A systematic review of physician retirement planning

Background Physician retirement planning and timing have important implications for patients, hospitals, and healthcare systems. Unplanned early or late physician retirement can have dire consequences in terms of both patient safety and human resource allocations. This systematic review examined existing evidence on the timing and process of retirement of physicians. Four questions were addressed: (1) When do physicians retire? (2) Why do some physicians retire early? (3) Why do some physicians delay their retirement? (4) What strategies facilitate physician retention and/or retirement planning? Methods English-language studies were searched in electronic databases MEDLINE, Web of Science, Scopus, CINAHL, AgeLine, Embase, HealthSTAR, ASSA, and PsycINFO, from inception up to and including March 2016. Included studies were peer-reviewed primary journal articles with quantitative and/or qualitative analyses of physicians’ plans for, and opinions about, retirement. Three reviewers independently assessed each study for methodological quality using the Newcastle-Ottawa Scale for quantitative studies and Critical Appraisal Tool for qualitative studies, and a fourth reviewer resolved inconsistencies. Results In all, 65 studies were included and analyzed, of which the majority were cross-sectional in design. Qualitative studies were found to be methodologically strong, with credible results deemed relevant to practice. The majority of quantitative studies had adequate sample representativeness, had justified and satisfactory sample size, used appropriate statistical tests, and collected primary data by self-reported survey methods. Physicians commonly reported retiring between 60 and 69 years of age. Excessive workload and burnout were frequently cited reasons for early retirement. Ongoing financial obligations delayed retirement, while strategies to mitigate career dissatisfaction, workplace frustration, and workload pressure supported continuing practice. Conclusions Knowledge of when physicians plan to retire and how they can transition out of practice has been shown to aid succession planning. Healthcare organizations might consider promoting retirement mentorship programs, resource toolkits, education sessions, and guidance around financial planning for physicians throughout their careers, as well as creating post-retirement opportunities that maintain institutional ties through teaching, mentoring, and peer support.


Background
Over the last 40 years, across multiple jurisdictions, a pattern has emerged whereby a disproportionate number of physicians continue to practice beyond the traditional retirement age of approximately 65 years old [1,2]. Accordingly, healthcare organizations often do not have effective succession strategies in place to manage their aging medical staff. The consequences of an older physician workforce can be dire and far-reaching. Replacing invaluable and experienced older physicians with trained but inexperienced younger physicians can be difficult [3]. In addition, the link between advancing age and deteriorating health may lead to increased medical errors, putting patient health at risk [4].
For an experienced physician, the decision regarding when to transition from practice to retirement can be about more than clinical [5] and technological competency [6], it can also involve internal emotional struggles. This is particularly the case when individuals have a strong sense of value attached to their work [7]. Evidence suggests that physicians' adjustment to later career transitions can be facilitated by planning for retirement [8]. The objective of this review was to examine when physicians retire, why they retire early or delay retirement, and what strategies exist to facilitate physician retention and retirement planning. To our knowledge, no earlier studies have consolidated the literature with these questions in mind amidst the widespread call in the literature for such recommendations [9].

Methods
The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed in the production and reporting of this systematic review [10].

Study selection
Published articles were comprehensively searched using MEDLINE, Web of Science, Scopus, CINAHL, AgeLine, Embase, HealthSTAR, ASSA, and PsycINFO databases from inception up to and including March 2016. Our search strategy included the keywords "physician" and "retire" with all appropriate synonyms. All authors participated in the identification and final selection of studies.

Study eligibility
The PRISMA flow diagram in Fig. 1 depicts the numbers of identified records, excluded articles, and included studies. Our inclusion criteria included published primary peer-reviewed journal articles with quantitative and/or qualitative analyses of physicians' plans for, and opinions about, retirement. Excluded studies were non-primary research studies (editorials and commentaries), articles that grouped physicians with other healthcare professionals, or that only included dentists. After discussion, all authors agreed to constrain the search strategy to English-language articles, with no limitations on publication date up to March 2016. The search was supplemented by handsearching the references of eligible studies and relevant review articles.

