WORKFORCE CSIRO PUBLISHING
Australian Health Review, 2015, 39, 582–587 http://dx.doi.org/10.1071/AH14176
Retirement patterns of Australian doctors aged 65 years and older Catherine M. Joyce1,2 BA(Hons), MPysch, GCHE, PhD, Adjunct Associate Professor Wei C. Wang1 PhD, Research Fellow Hayley M. McDonald1 BA(Hons), Research Assistant 1
School of Public Health and Preventive Medicine, Monash University, 6th Floor, The Alfred Centre, 99 Commercial Road, Melbourne, Vic. 3004, Australia. Email: [email protected]; [email protected] 2 Corresponding author. Email: [email protected]
Abstract Objective. To investigate retirements over a 4-year period among Australian general practitioners (GPs) and specialists aged 65 years and over, and factors influencing retirement. Methods. Data from Medicine in Australia: Balancing Employment and Life (MABEL) for the years 2009–12 were analysed for 435 GPs and 643 specialists aged 65 years and over at the time of entry to the MABEL survey. Discrete time survival analysis was used. Results. The retirement rates were 4.1% (2009), 5.1% (2010), 4.2% (2011) and 10.4% (2012). Retirement was associated with: (1) the intention to leave medical work in 2009 and 2010; (2) working fewer hours in private consulting rooms in 2010 and 2012; (3) having lower job satisfaction in 2009 and 2011; (4) being older in 2009; (5) working fewer hours in a public hospital in 2012; and (6) working fewer hours in a private hospital in 2010. Doctors who intended to reduce their working hours were less likely to retire in 2009. Conclusions. Strategies to support doctors at the late career stage to provide their valued contributions to the medical workforce for as long as possible may include increasing job satisfaction and addressing barriers to reducing work hours. What is known about the topic? Much of the available literature provides measures of retirement intentions. What does this paper add? The present study examined actual retirements and the factors associated with them. What are the implications for practitioners? Consideration should be given by policy makers to ensure that doctors are retained for as long as possible as active contributors to the medical workforce in a safe, appropriate manner. Additional keywords: discrete time survival analysis, longitudinal survey. Received 9 October 2014, accepted 19 March 2015, published online 22 June 2015
Introduction The retention of medical practitioners in the workforce is essential to meeting the healthcare needs of the community. Retirement rates have a major impact on workforce supply.1 Given that 25.5% of Australia’s doctors are aged over 55 years and 8.9% are aged over 65 years,2 there is likely to be a considerable number of doctors retiring in the coming decade. However, it is not uncommon for medical practitioners to continue working beyond traditional retirement age.3,4 The proportion of older doctors remaining in the workforce is not known, but approximately 15% of people aged 65 years and over in the general Australian population are active in the workforce, and this is higher among those who are university educated.5 Doctors who are transitioning from working life to retirement often gradually reduce their working hours,3 allowing them to enjoy a less-intense working life towards the end of their careers.6 Doctors’ retirements raise several challenges for the healthcare system, including loss of experience and knowledge,7 Journal compilation AHHA 2015
reduced support for junior doctors and potential exacerbation of projected future workforce shortages.8–10 Individual doctors themselves also face personal challenges when they leave the medical workforce. Navigating life away from a profession that has likely been a significant, often defining, part of their life for many years can lead to difficulties moving into this new stage.11–17 Therefore, their continued involvement for as long as possible in the workforce is likely to have benefits for both the provision of health care and for them as individuals. Although continued procedural work may not be appropriate for all doctors of advanced age, there are many clinical and nonclinical roles (e.g. in medical education and research)18 where senior doctors can make a valued contribution. There are several factors, other than age, that influence medical practitioners to make a decision or plan to exit the medical workforce. These include poor job satisfaction, feeling burnt out, high workloads, changes within the workplace, a feeling of limited support from a supervisor, limited control in their job, www.publish.csiro.au/journals/ahr
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poor team relationships and a desire for more free time.19–23 One study of general practitioners (GPs) aged 45–65 years found that one-third were planning to retire early.19 Comparatively, factors that can act as incentives to stay in the workforce include improved remuneration, adequate staffing levels, greater levels of support, flexible working hours, reduced bureaucracy and reduced workloads.19,21,22 Much of the available literature provides measures of retirement intentions rather than actual retirements, and thus the factors that are associated with actual retirements remain poorly understood. The aim of the present study was to investigate the rate of retirement from the Australian medical workforce among practitioners aged 65 years and over, as well as the factors that predict retirement over a 4-year period. Methods The study used data from the Medicine in Australia: Balancing Employment and Life (MABEL) longitudinal survey of doctors. The study methods have been published previously.24,25 Briefly, in 2008 all 54 750 doctors undertaking clinical work listed in the Medical Directory of Australia (http://ampcodirect.com.au) were invited by mail to participate in the survey. In subsequent years of the survey, previous respondents (continuing) as well as a ‘top-up’ sample (new) of doctors were surveyed.25 The sample for the present study was GPs and specialists aged 65 years and over and in clinical practice in 2008, or in their first year of the survey for those in top-up samples in 2009, 2010 or 2011. The study was approved by the Faculty of Economics and Commerce Human Ethics Advisory Group, University