This transcript has been edited for clarity.
Arthur L. Caplan, PhD: I'm Art Caplan, head of medical ethics at New York University School of Medicine. I want to welcome you to Medscape's ongoing series, Both Sides Now.
We have a very controversial topic today that I think you're going to find of keen interest. Should there be testing of older physicians to determine whether they are still competent to be practicing medicine or surgery, and if so, at what age should that testing begin?
Physicians and other healthcare staff, like baby boomers, are living longer and many are electing to continue practicing medicine longer. A census by the Federation of State Medical Boards found that in 2016, 29% of licensed physicians in the United States were age 60 or older, and that was up 4% from 2010. But with an aging physician population and a possible shortage of younger physicians coming to take their place, this raises some obvious questions. Is there an age at which a doctor should stop actively practicing medicine, even if they want to continue? Are they forgetting things, which puts patient safety at risk? Are they still able to make the best judgments? Do they still have the manual dexterity and the physical stamina to continue in certain areas of practice? Are they able to do the best for their patients or should others start to take their place?
To answer these questions (I hope, because they are difficult and complicated), I'm joined today by two distinguished guests. By video is Dr Mark Katlic, a surgeon and founder of the Aging Surgeon Program at Sinai Hospital in Baltimore, Maryland. This program offers nationwide comprehensive and confidential evaluation of competency in older surgeons requested by hospitals, licensing bodies, or physicians themselves. My second guest is Dr Dan Choi. He is an orthopedic spine surgeon in New York. He also chairs the Young Physicians Section of the Medical Society of the State of New York (MSSNY). Welcome, both of you, to Both Sides Now.
Dan, you have not been in medical practice quite as long as some of the people watching this. What made you take an interest in the area of competency and aging? Why did you begin to pay attention?
All Physicians Are Concerned About This
Daniel E. Choi, MD: I am in a practice with older physicians who are mentors. Some are in their forties, fifties, or sixties. This topic has been discussed online, on social media, and also in the medical literature, and we've had some lively discussions about it. I'm pretty young now but it will affect me one day as I practice, and I've talked with my older colleagues and heard their concerns.
I'm also involved with organized medicine where these issues are discussed regularly, like at the MSSNY. Also, the American Medical Association has taken positions on this topic. This affects public health and the safety of our patients, but at the same time we also want to respect the rights of practicing physicians as they age. To balance both, what is the best way forward? These are topics you can discuss on a policy level, but when I speak with [older] mentors and physicians I work with in the operating room (who are very competent), they [feel] pressure of [being questioned about whether they are] really competent. That is when the discussion gets lively.
Caplan: What about you, Mark—how did you get interested in this area?
Mark R. Katlic, MD: I've been interested in surgery and the elderly for many, many years and I've also been a chair of surgery for a number of years. Almost every chair of surgery and hospital president at some time in his or her career encounters an older physician who should have stopped practicing before he or she did. I recognized a number of years ago that no one was really addressing the issue.
Chairs of surgery, hospital presidents, and vice presidents of medical affairs need objective evidence upon which to make difficult decisions. We often went by hearsay, such as from an operating room nurse or a resident, and that is not the way to deal with a respected older colleague.
About 4 years ago, we built a 2-day comprehensive evaluation of older surgeons' physical and cognitive faculties. This program is different from another program that we and a number of hospitals have called a Late Career Practitioner Policy, which is typically a medical staff policy that says that every provider (ie, doctor, nurse practitioner, physician assistant) at a certain age should have an evaluation when coming up for re-credentialing. This generally involves a physical exam, eye exam, and neurocognitive screening evaluation.
Caplan: What age are they talking about?
Katlic: Between 70 and 75, and it differs by hospital. At Sinai Hospital, we arbitrarily chose age 75 because it's old enough where we actually might identify issues but it's not too old. Also, if one chooses the younger age, there is a greater population of physicians that need to be tested and it strains the resources of our PhD neuropsychologists. Other hospitals have chosen 70. I believe at Yale, New Haven, the age is 70. Some other hospitals around the country have chosen 72 or 74. So, again, the age is somewhere between 70 and 75 when one comes up for re-credentialing. I'm a proponent of hospitals having such a policy in place.
Caplan: When you do this testing, are people ornery? Are they collaborating? The knock comes at the door and somebody says that they have been requested by X to get the provider tested. What ensues? I assume it's not just general good humor and applause.
Katlic: Almost everyone who comes to our program is forced to do so. Two surgeons elected to come themselves of their own accord because they honestly wanted to believe that they remained competent. But by and large, it's someone who is forced by a hospital president or a chief of surgery to either come to our program or lose privileges immediately. They have all been very congenial, but some have not hidden the fact that they were forced to come.
