Experts Revisit Mandatory Age-Based Cognitive Testing for Physicians

Deborah Brauser

July 04, 2018

Experts are revisiting the controversial issue of mandatory, age-based cognitive testing to assess physician competence.

In a new review, they discuss scientific evidence of age-associated cognitive impairment, list resources for assessments and possible barriers to doing so, and make recommendations for moving forward, including "if you see something, say something" and "remediate when possible, facilitate retirement when necessary."

Dr James Ellison

Although previous research has shown a significant link between aging and changes in cognitive function, there are currently no mandatory testing or retirement practices in place for "our aging healthcare workforce," write the investigators, led by Anothai Soonsawat, MD, Bangkok Mental Health Rehabilitation and Recovery Center, Thailand. Therefore, a "more consistent approach" to assessing and aiding older physicians is needed.

"Aging is inevitable and no one should be stigmatized or penalized simply for growing older," write the authors. However, "early detection and assessment make possible greater prevention of medical errors, protection of the public, and enhancement of aging physicians' well-being."

Co-author James M. Ellison, MD, Swank Foundation Endowed Chair in Memory Care and Geriatrics at Christiana Care Health System, Wilmington, Delaware, and professor of psychiatry and human behavior, Thomas Jefferson University, Philadelphia, Pennsylvania, stressed to Medscape Medical News that nobody is advocating for all older physicians to be thrown out of practice, but for those who should retire, resources should be made available.

"The focus should not be on people who are not performing. The focus is on helping the whole profession make appropriate plans for the eventual transition from active practice," said Ellison.

The article was published online in the June issue of the American Journal of Geriatric Psychiatry.

Aging Population

Co-author Iqbal Ahmed, MD, Departments of Psychiatry and Geriatric Medicine at the University of Hawaii, Honolulu, noted they wrote the article to start a conversation about these issues.

"I think we need to have these discussions because of the aging of our field," said Ahmed, who is also a past president of the American Association for Geriatric Psychiatry (AAGP).

"It's a matter of how do we recognize [a problem] and how do we address it? Should there be a policy put into place? That's not to say that there's only one way, but we need to talk about how best to do it," he told Medscape Medical News.

"We need to address all of this so that we can get the best out of our physicians, which might mean their doing something different. A surgeon with tremor in his hand might go into teaching, administrative work, or supervising. It's figuring out how certain impairments affect certain performance issues and how to accommodate all of that."

A report from the Federation Physicians Data Center stated that in 2012, 26.3% of physicians were aged 60 years or older, up from 24.4% in 2010.

"There's an aging physician workforce, especially for men. In 2016, 36% of male US physicians were 60 or older. That's more than a third," said Ellison.

"These aging baby-boomer physicians have not been well prepared to think about their career as a trajectory that goes through training, practice, and then some kind of transition at the end of their professional life. That's for those who are healthy. If cognitive impairment intervenes, that raises different issues," he said.

Although age-related changes can also include impaired vision and motor function, the current article focuses on cognitive changes and the authors note that age-related impairments in memory are common, including episodic, semantic, and working memory, as well as complex attention and processing speed, leading to problems in, among other things, executive function and verbal fluency.

Mandatory Testing

A study published in 1994 showed that cognitive functioning was similar between 1002 physicians and 581 non-physicians up to age 50 years. Although non- physicians had more rapid cognitive decline after the age of 60, it was significant in both groups. Cognitive decline was similar between the groups after age 75.

Still, "there was considerable variability" in cognitive performance on an individual basis.

Other studies have shown a link to higher mortality rates when cardiovascular procedures were performed by older surgeons and when elderly patients hospitalized in the United States were treated by older physicians.

Because of accumulating research, a statement released in 2016 by the American College of Surgeons endorsed voluntary baseline physical and health assessments with subsequent re-evaluations.

The controversial Maintenance of Certification (MOC) program was created to evaluate and improve physician competence through periodic testing, performance evaluations, and more.

However, Soonsawat and colleagues note that the program's voluntary nature could lead to decreased identification of those who have the greatest impairment.

"Self-referral, of course, requires self-awareness. Even cognitively normal adults have been shown to be poor judges of their own cognitive performance," write the authors.

Instead, several countries have gone to mandatory age-based assessments, including New Zealand's professional development review as part of their regular practice review program.

The Federation of Medical Regulatory Authority of Canada established three levels of screening in 1993, with Level 1 referring to "competency screening of the entire physician population," the authors report.

