When I retired in 2019, at age 65, I never gave a second thought to re-entering the workforce. However, after less than a year as a recovering taxpayer, I decided to seek employment in a non-clinical capacity. My choice was either the pharmaceutical or health insurance industry, familiar places where I have spent the bulk of my career.
Since retiring, I have struck out in my attempts to gain full-time employment in either industry. Fortunately, I have cobbled together a few part-time jobs supervising nurse practitioners and physician assistants as a “collaborating physician” and consulting for a pharmaceutical organization. I am quite happy in this role, and I highly recommend consulting to baby boomer physicians whose careers may have been cut short by age discrimination.
Beware the Young Doctor and the Old Barber
In my experience, including conversations with colleagues, physicians seeking non-clinical careers have been subjected to significant hiring discrimination due to age-based prejudice and stereotyping — so-called ageism, a term coined by psychiatrist Robert N. Butler in 1968.(1) And just like their clinical counterparts, physicians engaged in non-clinical work have been passed over for promotions, evaluated less favorably, and blamed for failures or problems based on their age.
In one of the earliest observations of ageism involving physicians, Benjamin Franklin was quoted(2) nearly 300 years ago as saying: “Beware of the young doctor and the old barber.” This was obviously an admonition to stay clear of inexperienced young physicians and avoid older, physically unfit surgeons. Although technically only older individuals were considered in Butler’s definition of ageism, there is also the phenomenon of “reverse ageism” coming from older workers toward younger professionals.
Physicians in their sixth and seventh decades and beyond have a wealth of knowledge and experience. After practicing for 30 or 40 years, many are now in search of “encore” careers. What a shame to pass them over for less-experienced physicians, many of whom are undoubtedly burned out and simply seeking refuge from the drudgery of everyday practice. Physicians escaping practice for non-clinical jobs, as opposed to those who have a sincere interest in non-clinical positions, do not fare as well, according to preventive medicine physician Sylvie Stacy, MD, MPH, author of 50 Non-clinical Careers for Physicians.
Hiring Bias
Of course, I cannot prove that healthcare corporations have blatantly discriminated against me due to my age. It’s virtually impossible to make a case without legal representation and actions, and I have no intention of pursuing a lawsuit. Besides, hiring managers these days are well coached by human resources personnel on how to prevent ageist motives from surfacing in job interviews and rejection letters.
Still, that doesn’t mean hiring managers and HR employees are without bias. A study(3) of 234 HR employees in Switzerland confirmed the presence of a bias “blind spot” in their hiring decisions. There was a tendency to see themselves as less biased than their HR peers, or to be able to identify more cognitive biases in others than in themselves. Furthermore, male HR employees showed a greater bias blind spot than female HR employees.
When my 2019 position as medical director for a health insurance company was eliminated, my manager, a physician approximately 10 years my junior, called to inform me of the company’s decision. She read directly from a script prepared by the HR department and said she could not answer any questions. I was directed instead to an HR representative who was also participating on the phone call.
Recently, I received a rejection letter from a pharmaceutical company. I have over a dozen years of experience in “big pharma,” ranging from R&D to medical affairs, with proficiency as a medical reviewer of drug advertising and promotion. The job I applied for was right up my alley: medical affairs medical director. I interviewed separately with the hiring manager and her boss. A week or so later, I inquired about the status of my application. I received the following email from the hiring manager’s boss:
“Thank you again for your interest in the opportunity to work with us at [company name]. While we were impressed with your diverse background and aspirations, we have identified another high-caliber candidate that we will be looking to move forward with.” And then the kiss-off: “However, I’d like to keep you in mind for future opportunities if they should arise.”
Justifiable or Discriminatory?
Virtually every state has age and disability discrimination laws that protect physicians from ageism. Yet, prejudice against older physicians — indeed, aging workers in general — is growing. In the case of physicians, discrimination arises mainly because assumptions are made about the effects of age on performance. Older physicians are believed to be more prone to cognitive impairment and physical decline. Individuals with a strong bias against hiring elderly physicians or maintaining them on staff point to a correlation in some studies(4) between adverse patient events and older age.
However, arbitrarily removing older physicians or denying them jobs is without merit. For most operative procedures, for example, the age of the surgeon is not an important predictor of operative risk or outcome, including mortality.(5)
While older physicians may be less likely to adopt new treatment approaches in their practice and have less factual knowledge (based on board recertification exam results), a recent analysis(6) showed that longer professional experience was not associated with lower quality medical care, contradicting an earlier, frequently cited study,(7) indicating an inverse relationship between physicians’ clinical experience and quality.
In a separate study(8) that examined the effect of residency training and experience on patient outcomes, the authors found that overall patient care appeared to be safe, whether delivered by resident physicians or more experienced staff. If anything, research findings(9) support efforts to secure adequate training and supervision for early-career physicians in light of the fact that more-experienced physicians — in particular, those practicing emergency medicine — are about one-third less likely to commit errors compared with younger physicians.