of Melbourne, and the Monash University Standing Committee on Ethics in Research Involving Humans. Variables used The outcome variable of retirement was measured with the question ‘Are you permanently retired from all types of paid work?’, with response options no (0) and yes (1). MABEL surveys collect information on a wide range of personal and professional characteristics and attitudes. Variables included in the present study were: age (65–69 = 0, 70 = 1), gender (male = 0, female = 1), cohabitation status (‘Are you currently living with a partner or spouse?’; no = 0, yes = 1), financial circumstances (‘Given my current financial situation and prospects, I believe I will have enough to live on when I retire’; strongly disagree = 0, disagree = 1, neutral = 2, agree = 3, strongly agree = 4), general health status (‘In general, would you say your health is. . .’; excellent = 0, very good = 1, good = 2, fair = 3, poor = 4), and doctor type (GP = 1, specialist = 2). Job satisfaction is measured in MABEL with a 10-item version of a Job Satisfaction Scale developed by Warr et al.,26 with responses on a five-point scale (very dissatisfied = 0, moderately dissatisfied = 1, not sure = 2, moderately satisfied = 3, very satisfied = 4). In the present study, only the overall job satisfaction item was used. Doctors’ employment arrangements were measured by number of hours per week (continuous) in: (1) a public hospital (including psychiatric hospital); (2) a private hospital; and (3) private medical practitioner’s rooms or surgery. Working in private practice (no = 0, yes = 1) and regularly contributing to a
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superannuation scheme (no = 0, yes = 1) were included as categorical variables. Four measures of future workforce participation intentions were included. The first of these related to preferences regarding working hours, ‘Would you like to change your hours of work (including day time and after hours)?’, with three response options: increase = 0; no change = 1; and decrease = 2. Respondents were also asked, ‘What is the likelihood that you will: (1) leave patient care within 5 years; (2) leave medical work entirely within 5 years; (3) reduce your clinical workload in next 5 years?’, all of which had a five-point response scale: very unlikely = 0, unlikely = 1, neutral = 2, likely = 3, and very likely = 4. Analysis Doctors responding ‘yes’ to the retirement question in MABEL are directed not to complete most sections of the questionnaire in that year. Therefore, data on doctors’ characteristics and intentions collected in previous years were used in analyses. The potential sample for the present study was a total of 1545 doctors, comprising 787 doctors aged 65 years in 2008 and 758 doctors aged 65 years who entered the study at a later year as part of a top-up sample. The final sample for analysis in the present study was 1078 doctors, after excluding cases due to loss to follow up or lack of available information on predictor variables in previous years as required for analysis. The numbers excluded per year were as follows: 2008, n = 84; 2009, n = 13; 2010, n = 27; 2011, n = 31; and 2012, n = 312 (all newly recruited doctors aged 65 years and over in 2012). In order to investigate whether retirement occurs, when it is most likely to occur and how retirement occurrences vary over time, discrete time survival analysis was used. The data were prepared as outlined by Muthén and Masyn.27 A score of 0 reflected no retirement event occurred and a score of 1 was designated to doctor who reported retirement occurrence with the subsequent years being treated as missing due to having experienced the event. In the discrete time survival analysis model, the four binary time-specific event indicators were regressed on the set of time-invariant covariates. Discrete time survival analysis was performed using Mplus version 7.1,28 using Maximum Likelihood estimation with Robust standard errors (MLR), with results reported as odds ratios (OR). A two-stage approach was used, in which personal and professional variables, employment and working settings only were entered in the first stage, and the intentions variables added at the second stage. Results The overall response rate for MABEL in 2008 was 19.36% (representing almost one in five Australian doctors), and 15.19% for those aged 65 years. Response rates for doctors aged 65 years and over in MABEL 2009, 2010, 2011 and 2012 were 82.64%, 82.24%, 75.51% and 75.32%, respectively. For continuing doctors only (excluding the top-up samples) aged 65 years, the response rates in 2009, 2010, 2011 and 2012 were 84.02%, 82.53%, 77.06% and 76.10%, respectively. Respondent characteristics are summarised in Table 1. The study sample included a similar proportion of females to the medical labour force population aged 65 years for the same
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Table 1. Respondent profile by gender Data are presented as the number of respondents in each group, with percentages in parentheses or as the mean s.d. GP, general practitioner Variable No. respondents Doctor type GP Specialist Age (years) 65–69 70 Living with a partner Yes Overall job satisfaction Moderately or very satisfied Believe I will have enough to live on when I retire Agree or strongly agree Health status Excellent Very good Good Fair Poor Working in a private practice Yes Regularly contributing to a superannuation scheme Yes Like to change working hours Increase No change Decrease Likely or very likely within 5 years to: Leave direct patient care Leave medical work entirely Reduce clinical workload Working hours by settings Public hospital (including psychiatric hospital) Private hospital Private medical practitioner’s rooms or surgery
