May 9, 2006 (Chicago) — As many as 8000 physicians in current practice are likely to have some form of cognitive impairment, and the existing medical literature provides little guidance. Only 5 articles on the subject have been published in the last 2 decades, according to the results of a study presented here at the annual scientific meeting of the American Geriatrics Society.
"Based on our own experience clinically of having cared for and evaluated physicians who either were suspected of, or turned out to have dementia, we started thinking about the problem of how you deal with this with respect to people who are actually still practicing clinical medicine," Greg A. Sachs, MD, told Medscape. Dr. Sachs is professor of medicine and chief of the Section of Geriatrics, Department of Medicine, at the University of Chicago Hospitals in Illinois. "When we went to do a formal literature review, we found that there was very little actually in print that directly addressed this."
Dr. Sachs described the poster as both a literature review and a conceptual analysis of how the dominant model of handling physician impairment falls short when applied to dementia.
The epidemiology is based on the prevalence of dementia in the general population, and the age of practicing physicians. Between 5% to 10% of the population aged 65 years or older has dementia, and approximately 80,000 physicians aged 65 years or older are active in patient care. Therefore, according to the study, as many as 8000 physicians may have dementia.
A MEDLINE search using the terms "physician impairment," "impaired physician," and "physician health" brought up 1653 articles, of which just 5 specifically addressed cognitive impairment or dementia, the authors note.
"On the one side is the dominant model, where physicians have problems like mental illness, depression, or substance abuse," Dr. Sachs told Medscape. "People recognize the problem, confront the physician, and the physician acknowledges that there is a problem. The physician then seeks treatment through various sorts of programs, is successfully treated in many circumstances, and is certified to return to work with some kind of ongoing monitoring."
This model does not work quite as well with dementia, according to Dr. Sachs. Older physicians are more likely to work in smaller practices, work alone, or in rural areas, he said. Or, they may be in positions of seniority, where peers and staff are reluctant to confront them.
Nor do screening tools necessarily perform well in highly educated people. "A physician could screen fine, even though they have significant problems," Dr. Sachs said.
Furthermore, he told Medscape, the vast majority of patients with Alzheimer's disease are not aware of their cognitive deficit. "It's not a matter of denial; they literally forget that they're forgetting. They don't have insight. So expecting someone with dementia to admit that there's a problem and seek treatment...the model starts to fall apart," said Dr. Sachs.
In addition, treatments available for Alzheimer's disease are modestly effective, while the illness is progressive and irreversible.
"Our conclusion was that basically there's very little research on this area. We need research, even about the prevalence of the problem, and new models for dealing with this issue," Dr. Sachs said.
He added that he would not try to guess the kinds of physicians who are likely to have dementia, "but if every one of those  physicians is taking care of, depending on their specialty, a few hundred or a thousand or a couple thousand patients, all of a sudden you multiply it out and you figure there may be tens of thousands or hundreds of thousands, or even more patients who are potentially currently being cared for by a physician with cognitive impairment."
Dr. Sachs explained that he and his coauthor, Caroline N. Harada, MD, also from the University of Chicago Hospitals, used criteria for dementia or Alzheimer's disease in their study, while some researchers would look for even earlier disease, such as mild cognitive impairment, a forerunner of Alzheimer's disease. "So potentially there are even more people who may have mild cognitive impairment who are practicing," Dr. Sachs pointed out.
In a request for independent commentary, Matthew McNabney, MD, assistant professor in the Division of Geriatrics at Johns Hopkins School of Medicine in Baltimore, Maryland, told Medscape, "It's pretty intriguing. Dementia in people who have higher education is sometimes harder to detect at an early stage. Although I have no idea what the prevalence of people with diagnosable dementia who remain in practice, that's certainly theoretically something that would be a concern," he said.
"Anecdotally, I can say there have been physicians that I have encountered that potentially have shown lack of precision in their thinking. The diagnosis would certainly be plausible," he told Medscape.
Dr. McNabney agreed that raising the issue would be awkward. "There is an additional layer of awkwardness when you're addressing it between peers, physician to physician, and that needs to be dealt with, or somehow confronted and addressed, to make sure that patient safety is assured," he added.
"It would be very delicate, because, implicit in that is that either now or in the near future, they're not safe to continue their trade. It's just like trying to tell somebody they should stop driving, or that they should not live alone. It's a direct threat to their independence and livelihood. So it's really difficult, yet obviously the right thing to do," Dr. McNabney concluded.
The authors report no relevant financial relationships.
AGS 2006 Annual Scientific Meeting: Abstract A39. Presented May 4, 2006.
Reviewed by Carol Peckham
Medscape Medical News © 2006
Cite this: Richard Hyer. Cognitive Impairment in Older Physicians May Be Widespread - Medscape - May 09, 2006.