Published On Jun 10, 2015
Out of Practice
Does being a physician come with an expiration date? And if it should, how can age-related competence be measured?
WHEN PETER W. CARMEL recently turned 78, the former president of the American Medical Association reflected on what it means to be a surgeon. “The image of myself, the image I have of me in my head, is of someone who can do very delicate, intricate operations,” says Carmel, chair emeritus of the Department of Neurological Surgery at the University of Medicine and Dentistry of New Jersey. During most of his career, the operations he performed tended to be grueling affairs, many lasting more than 12 hours. “The reality is I can no longer physically do that,” he says.
Over the past eight years or so, Carmel has gradually cut back to where he now spends no more than 90 minutes at a time in surgery. And like an athlete who ramps down his training, Carmel has seen his stamina in the operating room wane. Having begun to question what will happen if something goes wrong, even in a simple case, he expects to give up surgery entirely this year, continuing to see patients only in his office.
Stepping back incrementally from medical practice in this way is one solution for a generation of aging physicians. A Virginia Healthcare Workforce Data Center survey found that by age 65 more than one-third of physicians still on the job were working part-time; by 70, fewer than half still had full-time schedules. Presumably, most of those doctors have cut back because they wanted to, and that’s how Carmel thinks it should work—that physicians can be trusted to do the right thing, curtailing or ending their medical careers when aging begins to impinge on their ability to practice safely.
Yet not everyone quits when it’s time, and researchers who study aging among physicians have come across stories of dangerous decline. One surgeon, revered as a mentor, never fully learned laparoscopy, and his open abdominal surgeries got so bloody that for years his hospital staff had to order extra blood whenever he operated. Another older physician, only marginally competent, was kept around because of the size of his practice. And a solo internist got by only because his wife, who was not a doctor, stepped in to “guide” him through his work.
Surgeon Ralph B. Blasier of OSF St. Francis Hospital in Escanaba, Mich., who also has a law degree, has written about the issues of aging physicians, and he points out that getting older causes physical and cognitive decline in everyone. But when it happens to doctors, the consequences for their patients are potentially lethal. Blasier cites a study in Neurology that found a direct correlation between the length of time a surgeon has been licensed and the likelihood that a patient will die during carotid endarterectomy. He also points to a Clinical Orthopaedics and Related Research study of knee replacement in which patients of younger surgeons had fewer complications.
Still, there’s little hard-and-fast evidence that older doctors are generally worse for their patients. A University of Michigan study of more than 460,000 patients found that for most procedures the age of the surgeon didn’t predict outcomes. Advanced age was more likely to cause trouble in complex procedures or when an older surgeon performed surgeries with less frequency.
Against this backdrop, what, if anything, needs to be done? And what’s the best way to determine who may no longer have what it takes? Chronological age, by itself, is almost certainly not a good gauge, and laws against age discrimination make it difficult to dictate that physicians must retire at 65—or at 75 or 85. Yet leaving it up to doctors themselves runs the risk that physicians who are no longer competent may cause injury or death.
Medicine is a hierarchical field that has always revered its seniors and storied experts. Now the profession faces a time when some of those men and women must be asked to come down from their pedestals and be assessed for their basic abilities to continue to help their patients.
THERE ARE MANY REASONS, of course, why physicians might want to keep going even when skills falter. Prestige, money or a sense of vocation tied closely to identity all play a role. Or doctors simply may not realize they’re slowing down, says William Norcross, executive director of the University of California, San Diego’s Physician Assessment and Clinical Education (PACE) Program. “Some of my most difficult cases have been when I’ve had to explain to older doctors that their hand-eye coordination is deficient and their memory is failing and their ability to think through complex situations is demonstrably bad,” Norcross says. “Nine times out of 10, their answer is, ‘You must be wrong. I feel fine.’”
Such conversations are made more difficult because there is rarely a bright line between competence and incompetence, and evaluation measures may be failing to assess physicians effectively throughout their careers—not just at the end. The Joint Commission, an independent organization tasked with accrediting and certifying health care organizations, requires doctors to undergo assessments such as the Ongoing Professional Practice Evaluation (OPPE) to be reappointed to a hospital staff. Yet some physicians feel that OPPE indicators aren’t robust, and they tend to be aimed at discovering deficiencies in practice and mistakes that people have made, rather than looking at how to encourage and ensure competency.
Blasier observes that in his specialty of orthopedic surgery, initial board certification requires doctors to meet high standards, but the requirements for recertification are much weaker. Until 1986, orthopedic surgeons were granted lifetime certification, while those certified since 1986 now must be recertified within 10 years, and those who gained their credentials since 2000 are subject to an additional Maintenance of Certification (MOC) program. Only 6.1% of those who hold those pre-1986 lifetime certifications—older surgeons, in other words—now participate voluntarily in MOC.
IN EFFORTS TO FIND physicians whose competence and effectiveness might be faltering, some hospitals have initiated age-based assessments. At Driscoll Children’s Hospital in Texas, for example, physicians over 70 who are up for reappointment now have to undergo physical and cognitive evaluations assessing skills in their specialties. At Stanford Hospital and Clinics and at Lucile Packard Children’s Hospital in California, physicians get physical exams, cognitive screening and peer assessment at age 75.
Three years ago, the University of Virginia Health System also began testing doctors who are 70 or older. The UVA program uses the Repeatable Battery for the Assessment of Neuropsychological Status, which is designed to identify cognitive decline and scores doctors in areas such as language, delayed memory and attention. While RBANS has been used successfully to test other groups such as patients with Alzheimer’s disease, it’s difficult to know yet whether it can pick up cognitive changes that would be particularly useful in assessing physicians.
