Physicians after 65 M.O. VINCENT, FRCP[CI
There is a difference between ageing and getting senile. We are all approaching old age; is anyone going the other way? Yet I believe very few of us will ever be senile. Senility is an organic brain syndrome associated with ageing, but not a frequent accompaniment of it. There is a bit of folklore among physicians - that they all die young, usually of coronaries resulting from their dedication and overwork. This myth helps the physician rationalize his avoidance of planning for retirement or old age. However, available evidence suggests that physicians live longer than their peers. The life expectancy of US physicians in each 10-year age group is longer than for all US males.1 Similar studies in Britain show that the death rate for physicians is 11 % below that predicted from the national death rate.2 Recently, I reviewed admissions to the Homewood Sanitarium to see how many physicians were admitted because of senility. I looked at our inpatient experience over the 17 years 1960 to 1977. I reviewed the chart of every physician who was 65 or over at the time of his admission, since this would be the likely method of identifying a significant number of senile physicians. The Homewood Sanitarium admits patients both for treatment of acute psychiatric disorders, including alcoholism and drug addiction, and also for chronic disorders such as organic brain syndrome requiring continuing care. The Homewood Sanitarium is a 307-bed, fully accredited, private psychiatric hospital, which has been operating continually in Guelph, Ontario, since 1883. Physicians seeking Dr. Vincent is executive director of the Homewood Sanitarium, 150 Delhi St., Guelph, Ont. NiE 6K9, and requests for reprints may be addressed to him there. The article and the one following are based on a paper presented at the third national conference on the impaired physician, Minneapolis, Sept. 29 to Oct. 1, 1978.
psychiatric hospitalization frequently who had endured constant therapy prefer a private hospital removed with steroids, osteoporosis and sponfrom their own communities. Further, taneous fractures. since we provide long-term care, phyIf other studies support these findsicians with organic brain syndrome ings, the conclusion would be that would not be excluded, as they would for the physician, the problems of be in some private psychiatric facil- alcoholism, drug addiction and affecities that admit only acute cases be- tive disorders are much more frelieved to be reversible. quent than senility. Thus the major threats to the wellbeing of the physician in his later years appear to be Present study the same as those in the middle years. Two hundred physicians were Further, the lifestyle of the early and treated as inpatients in the Home- middle years appears to influence the wood Sanitarium from 1960 to 1977; likelihood of a physician's being adof these, 32 were admitted after their mitted to a psychiatric hospital in 65th birthday (Table I). his later years. Duffy and Litin's3 It is surprising and certainly sig- study of 93 physicians admitted to nificant that only five had chronic the psychiatric unit of the Mayo organic brain syndromes without Clinic parallels these conclusions. complicating factors, specific diag- Only 3 of their 93 physicians sufnoses being senile dementia or cere- fered from chronic brain syndromes; bral arteriosclerosis. The age range two had senile brain disease and one of these physicians was from 70 to had cerebral arteriosclerosis. Medical code violations handled by 81, with an average of 76. They had retired at an average age of 71. the Virginia State Board of Medicine Four other physicians (with an between 1967 and 1976 indicate average of 74) had chronic organic that of 356 physicians who came to brain syndromes complicated by the board's attention, only 8 (2.3%) other factors - abuse of alcohol and were diagnosed as senile.4 Thus senilbarbiturates, combined with emotion- ity makes up a very small percentage al disturbances. of physicians that come before liThus, in a select population where censing bodies through disciplinary one might anticipate discovery of procedures. many senile physicians, of 32 physicians admitted at age 65 or older, Proper perspective only 5 were admitted primarily beThese studies put the frequency of cause of senility, and 4 more were admitted because of alcoholism or senility in physicians in proper perbarbiturate excess in conjunction spective. In overall numbers, it is a small but none the less important with their organic brain changes. problem. The causes and prevention As Table I indicates, alcohol or drug dependency was a major con- of senile brain disease or arterioscletributing factor in the admission of rotic brain disease are still not fully 18 of the 32 physicians, while 14 understood, but there is little reason physicians were admitted who had no to believe that senility presents a alcohol or drug problems. Of the greater threat to physicians than to latter group, nine were suffering from other people. We do, however, reaffective disorders, usually depres- present a rather unique problem in sion. Five of those suffering depres- the frequency with which we do not sion had major physical disabilities retire. Typically, the older physician - such as the physician with a 25- finds decreasing physical stamina year history of rheumatoid arthritis rather than loss of mental acuity a
998 CMA JOURNAL/APRIL 21, 1979/VOL. 120
14 '44.."'.44
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.'."
