Annotated Bibliography for Physicians in Pre-retirement Years

(Revised 10/08)

Anast GT. Editorial: Managing a successful retirement. Surgery 1997;121:474-476.

The most important factor is psychological preparation. The tendency is to identify totally with the profession from a personal standpoint. There is a loss of identity in exchange for a freedom that is unfamiliar, and can seem meaningless in the absence of useful work. This affect can be devastating. The secret to success and happiness in retirement is to see it as a new career and prepare just as assiduously as you did for your career in medicine. process. People often make the incorrect assumption that if there is enough money, the rest will follow. The psychological adaptations to retirement are the most important. The major problems are emotional and mental and require a real period of adjustment.

Among the adjustments: 1) change in self-identity, 2) separation from colleagues, 3) need to develop new social contacts, 4) need to develop meaningful pursuits,5) need to develop routine, and 6)need to adjust to new spousal relationship. Retirement is rarely, if ever seamless. It can be traumatic and certainly will be in the absence of a rational plan. Maintaining self-esteem and achieving a new identity are important tasks. Ed. Note: Contains good summary of the issues.

Katz JD. Issues of concern for the aging anesthesiologist. Anesthe Analg 2001;92:1487-92.

The practice of medicine requires a high degree of knowledge and skill as well as mental and physical stamina. Those failing to maintain these standards are at risk of causing serious injury to their patients. Other professions with similar demands are more aggressive about monitoring their practitioners, the airline industry being a good example. This article summarizes what is currently understood about the physiology of aging and the implications for the practice of medicine. Concomitants of aging include diminished ability to perform complex cognitive activities, disturbances of vision and hearing, decreased ability to process new information, increased susceptibility to adverse effects of stress, and decreased ability to withstand disturbances of the sleep/activity cycle.

Katz found that among retired anesthesiologists, demands of night call, demands of work load, burnout and economic factors were the most frequently cited reasons for retirement. Ed. Note: Good introduction to the subject.

Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: The relationship between clinical experience and quality of healthcare. Ann Int Med 2005;142:260-273.

Evidence suggests that there is an inverse relationship between the number of years a physician has practiced and the quality of care provided. The authors conducted a systematic review of studies relating medical knowledge and quality of care to years in practice and physician age. 32 of 62 (52%) evaluations reported decreased performance with increasing years in practice for all outcomes assessed. 13 evaluations (21%) reported decreased performance for some outcomes but no association for others. Two studies (4%) reported increasing performance for some or all outcomes.

Conclusions: Physicians who have been in practice longer may be at risk for providing lower quality care. This relationship held for medical knowledge, adherence to nationally accepted guidelines and standards, and patient outcomes. This was consistent across medical specialties. Ed. Note: A frequently cited article with important implications for emergency physicians.

Weinberger SE, Duffy FD. Editorial. "Practice Makes Perfect . . . or Does It?" Annals of Internal Medicine 2005;143:302-303.

Based on the article by Choudhry et al, this editorial argues that practice does not make perfect but must be accompanied by ongoing active effort to maintain competence in quality of care. The physician's commitment to strive for excellence is a critical responsibility. New educational programs for physicians must incorporate principles of adult learning and link education and clinical care. Physicians must know the current evidence-based standards of care. Certifying organizations and specialty societies are challenged to revise their education and certification standards. There should be a linkage between quality of care, evaluation of performance, and lifelong education and clinical practice. The goal is continuous professional development and public accountability for the highest-quality patient care.

