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Should Doctors Be Tested for Competence at Age 65?

Discussion in 'Doctors Cafe' started by Nada El Garhy, Apr 29, 2017.

  1. Nada El Garhy

    Nada El Garhy Golden Member

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    The Case for Testing Older Physicians

    Should older physicians be forced to stop practicing once they begin to slow down? Some experts in competency testing are calling for doctors to be evaluated as early as age 65, arguing that that's when physical and mental disabilities start to become apparent.

    A few hospitals have already started evaluating physicians in their 70s for competency. When results show significant impairment, these physicians are required to get remediation, submit to limitations of their privileges, or retire completely, depending on the severity of the impairment.

    Some experts argue that the cutoff age for these exams should be 65 years, which would have a huge impact on America's doctors. Owing to the baby boom, 240,000 doctors are now in that age group—a fourfold increase since 1975, according to the American Medical Association (AMA).


    In June 2015, delegates to the AMA decided to bring together stakeholders to create guidelines for such testing. But other physician groups are still on the fence, and the issue divides the medical community.

    Proponents of age-based testing say it's no longer permissible to simply allow aging physicians to determine when they should retire, because many of them stay on after impairment sets in. But critics assert that younger physicians are just as likely to be impaired, and targeting older physicians is unnecessarily humiliating.

    Senior Doctors Are Divided

    Doctors in their 70s are taking leading roles on both sides of the debate.

    Claire Wolfe, MD, a 71-year-old physiatrist in Dublin, Ohio, was a key player in the AMA's decision to draft preliminary guidelines. She's a member of the governing council of the AMA Senior Physicians Section, which spearheaded the AMA's decision to take up the issue.

    Last year, the section introduced a resolution to the AMA House of Delegates calling for mandatory testing of older physicians. After spirited debate, the House referred the matter for study. The resulting study,[1]presented at this year's annual meeting, proposed what the AMA should do, and the House approved it in May with reportedly little debate.


    Dr Wolfe says there are several reasons why age-based testing is needed. "Unfortunately, older physicians don't always know when to quit practicing," she says, and "it's very difficult to get physicians to identify impaired colleagues" and convince them to quit.

    She says older physicians who aren't impaired should be allowed to practice no matter how old they are. Even when impairments are identified, every effort should be made to help physicians alter their practice without ending their careers, she says. But if they have serious impairments, such as dementia, they'll need to resign.

    Dr Wolfe fully expects that many physicians will resist age-based testing. "This isn't going to be an easy sell to the medical community," she says.

    Insurgents against the policy are already at the barricades—for example, Frank E. Stockdale, MD, also a septuagenarian. The 79-year-old breast cancer physician leads a group of 13 older physicians who have forced Stanford Medical Center to rewrite its age-based testing policy and have rallied Stanford faculty to come out against it.

    "Older physicians aren't the problem," says Dr Stockdale. "Mid-career physicians are responsible for a disproportionately higher number of bad outcomes."


    Although he's slowing down physically, Dr Stockdale says he has learned to adjust. "My memory isn't as good as it used to be and I don't play basketball anymore, but that doesn't mean I'm not competent to practice medicine," he says. "You learn to compensate." Older physicians tend to see fewer patients; focus on patients with less acuity; and spend more time with them, which patients like, he says.


    Dr Wolfe has a markedly similar view about her own ability to continue practicing. Although she now works just 2 days a week, she doesn't think she's lost her mental acuity. "If I started to lose it, my colleagues would tell me." But she thinks many other end-of-career physicians are less willing to quit when impairment strikes. "Doctors say they'll know when they need to quit, but in many cases they won't do it," she says.

    A Call for Preliminary Guidelines

    The AMA Senior Physicians Section is just a couple of years old, and age-based testing was a topic for the section to make its mark, Dr Wolfe says. "We thought this issue was where we could be of value to the AMA." For the past few AMA meetings, the section has been inviting experts on physician performance and quality to speak on the aging doctor. She says the sessions drew so many attendees that there were no chairs left.

    She's somewhat disappointed with the AMA report, however. The 21-page document "presented a lot of powerful reasons why testing is needed, but the recommendations didn't come out forcefully for testing," Dr Wolfe says. "A lot of people felt they were a little tepid."

    Rather than fully embrace this approach, the report states that "formal guidelines on the timing and content of testing of competence may be appropriate," and called for the creation of "preliminary guidelines."


