Age-Based Testing of Physician Competence Stirs Controversy

Nancy A. Melville

April 04, 2017

DALLAS – As an ever-increasing numbers of physicians continue working well into older age, pressure is mounting to address the currently unresolved, and controversial, question of how, or if, age-based assessments of physician competency should be addressed.

"Our workforce of physicians is aging," said James Ellison, MD, MPH, the Swank Foundation Endowed Chair in Memory Care and Geriatrics with the Christiana Care Health System, in Wilmington, Delaware, in speaking at a session of the American Association for Geriatric Psychiatry (AAGP) 2017 on developments in the contentious issue.

"In 2020, 18% of physicians will be over 65, and yet these are very valuable people in terms of patient care, and for their own quality of life, many want to keep working."

In many cases, said Dr Ellison, that's not a problem ― key factors that are part of being a physician, including having generally higher baseline functioning and education ― help reduce some of the known changes in cognition that can occur with aging.

But other age-related changes, such as declines in visuospatial skill or manual dexterity, can be unavoidable and have a negative effect on the ability to practice, particularly in some areas of medicine, including the surgical specialties.

The American Medical Association (AMA) weighed in on the issue in 2015 with a call for guidelines on competency assessment testing. It currently has a task force working on possible solutions.

"The reason for the assessment is so we can police our own profession and maintain control without the need for mandatory retirement ages," said Dr Ellison.

Some professions, including those of air traffic controllers, pilots, and agents of the Federal Bureau of Investigation, have mandatory ages for retirement, but in medicine, efforts at mandatory assessment have not gone well.

In 2012, Stanford Hospital and Clinics implemented a controversial policy that required physicians aged 75 and older to undergo peer evaluation of clinical performance, cognitive and physical examinations, and other testing every 2 years.

Amid protest from physicians who criticized the policy as age discrimination, senior faculty members voted in 2015 to reject the policy.

A key argument in favor of age-related assessment is that those with cognitive decline or mild cognitive impairment may fail to recognize or be willing to act on their own decline, as was shown in a 2006 study published in JAMA.

That study concluded that "while suboptimal in quality, the preponderance of evidence suggests that physicians have a limited ability to accurately self-assess. The processes currently used to undertake professional development and evaluate competence may need to focus more on external assessment."

The Upside of Assessment

In discussing evidence on the changing levels of competency across age groups in medical practice, Marcia A. Lammando, RN, program director for the Foundation of the Pennsylvania Medical Society's LifeGuard program, in Harrisburg, Pennsylvania, reviewed 1618 practices in Quebec between 2001 and 2010. Lifeguard is a clinical competency skills assessment program.

The review showed that physicians older than 70 had a threefold increased rate for licence cancellation due to incompetence compared to those younger than age 70 – 31% vs 10%, respectively. For physicians aged 65 to 69, the rate that was only slightly higher than average, at 13%.

In addition, physicians aged 65 to 69 had almost double the rate of recommended remediation compared to those under age 65 – 18% vs 10%.

Findings from Ontario indicated that 22% of physicians older than 75 had gross deficiencies in their practice, compared to 16% among those aged 50 to 74, and 9% of those younger than 49.

Interestingly, although physicians aged 55 and older had worse performance compared to those younger than 55, there was little difference in physicians' performance outcomes in the 55- to 69-year-old group and those older than 70.

Late-career assessments, though not always welcome, can have important benefits for physicians, Lammando said.

"It can help increase self-awareness and pinpoint the areas of improvement the physician may not have been aware of. Assessment can in fact delay retirement for some physicians," she said.

"If a practice modification can be identified and the change can keep a physician working for 3 to 5 years, for instance, that's better for the organization and patients, and certainly for the physician's well-being," Lammada added.

The process can also be a means for easing into retirement, she added.

"Physicians will often have their entire persona wrapped in being an MD, so we have a transitional psychiatrist who can work with them, and we also have a panel of 'successfully retired' physicians to help."

No Standardized Testing

Just as there is high variation in physician competence in older age, there is variation in assessment processes among the health systems that have implemented age-based screening.

Lammando noted that the California Public Protection and Physician Health has established policies and procedures for age-based screening guidelines that have influenced other programs around the country. A key factor, she underscored, is standardization.

"An important consideration is who performs the assessment – if it's performed within a practice or institution, a lot of bias can be introduced. If the assessment is performed at a regional or national center, the risk of bias is decreased, and there is typically more expertise and standardization in the assessment," she said.

Assessments performed proactively can help avoid some of the unwanted aspects of reactive assessments, which typically involve physicians being referred as a last resort, often placing the physician in a more defensive position, Lammando added.

With proactive assessments, baselines can be established for medical staff at a certain age, and the process is more standardized, with all physicians or providers being assessed upon reaching a predetermined age.

"The goal of assessment would be safe patient care, quality improvement and maximizing patient health," she said.

Dr Ellison and Marcia Lammando have disclosed no relevant financial relationships.

American Association for Geriatric Psychiatry (AAGP) 2017. Presented March 25, 2017.

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