By Ben Reinking, M.D.
UI Carver College of Medicine
Iowa, like the rest of the country, faces a physician shortage. We rank 44 in the nation for physicians per capita, and fourteen of our 99 counties have two or fewer physicians serving the entire county. ¹
Efforts are underway to address this shortage. Most are aimed at the front end of the pipeline. These include increasing the percentage of Iowa students attending in-state medical schools, adding residency positions, and working to recruit and retain Iowa graduates and those with Iowa ties. That work matters. Those physicians will build careers and raise families here. In addition to providing medical care, retaining young professionals strengthens communities and supports the long-term vitality of our state.
It is equally important, however, to look at the rest of the workforce. Approximately 450 physicians stop practicing in Iowa each year, and in four of the last five years for which figures were available, departures exceeded arrivals. About one-third of that loss is due to retirement. ¹ There are also indications that physicians are leaving clinical practice at higher rates than in the past. ² Recruiting a physician out of training is one challenge. Retaining that physician throughout a long career is another.
A few questions naturally follow. What does an experienced physician contribute to practice? What are our attitudes toward mid- and late-career physicians, particularly as they relate to aging? And how do we ensure competence is maintained as physicians move further from training, without pushing capable physicians out of practice early?
The Pros and Cons of Experience
When discussing physician experience and aging, two stereotypes commonly emerge. The first is the wise practitioner who draws on experience to consistently make sound clinical decisions. The second is the weary physician who practices medicine exactly as they did during training, without adopting new evidence or guidelines, and who therefore poses a potential risk to patients. While there is a kernel of truth in each caricature, the reality is far more nuanced.
First, it is impossible to ignore the value of experience. We all learned about evidence-based medicine, but we often forget its full meaning. David Sackett defined evidence-based medicine as the integration of current best evidence with clinical expertise in making decisions about patient care. ³
When people talk about evidence-based medicine, they often focus on what the literature says while undervaluing lived experience. Experience is what we draw upon when the patient before us did not read the textbook or the latest study, when two conditions interact in a way no guideline anticipated, or when the technically correct intervention is not the best choice for the individual sitting in front of us. Experience provides a library of comparable patients against which the current case can be judged, and it enriches the pattern recognition that drives much of clinical diagnosis.
There is also institutional and community knowledge that is difficult to quantify. An experienced physician knows whom to call for a difficult referral, understands the resources available in the community, and has a relationship with the referring physician two towns over. Those assets benefit patients and colleagues alike, and they are often acquired only through years of practice.
At the same time, physicians do not escape the effects of time. Aging and increasing time out of training both influence our ability to practice. Given that we are entrusted with the health and lives of others, it is important to examine these factors honestly. Aging is associated with slower processing speed, reduced ability to inhibit irrelevant information, and changes in hearing, vision, manual dexterity, and visuospatial ability. ⁴
The impact of aging on clinical practice has been studied extensively, although the findings are nuanced. Recent systematic reviews suggest that increasing age and years from training are associated with less current medical knowledge and lower adherence to guidelines, but that those differences do not consistently translate into worse patient outcomes. ⁵ Other studies have found that the relationship between physician age and outcomes varies by specialty and practice setting, ⁶ and that procedural volume may matter more than age. In one recent analysis, high-volume surgeons maintained consistent outcomes into their late sixties, while lower-volume surgeons showed age-related differences considerably earlier. ⁷
My interpretation of this literature is that age and time from training primarily create a knowledge-currency challenge. Ongoing clinical engagement, patient volume, and deliberate professional development appear to be more important determinants of performance than age alone.
Cognitive testing studies involving more than 1,000 physicians have demonstrated that cognitive scores decline with age on average, but that variability among individuals widens considerably. ⁸ Some physicians remain cognitively intact well into later life, while others experience more rapid decline. That variability suggests that chronological age alone is a poor marker of clinical ability.
Maintaining and Assessing Competence
Based on the information discussed above, it is impossible to ignore that age, experience, competence, and knowledge currency are related. The relationship, however, is far from straightforward. Age is not the only driver of the differences observed across physicians. In fact, patient volume, complexity of practice, and continued professional engagement may be even more important.