Overall, the literature on this subject is complicated and varies greatly. There are so many potential levels of conflict and dispute in initiating compulsory age-based evaluations for physicians — as some authors(10) have recommended — that make it a treacherous undertaking. And given the absence of high-quality data demonstrating that aging physicians generate more errors and adverse patient outcomes than their younger counterparts, any policy compelling mandatory retirement or screening at a certain age could be challenged as discriminatory.
It has been suggested(11) that requiring older physicians to undergo competency testing without cause may reflect ageist attitudes rather than genuine concerns about patient safety. Mandated testing has been opposed on professional, legal, social, and theoretical grounds.(12)
Theoretical Considerations
Why have studies reported discrepant findings about the relationship between age and quality? It has been theorized(13) that over time, physicians develop complex social, behavioral, and intuitive wisdom, as well as the ability to compare current patients against similar past patients. Accumulated knowledge coupled with an acquired understanding of patient types might lead to better treatment — care that is not captured by common quality indicators and guideline-based outcome measures.
It is disturbing that the lack of adherence to guidelines by older physicians is often reported as deficient care. An understanding of how experience counts toward “evidence-based medicine” and how patient types can lead to better quality is not taken into account. This highlights some of the problems with the narrow definitions and proxies for physician experience, such as age or years in practice, used in many research studies.
Standardized examinations and other measures of medical knowledge likewise may be poor proxies for physician performance. Until scientists discover a biomarker for wisdom, perhaps the best way to assess a physician’s competence is to observe their practice. Performance cannot be reduced to a set of numbers that purport to reflect its quality.
Regrettably, in addition to the myriad issues attending the assessment of the competency of aging doctors, the digital revolution is likely to contribute to a hiring bias against older physicians. Aging physicians are apt to be viewed as less technologically savvy than younger doctors. It is a fact that older workers have lower levels of digital skills than younger workers across nearly all occupations, including health professionals.(14) However, AARP conducted a survey(15) of 1,322 individuals ages 40–65 and in the workforce. The survey revealed 74% are interested in receiving new job skills, and 94% are willing to learn new skills if requested by a current or potential employer.
Retirement Reconsidered
Although there is a general consensus that ageism is a significant problem in healthcare, the narrative usually focuses on how it has crept into the care of older adults, leading to both under- and over-treatment. In comparison, the hiring and firing of older physicians receives much less attention. There are even fewer data relating to the effect of experience and age on the skills and performance of non-clinical physicians in industry settings — pharmaceutical, health insurance, government, and others.
Industry jobs typically are considered greener pastures for older physicians nearing retirement or those forced out of practice due to competency issues. However, the pharmaceutical industry has been the subject of several age (and gender) discrimination lawsuits. Most of them have been filed by sales and marketing personnel rather than physicians. The basis of plaintiffs’ actions usually centers on the unfounded stereotype that older workers are less valuable, less capable, or less committed to an organization’s long-term goals. An industry insider observes, “Pharma has been purging older employees for some time, and when you reach the magic age of 50+, you’re going to be pushed to take ‘early retirement.’ ”(16)
Was it a coincidence that my job was eliminated just a few months after my 65th birthday? My experience suggests ageism limits both clinical and non-clinical opportunities for physicians advancing in age, and this is very concerning given that 47% of active physicians in the United States in 2021 were 55 or older,(17) and some plan to practice until they are in their 70s or 80s. Moreover, mandatory retirement would exacerbate physician shortages. By 2034, the nation is projected to have a shortfall of between 37,800 and 124,000 physicians, affecting both primary and specialty care.(18)
Instead of retiring, many physicians are choosing to work simply for the joy of working, well past the point of financial independence. Much of their professional identity is tied to work, they don’t have a “bucket list” or activities outside their career they want to explore, and they don’t feel the need to retire to be happy. Physicians such as these have realized their purpose and reached a state of fulfillment that the Japanese refer to as ikigai, similar to what the French refer to as raison d’être. It’s when the following factors are simultaneously present:
You love to do it.
You are good at it.
The world needs you.
You get paid for doing it.
Once you reach ikigai, the question is, “Why stop?”
Conclusion
The issue of when to retire is a complex professional, intellectual, and emotional decision. In the late 1960s, at a congressional hearing on the Age Discrimination in Employment Act (the ADEA), Nevada Sen. C. Clifton Young emphasized that age is just a number. He said, “People grow old by losing their enthusiasm, deserting their ideals, abandoning their joy of life, and no longer looking forward to the challenges of adventure and change. Instead of yearning for retirement, the desire for a vigorous, active life and the wish and ability to work hard and look forward with hope instead of fear often exists in men and women for 70 years or more.”(19)
Hiring managers would do well to remember Young’s remark and not overlook the vitality and talent of seasoned physicians. Older doctors are among the brightest and most versatile medicine has to offer.
References
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Berk WA, Welch RD, Levy PD, et al. The Effect of Clinical Experience on the Error Rate of Emergency Physicians. Ann Emerg Med. 2008 Nov;52(5):497–501. https://doi.org/10.1016/j.annemergmed.2008.01.329 .
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