Should Doctors Be Tested for Competence at Age 65?

Leigh Page


October 28, 2015

In This Article

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.


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