Lees E et al. Emotional impact of retirement on physicians. Harris County Medical Society Study. Texas Medicine 97;2001: 72-74

Questionnaires mailed to 689 retired members of Harris County Medical Society. Response rate was 47%. Participants had been retired a mean of 6.6 years at time of study. Most respondents were content in their retirement years. The first year appeared to be the most stressful. Retirement had a predominantly positive impact on the emotional state. However, a substantial minority did experience depression. Factors correlated with depression: Poor health, diminishing cognitive skills, poor health of spouse, unhappy marital relationship. Activities during retirement - most engaged in a broad range of satisfying activities, including physical exercise. Most were financially comfortable. More spousal relationships improved than deteriorated. One-third of physicians agreed that retirement years were the best years of their lives

Hultman JA. The aging physician: Use it or lose it; the importance of staying in shape - your lifestyle. Podiatry Management 2002; June-July

Average life expectancy continues to increase. Instead of expecting 25 year careers, it may be possible to practice for 50 or 60 years. The practice of medicine requires continuous learning, a high level of energy and endurance, as well as the ability to handle stress. At steady loss of bone density, decline of muscle mass, flexibility, reflexes, balance, joint motion and circulation have been accepted as normal aging. Recent study suggests that simple exercise programs may prevent, lessen, or in some cases reverse these declines. Those who stay actively involved in life are less likely to suffer memory loss and depression. "The simplest way to become proactive is to shift the paradigm from 'as we get older we decay' to 'as we get older we continue to develop' " . There is evidence to suggest that exercise and intellectual stimulation may stave off loss of intellectual function.

Knoops KTB, deGroot LCPGM, Kromhout D, et al. Mediterranean diet, lifestyle factors and ten-year mortality in elderly European men and women: The Hale project. JAMA 2004;292:1433-1439.

There is evidence that the incidence of many diseases cannot be solely attributed to genetic differences between populations but are likely due to differences in lifestyle, with dietary factors and physical activity as leading candidates). In European men and woman aged 70 through 90, adherence to a Mediterranean diet pattern, moderate alcohol consumption, non-smoking status, and physical activity each was associated with a mortality rate of about 1/3 that of those with none or only one of these protective factors. This included an 83%reduction in coronary disease, 91% reduction in diabetes in women, and 71% reduction in colon cancer in men.

A simple set of lifestyle practices that appears to have a significant impact on all-cause mortality rates.

Dietary Guidelines for Americans 2015-2020. Dept Health and Human Services, Dept Agriculture.
A publication of the U.S. Department of Agriculture, this is a comprehensive guide to the latest nutritional recommendations.

Exercise: A guide from the National Institute on Aging.
A comprehensive, easy to read publication on all aspects of exercise including safety, sample exercises, activity and progress charts, exercise plans, and information on nutrition.

Surgeon General's Report Fact Sheet: Older Adults.
Discusses the benefit of regular physical activity and fitness. Ed. Note: Good summary.

National Institute on Aging, Building 31, Room 5C27; 31 Center Drive, MSC2292, Bethesda, MD 20892.
A branch of the National Institutes of Health with an extensive library of publications on topics related to aging. Besides sections on men's and women's health, safety, care giving, life extension, exercise and nutrition, there are extensive links to information on research related to aging.

Eva KW. The aging physician: Changes in cognitive processing and their impact on medical practice. Academic Medicine, 77:2002:S1-S6.

There is literature to suggest that aging induces cognitive changes in the way that diagnosticians approach clinical cases. There are discrepant findings, however, in terms of whether performance improves or declines with aging. This was a comprehensive literature search for articles focused on physician competence, physician assessment and continuing competence. It was found that age as well as foreign education and certification status predicted performance, older physicians performing less well than younger physicians. There is evidence that older practicing physicians are less likely to have up-to-date knowledge bases. Additionally, they seem prone to premature closure with regard to history taking, problem solving, physical examination, communication and record keeping. However, older physicians performed just as well as younger on exams as long as the questions are directed at knowledge that had not changed since they were trained.

Strategies are proposed to assist the older clinician in light of these findings. Ed. Note: Comprehensive discussion of cognitive changes with aging.

Waeckerle JS. Circadian rhythm, shiftwork and emergency physicians. Ann Emerg Med 1994;24:959-961.