period (12.2% in 2008, rising to 13.7% by 2012).2,29 In 2008, 44% of doctors aged 65 years and over were GPs, 40% were specialists and the remaining 16% had other or unreported roles.29 In 2008, 24% of doctors aged 65 years and over were in the 75 years age category (including 25% of males and 17% of females),29 which is broadly consistent with our figures for those aged 70 years. Finally, the total average working hours for our sample were 29.7 h per week, compared with approximately 31 h per week for the medical labour force population aged 65 years in 2008.29 Over one-third (33.8%) of doctors (34.3% males and 30.1% females) indicated that they would like to decrease their working hours. Most doctors expressed being likely or very likely to leave direct patient care (82.4%), to leave medical work entirely (74.2%) and to reduce clinical workload (86.5%) within the next 5 years. The retirement rate for each year was 4.1% (2009), 5.1% (2010), 4.2% (2011) and 10.4% (2012). The association of background characteristics and other variables to retirement in each year is indicated in Table 2. Inclusion of the intentions variables resulted in only minor changes to the significant
Male
Female
Total
932 (86.5%)
146 (13.5%)
1078
357 (38.3%) 575 (61.7%)
78 (53.4%) 68 (46.6%)
435 (40.4%) 643 (59.6%)
600 (64.4%) 332 (35.6%)
114 (78.1%) 32 (21.9%)
714 (66.2%) 364 (33.8%)
865 (92.8%)
94 (64.4%)
959 (89%)
870 (93.4%)
137 (93.8%)
1007 (93.4%)
635 (68.2%)
98 (67.1%)
733 (68%)
221 (23.7%) 368 (39.5%) 246 (26.4%) 85 (9.1%) 12 (1.3%)
41 (28.1%) 58 (39.7%) 34 (23.3%) 11 (7.5%) 2 (1.4%)
262 (24.3%) 426 (39.5%) 280 (26.0%) 96 (8.9%) 14 (1.3%)
797 (85.5%)
126 (86.3%)
923 (85.6%)
753 (80.8%)
124 (84.9%)
877 (81.4%)
22 (2.4%) 590 (63.3%) 320 (34.3%)
4 (2.7%) 98 (67.1%) 44 (30.1%)
26 (2.4%) 688 (63.8%) 364 (33.8%)
771 (82.7%) 694 (74.4%) 810 (87%)
117 (80.1%) 106 (72.6%) 123 (84.3%)
888 (82.4%) 800 (74.2%) 933 (86.5%)
8.65 ± 15.05 2.61 ± 6.75 19.12 ± 17.02
5.66 ± 11.47 2.11 ± 6.33 17.25 ± 14.43
8.25 ± 14.65 2.54 ± 6.69 18.87 ± 16.70
associations, so results reported are for the second-stage model with all variables. The only differences are that age was significantly related to retirement in 2010 and 2012, as well as 2009, in Stage 1, but these became non-significant in Stage 2 when the intentions variables were included. Job satisfaction was negatively associated with retirement in two of the four years. Doctors who reported higher job satisfaction were 30% (OR = 0.70) and 44% (OR = 0.56) less likely to retire in 2009 and 2011, respectively, compared with doctors who reported lower job satisfaction. Doctors who worked longer hours were less likely to retire. For every additional hour working in consulting rooms, doctors were 3% (OR = 0.97) and 2% (OR = 0.98) less likely to retire in 2010 and 2012, respectively. Similarly, for every additional hour worked in the public hospital setting, doctors were 3% (OR = 0.97) less likely to retire in 2012, whereas in 2010 doctors were 8% (OR = 0.92) less likely to retire for every hour worked in a private hospital setting. Doctors who were aged 70 years and over were approximately threefold (OR = 3.04) more likely to retire in 2009 compared with doctors who were aged between 65 and 69 years.
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Table 2. Associations of retirement with personal, professional, employment and intentions measures *P < 0.05, **P < 0.01 2009 Age Gender Currently living with a partner Enough financial support when retire General health status Doctor type Overall job satisfaction Hours worked per week in: Public hospital setting Private hospital setting Private medical practitioner’s rooms or surgery Working in a private practice Regularly contributing to a superannuation scheme Intention to change working hours Intention to leave direct patient care in 5 years Intention to leave medical work entirely in 5 years Intention to reduce clinical workload in 5 years
Odds ratio (95% confidence interval) 2010 2011
2012
3.04** (1.46, 6.34) 0.60 (0.17, 2.13) 1.31 (0.43, 4.01) 1.09 (0.86, 1.37) 1.09 (0.82, 1.45) 1.17 (0.46, 3.02) 0.70* (0.52, 0.94)
1.93 (0.95, 3.95) 0.76 (0.22, 2.64) 1.84 (0.43, 7.79) 1.05 (0.76, 1.45) 0.92 (0.65, 1.31) 1.58 (0.72, 3.48) 0.72 (0.51, 1.02)
1.36 (0.62, 2.97) 0.89 (0.27, 2.89) 0.87 (0.25, 3.02) 1.01 (0.76, 1.36) 1.07 (0.75, 1.51) 1.10 (0.45, 2.69) 0.56** (0.42, 0.75)
1.57 (0.88, 2.79) 0.82 (0.37, 1.82) 1.28 (0.52, 3.13) 0.94 (0.72, 1.23) 0.91 (0.69, 1.20) 0.98 (0.51, 1.88) 1.01 (0.68, 1.49)
1.01 (0.98, 1.03) 1.02 (0.98, 1.06) 1.00 (0.97, 1.04) 0.60 (0.26, 1.38) 1.61 (0.66, 3.94) 0.45* (0.23, 0.89) 0.87 (0.55, 1.39) 1.85** (1.18, 2.92) 1.05 (0.87, 1.26)
0.99 (0.97, 1.02) 0.92* (0.85, 0.99) 0.97* (0.95, 1.00) 1.70 (0.66, 4.36) 1.19 (0.58, 2.45) 0.56 (0.26, 1.23) 0.79 (0.53, 1.20) 2.34** (1.48, 3.69) 1.01 (0.78, 1.33)
1.00 (0.97, 1.03) 1.01 (0.97, 1.05) 0.97 (0.96, 1.01) 0.88 (0.31, 2.46) 1.20 (0.47, 3.05) 0.74 (0.37, 1.50) 0.81 (0.50, 1.31) 1.63 (0.97, 2.73) 1.12 (0.79, 1.57)
0.97* (0.95, 1.00) 1.00 (0.96, 1.04) 0.98* (0.95, 1.00) 1.04 (0.41, 2.64) 0.82 (0.44, 1.52) 0.78 (0.44, 1.37) 1.38 (0.62, 3.09) 1.72 (0.93, 3.19) 0.92 (0.71, 1.20)
Intention to leave medical work was a predictor of retirement in 2009 and 2010. Doctors who intended to leave medical work entirely in the next 5 years were nearly twofold (OR = 1.85) and almost 2.5-fold (OR = 2.34) more likely to retire in these two time periods. Doctors with an expressed preference to reduce their working hours were 55% (OR = 0.45) less likely to retire in 2009. We found no differences between male and female doctors, or between GPs and specialists, in likelihood of retirement. We also found that retirement was not associated with cohabitation, perceived adequacy of financial support, general health status, being in private practice or contributing regularly to a superannuation scheme. Discussion The present study provides one of the first rigorous analyses of Australian doctors’ retirement patterns and the factors influencing them. The findings indicate that intention to retire does predict actual retirement within a 4-year period. However, at the same time it is of note that nearly three-quarters of doctors (70.2%) reported intending to leave medical work entirely within 5 years, whereas only approximately one in five (18.7%) actually retired within the time frame of our study. This indicates that although intention to retire is important, other factors are also influential. In particular, job satisfaction remains important for late career doctors. This is consistent with the literature linking doctors’ job satisfaction with decisions to leave the workforce30,31 and highlights the importance of this factor in workforce retention right across the career span. Hays et al. developed a model of retention in rural practice that identified pressures to stay as well as pressures to leave, and triggers that could alter the balance between these to result in actually leaving rural practice.32 Retirement decisions can be understood in a similar way. Factors such as high workload and feeling unsupported are likely to favour retirement,19,23 whereas loss of status and income will favour staying in the workforce.12,14 The present study did not