Our very first client was a number of years ago. He has allowed us to use his name and his hospital has allowed us to use their name. Dr Herb Dardik at Englewood, New Jersey, is a famous vascular surgeon who was forced to come through our program. He is now in his eighties and has become an advocate for the program. He has done interviews and gone public with his support of the program. But you're absolutely right, Art—most people come kicking and screaming.
Starting Out While Also Looking Ahead
Caplan: Dan, you are at the start of your career. Knowing what you know about your specialty, which can be pretty demanding and physically tough and exacting, how long do you see yourself doing this?
Choi: I love doing spine surgery and I can see that my partners love operating as well. Being a surgeon is a calling, and we put ourselves through this rigorous training to get to this point because ultimately we look forward to those days in the operating room. We love it, but it is a very physically rigorous activity. After a day in the operating room and three long spine surgeries, I'm on my couch with my mind wiped and my legs hurting. As orthopedic spine surgeons, we also know that there is physical wear and tear on our bodies. I know older colleagues who have had disc herniations themselves and have required operations. We're spending hours at a time with our necks flexed.
I know there is a physical limitation to how long I may be able to keep this up. I would love to operate as long as possible, as long as I don't suffer burnout and I continue to enjoy it. I hope I can do this for the rest of my life. I see people approaching 70 or 75 who still love what they are doing, and it's a tough situation to say that we need to look at whether they can do this or not.
Does Specialty Affect Longevity of Practice?
Caplan: Mark, is Dan, in his particular specialty, more likely to face age as a limiting factor at some point in his career than if he were a psychiatrist, dermatologist, radiologist, or some other specialty? Are you aware of any sort of differences in physical stamina or dexterity, or things like that?
Katlic: I don't have evidence in the literature that different specialties have different rates of problems. However, I don't think it's hard to believe that surgeons and those who use their hands as well as their minds are likely to have issues earlier than others. That is why our program comprehensively tests hand-eye coordination, balance, and fine motor skills in addition to cognition.
On the other hand, it's really the cognition that gets people into trouble, by and large. Typically, physical problems can be dealt with. Taking somebody off the call schedule, for example, helps a great deal. Most psychiatrists and even internists don't quite have the physical demands. They are not standing all day and they are not leaning over and bending and twisting. Hand-eye coordination and the ability to make quick decisions in emergency circumstances may not be as crucial. They often have time to seek a second opinion from a colleague or to do some additional testing. I do think that surgeons and procedural specialists are in a somewhat different category and need to be scrutinized maybe a little bit more.
The American College of Surgeons' official policy about aging surgeons is that one should have a voluntary evaluation between age 65 and 70 that includes a physical exam, an eye exam, and some online confidential neurocognitive screening. The Society of Surgical Chairs, just a month ago, published its recommendation. This is a group of about 200-some chairs of surgery, and they came out much more strongly. They advocated for a mandatory evaluation at age 65.
Caplan: Isn't it true that pilots and those in certain other professions have to do a mandatory evaluation at 65?
Katlic: Absolutely, and that raises the subject of age discrimination. The [Americans with Disabilities Act and the Age Discrimination in Employment Act of 1967] make it illegal to make hiring and firing decisions based upon chronologic age, but Congress has made exceptions for airline pilots, park rangers, lighthouse workers, FBI agents—people who carry guns or are responsible for the safety of large numbers of people. It would require an act of Congress to come up with a mandatory retirement age for doctors or surgeons. I am 100% against a mandatory retirement age. I believe that it's reasonable to screen people at a certain age, but we should not even think about mandatory retirement age based upon chronologic age because of the enormous variability among individuals. We know 80-year-olds who can play vigorous tennis and learn new languages, and other 80-year-olds who can't walk to the mailbox.
Caplan: In my work, I spend a lot of time frequently around people who are dying and mediating controversies and ethical issues that come up. It naturally makes you think a little bit about your own death and how it would be. From your vantage point of testing people, seeing variability, and seeing some fall to the wayside, has that shaped your thinking about your own career and future in medicine?
Katlic: It definitely has. I'm 68 years old and I'm still operating every day as a general thoracic surgeon—I actually did a case this morning—and I'm chief of surgery at my hospital. I just signed a 5-year contract and at the end of that, when I'm 73, I plan to stop operating as primary surgeon and will likely step down as chair as well. So, I've actually picked the date.
I've also encouraged my colleagues and friends to tell me or anybody else in the organization if they believe at any point that I've lost a step, or I'm not as good as I used to be. There is a line I like to quote from an anonymous author: "You want to leave the stage while they're still clapping."
How Do You Address Concerns About Aging Coworkers?