Level 1 screening is used in Alberta and Nova Scotia, as well as in the United Kingdom through the National Health Service. However, countries without nationalized healthcare face different barriers, write the journal authors.

Hot-Button Issue

In the United States, the performance of credentialed physicians is regularly assessed at hospitals, but often through peer review. However, physicians may be hesitant to report their colleagues' impairments.

Other age-based assessment programs at specific healthcare systems, such as the Late Career Practitioner Policy introduced at Stanford in 2012, have faced push-back.

Alternatives include evaluations such as the Physician Assessment and Clinical Education Program Aging Physician Assessment (PAPA) program, which was started in San Diego, California. In it, physicians around the age of 70 years are referred for both physical and mental health screening.

However, there are several obstacles to any type of cognitive assessment of physicians. These include underreporting of problems by physicians, their patients, and colleagues; concerns over age discrimination; payment issues; problems with the technology used in screening; and fear over privacy violations.

Ellison and Ahmed were part of presentations addressing these issues at the 2017 AAGP and 2018 APA annual meetings.

An article by Medscape Medical News on the AAGP presentation garnered more than 100 comments from clinicians, which ran the gamut from "it's wrong to discriminate against someone based on a single factor over which they have no control" and "sounds like a scam" to "age-based testing is reasonable in setups where there is no arbitrary age limit for retirement."

"A screening program put into place for the purpose of making it more difficult for physicians to remain in practice, despite their strengths and abilities, would not be valuable. It would be harmful," said Ellison.

"But if discussion of this topic focuses us all on the value of thinking about...changes in our practice throughout a career, that's a positive outcome," he added.

Recommendations

In addition to urging the acknowledgment that age-associated cognitive change is real, the authors list five recommendations:

  1. If you see something, say something. Patients and colleagues should report even early red flags, "with the ultimate goal of detecting and then treating any reversible conditions or helping the individual to manage the consequences of an irremediable condition."

  2. Use available assessment programs. This includes the PAPA program, which is open to US physicians, as well as hospital programs.

  3. Consider pushing for a standardized approach, including a routine 360-degree assessment.

  4. Remediate, or facilitate retirement. For those with reversible impairments, remediation could include substance abuse treatment, psychotherapy, or practice accommodations. For others, help should be given in preparing a strategy for leaving practice. Either route should be on an individual basis.

  5. Improve the retirement process.

However, the authors note that evidence for these recommendations "is sorely lacking," so they should be "taken as provisional."

"Age-based screening of the entire population of physicians is worth consideration, although technical and acceptability issues must be resolved," they add.

Ellison stressed that anyone evaluated "should not be subjected to any unfair or inappropriate or age-discriminatory assessment. On the other hand, healthcare institutions have a fiduciary responsibility and concern about public welfare," he said.

"So some sort of uniform approach is needed for identifying and assisting people with cognitive aging or medical problems that might interfere with performance to a certain degree."

He added that physicians should be prepared for all of this as early as medical school so that they know what they'll be facing at every step of their professional journey.

Comparison to Pilots

In an accompanying editorial, Aartjan T.F. Beekman, MD, PhD, Department of Psychiatry, VU University Medical Center, Amsterdam, The Netherlands, notes the US Federal Aviation Administration set age limits for pilots back in 1959.

"Physicians are not pilots, but many of the arguments relevant to balancing the security interests of airline travel and the 'fair treatment of experienced pilots' are also relevant to medicine," Beekman writes.

He adds that "results are mixed" on whether age is in fact related to cognitive dysfunction and how that relates to physician performance — especially on an individual basis.

"Any set age limit would both tend to miss some malfunctioning physicians and incriminate many others who function well," writes Beekman.

Still, he agrees with the authors that those with cognitive decline are not likely to realize the decline.

So should standardized, mandatory, age-related impairment screening be mandatory for physicians older than a set age? He notes that the authors make good points, especially in the interest of patient safety. However, it should be done so with a carefully thought-out plan — and with compassion.

"Both ethical and economic debates about screening tend to tip when the perspective of those screened [see] positive change," writes Beekman.

"In a similar vein, the acceptability of a standard screening of our older colleagues will improve if either remediation or retirement is a realistic option. In the interest of both our patients and ourselves, let's hope this happens," he concludes.

The authors have reported no relevant financial relationships.

Am J Geriatr Psychiatry. 2018;26:631-640, 641-642. Abstract, Editorial

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