key: cord-0716293-9pu3ga2z
authors: Binder, William; Abrahams, Casey O.; Fox, Jordan M.; Nestor, Elizabeth; Baird, Janette
title: The age‐old question: Thematic analysis of focus groups on physician experiences of aging in emergency medicine
date: 2021-07-05
journal: J Am Coll Emerg Physicians Open
DOI: 10.1002/emp2.12499
sha: 2e5794f7644b5ff21366a7afd848c7d4d3530ff6
doc_id: 716293
cord_uid: 9pu3ga2z

OBJECTIVES: Emergency medicine has a demanding work environment. Characteristics influencing longevity among older physicians in emergency medicine have been the subject of ongoing discussion. The American College of Emergency Physicians (ACEP) released a policy statement in 2009 suggesting accommodating emergency physicians in preretirement years. We engaged emergency physicians to determine awareness of the ACEP policy and issues faced in preretirement years. METHODS: We conducted a series of online focus group discussions with a purposive sample of emergency physicians, age ≥ 50 years. The discussion guide was developed from the ACEP policy statement and relevant literature. Groups were audio recorded, transcribed, and analyzed with a thematic coding system developed iteratively by the 4‐person team. Emerging themes were identified, organized, and presented with illustrative quotations. RESULTS: A total of 28 emergency physicians participated in 4 focus groups, with between 6 and 9 participants in each group. These physicians had between 17 and 35 years of clinical experience (median = 27), 6 were female (21%), and the majority (n = 26, 93%) worked in academic emergency medicine. Only 1 emergency physician was fully aware of the ACEP policy. Three principal content areas were identified: workload demands that change as physicians age, wellness and physician social equity, and senior emergency physician value. Interwoven across all of these was the focus on leadership and solutions to issues. Issues facing emergency physicians in their preretirement years were identified; commitment from emergency medicine site and national leadership and buy‐in from junior colleagues was emphasized. Generational conflicts in recognizing the contribution and needs of preretirement emergency physicians was a major barrier to solutions. CONCLUSIONS: Workload demands, wellness and physician social equity, and concerns about value as a senior physician are major themes confronting preretirement emergency physicians. Generational divides, deficits in local and national leadership, and the health detriments of rotating schedules and night shifts are barriers to longevity in emergency medicine. Further research on the value of senior physicians and the impact of hospital and departmental financial models on adopting accommodations for senior emergency physicians is needed.

the health detriments of rotating schedules and night shifts are barriers to longevity in emergency medicine. Further research on the value of senior physicians and the impact of hospital and departmental financial models on adopting accommodations for senior emergency physicians is needed.

aging, emergency medicine, focus group, physician perspectives, qualitative research

Of the over 900,000 licensed physicians in the United States, there are 42,000 practicing emergency physicians, or about 1 physician per 7700 persons in the United States. Only internal medicine, family medicine, and pediatrics have more practicing physicians within a specialty and a lower physician-to-patient ratio. 1 Unlike the US physician workforce, emergency medicine practitioners skew toward a younger demographic. Of all practicing physicians, 15% are over 65 years, 44%

of physicians are >55 years old, and in some specialties including pulmonary medicine, cardiology, neurology, and orthopedics, over 50% of physicians are older than 55 years. In contrast, only 35% of emergency physicians are older than 55 years. 1, 2 This generational divide creates a unique set of challenges for the senior emergency physician.

