Review Supports Mandatory Testing of Aging Physicians

Marcia Frellick

August 15, 2017

UPDATED August 16, 2017 // Aging physicians should be required at a certain age to have a cognitive evaluation combined with anonymous feedback by peers regarding their wellness and competence, authors argue in a recent review.

Lead author E. Patchen Dellinger, MD, from the Department of Surgery, University of Washington, Seattle, told Medscape Medical News there is no magic age when retirement is right for physicians, even though several other professions do set such bars.

Commercial airline pilots, for example, can be aged no older than 65 years, and 33 states and Washington, DC, set mandatory retirement ages for judges.

But consideration should be more nuanced for physicians, Dr Dellinger said.

"There are many older physicians who have a wealth of experience and who are practicing very well, and the last thing on earth we want to do is discourage those physicians from continuing to practice," Dr Dellinger said. Among the consequences of that, he added, would be worsening the physician shortage.

"On the other hand, the data are unequivocal that there is, on average, a reduction in cognitive and physical abilities with age...and we need to kindly encourage those who should be reducing their practice to do so," he said.

According to the review, published online July 19 in JAMA Surgery, research shows that between ages 40 and 75 years, mean cognitive ability drops by more than 20%, but there is large variability individually. Dr Dellinger notes that although the journal is for surgeons, the review is meant for all physicians.

Nearly One in Four Physicians Is Aged 65 Years or Older

The authors point out that the number of aging physicians is growing. Since 1975, the ranks of physicians aged 65 years and older who were practicing in the United States increased by more than 374%. In 2015, nearly one in four (23%) practicing physicians was at least 65 years old.

Dr Dellinger said national, or even statewide, regulations on testing aging physicians are unlikely in the near future: "There's not the political will for that at this point," he said. "Hopefully, eventually we will get there."

For now, the authors encourage physicians to voluntarily have thorough physical examinations and discuss issues surrounding aging with their physicians.

They add that local medical societies could help with reviews of solo practitioners, especially those in underserved areas who do not have partners or staff.

Liability insurance companies, the authors suggest, could offer lower fees for physicians who voluntarily submit to exams and rigorous peer evaluations.

But healthcare organizations should also follow the lead of a few institutions that have required testing, the authors say.

They write that they are not aware of any institutions that have mandatory retirement ages, but they mention three that require health or competence assessments. For example, the University of Virginia Health System in Charlottesville requires physical and mental testing starting at age 70 years to obtain the privileges requested. Starting at age 75 years, the exam happens every 2 years. At Stanford Hospitals and Clinics in California, physicians aged 74.5 years or older must have an assessment by peers that addresses clinical performance and a physical exam related to privileges the physician is seeking.

Driscoll Children's Hospital in Corpus Christi, Texas, also reportedly requires periodic exams for physicians starting at age 70 years.

In Ontario, Canada, the College of Physicians and Surgeons asks for peer assessments of physicians' practices for all physicians aged 70 years or older, a random sampling of other physicians, and all physicians who were pegged in investigations as having clinical deficiencies.

The authors urge large professional medical organizations to develop policies to address aging of physicians while leaving workplaces flexibility in shaping their policies.

In 2016, the American College of Surgeons recommended that starting when they are 65 to 70 years old, surgeons should voluntary undergo physical exams and visual testing, with regular evaluations after that. The college also recommended that surgeons voluntarily assess their own neurocognitive function with online tools and report any concerning results.

The American Medical Association in 2015 called for guidelines on competency assessment testing.

David Norris, MD, 45, a cardiothoracic anesthesiologist in Wichita, Kansas, and a business consultant for physicians, told Medscape Medical News he thinks the tests are necessary, but more so for surgeons, because of the dexterity required.

Age of mandatory testing, he says, should vary by specialty and by immediate risk posed to a patient's life. "For someone [performing] more invasive [procedures], you might want to start screening earlier," he said.

That would be in line with current requirements for boards of different specialties that have different periods for recertifying, he notes.

Dale Carrison, MD, 77, is chief of staff of the University Medical Center of Southern Nevada in Las Vegas. He told Medscape Medical News he works clinically and administratively 60 to 80 hours a week and says mandatory cognitive testing for physicians "is ridiculous."

"[Testing] has to be performance-based. Otherwise, it's just age discrimination," he says. "That's like telling me you have to have a certain test because you're a female."

He says there needs to be some behavior that calls attention to a physician, not the physician's age, and he's seen plenty of addiction at much younger ages, for instance, that would be more dangerous.

"Mandatory testing isn't going to fix the problem," he says. "It's simply another administrative or bureaucratic roadblock to put in front of someone."

Dr Norris also raised the question of who would pay for all the required testing and evaluations and what consequence would be for low scores on an evaluation.

But he agrees with the authors that the medical profession needs to address this quickly.

Without introducing competency and wellness testing of physicians, others "may impose more draconian measures," the researchers write.

Dr Dellinger said the danger is that legislators could start putting restrictions on licenses without adequate input from the medical profession.

"It's time for the medical profession to start giving this a lot of thought before some big event gets a lot of publicity and causes politicians to start getting involved," he said.

Support for this project was provided by the Greenwall Foundation. The authors, Dr Carrison, and Dr Norris have disclosed no relevant financial relationships.

JAMA Surg. Published online July 19, 2017. Abstract

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