find any association between anticipated level of financial support during retirement and actual retirements, which may be due to the ability of the measure used to capture this with precision and in a way that discriminates effectively. Job satisfaction can be thought of as one of the trigger factors that could tip the balance. Therefore, interventions to increase doctors’ job satisfaction are likely to have positive effects for retention of late career doctors as well as those at earlier stages. Doctors who expressed a desire to reduce their working hours were less likely to retire, as were doctors working longer hours. This is consistent with the available literature regarding doctors’ retirement, where the common pattern is reduction of hours before withdrawal from the workforce.3 Therefore, the opportunity to reduce hours may delay full retirement. Future research could provide empirical confirmation of this proposition. We found that intentions associated with clinical work specifically were not associated with retirement. Neither the intention to leave direct patient care nor the intention to reduce clinical workload was associated with retirement. This suggests that decisions about the amount of clinical work, and the balance between clinical and non-clinical work, are separate to retirement decisions. The present study has some limitations. Doctors who had retired may have been less likely to respond to the survey, meaning that the retirement rates we have modelled are underestimates of the true rate. It is difficult to assess the representativeness of the study sample, because population data are also likely to be affected by non-response from retiring doctors. Comparisons between MABEL and national medical labour force data show reasonably good agreement in the proportion of doctors aged 65 years and over in 2009: 8% vs 8.49%;33 2010: 9.10% vs 11.46%;34 2011: 9.20% vs 10.79%;35 and 2012: 10.60% vs 11.90%.2 In each year, older doctors are slightly under-represented in MABEL. National medical labour force data presented in the Results section also indicates a reasonable congruence with our sample with regard to age, gender and hours worked, with some suggestion of an over-representation
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Competing interests
of specialists in our sample. A strength of the study is that the MABEL cohort has been shown to be broadly representative of the national population.24 Further research could explore aspects that we have not investigated in detail, including patterns and determinants of reductions in hours of work and changes in clinical–non-clinical work balance. Because we focused on those aged 65 years and over, our study does not provide information about early retirements, which may have different determinants. For example, general health status was not associated with retirement in the present study but may be an important factor in early retirements. The findings suggest that it is desirable to support doctors winding down as a means of retaining them in the workforce for longer. There are several potential barriers to a gradual decrease in professional work that may be useful to address in this regard. First, for doctors who have been employed and are entitled to superannuation, reducing work hours before retirement may affect superannuation payout levels. Second, compliance measures, such as registration, continuing professional development (CPD) and professional indemnity insurance, can be prohibitive for doctors who are undertaking relatively small amounts of clinical work and generating relatively small revenue from this. Prior to the establishment of a national registration scheme in 2010, registration was managed by boards in each state and territory, some of which had an ‘occasional practice’ registration category. This provided for doctors who had retired from their full-time clinical role but continued to undertake limited clinical work. Doctors holding this category of registration when the new scheme came into effect were permitted to retain it and, as of April 2013, there were approximately 1000 such doctors.36 However, this can only be renewed a maximum of three times and no new registrants are admitted to this category.36 The choice now is ‘general registration’, which requires professional indemnity insurance and 50 h of CPD per year, or ‘non-practising registration’, under which clinical activity is not authorised. These changes to registration arrangements may have influenced the higher rate of retirement observed in 2012 compared with 2009–11. This higher rate may also simply be due the increased age of the sample. Retention of doctors of advanced age in the medical workforce raises potential concerns about quality and safety standards, but it is to the loss of the profession, and the health system, if some innovative thinking cannot be brought to bear to try to support doctors in late career who wish to scale back, but not completely discontinue, their clinical work. These are systemic issues that can be addressed at the policy level to ensure that doctors are retained for as long as possible as active contributors to the medical workforce in a safe, appropriate manner.
14
Conclusion
15
The medical profession has traditionally been ahead of society more broadly in terms of retaining older workers in the workforce beyond ‘standard’ retirement age. Given the continued growth in demand for health services associated with the aging of the general population, rising prevalence of chronic conditions and ongoing increases in expectations, it is important that support for older doctors to provide their valued contributions for as long as possible are continued and enhanced.
None declared. Acknowledgements This research was funded by a grant from the National Health and Medical Research Council.