Caplan: Dan, if you were to see somebody in your own practice or somewhere else, and you thought that that person had lost a step or was raising suspicions about age-related cognitive impairment or maybe stamina, what would you do? I'm asking this partly to get some advice for other young doctors.
Choi: One of the oaths that we take as physicians is to do no harm, and that is why we take seriously this idea of self-policing. We have the American Board of Orthopaedic Surgery, the American College of Surgeons. We have different boards and credentialing processes that we all have to go through and then recertify every 10 years. Processes are in place. There is a culture among surgeons similar to the military or the police, where no one looks kindly upon a physician ratting out another physician, or a physician being an expert witness to attack another surgeon in a malpractice lawsuit. I think most surgeons would say that is frowned upon.
But I still think the duty is to the patient first. If you notice something that is very obvious, there are ways to escalate your concerns and you should do it in a fair manner. Every hospital that I work at currently has a quality assurance conference or a morbidity and mortality conference, where physicians are supposed to submit their cases to get scrutinized. Usually at those meetings you have five different surgeons from different specialties, nurses, and administrators. All these different perspectives are looking at a situation that is usually very multifaceted in any kind of complication.
If you can go through those routes, that is a fair way of escalating your concerns. If you are concerned, you should bring it up. I would not just ignore it and think that was a fluke. There are definitely channels through your academic institutions or private hospitals that one can go through that are usually self-policing enterprises.
Caplan: Do you feel that there is a duty to do this?
Choi: Absolutely, I do.
Who Polices Private Physicians and Rural Doctors?
Caplan: There are docs who are in private practice who are practicing by themselves. There are small-town docs in rural America, some of whom are watching the show. Who is going to peer-review them? Who is going to flag them? Should we institute more regular testing just off the license?
Choi: I think that is where our national societies come into play. Our national boards and the American Medical Association and American College of Surgeons have both put position papers on this. They had stakeholders come in to talk about these issues in the fairest way from a national standpoint, because these are national physician governing organizations. I think there may be a place for something like this where we standardize some kind of assessment. But again, it would have to be done very fairly and in a way that does not punish physicians.
Caplan: Mark, what do you think about that with solo practitioners? Often the patient population they serve is extremely grateful that they are there, do not want to lose them, and might be forgiving of a slowing down or missing a step. Nonetheless, poor-quality medicine certainly isn't something that you want to endorse or tolerate over a period of time. How do we manage folks who are outside the hospital, outside the group practice?
Katlic: It is a difficult situation and I agree with Dan that we have to balance patient safety on one hand with the dignity of that committed practitioner and his or her resource to society. There are counties in the United States that don't have a single board-certified surgeon, and others that may have one older surgeon. We don't want to take away the resource of that experienced practitioner who has devoted his or her life to the field. But it definitely is more difficult.
My only answer is that each specialty society needs to step up and do more because these evaluations almost need to be specialty specific. The boards of medicine in each state could take a first step and require some sort of basic screening for licensure. I suspect that that would be very controversial, but we all need to do more than we're doing right now. My fear is that if we don't police ourselves better, the US government will get involved and then we'll have a mandatory retirement age, which I'm 100% against.
Caplan: Dan, do you think that mandatory retirement is just out of the question, even if you got to 100? I saw a news story when getting ready for our conversation today about a physician in France who at 102 was still chugging along. Is there any cut-off?
Choi: I'm 100% on board with Mark here that a mandatory retirement age would be devastating to the patients and to the profession. To endure this path and then all of the regulations that are already on medicine, you really have to love [the profession] and have the desire to help your patients.
They have [said that] being a physician is part of your identity. You do it because you love it. Physicians provide an immense value to society with what they are doing. I don't think a mandatory cut-off age would be helping physicians or patients at this point. There is so much variability between what different specialties require to be competent. An age cut-off is just too subjective.
Is Testing Adequate?
Caplan: Mark, do you think the available testing and the examinations that you do are adequate for picking up problems? In other words, is it too late by the time you test someone and they are failing? Should there be more sophisticated tests that would say that the provider is at risk earlier? What is the state of the testing itself?
Katlic: With respect to the Late Career Practitioner policies, I think that because it's a screening test at a certain age, it needs to follow the principles of any screening test. You need to do the test in a population where you are likely to have some positives or some abnormalities. You just can't test every 40-year-old and every 50-year-old; it's just not practical. We need to balance practicality with effectiveness.
I believe it's reasonable to pick a certain age, like 65, 70, 75, and do basic screening with a physical exam, eye exam, and neurocognitive screening evaluation. A number of hospitals have had these policies for 2, 3, or 4 years now and I believe we will soon see some published real-world results from those programs. In the 70- to 75-year-old age group, I would guess that 5% or 10% of tested physicians will show some cognitive deficit and something will need to be done, whether they are encouraged to cut back their practice, get second opinions, or teach but not practice clinically. I believe we will have some real-world data soon that can answer your question better, Art.