    Dr Stockdale has a very different view of the AMA report. Having read many of the same studies cited in the report while on a Stanford committee probing the issue, he thinks it accepted favorable findings on age-based testing "with an uncritical eye." A lot of the studies, he maintains, "depend on samples that are too small, or make conclusions based on very slight differences in performance that have no clinical importance."

    The Stanford professor says his own informal review of the data shows that older doctors aren't responsible for more mistakes than those of other age groups. For example, when he looked at "never" events—serious events that could have been prevented—"the percentage involving older physicians was not disproportionate for this age group," he says.

    Some Hospitals Have Created Policies

    A small but growing number of hospitals have age-based testing policies, according to Jonathan Burroughs, MD, a healthcare consultant in New Hampshire.

    Altogether, he says, about 50 hospitals he advises have some kind of policy to screen older providers. He cites age-based testing programs at Driscoll Children's Hospital in Corpus Christi, Texas; Jewish Hospital and Sts. Mary and Elizabeth Hospital in Louisville, Kentucky; and Portsmouth (New Hampshire) Regional Hospital.

    In many cases, hospitals that initiated policies "had an issue with an older doctor who was incapacitated but had not yet gotten into trouble," Dr Burroughs says. "This was a ticking time bomb."

    He added that some hospitals considered age-related policies but then backed off, after pushback from doctors on staff. "They (hospitals) know this is the right thing to do, but they're worried about upsetting their doctors," Dr Burroughs says. "Ultimately, most hospitals are going to put patient safety ahead of physician autonomy."

    A formal policy on age-based testing is necessary, he says, because hospitals that choose to sanction on older physician will need to have an airtight case that he or she is too impaired to practice, and then provide solutions that treat the doctor fairly without violating the law.

    What's an Appropriate Cutoff Age?

    Dr Burroughs, a 65-year-old former emergency physician, thinks that hospitals should start testing doctors at his current age, because that's when age-based disabilities start to become pronounced in some physicians. But in his consultant role, he recommends age 70 years, and then seeks to reduce the age limit after the policy becomes more acceptable to physicians on staff.

    "It has to do with 'change management,'" he says. "A lot of doctors on staff are in their 60s and are more likely to accept the policy if it's limited to older physicians."

    Even at age 70, though, many physicians would be affected if every hospital had such policies. According to the Federation of State Medical Boards,[2] 64,000 physicians in their 70s had an active license in 2010.


    What's more, the number of older physicians has been rising as the baby boom generation reaches retirement. According to the AMA,[3] the proportion of physicians aged 65 years or older rose from 9.4% in 1985 to 15.1% in 2011.

    How would older physicians be tested? Under D Burroughs' approach, they would get a face-to-face "fitness to work" evaluation by a vocational specialist—someone who is trained to assess commercial airline pilots and other professionals. The evaluation takes about an hour and covers cognitive, metabolic, psychological, and physical domains. Doctors who have any possible deficits in any of these areas would be directed to a more intensive exam.

    Dr Burroughs says the initial evaluation costs about $300-$500, which he thinks the hospital should pay for. Doctors identified as impaired in some way would confidentially work out a mutually agreed-upon resolution with hospital authorities on what work they could continue to perform. For example, an older doctor might agree not to take overnight call, deal with lengthy surgeries, or work long shifts.

    Experts often mention the option of simply stopping doctors from practicing when they reach a specific age. For example, US commercial pilots are required to retire at age 65 years, and 15 years ago, some hospitals in Britain's National Health Service required surgeons to retire at age 65, but that policy has reportedly been rescinded.

    Mandatory retirement would be easier to administer than testing programs, but experts have roundly rejected this option, noting that many physicians are quite capable of practicing into their 80s (such as famed cardiac surgeon Dr Michael E. DeBakey) and that forcing all older doctors to retire would hasten a looming physician shortage. Almost one third of physicians were 60 years of age or older in 2012, according to the Association of American Medical Colleges.[4]

    The Push to Standardize Policies

    AMA officials are just beginning to plan how they'll carry out the House's recent action, according to Richard E. Hawkins, MD, vice president of medical education programs at the AMA. The first step is to convene a meeting of stakeholders in such areas as continuing education, licensure, and certification, as well as representatives of medical societies, he wrote in an email to Medscape. Dr Hawkins added, "We expect the first meeting to be held in the next 6 months."

    Although no state or specialty society has endorsed age-based testing, some of them are studying the matter. In emails to Medscape, a spokesman for the American College of Surgeons (ACS) said that an ACS task force is focusing on the matter, and a spokeswoman for the California Medical Association (CMA) said that it is studying the issue.