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Australian Health Review, 2015, 39, 582–587 http://dx.doi.org/10.1071/AH14176
Retirement patterns of Australian doctors aged 65 years and older Catherine M. Joyce1,2 BA(Hons), MPysch, GCHE, PhD, Adjunct Associate Professor Wei C. Wang1 PhD, Research Fellow Hayley M. McDonald1 BA(Hons), Research Assistant 1
School of Public Health and Preventive Medicine, Monash University, 6th Floor, The Alfred Centre, 99 Commercial Road, Melbourne, Vic. 3004, Australia. Email: [email protected]; [email protected] 2 Corresponding author. Email: [email protected]
Abstract Objective. To investigate retirements over a 4-year period among Australian general practitioners (GPs) and specialists aged 65 years and over, and factors influencing retirement. Methods. Data from Medicine in Australia: Balancing Employment and Life (MABEL) for the years 2009–12 were analysed for 435 GPs and 643 specialists aged 65 years and over at the time of entry to the MABEL survey. Discrete time survival analysis was used. Results. The retirement rates were 4.1% (2009), 5.1% (2010), 4.2% (2011) and 10.4% (2012). Retirement was associated with: (1) the intention to leave medical work in 2009 and 2010; (2) working fewer hours in private consulting rooms in 2010 and 2012; (3) having lower job satisfaction in 2009 and 2011; (4) being older in 2009; (5) working fewer hours in a public hospital in 2012; and (6) working fewer hours in a private hospital in 2010. Doctors who intended to reduce their working hours were less likely to retire in 2009. Conclusions. Strategies to support doctors at the late career stage to provide their valued contributions to the medical workforce for as long as possible may include increasing job satisfaction and addressing barriers to reducing work hours. What is known about the topic? Much of the available literature provides measures of retirement intentions. What does this paper add? The present study examined actual retirements and the factors associated with them. What are the implications for practitioners? Consideration should be given by policy makers to ensure that doctors are retained for as long as possible as active contributors to the medical workforce in a safe, appropriate manner. Additional keywords: discrete time survival analysis, longitudinal survey. Received 9 October 2014, accepted 19 March 2015, published online 22 June 2015
Introduction The retention of medical practitioners in the workforce is essential to meeting the healthcare needs of the community. Retirement rates have a major impact on workforce supply.1 Given that 25.5% of Australia’s doctors are aged over 55 years and 8.9% are aged over 65 years,2 there is likely to be a considerable number of doctors retiring in the coming decade. However, it is not uncommon for medical practitioners to continue working beyond traditional retirement age.3,4 The proportion of older doctors remaining in the workforce is not known, but approximately 15% of people aged 65 years and over in the general Australian population are active in the workforce, and this is higher among those who are university educated.5 Doctors who are transitioning from working life to retirement often gradually reduce their working hours,3 allowing them to enjoy a less-intense working life towards the end of their careers.6 Doctors’ retirements raise several challenges for the healthcare system, including loss of experience and knowledge,7 Journal compilation AHHA 2015
reduced support for junior doctors and potential exacerbation of projected future workforce shortages.8–10 Individual doctors themselves also face personal challenges when they leave the medical workforce. Navigating life away from a profession that has likely been a significant, often defining, part of their life for many years can lead to difficulties moving into this new stage.11–17 Therefore, their continued involvement for as long as possible in the workforce is likely to have benefits for both the provision of health care and for them as individuals. Although continued procedural work may not be appropriate for all doctors of advanced age, there are many clinical and nonclinical roles (e.g. in medical education and research)18 where senior doctors can make a valued contribution. There are several factors, other than age, that influence medical practitioners to make a decision or plan to exit the medical workforce. These include poor job satisfaction, feeling burnt out, high workloads, changes within the workplace, a feeling of limited support from a supervisor, limited control in their job, www.publish.csiro.au/journals/ahr
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poor team relationships and a desire for more free time.19–23 One study of general practitioners (GPs) aged 45–65 years found that one-third were planning to retire early.19 Comparatively, factors that can act as incentives to stay in the workforce include improved remuneration, adequate staffing levels, greater levels of support, flexible working hours, reduced bureaucracy and reduced workloads.19,21,22 Much of the available literature provides measures of retirement intentions rather than actual retirements, and thus the factors that are associated with actual retirements remain poorly understood. The aim of the present study was to investigate the rate of retirement from the Australian medical workforce among practitioners aged 65 years and over, as well as the factors that predict retirement over a 4-year period. Methods The study used data from the Medicine in Australia: Balancing Employment and Life (MABEL) longitudinal survey of doctors. The study methods have been published previously.24,25 Briefly, in 2008 all 54 750 doctors undertaking clinical work listed in the Medical Directory of Australia (http://ampcodirect.com.au) were invited by mail to participate in the survey. In subsequent years of the survey, previous respondents (continuing) as well as a ‘top-up’ sample (new) of doctors were surveyed.25 The sample for the present study was GPs and specialists aged 65 years and over and in clinical practice in 2008, or in their first year of the survey for those in top-up samples in 2009, 2010 or 2011. The study was approved by the Faculty of Economics and Commerce Human Ethics Advisory Group, University