Data extraction
The following information was extracted from qualifying studies: (i) geographic information, study design, data collection methodology, response rate, physician specialty; (ii) expected and actual retirement age; (iii) descriptive statistics related to demographic characteristics of the sample; and (iv) findings related to reasons for retiring, reasons for delaying retirement and obstacles to continued practice.

Quality assessment
Three authors (ADH, AB, and NW) worked in pairwise rotation to independently review qualifying articles for methodological quality. The corresponding author (MPS) resolved any disagreements that could not be settled by consensus. We used the seven-item, Newcastle-Ottawa Quality Assessment Scale to assess the risk of bias for the 55 studies that had used quantitative methods [11]. The adapted Critical Appraisal of a Qualitative Study Tool from the Center for Evidence-Based Management was used to assess 10 studies that used qualitative methods [12]. All studies examined by quality assessment were given equal weighting and both quality assessment tools were selected on the basis of previously demonstrated reliability and validity when examining the views of healthcare professionals [13][14][15].

Terminology
Early retirement is referred to in this study as either retirement that occurs earlier than the physician had planned [16] or to an exit from their profession at a relatively early age (i.e., younger than age 65) as compared to peers [17]. On time retirement refers to the conventional age of retirement, that is, at or around age 65 [18]. The literature commonly refers to retirement as late or delayed if physicians continue to work in a full-time capacity beyond the traditional age of retirement [19].

Synthesis
Thematic analysis was used to identify and stratify concepts related to physician retirement timing into themes and subthemes [20]. Thematic analysis is an inductive qualitative data analysis process in which data are prepared, then organized using open coding to create categories and themes to build a conceptual understanding of a particular phenomenon and analyze the meaning of data within their particular context [21]. Table 1 summarizes the characteristics of the 65 studies included in this review. The studies were published between 1978 and 2015, with 33 studies based in the United States, others in Australia, Canada, Finland, Israel, Netherlands, New Zealand, the United Kingdom, and one across 20 countries of high-, medium-, and lowincome economies. A variety of practicing and retired physicians were sampled with a range of specializations from general and multidisciplinary physicians to anesthesiologists, dentists, general and specialist surgeons, obstetrician-gynecologists, otolaryngologists, ophthalmologists, pediatricians, psychologists, radiologists, and urologists. Tables 2 and 3 summarize the quality of the included studies. Qualitative studies [9,18,[22][23][24][25][26][27][28][29] were found to be methodologically strong, with credible results deemed relevant to practice. The majority of quantitative studies had adequate sample representativeness (76% of studies), had justified and satisfactory sample size (89% of studies), used appropriate statistical tests (59% of studies), and collected primary data by self-reported survey methods (91% of studies). Studies were rated poorly on the ascertainment of exposure (i.e., how the outcome of interest was obtained either by secure record, structured interview, or self-reported) due to the use of nonvalidated measurement tools (51% of studies). Nearly half (49%) of the studies were rated poorly for comparability since they did not control for any potential confounders.

Physician retirement age
Physicians' actual retirement age and their intended or planned retirement age are distinguished in Table 4. Physicians' intended or planned retirement age refers to the age they speculate they will most likely be when they reach retirement [30]. This differs from physicians' actual retirement age, represented by the chronological age at which they reported being fully retired [31]. Comparisons of on-time, early, and delayed retirement were made in a context relative to physician peers [16,32,33] and across subspecialties [31,34]. In some instances, comparisons were made to other professional groups such as social workers [35].
Our findings suggest the average age for actual and expected retirement was commonly reported to be between 60 and 69 years, respectively. Several studies [7,18,22,30,31,[36][37][38][39] examined the age that physicians expected to retire, and the age they actually retired (underlined in Table 4). The actual retirement age was found to be consistent with their expected retirement in all studies where the actual and expected retirement ages were jointly reported. These studies highlight that a variety of methods are used to determine usual age at retirement and that physicians' retirement intentions can, but not always, translate into actual retirement behaviors.

