This transcript has been edited for clarity.
Robert D. Glatter, MD: Welcome. I'm Dr Robert Glatter, medical advisor for Medscape Emergency Medicine. Joining me today is Sandeep Jauhar, a practicing cardiologist and professor of medicine at Northwell Health, a frequent New York Times op-ed contributor, and highly regarded author of the upcoming book My Father's Brain: Life in the Shadow of Alzheimer's.
We are here today to discuss the rationale for age competency exams for practicing physicians.
Sandeep Jauhar, MD: Thanks for having me.
Glatter: Your recent op-ed piece in The New York Times caught my eye. In your piece, you refer to a 2020 survey in which almost one third of licensed doctors in the United States were 60 years of age or older, up from a quarter in 2010. You also state that, due to a 20% prevalence of mild cognitive impairment in persons older than 65, practicing physicians above this age should probably be screened by a battery of tests to ensure that their reasoning and cognitive abilities are intact. The title of the article is "How Would You Feel About a 100-Year- Old Doctor?"
How would you envision such a process? What aspects of day-to-day functioning would the exams truly be evaluating?
Jauhar: A significant number of people over 65 have measurable cognitive impairment. By cognitive impairment, we're not talking about dementia. The best estimates are that 1 in 10 people over age 65 have dementia, and roughly 1 in 5 have what's called MCI, or mild cognitive impairment, which is cognitive impairment out of proportion to what you'd expect from normal aging. It's a significant issue.
The argument that I made in the op-ed is that neurocognitive assessment is important. That's not to say that everyone over age 65 has significant cognitive impairment or that older doctors can't practice medicine safely and effectively. They absolutely can. The question is, do we leave neurocognitive assessment to physicians who may possibly be suffering from impairment?
In dementia, people very often have impaired self-awareness, a condition called anosognosia, which is a neurological term for not being aware of your own impairment because of your impairment.
I would argue that, instead of having voluntary neurocognitive screening, it should be mandated. The question is how to do that effectively, fairly, and transparently.
One could argue a gerontocracy in medicine today, where there are so many older physicians. What do we do about that? That really is something that I think needs to be debated.
Glatter: The question I have is, if we (ie, physicians and the healthcare profession) don't take care of this, someone's going to do it for us. We need to jump on this now while we have the opportunity. The AMA has been opposed to this, except when you have reason to suspect cognitive decline or are concerned about patient safety. A mandatory age of retirement is certainly something they're not for, and we know this.
Your argument in your op-ed piece is very well thought out, and you lay the groundwork for testing (ie, looking at someone's memory, coordination, processing speed, and other executive functions). Certainly, for a psychiatrist, hearing is important, and for a dermatologist, vision is important. For a surgeon, there are other issues. Based on the specialty, we must be careful to see the important aspects of functioning. I am sure you would agree with this.
Jauhar: Obviously, the hand skills that are important for ophthalmological surgery certainly aren't required for office-based psychological counseling, for example. We have to be smart about how we assess impairment.
You describe the spectrum of actions. On the one hand, there's mandatory retirement at the age of 65 or 70 years. We know that commercial pilots are mandated to essentially retire at 65, and air-traffic controllers must retire in their late fifties.
We know that there's a large amount of variability in competence. There are internists in their eighties with whom I've worked, and I'm absolutely wowed by their experience and judgment. There are new medical resident graduates who don't really seem to have the requisite level of competence that would make me feel comfortable to have them as my doctor or a doctor for a member of my family.
To mandate retirement, I think the AMA is absolutely right. To not call for any kind of competency testing, to me, seems equally unwise. Because at the end of the day, you have to balance individual physician needs or wants to continue practicing with patient safety. I haven't really come across too many physicians who say, "There's absolutely no need for a competency testing."
We have to meet somewhere in the middle. The middle is either voluntary cognitive competency testing or mandatory. I would argue that, because we know that as the brain changes we have cognitive impairment, but we're not always aware that we need help, mandatory testing is the way.
One other thing that you mentioned was about having the solution imposed on us. You and I are doctors. We deal with bureaucracy. We deal with poorly thought-out solutions to issues in healthcare that make our lives that much more difficult. I don't want that solution imposed on us by some outside agency. I think we need to figure this out within medicine and figure out the right way of doing it.