of Melbourne, and the Monash University Standing Committee on Ethics in Research Involving Humans. Variables used The outcome variable of retirement was measured with the question ‘Are you permanently retired from all types of paid work?’, with response options no (0) and yes (1). MABEL surveys collect information on a wide range of personal and professional characteristics and attitudes. Variables included in the present study were: age (65–69 = 0, 70 = 1), gender (male = 0, female = 1), cohabitation status (‘Are you currently living with a partner or spouse?’; no = 0, yes = 1), financial circumstances (‘Given my current financial situation and prospects, I believe I will have enough to live on when I retire’; strongly disagree = 0, disagree = 1, neutral = 2, agree = 3, strongly agree = 4), general health status (‘In general, would you say your health is. . .’; excellent = 0, very good = 1, good = 2, fair = 3, poor = 4), and doctor type (GP = 1, specialist = 2). Job satisfaction is measured in MABEL with a 10-item version of a Job Satisfaction Scale developed by Warr et al.,26 with responses on a five-point scale (very dissatisfied = 0, moderately dissatisfied = 1, not sure = 2, moderately satisfied = 3, very satisfied = 4). In the present study, only the overall job satisfaction item was used. Doctors’ employment arrangements were measured by number of hours per week (continuous) in: (1) a public hospital (including psychiatric hospital); (2) a private hospital; and (3) private medical practitioner’s rooms or surgery. Working in private practice (no = 0, yes = 1) and regularly contributing to a
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superannuation scheme (no = 0, yes = 1) were included as categorical variables. Four measures of future workforce participation intentions were included. The first of these related to preferences regarding working hours, ‘Would you like to change your hours of work (including day time and after hours)?’, with three response options: increase = 0; no change = 1; and decrease = 2. Respondents were also asked, ‘What is the likelihood that you will: (1) leave patient care within 5 years; (2) leave medical work entirely within 5 years; (3) reduce your clinical workload in next 5 years?’, all of which had a five-point response scale: very unlikely = 0, unlikely = 1, neutral = 2, likely = 3, and very likely = 4. Analysis Doctors responding ‘yes’ to the retirement question in MABEL are directed not to complete most sections of the questionnaire in that year. Therefore, data on doctors’ characteristics and intentions collected in previous years were used in analyses. The potential sample for the present study was a total of 1545 doctors, comprising 787 doctors aged 65 years in 2008 and 758 doctors aged 65 years who entered the study at a later year as part of a top-up sample. The final sample for analysis in the present study was 1078 doctors, after excluding cases due to loss to follow up or lack of available information on predictor variables in previous years as required for analysis. The numbers excluded per year were as follows: 2008, n = 84; 2009, n = 13; 2010, n = 27; 2011, n = 31; and 2012, n = 312 (all newly recruited doctors aged 65 years and over in 2012). In order to investigate whether retirement occurs, when it is most likely to occur and how retirement occurrences vary over time, discrete time survival analysis was used. The data were prepared as outlined by Muthén and Masyn.27 A score of 0 reflected no retirement event occurred and a score of 1 was designated to doctor who reported retirement occurrence with the subsequent years being treated as missing due to having experienced the event. In the discrete time survival analysis model, the four binary time-specific event indicators were regressed on the set of time-invariant covariates. Discrete time survival analysis was performed using Mplus version 7.1,28 using Maximum Likelihood estimation with Robust standard errors (MLR), with results reported as odds ratios (OR). A two-stage approach was used, in which personal and professional variables, employment and working settings only were entered in the first stage, and the intentions variables added at the second stage. Results The overall response rate for MABEL in 2008 was 19.36% (representing almost one in five Australian doctors), and 15.19% for those aged 65 years. Response rates for doctors aged 65 years and over in MABEL 2009, 2010, 2011 and 2012 were 82.64%, 82.24%, 75.51% and 75.32%, respectively. For continuing doctors only (excluding the top-up samples) aged 65 years, the response rates in 2009, 2010, 2011 and 2012 were 84.02%, 82.53%, 77.06% and 76.10%, respectively. Respondent characteristics are summarised in Table 1. The study sample included a similar proportion of females to the medical labour force population aged 65 years for the same
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Table 1. Respondent profile by gender Data are presented as the number of respondents in each group, with percentages in parentheses or as the mean s.d. GP, general practitioner Variable No. respondents Doctor type GP Specialist Age (years) 65–69 70 Living with a partner Yes Overall job satisfaction Moderately or very satisfied Believe I will have enough to live on when I retire Agree or strongly agree Health status Excellent Very good Good Fair Poor Working in a private practice Yes Regularly contributing to a superannuation scheme Yes Like to change working hours Increase No change Decrease Likely or very likely within 5 years to: Leave direct patient care Leave medical work entirely Reduce clinical workload Working hours by settings Public hospital (including psychiatric hospital) Private hospital Private medical practitioner’s rooms or surgery