Reasons for retiring early and obstacles to practice
Common reasons for retiring early included low job satisfaction, medicolegal issues, health concerns, and financial troubles. Low job satisfaction involved perceptions of low job control, low morale, and dissatisfaction with the internal justice system of medicine as a self-regulated profession [5,9,28,40]. This disillusionment was expressed by a sense of frustration with colleagues [27,35], feeling undervalued, lacking prestige [16,41], and a loss of interest in their work [10]. Excessive workload [17,42] and burnout     were associated with intentions to retire [28,43]. Medicolegal issues often arose from a lack of satisfaction with the regulation of medicine for reasons of unwelcome change, bureaucracy, oppressive management [26,35,44], and issues with physician partners [26,45]. Experiencing poor health, cognitive decline, difficulty sleeping, and psychological distress were also factors leading to a physician's retirement [15,18,19,34,36,38,[46][47][48][49][50].  (2) Statistical test: A, the statistical test used to analyze the data is clearly described and appropriate, and the measurement of the association is presented, including confidence intervals and the probability level (P value) (1 point); B, the statistical test is not appropriate, not described or incomplete (no points).
The decision to retire early was also linked to preserving one's health to lead a healthy retirement [51,52]. Financial issues contributing to a physician's early retirement included: increasing costs of retaining a practice, malpractice costs, and other economic pressures [5,25,37,39,47,52], insufficient financial remuneration, and pension security [7,46,52,53]. However, one study [42] found that retirement was not associated with perceived adequacy of finances, or general health status. Several studies noted that physicians working in institutions or in countries where the policy landscape changed considerably were more inclined to retire in part due to poor work satisfaction that resulted from changing circumstances around the delivery of care and doctoring regulations [29]. Table 5 summarizes the obstacles related to continuing practice.
The continuation of medical practice is deeply rooted in a desire to keep active and focus on the social and intellectual elements of continuing to practice [46,47,56]. Physicians expressed concerns over their decision to retire, due to fear of losing their primary identity or purpose [9,19,50,57], or being uncomfortable with the methods used to enforce their retirement [58]. Retirement concerns also stemmed from personal issues such as a fear of potential changes in the relationship with their spouse following retirement [58], a fear of excessive leisure time Table 3 Assessment of qualitative studies included in this review Batchelor, 1990 Is the research method (study design) appropriate for answering the research question?
How was the fieldwork undertaken? Was it described in detail? Are the methods for collecting data clearly described?
Could the evidence (fieldwork notes, interview transcripts, recordings, documentary analysis, etc.) be inspected independently by others?
Are the procedures for data analysis reliable and theoretically justified? Are quality control measures used?
. Was the analysis repeated by more than one researcher to ensure reliability?
Are the results credible, and if so, are they relevant for practice?
Are the conclusions drawn justified by the results?

Strategies to facilitate physician retention and retirement planning
Key strategies to facilitate physician retention and retirement planning included offering flexible work hours, minimal work barriers, enhancing work satisfaction, prioritizing physician health, and attention to finances. In particular, options such as part-time employment and less bureaucracy were suggested as ways to facilitate a working environment that would be amenable to physicians overburdened by work demands in ways that might foreshorten their career. In addition, providing opportunities for professional development to help physicians develop or change the content of their work was offered as an important means of retention, as well as a mechanism for making successful later career transitions out of medicine. Attention to personal matters such as physicians' own health and finances in ways that reduced work-related stress or protected physicians' income through pension plans were also important in enhancing physician retention and enticing continued practice. Table 6 summarizes the retention schemes described by the studies included in this review.