The AMA is on board with this. They haven't called for mandatory testing, but they have said that if testing were to occur, these are the guidelines. The guidelines are fair and equitable, not too time-consuming, transparent, and not punitive. If someone comes out and doesn't test well, we shouldn't force them out of the profession. We can find ways to use their experience to help train younger doctors, for example.
Glatter: I wanted to segue to an area where there has been some challenge to the legality of these mandatory types of age restrictions and imposing the exams as well. There's been a lawsuit as well by the EEOC [Equal Employment Opportunity Commission], on behalf of Yale. Basically, there's been a concern that ageism is part of what's going on. Yale now screens their providers beginning at age 70, and they have a program. UCSD has a program in place. Obviously, these institutions are looking at it. This is a very small part of the overall picture.
Healthcare systems overall, we're talking about a fraction of them in the country, are really addressing the issue of competency exams. The question is, where do we go from here? How do we get engagement or adoption and get physicians as a whole to embrace this concept?
Jauhar: The EEOC filed a lawsuit on behalf of the Yale medical staff that argued that Yale's plan to do vision testing and neurocognitive screening — there may be a physical exam also — constitutes age discrimination because it's reserved for doctors over the age of 70. Those are the physicians who are most likely to have cognitive impairment.
We have rules already for impaired physicians who are, for example, addicted to illicit drugs or have alcohol abuse. We already have some of those measures in place. This is focused on cognitive impairment in aging physicians because cognitive impairment is an issue that arises with aging. We have to be clear about that.
Most younger physicians will not have measurable cognitive impairment that would impair their ability to practice. To force young physicians (eg, physician in their forties) to undergo such screening, all in the name of preventing age discrimination, doesn't strike me as being a good use of resources. They're more likely to be false positives, as you know from Bayesian statistics. When you have low pretest probability, you're more likely to get false positives.
How are we going to screen hundreds of thousands of physicians? We have to make a choice about the group that really is more likely to benefit from such screening. Very few hospitals are addressing this issue and it's going to become more important.
Glatter: Surgeons have been particularly active in pushing for age-based screening. In 2016, the American College of Surgeons started making surgeons at age 65-70 undergo voluntary health and neurocognitive assessments, and encouraged physicians to disclose any concerning findings as part of their professional obligation, which is pretty impressive in my mind.
Surgeons' skill set is quite demanding physically and technically. That the Society of Surgical Chairs took it upon themselves to institute this is pretty telling.
Jauhar: The overall society called for screening, but then in a separate survey of surgical chairs, the idea was advanced that we should have mandatory retirement. Now, I don't particularly agree with that.
I've seen it where you have the aging surgeon who was a star in their day, and no one wants to say anything when their skills have visibly degraded, and no one wants to carry that torch and tell them that they need to retire. What happens is people whisper, and unfortunately, bad outcomes have to occur before people tend to get involved, and that's what I'm trying to prevent.
Glatter: The question is whether older physicians have worse patient outcomes. The evidence is inconclusive, but studies have shown higher mortality rates for cardiovascular surgeons in terms of the procedures that they do. On the flip side, there are also higher mortality rates for GI surgery performed by younger surgeons. It's a mixed bag.
Jauhar: For specialized surgery, you need the accrual of a certain amount of experience. The optimal age is about 60, because they've seen many things and they've seen complications. They don't have a hand tremor yet so they're still functioning well, and they've accrued a lot of experience. We have to be smart about who we screen.
There's a learning curve in surgery. By no means am I arguing that younger surgeons are better surgeons. I would say that there's probably a tipping point where once you get past a certain age and physical deterioration starts to take effect, that can overshadow the accrual of cognitive and surgical experience. We have to balance those things.
I would say neurocognitive screening and vision testing are important, but exactly what do you measure? How much of a hand tremor would constitute a risk? These things have to be figured out. I just want doctors to be leading the charge here and not have this imposed by bureaucrats.
Glatter: I was reading that some doctors have had these exams administered and they can really pass cognitive aspects of the exam, but there have been nuances in the actual practicing of medicine, day-to-day functioning, which they're not good at.
Someone made a comment that the only way to know if a doctor can do well in practice is to observe their practice and observe them taking care of patients. In other words, you can game the system and pass the cognitive exam in some form but then have a problem practicing medicine.
Jauhar: Ultimately, outcomes have to be measured. We can't adopt such a granular approach for every aging physician. There has to be some sort of screening that maybe raises a red flag and then hospitals and department chairs need to investigate further. What are the outcomes? What are people saying in the operating room? I think the screening is just that; it's a way of opening the door to further investigation, but it's not a witch hunt.