period (12.2% in 2008, rising to 13.7% by 2012).2,29 In 2008, 44% of doctors aged 65 years and over were GPs, 40% were specialists and the remaining 16% had other or unreported roles.29 In 2008, 24% of doctors aged 65 years and over were in the 75 years age category (including 25% of males and 17% of females),29 which is broadly consistent with our figures for those aged 70 years. Finally, the total average working hours for our sample were 29.7 h per week, compared with approximately 31 h per week for the medical labour force population aged 65 years in 2008.29 Over one-third (33.8%) of doctors (34.3% males and 30.1% females) indicated that they would like to decrease their working hours. Most doctors expressed being likely or very likely to leave direct patient care (82.4%), to leave medical work entirely (74.2%) and to reduce clinical workload (86.5%) within the next 5 years. The retirement rate for each year was 4.1% (2009), 5.1% (2010), 4.2% (2011) and 10.4% (2012). The association of background characteristics and other variables to retirement in each year is indicated in Table 2. Inclusion of the intentions variables resulted in only minor changes to the significant
Male
Female
Total
932 (86.5%)
146 (13.5%)
1078
357 (38.3%) 575 (61.7%)
78 (53.4%) 68 (46.6%)
435 (40.4%) 643 (59.6%)
600 (64.4%) 332 (35.6%)
114 (78.1%) 32 (21.9%)
714 (66.2%) 364 (33.8%)
865 (92.8%)
94 (64.4%)
959 (89%)
870 (93.4%)
137 (93.8%)
1007 (93.4%)
635 (68.2%)
98 (67.1%)
733 (68%)
221 (23.7%) 368 (39.5%) 246 (26.4%) 85 (9.1%) 12 (1.3%)
41 (28.1%) 58 (39.7%) 34 (23.3%) 11 (7.5%) 2 (1.4%)
262 (24.3%) 426 (39.5%) 280 (26.0%) 96 (8.9%) 14 (1.3%)
797 (85.5%)
126 (86.3%)
923 (85.6%)
753 (80.8%)
124 (84.9%)
877 (81.4%)
22 (2.4%) 590 (63.3%) 320 (34.3%)
4 (2.7%) 98 (67.1%) 44 (30.1%)
26 (2.4%) 688 (63.8%) 364 (33.8%)
771 (82.7%) 694 (74.4%) 810 (87%)
117 (80.1%) 106 (72.6%) 123 (84.3%)
888 (82.4%) 800 (74.2%) 933 (86.5%)
8.65 ± 15.05 2.61 ± 6.75 19.12 ± 17.02
5.66 ± 11.47 2.11 ± 6.33 17.25 ± 14.43
8.25 ± 14.65 2.54 ± 6.69 18.87 ± 16.70
associations, so results reported are for the second-stage model with all variables. The only differences are that age was significantly related to retirement in 2010 and 2012, as well as 2009, in Stage 1, but these became non-significant in Stage 2 when the intentions variables were included. Job satisfaction was negatively associated with retirement in two of the four years. Doctors who reported higher job satisfaction were 30% (OR = 0.70) and 44% (OR = 0.56) less likely to retire in 2009 and 2011, respectively, compared with doctors who reported lower job satisfaction. Doctors who worked longer hours were less likely to retire. For every additional hour working in consulting rooms, doctors were 3% (OR = 0.97) and 2% (OR = 0.98) less likely to retire in 2010 and 2012, respectively. Similarly, for every additional hour worked in the public hospital setting, doctors were 3% (OR = 0.97) less likely to retire in 2012, whereas in 2010 doctors were 8% (OR = 0.92) less likely to retire for every hour worked in a private hospital setting. Doctors who were aged 70 years and over were approximately threefold (OR = 3.04) more likely to retire in 2009 compared with doctors who were aged between 65 and 69 years.
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Table 2. Associations of retirement with personal, professional, employment and intentions measures *P < 0.05, **P < 0.01 2009 Age Gender Currently living with a partner Enough financial support when retire General health status Doctor type Overall job satisfaction Hours worked per week in: Public hospital setting Private hospital setting Private medical practitioner’s rooms or surgery Working in a private practice Regularly contributing to a superannuation scheme Intention to change working hours Intention to leave direct patient care in 5 years Intention to leave medical work entirely in 5 years Intention to reduce clinical workload in 5 years
Odds ratio (95% confidence interval) 2010 2011
2012
3.04** (1.46, 6.34) 0.60 (0.17, 2.13) 1.31 (0.43, 4.01) 1.09 (0.86, 1.37) 1.09 (0.82, 1.45) 1.17 (0.46, 3.02) 0.70* (0.52, 0.94)
1.93 (0.95, 3.95) 0.76 (0.22, 2.64) 1.84 (0.43, 7.79) 1.05 (0.76, 1.45) 0.92 (0.65, 1.31) 1.58 (0.72, 3.48) 0.72 (0.51, 1.02)
1.36 (0.62, 2.97) 0.89 (0.27, 2.89) 0.87 (0.25, 3.02) 1.01 (0.76, 1.36) 1.07 (0.75, 1.51) 1.10 (0.45, 2.69) 0.56** (0.42, 0.75)
1.57 (0.88, 2.79) 0.82 (0.37, 1.82) 1.28 (0.52, 3.13) 0.94 (0.72, 1.23) 0.91 (0.69, 1.20) 0.98 (0.51, 1.88) 1.01 (0.68, 1.49)
1.01 (0.98, 1.03) 1.02 (0.98, 1.06) 1.00 (0.97, 1.04) 0.60 (0.26, 1.38) 1.61 (0.66, 3.94) 0.45* (0.23, 0.89) 0.87 (0.55, 1.39) 1.85** (1.18, 2.92) 1.05 (0.87, 1.26)
0.99 (0.97, 1.02) 0.92* (0.85, 0.99) 0.97* (0.95, 1.00) 1.70 (0.66, 4.36) 1.19 (0.58, 2.45) 0.56 (0.26, 1.23) 0.79 (0.53, 1.20) 2.34** (1.48, 3.69) 1.01 (0.78, 1.33)
1.00 (0.97, 1.03) 1.01 (0.97, 1.05) 0.97 (0.96, 1.01) 0.88 (0.31, 2.46) 1.20 (0.47, 3.05) 0.74 (0.37, 1.50) 0.81 (0.50, 1.31) 1.63 (0.97, 2.73) 1.12 (0.79, 1.57)
0.97* (0.95, 1.00) 1.00 (0.96, 1.04) 0.98* (0.95, 1.00) 1.04 (0.41, 2.64) 0.82 (0.44, 1.52) 0.78 (0.44, 1.37) 1.38 (0.62, 3.09) 1.72 (0.93, 3.19) 0.92 (0.71, 1.20)
Intention to leave medical work was a predictor of retirement in 2009 and 2010. Doctors who intended to leave medical work entirely in the next 5 years were nearly twofold (OR = 1.85) and almost 2.5-fold (OR = 2.34) more likely to retire in these two time periods. Doctors with an expressed preference to reduce their working hours were 55% (OR = 0.45) less likely to retire in 2009. We found no differences between male and female doctors, or between GPs and specialists, in likelihood of retirement. We also found that retirement was not associated with cohabitation, perceived adequacy of financial support, general health status, being in private practice or contributing regularly to a superannuation scheme. Discussion The present study provides one of the first rigorous analyses of Australian doctors’ retirement patterns and the factors influencing them. The findings indicate that intention to retire does predict actual retirement within a 4-year period. However, at the same time it is of note that nearly three-quarters of doctors (70.2%) reported intending to leave medical work entirely within 5 years, whereas only approximately one in five (18.7%) actually retired within the time frame of our study. This indicates that although intention to retire is important, other factors are also influential. In particular, job satisfaction remains important for late career doctors. This is consistent with the literature linking doctors’ job satisfaction with decisions to leave the workforce30,31 and highlights the importance of this factor in workforce retention right across the career span. Hays et al. developed a model of retention in rural practice that identified pressures to stay as well as pressures to leave, and triggers that could alter the balance between these to result in actually leaving rural practice.32 Retirement decisions can be understood in a similar way. Factors such as high workload and feeling unsupported are likely to favour retirement,19,23 whereas loss of status and income will favour staying in the workforce.12,14 The present study did not