Because of its demanding work environment, factors influencing longevity among older physicians in emergency medicine have been the subject of ongoing discussion. The American College of Emergency Physicians (ACEP) suggested that considerations should be made for accommodating emergency physicians in preretirement years. 3 Specific recommendations included shortening shifts and eliminating overnights. 3 A randomized survey of ACEP members over age 55 years supported the role of a national emergency medicine organization's endorsement of practice modifications that would promote career longevity for emergency physicians. 4 However, a survey of academic emergency medicine leaders noted that only a quarter of departments had a formal policy to accommodate aging faculty. 5 Individual issues affecting aging in medicine have been identified previously. Debate continues to churn regarding the competency and abilities of the aging physician, as well as concerns about cognitive and physical decline. At present, mandatory retirement for physicians is not standard. Significant variability has been demonstrated in older physicians, with some retaining skill and adding value, whereas others become impaired. [6] [7] [8] [9] [10] [11] A recent report described a cognitive screening program for recredentialing physicians ≥ 70 years that led to 13% of physicians screened leaving practice. However, in the same study, the rate of false positive screening was 57%, bringing into question the fairness and legality of such examinations to assess the cognitive ability of the senior physician. 12 "Crystalized intelligence"-the "accumulated wisdom and experience of older physicians-increases between 40 and 70 years of age, yet it appears difficult to define and measure the value of the senior physician." 13, 14 Generational differences have been identified that can have an impact on the structure, function, and culture of an emergency department. Younger emergency physicians believe that experiential learning can be offset by expanding technology, such as simulation and the acquisition of new skills including ultrasound. 15 Older physicians frequently cite circadian rhythm disruption as a barrier to successful aging in emergency medicine, and intergenerational differences regarding work-life balance and attitudes toward physiologic differences can lead to staffing friction between colleagues. 15

There is a paucity of literature regarding the value of senior emergency physicians to both an ED and to an institution. Additionally, although there are occasional reports elucidating barriers to emergency physicians in their preretirement years, studies examining solutions for successful aging in emergency medicine are sparse.

In this study we sought to identify and thematically categorize workplace issues confronted by senior emergency physicians. We endeavored to elucidate potential barriers and provide possible solutions to the issues facing senior emergency physicians as they enter preretirement years.

This qualitative study design used a focus group discussion process with a purposive sample of emergency physicians. We attempted to achieve consensus opinion among the physician experts regarding issues confronting senior emergency physicians based on their responses to a series of semistructured questions. 16 An interview guide with semi-structured questions was developed by the authors (WB, EN, JB, and is available in Appendix A online meetings (hosted through Zoom) held with physicians who consented to attend. We aimed to achieve code saturation relevant to the investigation goals. 18 The institutional review board at the study site approved the study protocol, and participants received a $50 gift card for attending the group.

The online focus groups were audio recorded and the content of the discussions was transcribed by 2 of the authors (CA, JF). After each session the authors met and debriefed on the session and added additional questions and materials to be used in the discussion guide for subsequent sessions (see Appendix Table 1 ).

The content analyses, conducted after the last group was held, used the transcripts, with audio recordings available for additional information to support the data analysis. No identifying information was contained in these transcripts.

We employed an inductive approach to the thematic analyses of the focus groups' content. 19 We used this approach to identify the initial code and final themes for the content of the group. The authors (CA, JF, WB, JB) developed the initial coding structure from the group discussion guide and this was iteratively developed through the review and cross-review of the transcripts. The main themes and subthemes were developed independently by each author and then comparison and consensus agreement on the coding structure were attained before full coding of each group transcript was undertaken. The purpose of the coding structure was to identify common patterns of responses among the participants. 20 The results of the thematic analysis are presented as main themes, which were composed of barriers to successful aging

Career longevity is a major challenge for emergency physicians. In this qualitative study of 28 emergency physicians over 50 years old, participants identified 3 major factors influencing longevity: (1) adjustment of workload to age,

(2) wellness and physician social equity, and (3) senior physician value. These findings are important in the effort to support longevity in the emergency medicine workforce.

and subthemes with illustrative quotes. The study protocol, discussion guide, and content analyses were developed and implemented to meet the recommended standards for qualitative research. 21

A total of 28 emergency physicians participated in 4 focus groups, with between 6 and 9 participants in each group. These emergency physicians had between 17 and 35 years of clinical experience (median = 27 years, interquartile range: 23, 28.5), 6 were female (21%), the majority (n = 26, 93%) worked in academic or academic affiliated institutions.

All participants identified as Caucasian. Only 1 of the emergency physicians was fully aware of ACEP policy guidelines for physicians in preretirement years.

In response to our interview guide, the physician groups discerned numerous factors affecting successful aging in emergency medicine.

Taken together, 3 themes comprising barriers and solutions were noted and included the following: workload demands that change as physicians age, wellness and physician social equity, and the value of the senior emergency physician. Interwoven across all of these themes were underlying subthemes acknowledging generational divides between senior and younger physicians and the role of leadership in solving conflict.