I have the highest respect for older physicians, and I learn from them every day, honestly, especially in my field (cardiology), because some of the older physicians can hear and see things on physical exam that I didn't even know existed. There's much to be learned from them.
This is not intended to be a witch hunt or to try to get rid of older physicians — by any means. We want to avoid some of the outcomes that I read about in The New York Times comments section. It's not fair to our patients not to do at least some sort of screening to prevent those kinds of mistakes.
Glatter: I wanted to go back to data from Yale between October 2016 and January 2019, where 141 Yale clinicians who ranged in age from 69 to 92 years completed cognitive assessments. Of those, 18 clinicians, or about 13% of those tested, demonstrated cognitive deficits that were "deemed likely to impair their ability to practice medicine independently." That's telling. These are subtleties, but they're important to identify. I would love to get your comment on that.
Jauhar: It's in keeping with what we know about the proportion of our older citizens who have cognitive impairment. About 10% have dementia and about 20% have at least mild cognitive impairment. That's in keeping with what we know, and this was a general screening.
There are certain programs, like in San Diego, for example, where physicians are referred, and so there's a selection bias. But this was just general screening. It's worrisome. I'm an aging physician myself. I want fairness in this process because I'm going to be assessed as well.
I just don't really understand yet why there's so much circling of the wagons and so much resistance. It seems like it would be good for physicians also to be removed from situations where they might get into potential litigation because of mistakes and physical or visual impairment. It seems like it'd be good for patients and physicians alike.
Glatter: It's difficult to give up your profession, change fields, or become administrative at some point, and when to make that transition. As we all get older, we're not going to have the ability to do what we did in our twenties, thirties, and so forth.
Jauhar: Much of the resistance is coming from doctors who are used to high levels of autonomy. I'm certainly sympathetic to that because I don't want anyone telling me how to practice. The reason this is coming up and hasn't come up in the past is not because of loss of autonomy but because of an actual demographic change. Many physicians were trained in the 1960s, '70s, or '80s. They're getting to retirement age but they're not retiring, and we can speculate as to why that is.
In America's educational system, doctors incur a huge amount of debt. I know physicians who are still paying off their debt and they're in their fifties and sixties, so I'm very sympathetic to that. I'm not trying to force doctors out of practicing. I just want whoever is practicing to be competent and to practice safely. We have to figure out how to do that.
Glatter: The fact that there is a shortage of physicians forecast in the next 10-15 years makes many physicians reluctant to retire. They feel like they want to be part of that support network and we don't want to have a dire situation, especially in the rural areas. We're not immune from aging. We're human beings. We all have to realize that.
Jauhar: I know that the ACC is starting to debate this issue, in part because of my op-ed. My hope is that it will start a conversation and we will institute a plan that comes from physicians and serves our patients, and doesn't serve some cottage industry of testing or serve the needs of insurers or bureaucrats. It has to serve the doctor-patient relationship.
Glatter: In some random surveys that I've read, up to 30%-40% of physicians do support some type of age-based screening or competency assessment. The needle's moving. It's just not there yet. I think that wider adoption is coming.
Jauhar: Data are coming as more hospitals start to adopt these late practitioner programs. Some of the data that came out of Yale, for example, are very important. We're going to see more published data in this area, and it will clarify what we need to do and how big the problem is.
Glatter: I want to thank you again for your time and for writing the op-ed because it certainly was well read and opened the eyes of not only physicians, but also the public at large. It's a conversation that has to be had. Thank you for doing this.
Jauhar: Thanks for inviting me, Robert. It was a pleasure to talk to you.
Robert D. Glatter, MD, is assistant professor of emergency medicine at Lenox Hill Hospital in New York City and at Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York. He is an editorial advisor and hosts the Hot Topics in EM series on Medscape. He is also a medical contributor for Forbes.
Sandeep Jauhar, MD, is a practicing cardiologist and professor of medicine at Northwell Health. Jauhar is currently a contributing opinion writer for The New York Times. He has appeared frequently on National Public Radio, CNN, and MSNBC to discuss issues related to medicine, and his essays have also been published in The Wall Street Journal, Time, and Slate. Follow him on Twitter
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Cite this: Age Competency Exams for Physicians -- Yes or No? - Medscape - Jan 10, 2023.