find any association between anticipated level of financial support during retirement and actual retirements, which may be due to the ability of the measure used to capture this with precision and in a way that discriminates effectively. Job satisfaction can be thought of as one of the trigger factors that could tip the balance. Therefore, interventions to increase doctors’ job satisfaction are likely to have positive effects for retention of late career doctors as well as those at earlier stages. Doctors who expressed a desire to reduce their working hours were less likely to retire, as were doctors working longer hours. This is consistent with the available literature regarding doctors’ retirement, where the common pattern is reduction of hours before withdrawal from the workforce.3 Therefore, the opportunity to reduce hours may delay full retirement. Future research could provide empirical confirmation of this proposition. We found that intentions associated with clinical work specifically were not associated with retirement. Neither the intention to leave direct patient care nor the intention to reduce clinical workload was associated with retirement. This suggests that decisions about the amount of clinical work, and the balance between clinical and non-clinical work, are separate to retirement decisions. The present study has some limitations. Doctors who had retired may have been less likely to respond to the survey, meaning that the retirement rates we have modelled are underestimates of the true rate. It is difficult to assess the representativeness of the study sample, because population data are also likely to be affected by non-response from retiring doctors. Comparisons between MABEL and national medical labour force data show reasonably good agreement in the proportion of doctors aged 65 years and over in 2009: 8% vs 8.49%;33 2010: 9.10% vs 11.46%;34 2011: 9.20% vs 10.79%;35 and 2012: 10.60% vs 11.90%.2 In each year, older doctors are slightly under-represented in MABEL. National medical labour force data presented in the Results section also indicates a reasonable congruence with our sample with regard to age, gender and hours worked, with some suggestion of an over-representation
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Competing interests
of specialists in our sample. A strength of the study is that the MABEL cohort has been shown to be broadly representative of the national population.24 Further research could explore aspects that we have not investigated in detail, including patterns and determinants of reductions in hours of work and changes in clinical–non-clinical work balance. Because we focused on those aged 65 years and over, our study does not provide information about early retirements, which may have different determinants. For example, general health status was not associated with retirement in the present study but may be an important factor in early retirements. The findings suggest that it is desirable to support doctors winding down as a means of retaining them in the workforce for longer. There are several potential barriers to a gradual decrease in professional work that may be useful to address in this regard. First, for doctors who have been employed and are entitled to superannuation, reducing work hours before retirement may affect superannuation payout levels. Second, compliance measures, such as registration, continuing professional development (CPD) and professional indemnity insurance, can be prohibitive for doctors who are undertaking relatively small amounts of clinical work and generating relatively small revenue from this. Prior to the establishment of a national registration scheme in 2010, registration was managed by boards in each state and territory, some of which had an ‘occasional practice’ registration category. This provided for doctors who had retired from their full-time clinical role but continued to undertake limited clinical work. Doctors holding this category of registration when the new scheme came into effect were permitted to retain it and, as of April 2013, there were approximately 1000 such doctors.36 However, this can only be renewed a maximum of three times and no new registrants are admitted to this category.36 The choice now is ‘general registration’, which requires professional indemnity insurance and 50 h of CPD per year, or ‘non-practising registration’, under which clinical activity is not authorised. These changes to registration arrangements may have influenced the higher rate of retirement observed in 2012 compared with 2009–11. This higher rate may also simply be due the increased age of the sample. Retention of doctors of advanced age in the medical workforce raises potential concerns about quality and safety standards, but it is to the loss of the profession, and the health system, if some innovative thinking cannot be brought to bear to try to support doctors in late career who wish to scale back, but not completely discontinue, their clinical work. These are systemic issues that can be addressed at the policy level to ensure that doctors are retained for as long as possible as active contributors to the medical workforce in a safe, appropriate manner.
14
Conclusion
15
The medical profession has traditionally been ahead of society more broadly in terms of retaining older workers in the workforce beyond ‘standard’ retirement age. Given the continued growth in demand for health services associated with the aging of the general population, rising prevalence of chronic conditions and ongoing increases in expectations, it is important that support for older doctors to provide their valued contributions for as long as possible are continued and enhanced.
None declared. Acknowledgements This research was funded by a grant from the National Health and Medical Research Council.
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