Workload demands and the variable shift schedule were a consistent theme considered across the groups. Included in this were subthemes focusing on the physical impact of irregular shift schedules, requirements and demands to keep up with clinical skills, workplace culture, financial anxiety, as well as solutions to workload issues. Table 1 summarizes these discussions.

The majority of the senior physicians mentioned increasing difficulty with their workload, and all agreed that the overnight shifts

Patient volume "When I started it was not uncommon for the department to be empty at 2, 3, 4, in the morning. Now we have 15 people in the waiting room all night long. It is tougher for me to do night shifts without taking a nap." Physical effects "It's far more exhausting than when I was younger...the bouncing back from working at 2 am and coming back at 6 am." "It's much harder as you age for your biorhythms to swap back and forth from night today." "They're paying me to be quite miserable, physically and emotionally since I turned 50.″

Responsibilities "It's incumbent upon you as a senior provider to maintain competency, reading, sim centers; just one additional stress on top of everything else." New clinical practice "I think ultrasound is difficult for older physicians because it wasn't part of our training; we've had to learn it on our own.

We are not up to par with the junior physicians who did ultrasound fellowships." Security of employment was a barrier to implementing solutions across the issues raised by the physicians. Many reported that the salary differential between them and more junior colleagues not only resulted in less empathy for the issues discussed but also made them vulnerable to having to "put up with things" with the concern that younger physicians with lower salaries could replace them. One physician expressed concern that mobility in employment was also hampered by seniority, with more emphasis on income level than age

Parity Equity with other social policy advances "Maternity and paternity leave talks are overwhelming, but issues regarding senior physicians' needs are marginalized in favor of those issues. It is not seen as politically correct as these other issues that take priority in other industries." "There needs to be attention paid to wellness and the older physician the same way that we do for the younger physician and their development."

The only discussion of wellness has been for younger people. I don't see it at all in the context of aging, but I believe this is where the wellness discussion belongs." "I would love to drop usage of the word "burnout". We are not talking about burnout; we are talking about different stages of life. I think that is the paradigm we need to achieve." Isn't wellness the right of all of us as we age?

Advocacy "There should be parity in general benefits and in general stages of life. The focus is not on "us" unless we do have a seat at the table and bring them up as legitimate factors that are legitimate whether or not they cost money." Transparent process "There needs to be transparency. The rules that are established are the rules for everyone, not special rules for special people." Finding your niche at any age "It is every physician's responsibility to find a niche that works for them."

concerns. This lack of employment mobility was seen to reduce any bargaining ability that senior physicians could have in advocating for workload accommodations or social equity.

Group members gave examples of strategies adopted at their clinical site to accommodate senior physicians. These included discontinuing overnight shifts at a specified age; creating a points system with differentials for overnights, day shifts, and weekends; and encouraging senior physicians to swap overnight and weekend shifts with younger colleagues. Some physicians described accommodations they had individually negotiated with their site leadership for overnight shift reductions that involved a financial cost of "buying-out" of these shifts through salary reductions. A consensus was reached that a focus on the needs of, and advocacy for, senior physicians should be spearheaded by national professional organizations.

Relatedly, the group participants raised concerns regarding leadership and workplace culture at the site level. These physicians believe that accommodations for senior physicians should not be decided by democratic vote, but instead a policy should be implemented at the executive level to become the standard of care. Many agreed that an institutional policy around accommodations for senior physicians would help to transition senior physicians to different clinical care shifts and responsibilities. It was strongly recommended that leadership enact transparent and clearly stated workload policies that provide obvious long-term benefits to younger physicians in order to increase buy-in from those younger colleagues.

Our physician groups suggested that wellness and social issues for senior physicians were deemphasized in comparison to their junior colleagues, and they recognized the importance of advocacy in addressing inequities. Senior physicians in the groups noted that they had argued for the value of supporting the wellness of young families and early-career physicians but now felt that their efforts were not being reciprocated. Although financial costs were appreciable in developing family leave programs, 1 senior physician remarked, "it was the right thing to do." They noted that important progress had been made on issues of family leave and childcare for younger physicians. Conversely, however, senior physicians reported no progress as they confronted family issues in regard to older children and parents.