    The CMA is already tangentially involved in the issue. Along with the California Hospital Association, it sponsors a coalition called California Public Protection and Physician Health, which issued a guideline,[5] on how hospitals and group practices should conduct age-based assessments while still observing older physicians' legal rights.


    The guideline, released in April, states that assessments should include a physical examination, peer assessments, and a test of cognitive functions, which may be followed by further testing if any concerns are raised. Physicians identified with possible impairments would then meet confidentially with medical staff representatives to discuss reducing their scope of practice, or even dropping their privileges.

    The guideline, which elicited input from healthcare lawyers, stated that as long as these physicians make voluntary changes in privileges, they wouldn't be reported to their licensing board.

    Speaking of which, why not have specialty or licensing boards conduct age-based testing? Although seemingly logical, proponents of age-based testing tend to oppose this approach. "I think doctors would be very apprehensive about getting the licensure boards involved," Dr Wolfe says. "The concern would be that the process might not be confidential." Moreover, the boards haven't expressed any interest in taking on this issue.

    Stanford's Policy Under Fire

    The struggle over Stanford Medical Center's age-based testing policy shows how difficult it can be to implement such policies.

    The medical center initiated an age-based testing program in 2012 for doctors on staff who were approaching age 75 years. Around 17 physicians, including Dr Stockdale, were scheduled to have a physical exam, cognitive test, and peer review. But Dr Stockdale says he and several others refused to take the cognitive test, questioning its validity. "The administration was put in a tight spot," he recalls. "If they had followed the policy, they would have had to remove all of us, but they didn't want to do that."

    So the medical center set aside the cognitive test and appointed a committee, including Dr Stockdale, to study the test's validity. After 2 months surveying the literature, he says, the committee concluded that the cognitive test "does not rest on sound scientific grounds" and called for an end to the program.

    In an email to Medscape, Ann Weinacker, MD, a Stanford quality improvement expert representing the medical center, confirmed that the cognitive test was dropped because "there are insufficient data at present to support cognitive screening of late-career physicians."

    Instead, she says, Stanford is using "a more robust peer-review process," which both sides agree has been validated. Peer reviewers fill out the Clinical Excellence Core Competencies Evaluation form,[6] which is already used to evaluate residents. Dr Stockdale says low scores for residents have been linked to higher levels of disciplinary actions against them later in their careers.


    In response to the committee's call to end the program, the administration put it up for a vote. In what was reportedly the largest voter turnout ever among physicians on staff at the medical center, the policy prevailed, by a margin of 53% to 47%.[7]


    Dr Stockdale maintains that many physicians voted "yes" to please department chairs aligned with the administration. He and his allies pressed on with their campaign, however, bringing the matter to the attention of the Stanford University Faculty Senate—which represents all faculty members, not just doctors.


    In May, the faculty senate heard arguments from Dr Stockdale's group opposing the policy, and from Dr Weinacker and the dean of the medical school in its defense. The faculty senate then voted 20 to 9 to reject the policy.


    Dr Stockdale argues that the vote should be binding because Stanford faculty members are on staff at the medical center. But the administration contends the vote isn't binding because the medical center is independent of the university.


    Has anyone failed the Stanford assessment since its adoption? In her email, Dr Weinacker replied that the testing is "not a pass/fail screen," but rather, "it is intended to evaluate for concerns that may require further evaluation." She wouldn't say whether any doctors required further evaluation, but Dr Stockdale says that to his knowledge, no one has been found to be subpar, and no limitations have been put on anyone's privileges.

    How Big Is the Problem?

    There's no well-informed estimate on how many impaired older physicians might still be practicing, but there are many scientific studies on various aspects of this topic. The AMA report cites 72 such studies, many of which point to issues with older physicians, although they may not necessarily be age-related. For example:

    • A 2005 study[8] showed a much higher rate of disciplinary actions against doctors out of medical school for 40 years compared with those out of school 10 years.

    • Another study, also from 2005,[9] indicated that performance on a range of outcomes declined as physicians' years in practice increased.

    • A 2008 study[10] found "no notable relationship" between older physicians' own assessment of their cognitive skills and objective cognitive measures, indicating that the physicians may be unaware of their impairments.

    • Older surgeons, although competent in routine operations, performed more poorly in complicated procedures, such as coronary artery bypass graft surgery, according to a 2006 study.[11]
    But even the most convincing studies show that a significant percentage of older physicians have no serious competency problems, even when they're at an advanced age. For example, a 2010 study[12] found that one third of surgeons in their 70s still matched younger surgeons in competence on a variety of tasks.


