Retirement is ideally a personal choice, and incentives to work longer are probably not the way to stop workforce shrinkage
When is it time for a GP to retire?
The pace of change in new technology and clinical evidence is accelerating, making it harder for older doctors to stay on top of things.
But with a “workforce cliff” approaching as up to a fifth of GPs plan to retire, and a continuing decline in the number of graduates wanting to specialise in general practice, is there an argument for incentivising GPs to keep working as long as possible?
The pandemic inspired an all-hands-on-deck mentality, and showed that recently retired GPs could help in various capacities besides regular clinic days. Similar thinking may need to be applied more generally as we face a workforce shortage, especially in regional and rural Australia.
Currently, there’s no regulatory barrier. AHPRA does not conduct age-based assessments or specify a retirement age. GPs can continue to practise so long as they comply with the MBA’s registration standards and requirements of the National Law.
“I think if you have a mandatory retirement age, that’s ageism,” says Professor Craig Anderson, director of the George Institute’s neurological and mental health division. “If you’ve got adequate energy, capacity and intellect and you’re enjoying it and there’s adequate support from colleagues, that’s fine.
“I think AHPRA’s general mandate is a good thing, but it’s a bit light – AHPRA only really gets involved when there’s a problem. There’s probably a lot of GPs out there who are only just coping who AHPRA would only know about when there’s a complaint.”
Since 2017, however, the MBA has been eyeing mandatory health checks for doctors aged 70 and over.
The board has, in principle, accepted an advisory group recommendation that from age 70, doctors should have a confidential health check, including “cognitive screening”, once every three years. They should also have a formal performance review process, that would come with CPD credit.
Should legal obstacles stand in the way of mandating health checks, the MBA would consider further research into any age-related risk posed by doctors over aged 70 continuing to practise.
“There is strong evidence that there is a decline in performance and patient outcomes with increasing practitioner age, even when the practitioner is highly experienced,” the board says.
While the MBA sounds like it means business, the proposal is still only under consideration. Introducing mandatory health checks just as older GPs were being encouraged to boost a pandemic surge workforce may not have been looked on favourably.
The need to boost a declining workforce could also be holding back introduction of the checks.
In GPs, age-related decline can show itself in any number of areas, according to Professor Anderson.
GPs have responsibilities that extend beyond the consulting room, he says, including attending CPD courses, dealing with medico-legal issues, vaccine storage, CPR update training, infection control and, for hospital-based GPs, fire emergency training – the list goes on.
“And on top of all of that, you have to manage your business in primary care, so you’re basically worrying about the bottom line and maybe managing staff,” he says.
“It’s going to manifest in very subtle ways like fatigue, or maybe errors in documentation, putting the wrong date of birth on a script pad, or forgetting to lock the fridge or to put something in by the due date.”
But he warns GPs not to count on colleagues flagging any changes in behavior, since approaching someone to express their concern can be difficult and seen as intrusive.
“Most people retire when they just find the whole thing not enjoyable any more and they are financially equipped – that can tip the balance,” he says, adding that fatigue and a low mood are often the main triggers.
The RACGP, meanwhile, does not provide advice or guidance on the best age to retire, which it says is a personal decision – assuming there are no problems with competency. The college does, however, have a guide to closing a medical practice which is geared toward those planning to retire.
“I think there’s a real danger in trying to make rules around what’s a very personal decision for a doctor, but also a decision that can have implications for the people around them,” says RACGP rural chair, Dr Michael Clements.
“There’s certainly been attempts in other industries to try and come up with a magic number that’s going to give people safety, but the risk is that you either make it too early or too late. So rather than try to come up with a hard-and-fast rule, we think it really is up to the individual doctor, and their role in the community, as to when the appropriate time is.
“But we need to support doctors, both those who decide that it’s time to retire and those who think they can extend safely.
“And as GPs, we are so varied – we can go off into sub-specialty areas that are inherently low risk. So you couldn’t come up with a rule.”
Testing cognitive and other abilities has sometimes been suggested as an alternative to a mandatory age for retirement.
Queensland GP Dr David King, who has done assessments for AHPRA, says testing brings “problems with validity, accuracy and reliability”.
“But we do know from evidence that elder GPs, although they’re more experienced, can get a bit behind with new knowledge. I’m getting towards that stage where I’m struggling to keep up with new technology and change.”
The pace of change in general practice increased during the pandemic, with telehealth and e-prescribing two areas that challenged older GPs.
“A number of people are notified who are in their 70s, some even into their 80s. Some decide to retire before we can actually get to visit them because they realise they’re no longer up to it. There are many reasons: with many of them, their record-keeping is an issue, or they’re one-finger typists and they’ve tried to have dual systems with written notes and someone else transcribing.”
Dr Clements says the profession should be very cautious about introducing incentives, financial or otherwise, to stay in practice. So using older GPs to help slow the fall in workforce numbers may not be an option after all.
“You’d want to see some safeguards,” he says, “the reason being that if people start to recognise that their ageing is leading to any kind of impairment, their physical impairment or slowness, it’s really important that there’s no barriers towards them being able to retire gracefully.
“If we have financial incentives in place for them to continue working, that might, sadly, encourage people who should really step down to continue. Certainly, there have been case reports where AHPRA has seen some decisions made by some very senior GPs and that they felt may be age-related, but it’s very hard to prove that.
“And just because they occasionally get a report about incidents in older people doesn’t mean that all older people shouldn’t be working. You’ve got to be really careful about the unintended consequences,” Dr King says.
During the pandemic, several of Dr King’s recently retired colleagues contributed by working in respiratory clinics, on public health phone lines, supporting clinicians and helping write guidelines.
“I think it’s good to keep them as a potential surge workforce and to have mechanisms in place for them to be able to stay on, but it does really need to be a personal decision.”
And this potential surge workforce is large: Dr Clements warns that about one in five GPs is set to retire in the next five years.
“We’ve got a bit of a ‘workforce cliff’ coming up,” he says. “We’re already short, and in the next five years, we’re going to be a lot shorter.”