Again, the importance of leadership in creating equity at the national and clinical site level was raised. 

Changing the culture "A program to care for the aging physician to change the culture of the younger generation....eventually they will be in that position themselves." "Broaden view of value to include non-clinical contributions." Leadership I think it takes a strong leader to say 'I want my experienced physicians to move their careers along for the benefit of the department.'" "Try to create a path for everyone that even young physicians would buy into, because they will be there eventually...(we all want) a lasting career that will get you to 65 no matter how old you are now...the end goal is for a long, fruitful career, right now it is not designed to be like that."

physicians reflected upon the substantial contributions to their respective EDs, but most of these physicians felt a lack of appreciation for their longstanding involvement. Although the physicians in the group recognized younger physicians were often able to see patients quickly Language around senior physicians was also examined. One physician stated that the term "older" leads to discrimination and ageism, as it offers a rationale by which other departmental members can diminish or marginalize the contributions of the senior physicians.

Several of the physicians in the focus groups practiced at community or academic-affiliated sites. Under current models of staffing, community-based physicians have limited opportunity for altering workload demands in exchange for administrative roles, and issues surrounding wellness and equity for this subset of physicians were noted to be substantially different and mostly neglected. Solutions to this dilemma were not proposed.

Although the number of participants contributing to the focus groups was sufficient to identify the main themes, we recognize that it was a 

The results of the focus groups revealed several main themes and subthemes examining barriers to successful aging in emergency medicine. Workload was further affected by attitudes of younger physicians toward staffing. As 1 physician noted, younger physicians had the attitude that if you could not handle nights, you should not be working.

Indeed, 1 senior physician reported that residents were coached not to work at a facility that provides accommodations toward older physicians, as this could result in being taken advantage of by a mature department.

The generational divide between younger and senior physicians is often reflected in the approach local departmental leadership takes toward senior physicians. Some groups have a culture in which senior physicians are offered a reduction in night shifts while still maintaining full-time status. 6, 23, 24 However, this often requires a well-staffed academic department with a top down (chairperson) approach toward scheduling. Community groups with lean staffing are often unable to comply with ACEP's guidelines regarding scheduling, and night shifts continue to be a contributing factor toward premature retirement. 22 In response to longer lifespans and perturbations in markets, physicians retire at a later age. 25 This has left some emergency physicians feeling financially and emotionally vulnerable to workload demands.

As several of our physician participants noted, in departments with younger leadership, senior physicians fear being "let go." Shanafelt et al. affirm this notion but create an economic argument for physician retention, stating that costs associated with turnover, onboarding, lost revenue, loss of mentorship, and optimizing efficiency are profound. This is typically a blind spot in most academic medical centers. 26 Wellness and equity were recognized by our participants as an important theme in preretirement years. Promotion of wellness has been considered an antidote to physician burnout, which is recognized to be widespread among US physicians. 27 About 50% of all US physicians display symptoms of burnout, ≈70% of US emergency physicians report a degree of burnout, and, in 1 study of emergency physicians, nearly half of survey respondents intended to retire early. [28] [29] [30] Numerous factors have been cited as a cause for burnout in emergency physicians, including modifiable ED factors, such as overcrowding, workplace violence, scheduling, and leadership issues. 23, 31 Although burnout is increasingly noted to be a systems-level issue rather than an individual problem, promoting physician well-being often is considered at an individual and small group level. 24,32 ACEP's wellness handbook, for example, casts responsibility onto the individual physician, noting that aging physicians have a choice to live a healthy lifestyle in order to last longer in emergency medicine. 33 Most organizations that do endeavor to create a systems response to burnout and wellness are unable to move past a beginner or novice phase in which individual interventions are promoted, and systemwide interventions are at best discussed but not implemented. 26 Most wellness interventions center around resident hour restrictions and programs promoting mindfulness, stress management, and other individual efforts for younger and early career physicians. 29 Our participating physicians recognized that wellness and burnout have been framed as a discussion for residents and early career physicians who face complex issues in balancing work with childcare responsibilities.

