Should Doctors Be Tested for Competence at Age 65?

Leigh Page

Disclosures

October 28, 2015

In This Article

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."

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