Discussion
Our review confirmed that physicians are likely to remain in their practice beyond the traditional retirement age of 65. To put these results into context, it is worthwhile to first consider that in recent decades, workers are generally tending toward later retirement. While a person aged 50 in the workforce during 1997 was expected to continue working 13 more years, an average worker of the same age in 2009 was expected to work an additional 3 years, eventually retiring at an age of 66 on average [60]. This systematic review illustrates that the average age physicians expect to retire lies closest to age 60 while their age at actual retirement is closer to 69. This represents an average of 3 years later than the general population. Retirement trends have been shifting over the last few decades in response to an increasing lifespan, adjustments to economic market fluctuations, and concerns about the sustainability of social security entitlements [61,62]. In particular, concerns about economic market fluctuations are particularly relevant for physicians who tend not to have access to group pension funds that other workers, such as teachers or health-care administrators, might have access to. We found delayed retirement among physicians is likely to be influenced by flexibility and intensity of working hours, work satisfaction, career opportunities, resource adequacy, intrinsic value, convenience, financial incentives, and relations with co-workers. As one might expect, these are many of the same determinants that impact retirement among other professionals. However, it is also likely that other factors such as attachment to work and strong work identity may serve as an additional rationale for working beyond the traditional retirement age [29]. Furthermore, it is likely that the advanced training and late entry into the work force also renders physicians more likely to retire later than the average worker.
Physician's early retirement, like that of other professions, is often brought about by negative dimensions of work satisfaction. Where physicians may differ from the general population is in the complex nature of their work, which involves a unique combination of advanced training, autonomy, skill, experience, leadership, and decision-making that can have life or death consequences. Many studies have examined the implications  [39]; Hall [5]; Landon [49] Health: continuing good or better than expected health at expected retirement age, strategies to reduce work-related stress, support prioritizing health Brett [51]; Davidson [52]; Draper [80]; Luce [7]; Pit and Hansen [16] Finances: protected pensions, being highly paid, financial necessity Brett [51]; Davidson [52]; Eagles [30]; French [36]; Hall [5]; of physician burnout [43,63], thus suggesting that physicians face unique challenges as it relates to extending their careers. Physicians' early retirement is an important concern as other research attests to the risks to patient care associated with physician shortages [64]. While the studies examined in this review did not highlight gender as an important factor relevant to early retirement, there is evidence to indicate that there are high burnout rates among women physician [65]. This is likely to influence physician retirement rates in ways that were not captured in the studies reviewed here, and relevant given than women live longer than men on average and are increasingly entering medicine. Successful retirement planning was found to be related to being prepared for the financial demands, physical changes, and psychosocial dynamics associated with aging and leaving the workforce, consistent with prior research based on the general population [66][67][68]. Findings based on these studies of physicians suggest that a reduction of working hours may present as one of the most successful instruments for staff retention [17]. A shift toward non-clinical duties such as teaching and mentorship may also help with retention [42] and also facilitate knowledge transfer to younger professionals. The theory of purposeful work behavior [59] posits that, when job characteristics act in concert with individuals' motivational striving, psychological meaningfulness may be gleaned from their work. Thus, if physicians are given opportunities to pursue preferred work tasks such as teaching over clinical rounds [30,69], then their experiences of greater meaningfulness in their work may trigger task-specific motivation [70]. This can result in a willingness to continue working in hospital settings in a way that benefits the enterprise as a whole.
On the whole, health was also shown to be an important factor determining whether physicians chose to remain in the workforce. Excessive workload and poor health were found to be major reasons a physician may choose to retire. As such, healthcare organizations may consider strategies that improve physician health by addressing the physical fitness and risk-related habits of physicians. Some potential interventions might include fostering a culture that is supportive of taking sick days [71] along with proper mechanisms that allow physicians not to overburden one another when taking sick days. Findings from most of the studies included in this review also indicate that a supportive and highly satisfying work environment facilitates physician retention.
Organizations can have a role in facilitating the graceful and timely exit of the well-established physician but should exercise caution that the approach taken is not driven by ageist stereotypes or leading to feelings of being "pushed out" [26]. Physicians retiring beyond the traditional retirement age will have accumulated decades of knowledge and experience, and offer an invaluable resource to the medical enterprise [42]. The challenge is that, without foresight of the timing associated with physicians' plans for retirement, institutional hospital succession plans come to a halt. The timing of physician retirement becomes particularly salient, not only for human resources planning but also for patient care continuity and transitions of care in hospital enterprises where mentors of the younger hospitalist workforce may be scarce [3]. In this way, the medical enterprise must strike a delicate balance between encouraging preparation for retirement and delaying the timing and eventual transitions of its most experienced staff who will be replaced by a growing pool of younger physicians who stand waiting in the wings for professional opportunities.

