choosing shifts. Though they do their fair share of weekends and holidays, physicians matriculate to a point of completely eliminating night shifts. Physicians with fewer than two years of longevity fill in on the late shift when necessary. “We have several docs in their 60s working day shifts, and doing quite well,” Dr. LaSalle reported. “Ask yourself, ‘Am I doing the best thing for the patient by being here?’ If the answer is yes, go at it. But if you are cutting corners, maybe you need to look at whether a change is needed. My first responsibility must be to my patient, not to my cash flow or my ego.”
Value of Senior Physicians
Marc Borenstein, MD, the chairman of emergency medicine for Newark Beth Israel Medical Center in New Jersey, is another believer in the value of senior physicians. “In general, I have found that some of life's more difficult and painful experiences that are not typically experienced until one is older build compassion and sensitivity, and help decrease the application of judgmental attitudes toward others,” he said. “Older physicians need to deliver energy, passion, enthusiasm, and excellence in areas such as teamwork and communication. No one wants to hire a doc who is burned out or jaded, regardless of age.”
Senior physician Harry Kintzi, MD, of Lancaster, PA, had a unique position on this issue, noting that perceptions about senior physicians often depend on an individual's own age viewpoint. “If you're young, you don't want to be taken advantage of by the elders. If, on the other hand, you are one of the elders and have paid your dues over the years, there should be some benefits and advantages,” he said. “If younger physicians keep changing jobs every few years, they never transition into the elder/senior category.”
Dr. Kintzi said emergency department leadership needs to “think to the future. Either make some concessions to senior docs or find new grads who can be worked hard and paid less with little chance of achieving longevity,” he said. Asked what makes work easier for a physician over age 55, Dr. Kintzi said groups should eliminate or decrease night shifts by hiring nocturnists with a good pay differential and adequate staffing for the acuity of each shift.
Ben Wedro, MD, an emergency physician at the Gundersen Clinic in La Crosse, WI, works with a group that employs egalitarian principles from day one. “I am almost a senior physician, and it is my input into group policy over the past 20 years that has shaped our department policy to promote longevity and physician health. The key is to invest in the workings of the department and the institution. Those physicians who have decided only to see patients and not become part of the policy process are resigned, perhaps deservedly so, to the decisions of those to whom they delegated the responsibility.”
Nathan Frederick, DO, an emergency physician with the Conway Emergency Group in Conway, SC, is hoping to create his own plan for the future. “My goal for practicing over the age of 55 is to have decreased clinical hours, and become more involved in the administrative aspects of emergency medicine. I have started obtaining training to work toward this goal,” he said.
Many of the younger physicians were already considering what they could do now to ease the transition to senior practitioner, mostly due to the fact that their employers obviously weren't going to do it for them. And they're right: This issue isn't going to go away. I'll let Pam Bensen have the last word because she instigated this discussion for me in the first place.
“In the 1960 and 1970s, the pioneers of emergency medicine fought to get the specialty recognized and to establish boards to meet the growing need for emergency physicians to staff the nation's emergency rooms,” she said. “Today we are seeing the beginning of an exodus. We cannot fill all the advertised EP positions. If we fail to recycle and retain our older physicians what will happen? The young emergency physicians we have fought for will find their careers less satisfying. How long will it take before they [tire] and join the exodus? Who will replace them? How will we fill the need for emergency physicians? At what age did I cease to be an emergency physician?”