Erratic shift scheduling is a major source of stress for emergency physicians and may be the single most important factor in attrition. There are detrimental effects on sleep patterns, performance tasks and mood on night shifts. There are associated disturbances of sleep, feelings of malaise, GI complaints, mood swings, and reduced performance capabilities. Approximately 1/3 of individuals suffer significantly and another 1/3 experience minimal if any effects.

Smith-Coggins R, Rosekind MR, Hurd S, Buccino KR. Relationship of day versus night sleep to physician performance and mood. Ann Emerg Med 1994;24:928-934.

This study of six emergency physicians monitored during day-time work and night-time work, tested with mood ratings and performance tests, DEGs and DMGs. They found that physicians had significantly less sleep when sleeping during the day, there were significant performance decrements, greater likelihood to make errors, and reported feelings of being less happy.

Adams SL, Roxe DM, Weiss J, et al. Ambulatory blood pressure and Holter monitoring of emergency physicians before, during, and after a night shift. Acad Emerg Med 1998;5:871-877.

12 emergency physicians were monitored before, during and after an eight-hour night shift with regard to ambulatory blood pressure, heart rate, cardiac rhythm and heart rate variability. They found an elevation of diastolic blood pressure during a night shift appeared to be activity or stress-related, rather than a result of a true diurnal variation. HRV analysis suggests that sympathetic tone is heightened both before and during work.

Keefover RW. Aging and cognition. Neurologic Clinics of North America 1998;16:635-643.

Approximately 5% of persons over the age of 65 suffer from dementia (76). (If there are 6,000 emergency physicians over the age of 65, approximately 300 would be expected to have some degree of impairment ). More subtle cognitive decline is discernable in 2/3 of all "normal older people." Causes of cognitive decline include systemic disease, alcoholism, cardiovascular disease, COPD, hospitalization, infectious disease. Prevalence of Alzheimer's Disease (AD) doubles with every five years of advancing age. Almost one-half of all individuals age 85 or older may be affected. Mentation in older people is extraordinarily sensitive to the effects of systemic illness. Crystallized versus fluid intelligence - The former is an individuals accumulated knowledge base, repeatedly accessed and expanded throughout life. The latter is the ability to evaluate and respond to novel events arising in the environment. There is considerably greater deterioration in fluid than crystallized intelligence with aging.

Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: The relationship between clinical experience and quality of healthcare. Ann Int Med 2005;142:260-273.

Evidence suggests that there is an inverse relationship between the number of years a physician has practiced and the quality of care provided. The authors conducted a systematic review of studies relating medical knowledge and quality of care to years in practice and physician age.

Results: 32 of 62 (52%) evaluations reported decreased performance with increasing years in practice for all outcomes assessed. 13 evaluations (21%) reported decreased performance for some outcomes but no association for others. Two studies (4%) reported increasing performance for some or all outcomes.

Conclusions: Physicians who have been in practice longer may be at risk for providing lower quality care. This relationship held for medical knowledge, adherence to nationally accepted guidelines and standards, and patient outcomes. This was consistent across medical specialties. Ed. Note: Frequently cited article with important implications for emergency physicians. Almost one-third of the membership of the american college of emergency physicians are over the age of 50.

Weinberger SE, Duffy FD. Editorial. "Practice Makes Perfect . . . or Does It?" Annals of Internal Medicine 2005;143:302-303.

Based on the article by Choudhry et al, this editorial argues that practice does not make perfect but must be accompanied by ongoing active effort to maintain competence in quality of care. The physician's commitment to strive for excellence is a critical responsibility. New educational programs for physicians must incorporate principles of adult learning and link education and clinical care. Physicians must know the current evidence-based standards of care. Certifying organizations and specialty societies are challenged to revise their education and certification standards. There should be a linkage between quality of care, evaluation of performance, and lifelong education and clinical practice. The goal is continuous professional development and public accountability for the highest-quality patient care.