Limitations and recommendations for future research
Research on the factors that influence physician retirement timing and planning for retirement is still in its early stages, and future exploration into the most promising interventions is needed to further delineate our preliminary findings. Some limitations of this review include the restriction to English language studies, which excludes the perspectives of physicians from non-English speaking regions. Furthermore, our analysis is based on a heterogeneous sample of physicians spanning across diverse specializations, with jurisdictional differences in regulations, mandatory retirement legislation, pension systems, and differences in remuneration across healthcare systems. In addition, because the studies examined in this review used a cross-sectional design and were limited in terms of the types of analyses they performed, we were unable to perform a meta-analysis of the included studies. Furthermore, our search was restricted to peer-reviewed literature, thus future research may enhance the findings of this study by examining the grey literature on this topic. Future studies can also benefit from exploring the healthcare context in which the physicians practice, gender differences as they relate to physician retirement planning and physicians' transitions from practice, and consider following physicians over time to better understand factors that facilitate planning for a transition from practice.
The abolition of policies of mandatory retirement across many countries has encouraged some physicians to extend their medical careers, generating greater unpredictability in later career transitions [5,31]. While several attempts, including our own study, have aimed at improving understanding of health workforce issues and implications of aging and timing of physicians' work, future policy research should continue forecasting physician retirement trajectories and human resource strategies in ways that can account for older physicians who want to remain in clinical practice beyond traditional retirement age [17,72,73]. Recommendations for next steps in policy reform at the organizational and health system level may come from within hospital and other related organizations which aim to address intentions to leave by improving psychosocial working conditions for the medical profession [64] and scaling back workloads to retain the best talent in experienced physicians [42]. Notably, healthcare managers may pursue recommendations for an "integrated" approach to recruitment, retention, and retirement planning that aids in better anticipating upcoming retirement transitions, shifts cultural attitudes toward retirement planning, and brings together a larger strategy to ameliorate succession planning.

Conclusions
Knowledge of when physicians plan to retire and how they can transition out of practice has been shown to aid effectual succession planning. This paper identified that the most common age of retirement for physicians was between 60 and 69. We examined the literature on reasons for early and delayed retirement, as well as strategies shown to be effective in supporting continuing practice. We found excessive workload, poor health, and low job satisfaction to be major reasons for why a physician may choose to retire early. Delayed retirement or reasons physicians' work lives were extended was explained by financial obligations, strong work identity, career satisfaction, and institutional flexibility. Strategies that supported continuing to practice included offering flexible work hours, minimal work barriers, enhancing work satisfaction, prioritizing physician health, and attention to finances. As this line of inquiry is still developing, we recommend future research and strategies consider the impact of a physician's flexible work hours, gradual reduction in responsibilities, and the ways in which resources for financial planning facilitate physician retirement planning. In addition, an important component of successful retirement planning concerns the creation of meaningful activity after retirement [31]; thus, healthcare organizations should consider promoting retirement resource toolkits, education sessions, and guidance around financial planning for physicians throughout their careers, as well as creating post-retirement opportunities that maintain institutional ties through teaching, mentoring, and peer support [68,69]. Preparation for a retirement that is tailored to physicians' career stages and specific age can avoid the complications that arise when a physician's career trajectory does not correspond to his or her expectations or what is in the best interests of the medical practice plan.