    However, Dr Stockdale disputes that loss of cognitive ability is the main reason why physicians make mistakes. "The major reason for errors," he says, "is not cognitive problems but behavioral ones," such as alcoholism, substance abuse, and failure to document, which occur more frequently in younger physicians. "The mid-career is a more risky time for physicians," he asserts. "These doctors are 15 years or more beyond training, and what they learned has started to wane."

    Rather than focus on end-of-career physicians, Dr Stockdale believes hospitals should beef up evaluations of all doctors, regardless of age. He noted that the Joint Commission already requires hospitals to regularly evaluate physicians' competence[13] in six areas, including patient care, clinical knowledge, and interpersonal skills.

    Is Cognitive Testing Right for Physicians?

    Owing to concerns about cognitive impairment in older physicians, many age-based testing programs use cognitive tests, such as MicroCog™ and the Montreal Cognitive Assessment, as assessment tools. Such tests have been used for years by physician health programs, which evaluate doctors who may be impaired.

    In many age-based testing programs, physicians start with a fairly short cognitive screening, such as the Mini-Mental State Examination. If the findings show any concerns, doctors then get the full-blown exam, which is given by a neuropsychologist and lasts about 10 hours, spread over 2 days.

    But as Stanford Medical Center concluded, cognitive tests haven't been validated for use on physicians. When scoring the test, the baseline for the general population is known, but experts say physicians should have to meet a higher baseline, which hasn't yet been identified.


    To establish the physician baseline, researchers would have to a conduct a very expensive round of testing in each metric, according to Peter Donovick, PhD, a neuropsychologist at Binghamton University in Binghamton, New York, who has tested physicians. "You would need to evaluate a large group of several hundred fully functioning physicians and put each of them through a thorough cognitive evaluation," he says.

    Doris Gundersen, MD, a psychiatrist who is president of the Federation of State Physician Health Programs and medical director of the Colorado physician health program, agrees that "no cognitive screening tests that I'm aware of have been validated specifically for the physician population," but she thinks age-based testing programs should use cognitive testing anyway. "We don't have the luxury of waiting for the 'gold standard' screening instrument," she says.

    However, some age-based testing programs in addition to Stanford's program don't use cognitive tests. The College of Physicians and Surgeons of Ontario requires active physicians who reach age 70 to be evaluated, but rather than use cognitive tests, they're assessed by their peers, who review the doctors' medical records and how they treat patients.[14]

    Some physicians would rather have peer review than a cognitive test. William Wilkoff, MD, a 70-year-old pediatrician in Brunswick, Maine, who retired 2 years ago, says he would feel uncomfortable with a cognitive test. "I wouldn't want to know that I have incipient Alzheimer disease and have only a few more years of clear thinking ahead of me," he says.

    This glimpse into the future is made possible with cognitive testing. In fact, Dr Gundersen and a colleague reported[15] that 80% of the physicians identified with mild cognitive impairment would develop dementia within 6 years.

    How Should Surgical Skills Be Evaluated?

    In addition to cognitive testing, many experts believe that surgeons and other procedure-oriented specialists should be further tested, on such things as hand/eye coordination, visual acuity, and trembling hands.

    The Aging Surgeon program at Sinai Hospital in Baltimore, for example, offers tests of surgical skills, such as the Biodex Balancing System™ (Biodex Medical Systems, Inc.; Shirley, New York), and Vision Coach™ 1 and 2 (Perceptual Testing, Inc.; San Diego, California). Mark R. Katlic, MD, chief of surgery at Sinai and founder of the program, says he's received about 100 inquiries from hospital CEOs and chiefs of surgery who have aging surgeons suspected of having impairments. However, no one has enrolled in the program yet.

    One reason may be the cost—$17,000 for 2 days of both physical and cognitive skills testing. Another reason is that sometimes, the need for testing goes away. "A number of these older surgeons voluntarily retired when threatened with our program," Dr Katlic says.


    Stuart A. Green, MD, a retired orthopedic surgeon, has studied surgical skills tests, such as computer-based exercises that teach surgical skills to residents. He has also looked at some of the same tests that Dr Katlic offers, such as quickly pointing to dots that pop up on a screen, and believes that computerized tests of driver's skills could be adapted for surgeons. But none of these tests have been validated to assess whether surgeons should continue practicing, he says.

    Dr Green became interested in age-based testing several years ago, when he served on the ethics committee of the American Academy of Orthopaedic Surgeons (AAOS). "Hospitals were trying to push out older physicians who seemed to be at risk," he recalls, and these surgeons would write the AAOS asking for help.