problem, but as Dr. E.P. Maynard5 reminds us in a paper written when he was 74: "It is romantic to want to die with your boots on, but it is disaster if your brain has ceased to keep pace with your boots." The major problem is the small proportion of physicians still in practice whose memories and judgement are mildly impaired by organic brain changes. This is an important issue: First there is the life and health of the public, besides its trust in the medical profession. Second is the welfare and reputation of the impaired physician, both of which may
4
'4'
4'*"'*"4"..
be severely jeopardized by his continuing to practise medicine. Third is loss of respect and indeed the autonomy of the medical profession if it does not deal appropriately with these issues. As professionals, we accept the obligation to monitor ourselves. As realists, we acknowledge that if we do not do this effectively, it will be done for us. I believe that we must develop procedures for detecting and dealing with the impaired physician. Both physicians and the public must be made aware of the procedures and encouraged to see
them as beneficial to all, rather than as primarily punitive to the involved physician. In the local hospital, more careful assessment by credentials committees of the annual reappointments of physicians over 65 would lead to earlier recognition of such problems. However this is a solution only to problems in a hospital, not to those in an office practice. In some provinces, such as Ontario, there is legislation requiring that anyone who leaves hospital practice as a result of negligence, incompetence or misconduct be reported to the provincial licensing body. This enables the licensing body to evaluate the ability of such physicians to practise, but of course there are many physicians who quietly leave hospital practice who do not come to the attention of the college. Similarly, there is no review of the physician who practises only in his office. One solution might be an annual evaluation of the practice of every physician over 70 at the time of the licence renewal.
Free to retire? The practising senile physician would not present a problem if physicians retired before they became senile. And physicians are likely to start retiring earlier as a result of several current trends. For instance: * Malpractice insurance is becoming more expensive. In the US this development has already influenced the retirement age of physicians. * More physicians are in salaried positions and group practice. A physician in such a situation is subject to greater pressure to retire; at the same time he is likely to have available a pension on which to do so. * Keeping up with rapid technical advances in medicine is becoming increasingly difficult. * Peer review is here already and recertification and relicensing may be on the way. As hospital privileges become more closely monitored, appointments to staff will be increasingly scrutinized.
* Perhaps physicians have always grumbled, but it is my impression that physicians are increasingly expressing disenchantment. They are fed-up with filling out forms and seeing their autonomy disappear. * We have a higher physician-topopulation ratio than ever before. Fear of retirement
Many people do not look forward to retirement. Physicians share this view, and in the past many have managed to avoid retirement; they tend, like other members of the public, to view retirement as a very stressful transition, often followed by serious maladjustment, physical and emotional deterioration and decreased life satisfaction and expectancy. However, recent studies6'7'8 suggest that retirement improves physical health rather than decreasing general life satisfactions. Physicians tend to be aware more of the negative than the positive as-
pects of retirement, partly because of professional contact with ill, retired people. The most important variable in adjustment to retirement is not retirement itself but rather the individual personality, which is not likely to change suddenly at the moment of retirement. Current research suggests that those who enjoy their work enjoy their retirement, while others are unhappy whether working or retired. This confirms Cicero - "It is their own vices and their own faults that fools charge to old age." One recently retired physician9 wrote that medical friends gave him a number of reasons why they did not retire. The commonest were: * I can't afford to quit; I still have kids in college. * I like what I am doing too much to quit. * I would hate to deprive my patients of the knowledge and skills I have accumulated over the years in my practice. He added:
CMA JOURNAL/APRIL 21, 1979/VOL. 120 1001