A lack of parity and ageism has marginalized wellness discussions for senior physicians; instead, these conversations often are centered around competency and retirement rather than extending careers. 6, 34 The final theme addressed by our focus groups examined the value of senior physicians. Whereas some studies suggest that outcomes in elderly patients treated by younger physicians are worse and result in a higher mortality, other research notes the positive impact of seniority on clinical efficiency, resource use, patient outcomes, and disposition in EDs. 10, 33, [35] [36] [37] In a commentary examining the accuracy of age-based competency screening programs, Armstrong noted that such programs "fail to recognize the value of the accumulated wisdom and experience of older physicians." 14 Our group reported noting a feeling of underappreciation from younger colleagues and leadership. This has been echoed in other venues. In a recent discussion of aging in medicine, 1 physician reported that in his early 60s he felt increasingly irrelevant. "I began to notice that my opinions expressed in morbidity and mortality meetings, journal club, and policy meetings were politely tolerated then dismissed by my younger colleagues." 39 Although data are scant regarding the value of experience and seniority in the canon of medicine, and in particular, emergency medicine, there is no question that senior physicians can offer mentorship to younger physicians, exhibit resilience, and provide a broad perspective regarding clinical care. Our group suggested that institutions and administrators broaden their views of successful metrics and pay credence to "citizenship" for senior physicians. 15 Our pilot study provides insights into the issues facing senior physicians in emergency medicine. Workload demands, wellness and physician social equity, and concerns about value as a senior physician were described as major themes. Future directions for research include the role and type of leadership needed to mitigate the consequences of aging and increase the longevity of emergency physicians. 40 Research using a phenomenographic approach may also provide fresh insights into the value of senior physicians. 41 Further examination of the impact of hospital and departmental financial models on staffing in academic, academic-affiliated, and community hospitals may provide additional insight into solutions to the age-old question of how to age in emergency medicine.

Association of American Medical Colleges

A census of actively licensed physicians in the United States

American College of Emergency Physicians. Considerations for Emergency Physicians in Pre-Retirement Years

Issues of concern to emergency physicians in pre-retirement years: a survey

A national survey of academic emergency medicine leaders on the physician workforce and institutional workforce and aging policies

The aging physician and the medical profession: a review

Prestige of training programs and experience of bypass surgeons as factors in adjusted patient mortality rates

Proficiency of surgeons in inguinal hernia repair: effect of experience and age

Association between physicians' experience after training and maternal obstetrical outcomes: cohort study

Physician age and outcomes in elderly patients in hospital in the US: observational study

Surgeon age and operative mortality in the United States

Cognitive testing of older clinicians prior to recredentialing

Best practices in assessing aging physicians for professional competency

Opportunities and challenges in valuing and evaluating aging physicians

Generational influences in Academic Emergency Medicine: structure, function and culture (Part II)

The Delphi technique: myths and realities

Standards for reporting qualitative research: a synthesis of recommendations

What influences saturation? Estimating sample size in focus group research

A general inductive approach for analyzing qualitative evaluation data

The Coding Manual for Qualitative Researchers

Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups

Night shifts in emergency medicine: the American Board of Emergency Medicine longitudinal study of emergency physicians

Strategies for provider well being in the emergency department

Physician well-being

A systematic review of physician retirement planning

The business case for investing in physician well-being

Prevalence of burnout among physicians: a systematic review

Quality of work life, burnout, and stress in emergency department physicians

Physician stress and burnout

Probability of early retirement among emergency physicians

The unique environmental influences of acute care settings on patient and physician well-being: a call to action

Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout

Being Well in Emergency Medicine: ACEPs guide to Investing in Yourself

Retirement decision making and workforce implications

Systematic review: the relationship between clinical experience and quality of health care

Emergency physicians choose wisely when ordering plain radiographs for low back pain patients

Effects of physician experience, specialty training, and self-referral on inappropriate diagnostic imaging

The impact of emergency physician seniority on clinical efficiency, emergency department resource use, patient outcomes, and disposition accuracy

Physicians Feel Ageism Less Than Nurses. Medscape

Systematic literature review of leadership in emergency departments

Phenomenography: a qualitative research approach for exploring understanding in health care

The authors have no conflict of interest.

WB and EN were responsible for the design of the study. JB conducted the discussion groups. CA and JF provided the transcripts of the discus-