    At first, Dr Green opposed age-based testing. But after meeting a surgeon who seemed to be cognitively impaired—and whose problem had been covered up—he proposed that the AAOS endorse such testing, but there wasn't much interest, he says. He felt vindicated when he read about the AMA vote.

    "I was waiting for the moment when someone would do something about this," he says. Now 72, Dr Green has stopped practicing because of back pain and not cognitive impairment, but he still teaches residents.

    Concerns About Overzealous Enforcement

    Some critics of age-based testing programs are concerned that they'll drive away older physicians who would rather retire than face the possibility of being diagnosed with dementia. "In an effort to identify a few addled physicians," Dr Wilkoff says, "how many really talented older physicians would you discourage from further practice?"

    Indeed, Dr Gundersen reports that when one hospital implemented an evaluation program for physicians at age 70, the handful of doctors who would be affected chose to retire rather than take the test—much the same as Dr Katlic discovered at Sinai Hospital.

    "It was simply because the policy was new and unfamiliar to these older physicians, who may have anticipated discipline," Dr Gundersen says. She thinks the problem could be addressed by being sensitive to affected doctors and educating them about the process.


    Dr Burroughs conceded that testing programs could get too "proscriptive." For example, he says physicians who have no significant deficits might be forced to limit their privileges, or the hospital might simply rely on the results of a cognitive screening test, rather than a vocational specialist's face-to-face evaluation.


    Such concerns point to the need to create guidelines for testing programs, as the AMA plans to do. Rather than forcing someone to retire, many programs allow older physicians who have been identified with impairments to opt for remedial training on their weaknesses, such as clinical record-keeping. Or they could agree to restrict their activities, such as not taking call, dropping procedural work, and seeing fewer patients while spending more time with each one.


    "In many cases, the solution is to change the way you practice, rather than to end your career," Dr Gundersen says. "Physicians will accept these programs once they see that only in some doctors will deficits be identified, and when they witness that these physicians will be treated in a confidential and respectful manner."

    What About Age Discrimination?

    Several federal laws, including the Age Discrimination in Employment Act, protect older physicians against adverse actions, even when they're just on staff and aren't direct employees of the hospital.

    Several attorneys who have studied the matter say age-based testing programs can comply with federal laws. Edwards Wildman Palmer, a large Boston law firm, reports[16] on its website that the program must demonstrate that it's "reasonably necessary" for public safety and that it would be impractical to test every doctor on staff individually.

    However, the risk of being charged with age-based discrimination by the Equal Employment Opportunity Commission (EEOC) in these cases is real.


    Consider the case of Warren Guntheroth, MD, a cardiologist at the University of Washington (UW) Medical School, as reported[17] by the Seattle Times.

    In 2006, when Dr Guntheroth was 79, the medical center started to investigate his skills after he was accused of becoming isolated from other doctors, writing inappropriately short assessments of patients, and misreading cardiology tests.

    Three outside doctors appointed to assess Dr Guntheroth concluded that only his clinical documentation was poor. As a result, UW decided to restrict his privileges. His patient records were monitored, he was limited on where he could practice, and he was required to attend sessions on cardiology topics.

    Dr Guntheroth claimed he was being retaliated against for publicly criticizing the medical school on several policy issues, and he reported the medical school to the EEOC. UW insisted that it wasn't engaging in age discrimination because none of the 14 other on-staff physicians older than 70 were under review.

    In 2008, the EEOC concluded that Dr Guntheroth had not "engaged in misconduct which would warrant the adverse treatment" he received, and there was "reasonable cause" to believe that he'd been discriminated against. Nevertheless, the EEOC didn't take any further action. To force UW to revoke its action against Dr Guntheroth, the EEOC would have had to sue the university, and the agency rarely brings lawsuits, the Times reported.

    Conclusion
    The AMA's ability to produce guidelines on age-based testing will depend to some extent on whether other physician groups endorse the policy, which they have balked at doing so far. Yet even if the AMA comes up with guidelines, it will be up to each hospital to adopt them, unless the Joint Commission establishes requirements.

    The policies themselves will need to weigh patient safety against the ability of physicians to continue practicing. Speaking on behalf of surgeons, Dr Katlic says, "We need to balance patient safety and liability risk with respecting the dignity of surgeons and their value to society."

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    Ghada Ali youssef likes this.

  2. Ghada Ali youssef

    Ghada Ali youssef Golden Member

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    I remember having a physiology doctor who has Alzheimer , one of my friends had his oral exam with this doctor ,, he says he paused a lot and repeated same questions

    so unproffesional
     


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