Studies examining aging physicians are also vulnerable to selection bias. Physicians whose performance declines may narrow their scope of practice or retire altogether. As a result, many of the older physicians included in these studies may represent a select group whose abilities have been preserved despite advancing age.
It is the responsibility of every physician to remain current and provide safe, competent care. Likewise, it is the responsibility of our governing bodies to develop policies and procedures that assess competence in an evidence-based manner while protecting both physician and patient interests. The question is not whether competence should be assessed, but how best to accomplish it.
The literature offers several approaches, each with advantages and drawbacks.
Age-triggered late-career assessment applies a uniform screening process at a predetermined age, most commonly around age 70. Its appeal is straightforward: a uniform trigger removes much of the discretion through which bias, personality conflicts, and inconsistent standards can operate. However, a study examining 29 U.S. organizations with such policies found that many leaders reported preemptive retirements as physicians approached the screening age. Physicians were leaving practice before anyone reviewed a chart, observed their care, or identified a concern. Many of those policies also lacked clearly defined appeals processes. ⁹ In a state that loses approximately 450 physicians annually, that is a consequence worth considering. ¹
Self-report and peer reporting are the mechanisms on which we often rely by default, but both have limitations. A systematic review of physician self-assessment found that among 20 comparisons between self-rated performance and external measures, 13 demonstrated little, no, or even inverse correlation. Accuracy was particularly poor among physicians who were least skilled and among those who were most confident. ¹⁰ Physicians are also often reluctant to report concerns about colleagues. ⁸
Importantly, self-assessment may fail in both directions. Perceived cognitive decline is frequently an unreliable indicator of actual ability, yet those perceptions may still influence a physician's decision to leave practice. ⁸
The approach that appears most meaningful, though also the most resource-intensive, is continuous performance assessment across an entire career. Such a model would include routine outcome review, structured chart audits, peer review, and multisource feedback for physicians at every stage of practice. Ideally, these assessments would serve not only as safeguards but also as opportunities for professional development and career evolution.
Within such a framework, targeted cognitive evaluation could be triggered when performance metrics raise concern rather than when a physician reaches a specific birthday. This approach would identify age-related or health-related changes without using age itself as the screening criterion.
The challenges are significant. Continuous assessment requires substantial institutional investment, physician buy-in, specialty-specific standards, and better normative data regarding cognitive testing in physicians. Furthermore, evidence linking cognitive test performance directly to clinical outcomes remains limited, and there is no clearly established threshold at which cognitive decline renders a physician unfit to practice. ⁸ A low score should be viewed as a reason for further evaluation, not as a diagnosis or a verdict.
Conclusion
The conversation about aging physicians is often framed as a choice between unrestricted practice and retirement. In reality, the path forward is considerably more nuanced.
Experience remains one of medicine's most valuable assets. The judgment acquired through decades of patient care cannot be replaced by guidelines, algorithms, or technology. At the same time, the profession must acknowledge that aging, like every other aspect of human biology, can affect performance. Our responsibility is to recognize those changes honestly and respond to them fairly.
An effective system should seek neither to shield physicians from scrutiny nor to remove them from practice based solely on age. Instead, it should create a culture of continuous assessment, lifelong learning, and professional development that extends across an entire career. Such a system serves the profession better than either caricature we began with.
Perhaps just as importantly, we should broaden our definition of what it means to remain in medicine. As physicians age, many may choose to pivot rather than retire completely. Teaching, mentoring, administration, quality improvement, clinical supervision, advocacy, and more focused clinical roles all provide opportunities to continue contributing while drawing on a lifetime of accumulated knowledge. These transitions honor experience while accommodating changes in health, stamina, and professional goals.
The challenge facing Iowa is not simply how to recruit more physicians. It is also how to help physicians build careers that are sustainable, adaptable, and fulfilling over decades. If we can create pathways that support both competence and flexibility, we may find that some of our most experienced physicians still have a great deal to contribute, even when their careers no longer look exactly as they once did.
References
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- Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn't. BMJ. 1996;312(7023):71-72. doi:10.1136/bmj.312.7023.71
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- White AA, Gallagher TH, Osinska PH, Kramer DB, Garrett KD, Mello MM. Ensuring safe practice by late career physicians: institutional policies and implementation experiences. Ann Intern Med. 2024;177(12):1702-1710. doi:10.7326/ANNALS-24-00829
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