There is a difference between ageing and getting senile. We are all approaching old age; is anyone going the other way? Yet I believe very few of us will ever be senile. Senility is an organic brain syndrome associated with ageing, but not a frequent accompaniment of it. There is a bit of folklore among physicians - that they all die young, usually of coronaries resulting from their dedication and overwork. This myth helps the physician rationalize his avoidance of planning for retirement or old age. However, available evidence suggests that physicians live longer than their peers. The life expectancy of US physicians in each 10-year age group is longer than for all US males.1 Similar studies in Britain show that the death rate for physicians is 11 % below that predicted from the national death rate.2 Recently, I reviewed admissions to the Homewood Sanitarium to see how many physicians were admitted because of senility. I looked at our inpatient experience over the 17 years 1960 to 1977. I reviewed the chart of every physician who was 65 or over at the time of his admission, since this would be the likely method of identifying a significant number of senile physicians. The Homewood Sanitarium admits patients both for treatment of acute psychiatric disorders, including alcoholism and drug addiction, and also for chronic disorders such as organic brain syndrome requiring continuing care. The Homewood Sanitarium is a 307-bed, fully accredited, private psychiatric hospital, which has been operating continually in Guelph, Ontario, since 1883. Physicians seeking Dr. Vincent is executive director of the Homewood Sanitarium, 150 Delhi St., Guelph, Ont. NiE 6K9, and requests for reprints may be addressed to him there. The article and the one following are based on a paper presented at the third national conference on the impaired physician, Minneapolis, Sept. 29 to Oct. 1, 1978.
psychiatric hospitalization frequently who had endured constant therapy prefer a private hospital removed with steroids, osteoporosis and sponfrom their own communities. Further, taneous fractures. since we provide long-term care, phyIf other studies support these findsicians with organic brain syndrome ings, the conclusion would be that would not be excluded, as they would for the physician, the problems of be in some private psychiatric facil- alcoholism, drug addiction and affecities that admit only acute cases be- tive disorders are much more frelieved to be reversible. quent than senility. Thus the major threats to the wellbeing of the physician in his later years appear to be Present study the same as those in the middle years. Two hundred physicians were Further, the lifestyle of the early and treated as inpatients in the Home- middle years appears to influence the wood Sanitarium from 1960 to 1977; likelihood of a physician's being adof these, 32 were admitted after their mitted to a psychiatric hospital in 65th birthday (Table I). his later years. Duffy and Litin's3 It is surprising and certainly sig- study of 93 physicians admitted to nificant that only five had chronic the psychiatric unit of the Mayo organic brain syndromes without Clinic parallels these conclusions. complicating factors, specific diag- Only 3 of their 93 physicians sufnoses being senile dementia or cere- fered from chronic brain syndromes; bral arteriosclerosis. The age range two had senile brain disease and one of these physicians was from 70 to had cerebral arteriosclerosis. Medical code violations handled by 81, with an average of 76. They had retired at an average age of 71. the Virginia State Board of Medicine Four other physicians (with an between 1967 and 1976 indicate average of 74) had chronic organic that of 356 physicians who came to brain syndromes complicated by the board's attention, only 8 (2.3%) other factors - abuse of alcohol and were diagnosed as senile.4 Thus senilbarbiturates, combined with emotion- ity makes up a very small percentage al disturbances. of physicians that come before liThus, in a select population where censing bodies through disciplinary one might anticipate discovery of procedures. many senile physicians, of 32 physicians admitted at age 65 or older, Proper perspective only 5 were admitted primarily beThese studies put the frequency of cause of senility, and 4 more were admitted because of alcoholism or senility in physicians in proper perbarbiturate excess in conjunction spective. In overall numbers, it is a small but none the less important with their organic brain changes. problem. The causes and prevention As Table I indicates, alcohol or drug dependency was a major con- of senile brain disease or arterioscletributing factor in the admission of rotic brain disease are still not fully 18 of the 32 physicians, while 14 understood, but there is little reason physicians were admitted who had no to believe that senility presents a alcohol or drug problems. Of the greater threat to physicians than to latter group, nine were suffering from other people. We do, however, reaffective disorders, usually depres- present a rather unique problem in sion. Five of those suffering depres- the frequency with which we do not sion had major physical disabilities retire. Typically, the older physician - such as the physician with a 25- finds decreasing physical stamina year history of rheumatoid arthritis rather than loss of mental acuity a
998 CMA JOURNAL/APRIL 21, 1979/VOL. 120
14 '44.."'.44
4 """'44
444.44
.'."