Our Aging Surgeon Program is very comprehensive. It's 7 to 8 hours of neurocognitive testing with additional physical testing, a neurology exam, an eye exam, and a physical exam. I'm confident that it can pick up problems. We have tested people in the age range of 55 to 81, so it's not exactly just the older age that is important. I do believe that our program is comprehensive enough to pick up real problems.
Should Patients Be Alerted?
Caplan: If I am flagged as having an issue, but I'm going to cut back my schedule or people are going to be in the room with me or whatever, do I have an obligation to tell my prospective patients that I'm on a reduced schedule or I have limits on my practice now?
Katlic: That is an excellent question. Personally, I'd see no reason not to, but I can also see where a physician just might be hesitant to do so. This subject has come up also in surgical communities.
What is different about the sleep-impaired surgeon, having been up all night, who must do several operations the next day? Does he or she have an obligation to tell patients? My position is that one should be perfectly honest with patients and perfectly honest with oneself. If you don't feel that you are capable, you should cancel the surgery or discuss it with the patient and let them make a decision. If you feel good, then it's reasonable to let the patient make the decision. You know better than I, Art, the principle of autonomy and, of course, we get into non-malfeasance here too. Yes, I think we should be as open with our patients as possible.
Caplan: Would you go there, Dan? That is a tough, tough standard.
Choi: It's tough. I agree with Mark. A full disclosure with our patients is always the way to go.
Don't Discount the Value of Experience
Choi: That has touched upon some of this testing and whatnot of physicians. When I read more about this topic of mandatory retirement, even for airline pilots and FBI agents, I always wonder what data are out there. What data are out there that show us that someone who is 65 or older and who is flying a plane is going to be more prone to plane crashes than someone who is younger than 65? Has a prospective blinded trial been done? I don't think so, right?
Caplan: I doubt it. It's probably the case that 65 was a date set back when people were not living as long as they are today. It's probably arbitrary.
Choi: Are we doing society good by eliminating that experience, where those pilots 65 and older may be able to avoid a plane crash? I remember Captain Sully here in New York. He was not a young guy and he helped avoid a tremendous disaster. I almost equate that to surgery. I'm a competent surgeon, I'm younger. I can tell you that an older surgeon is probably more willing than the younger surgeons to take on more complex cases, having performed something tens or hundreds of thousands of times versus just thousands of times within residency and fellowship. They are able to make judgments on the spot that only come with experience.
I think any kind of testing that is placed on older physicians also has to be evidence-based. Mark touched upon data that are coming out. It's very important to analyze these data and come out with testing that is evidence-based and will give us [information].
My understanding of neuro-psych testing from football players is that there has to be a baseline. And when you have a baseline, you can monitor whether there are fluctuations from the baseline. I'm not a neuropsychologist by any means, but are we going to start neuro-psych testing pre-med students? This opens a whole Pandora's box. Eighty-year-olds are on the road driving vehicles. Should we be testing them at the department of motor vehicles? I think we probably should.
Caplan: Yes, we should. More than in some of those other situations.
Choi: It just comes back to this whole thing. Mark, I agree with you 100% that if we don't self-police then the federal government will come after us, and they may police us and enact some law that does not make any sense. There are unintended consequences of that, but we just have to be careful about putting additional regulations on physicians. I am not a fan of that because there is burnout as it is, with us having to board-certify and maintain certification. There are two sides to this debate, but we have to be careful about going forward in terms of more regulation.
Caplan: I'm going to end by saying that I think there are three sides to this debate. We want a safe, competent, and high-quality level of practice. Every patient wants that. At the same time, the provider wants to practice as long as they can and consistent with their view of trading off maybe more experience for a little less stamina. But this hidden variable, this third element, is the manpower problem. We're still looking at shortages and maldistribution of resources. If you look at retirement just coming up naturally, there are going to be a lot of folks moving out of the system as that boomer generation passes through, so you need to weigh that. Do you want to have no medical care in the community or would you prefer to have someone who is on a reduced schedule? Tough choices.
You both shed great light on this complicated issue. I know that many in the audience are going to be interested in firing up a question or shooting us an email, which I hope they do. I will pass them on to both of you and we can continue the dialogue that way. This was very illuminating and I learned a lot. I want to thank you, and I want to thank you, the viewers, for watching Both Sides Now.
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Cite this: Arthur L. Caplan, Daniel E. Choi, Mark R. Katlic. Should Physicians Be Tested for Age Competency? Pros and Cons - Medscape - Sep 13, 2019.