UCSD’s PACE program, meanwhile, runs full evaluations each year on about 100 physicians, a third of whom are surgeons or proceduralists. Almost all of those doctors come to PACE via referral, with a third sent because of state medical board disciplinary action and the rest by their hospitals or medical groups. At PACE, physicians of all ages (the average is about 60) undergo a weeklong assessment that can include simulated procedures and tests of clinical judgment; standardized tests of medical knowledge; and evaluations of interpersonal skills and patient interactions. A health screening and a cognitive performance screening, using a computerized test called MicroCog, are also required.
Norcross notes that MicroCog doesn’t produce a diagnosis. But when doctors perform poorly, PACE sends them for a full neuropsychological evaluation that may last six hours or more. Although that uncovers a few physicians who have dementia, milder cognitive deficits are much more common. “In those cases, we have to look at what particular problems mean in light of what the physician does for a living,” Norcross says. If someone’s having trouble with fine motor skills and hand-eye coordination, for example, that may have a very different impact on a neurosurgeon than on a psychiatrist.
According to Norcross, around 12% of doctors who are referred to PACE each year fail completely, meaning they are deemed unsafe to practice medicine. A fifth of referrals get an all clear and the remaining two-thirds pass with some level of remediation recommended. That remediation can range from a course to improve note-keeping or communication with patients to limitations on the scope of practice.
WHILE A PROGRAM such as PACE can serve as an independent tool for evaluating older physicians who have been flagged for problems, it comes fairly late in the game, when issues have become severe enough to come to the attention of medical boards or hospital committees. But at least in the case of physicians who are employees, any alternative that tries to head off trouble by imposing age-based limits on practice is likely to run afoul of federal antidiscrimination laws.
The Age Discrimination in Employment Act (ADEA) makes it illegal to discriminate on the basis of age against any worker age 40 or older in hiring, firing, pay, job assignments, promotions, layoff, training, fringe benefits and any other term or condition of employment. And while there are a few exceptions—for example, a company can make decisions based on age if there’s a bona fide occupational qualification (BFOQ)—BFOQs have been interpreted narrowly so that age can be used as a proxy for ability only when there is no other, more individualized way to get at the issue. Typically, the only way an employer can get around the ADEA is if it’s superseded by federal law, as it is for airline pilots.
That means that in most cases where a policy excludes employees based on their age, there is no effective legal defense against a charge of age discrimination. The act of any employer “drawing a line, based just on age, frankly would amount to age discrimination under the ADEA,” says Carol Miaskoff, acting associate legal counsel for the U.S. Equal Employment Opportunity Commission (EEOC).
What’s more, under the Americans with Disabilities Act (ADA), an employer cannot require a medical examination without specific evidence that a medical condition is causing problems at work, and “the medical exam has to be proportional to the problem that triggered it,” notes Aaron Konopasky, senior attorney advisor at EEOC.
The ADEA and ADA are employment laws, and although the proportion of physicians employed by hospitals is rising—from 16% in 2006 to more than 25% today—most doctors still aren’t employees and at least technically don’t qualify for these protections. A licensing board that required age-based assessments couldn’t be challenged under the laws, even if that license was a requirement for a particular job. And assessments of skills, rather than medical health, would also fall outside the scope of ADA and ADEA protections if they were not triggered by age or a suspected medical condition. In practice, however, just the existence of these laws—and their underlying message that it’s wrong to use age as a tool to force people out of their professions—has seemed to discourage the use of such measures even when doctors aren’t employees.
OUTSIDE OF MEDICINE, a few professions do have mandatory retirement ages. Airline pilots and federal agents must retire at 65 and 57, respectively, and state and local governments set the ages at which police and firefighters must leave the job. And while having the same sort of automatic cutoffs for physicians may not be likely or even desirable, the life-or-death nature of their work does suggest a need for some kind of evaluation to ensure that doctors continue to practice safely as they age. “We just have to make it more acceptable” to assess older doctors’ abilities, says UCSD’s Norcross. “Pilots are intensively assessed, and if any problem is found it has to get fixed, or they don’t fly.”
For now, at least, it’s largely up to physicians themselves to know when to stop. When Carmel was chair of his department, he gave his power of attorney to a colleague and asked that surgeon to make sure Carmel’s medical privileges were revoked if he saw that Carmel was no longer competent.
Various types of checks and balances are common within surgical groups, Carmel says. But those amount to a voluntary and piecemeal approach to a problem that will only become more pronounced as the general population ages. Hospitals and medical boards need to get involved, perhaps by requiring a deeper level of ongoing assessment, with teeth. The painful reality is that everyone gets older, and there can’t be any special dispensation for doctors when the time comes to call it quits.
“Practicing Medicine Longer: The Effects of Aging on Physician Clinical Performance,” by Stephen Miller. UCSD TV, January 16, 2012. A video lecture that argues for ongoing physician evaluation.
“Do Physicians Referred for Competency Evaluations Have Underlying Cognitive Problems?” by Lauri L. Korinek et al., Academic Medicine, August 2009. The authors find cognitive difficulties in physicians referred for competency evaluation.
“Medical Masters: A Pilot Study of Adaptive Ageing in Physicians,” by Carmelle Peisah et al., Australasian Journal on Ageing, September 2009. A study of doctors deemed by their peers to be dealing well with aging.