problem, but as Dr. E.P. Maynard5 reminds us in a paper written when he was 74: "It is romantic to want to die with your boots on, but it is disaster if your brain has ceased to keep pace with your boots." The major problem is the small proportion of physicians still in practice whose memories and judgement are mildly impaired by organic brain changes. This is an important issue: First there is the life and health of the public, besides its trust in the medical profession. Second is the welfare and reputation of the impaired physician, both of which may
4
'4'
4'*"'*"4"..
be severely jeopardized by his continuing to practise medicine. Third is loss of respect and indeed the autonomy of the medical profession if it does not deal appropriately with these issues. As professionals, we accept the obligation to monitor ourselves. As realists, we acknowledge that if we do not do this effectively, it will be done for us. I believe that we must develop procedures for detecting and dealing with the impaired physician. Both physicians and the public must be made aware of the procedures and encouraged to see
them as beneficial to all, rather than as primarily punitive to the involved physician. In the local hospital, more careful assessment by credentials committees of the annual reappointments of physicians over 65 would lead to earlier recognition of such problems. However this is a solution only to problems in a hospital, not to those in an office practice. In some provinces, such as Ontario, there is legislation requiring that anyone who leaves hospital practice as a result of negligence, incompetence or misconduct be reported to the provincial licensing body. This enables the licensing body to evaluate the ability of such physicians to practise, but of course there are many physicians who quietly leave hospital practice who do not come to the attention of the college. Similarly, there is no review of the physician who practises only in his office. One solution might be an annual evaluation of the practice of every physician over 70 at the time of the licence renewal.
Free to retire? The practising senile physician would not present a problem if physicians retired before they became senile. And physicians are likely to start retiring earlier as a result of several current trends. For instance: * Malpractice insurance is becoming more expensive. In the US this development has already influenced the retirement age of physicians. * More physicians are in salaried positions and group practice. A physician in such a situation is subject to greater pressure to retire; at the same time he is likely to have available a pension on which to do so. * Keeping up with rapid technical advances in medicine is becoming increasingly difficult. * Peer review is here already and recertification and relicensing may be on the way. As hospital privileges become more closely monitored, appointments to staff will be increasingly scrutinized.
* Perhaps physicians have always grumbled, but it is my impression that physicians are increasingly expressing disenchantment. They are fed-up with filling out forms and seeing their autonomy disappear. * We have a higher physician-topopulation ratio than ever before. Fear of retirement
Many people do not look forward to retirement. Physicians share this view, and in the past many have managed to avoid retirement; they tend, like other members of the public, to view retirement as a very stressful transition, often followed by serious maladjustment, physical and emotional deterioration and decreased life satisfaction and expectancy. However, recent studies6'7'8 suggest that retirement improves physical health rather than decreasing general life satisfactions. Physicians tend to be aware more of the negative than the positive as-
pects of retirement, partly because of professional contact with ill, retired people. The most important variable in adjustment to retirement is not retirement itself but rather the individual personality, which is not likely to change suddenly at the moment of retirement. Current research suggests that those who enjoy their work enjoy their retirement, while others are unhappy whether working or retired. This confirms Cicero - "It is their own vices and their own faults that fools charge to old age." One recently retired physician9 wrote that medical friends gave him a number of reasons why they did not retire. The commonest were: * I can't afford to quit; I still have kids in college. * I like what I am doing too much to quit. * I would hate to deprive my patients of the knowledge and skills I have accumulated over the years in my practice. He added:
CMA JOURNAL/APRIL 21, 1979/VOL. 120 1001
