番茄社区

The idea that all doctors turning 65 or 70 should be routinely screened for age-related physical or mental slippage to assure they won't hurt patients sounds like overkill to

"There's already so much peer review, continuing education, maintenance of certification and self assessment" and testing, the 72-year-old San Diego oncology surgeon said last week after wrapping up a partial pancreatectomy.

"Regardless of your age, if your practice changes -- you become more difficult to deal with, you forget to show up in the OR, or you have complications, you misspeak when writing your orders -- that's what should trigger intervention and review," he said. Having a separate routine exam "will fail to capture the actual change in behavior and practice that's occurring."

Losing It With Age Inevitable

Yet many in the house of medicine are now disagreeing with views like Goldfarb's, saying many more doctors now practice at much older ages, and it's well known what years can do to memory, critical thinking skills, and manual dexterity, putting patients and organizations at risk.

That's why the American Medical Association's House of Delegates voted in its June meeting that the time has come to address the issue more systematically, perhaps with formal guidelines for timing and methods for competency testing of older doctors who wish to keep staff privileges.

Delegates approved from the AMA's Council on Medical Education, referencing 72 peer-reviewed papers, many of which enumerated myriad ways that advancing age diminishes a physician's abilities.

Some by , of McMaster University in Hamilton, Ontario, found that some older doctors experience declines in working memory, the ability to store and process information, are slower in completing complex tasks, have decreased hearing, visual acuity, manual dexterity, and visuospatial ability.

Plus, as they age, physicians have a "tendency" to rely more on pattern recognition and "gist-based processes" rather than more controlled processes, which "may result in unrecognized diagnostic errors" during evolving or complex clinical situations, the report said.

Of course, younger doctors can fail such tests too, but the likelihood increases with age. And formal guidelines "may head off a call for mandatory retirement ages or imposition of guidelines by others," the report said.

A large coalition of hospitals and doctors in California has taken the issue one step further than the AMA. Members of the California Medical Association, the California Hospital Association, and , with help from a healthcare law firm, in April It outlines specific legally defensible steps that medical executive committees and others might take to selectively screen older doctors' competencies.

"Case law clearly establishes that hospitals and physician groups can be held directly liable for injuries caused to patients by physicians where there was evidence of deficiencies in the physician's skills or judgment that posed a danger to patients," the California guideline said.

While more practice experience results in higher quality, the California report continued, "the effects of aging directly impact the specific physiological and cognitive functions relied upon by physicians in carrying out their job-related responsibilities." It added that multiple studies "found a direct correlation between decline in these areas of function and adverse outcomes for patients."

The report details not just the evidence justifying such systematic reviews, but suggests guidelines for selecting screening instruments and picking who should administer them. It suggests a process to reorient doctors who don't pass, and under what circumstances those doctors' failures must be reported to state licensing officials.

The policy should apply "equally to all members of the medical staff who have reached the specified age," which should be one where there is literature documenting "an increased risk of age-related impairments."

More Doctors 65+ Now Practicing

The AMA and California reports were propelled in part by recognition that of the 241,641 doctors now age 65 and older -- four times more than in 1975 -- 95,000 are still engaged in patient care. Of those, somewhere between 10,000 and 15,000 are actively practicing surgeons, some into their 80s and 90s, although it's unclear how many are still performing actual surgeries, the AMA said.

That's why the idea to screen older doctors deserves more attention, said , 71, a member of the governing council of the 65,000 member AMA's Senior Physicians section of doctors 65 or older that urged the resolution authorizing the AMA's report.

"We have no rules for physicians as they get older," she said. A year ago, the AMA delegates' debate over the resolution on the topic was tempestuous. "A lot of people got up and said 'This is ageism. This is bad. If people are losing their marbles, they'll be able to tell.'"

But that's unrealistic, she said. "People don't know when they're becoming a blithering idiot. If you're impaired, you're the last person to notice."

Wolfe added, "I've heard surgeons who are 80 say, 'I'm just as good now as I was when I was 50.' Well, I don't think so. I don't think your fine motor control is as good when you're 80. I don't care who you are. You're not God. That's one of the reasons we wanted this report."

For hospitals, the Joint Commission's Ongoing Professional Practice Evaluation and Focused Professional Practice Evaluation processes, and the 2-year physician credentialing review, are supposed to capture physicians who show impairment.

"You hope that if they do start having problems, their colleagues in the hospital will pick up and say something," said Wolfe, a physical medicine and rehabilitation specialist in Columbus, Ohio. But in reality, "sometimes that happens and sometimes it doesn't."

Another issue is the exodus of physicians from hospitals to ambulatory and office settings, away from hospital oversight. "The new paradigm is that most physicians don't go to the hospital anymore" because hospitalists fill that role, Wolfe says. "Most physicians are off in their office silos. Our concern was, should we be looking at physicians as they age" as is done for pilots and FBI agents, or wait until a problem goes to a medical board?

, executive vice president and chief medical officer of The Joint Commission, didn't comment on the AMA report. But she acknowledged that there's "tremendous opportunity for improvement in competency evaluation systems that most (hospital) organizations have."

"We know some organizations are challenged. They have a rainmaker and they don't want necessarily to lose income. That scenario happens," McKee said.

She also acknowledged that stringent physician accreditation rules that apply to hospitals do not apply to freestanding outpatient settings or ambulatory surgical centers, and the process "can't occur with the type of objectivity that would occur in a more complex organization like a hospital."

, is director of the Fitness for Duty program at the Physician Assessment and Clinical Education Program (PACE) at the University of California San Diego. That's where doctors in trouble are referred by licensing authorities and others for review and help after something has gone very wrong.

By then, Bazzo said, it's often too late, an incident has already occurred, "and we've seen a number of tragic career endings."

"And we have to ask, wouldn't it have been nice if we could have predicted someone at high risk for something like that, and perhaps remediated it at that point so it didn't happen?"

Myriad Views

Some doctors say competency screening should start a few years after doctors get their licenses.

"One might argue that the frequency should increase after age 65 -- although studies show decline sets in during the 20s," said , former pediatric surgeon at Boston Children's Hospital and 1959 graduate of Harvard Medical School. "The simple answer is that we should do cognitive and skill testing (not peer review, but testing) of all physicians on a regular basis -- I would think at least every 5 years."

, 66, chairman of cardiovascular medicine at the Cleveland Clinic Foundation, which reviews employed physicians annually for renewal of their 1-year contracts, said competency depends. "It is entirely feasible for physicians to remain productive well into their 70s, but it takes a rigorous effort of systematic assessment to make certain that quality is not compromised," he said.

And though older physicians "may suffer from some reduction in physical skills," they often "more than compensate through greater experience. I favor a policy that precludes age discrimination but includes rigorous assessment of patient care skills," Nissen said.

62, an emergency physician in Houston, said she sees "how people might think it's a little bit discriminating" to start screening at a certain age. Doctors can have competency issues "at any age, whether it be the few with alcohol or drug problems or because they suffered an illness.

"But the preponderance of problems are going to be at older age ... and as long as the medical staff decides the age, then it's less an issue of discrimination."

The Massachusetts Medical Society also is looking at the issue, said psychiatrist , 73, former director of the society's Physician Health Services. He said he's pleased the AMA and California groups are taking these steps, and acknowledged that aging doctors can pose problems.

At the American Psychiatric Association's May meeting, someone spoke about concerns that an elderly doctor was not doing well. But when he went to hospital administrators "no one wanted to deal with it. And that's traditionally the way it's been, and that has to change," Sanchez said.

But he wondered if screening should be tailored to specialty rather than across the board. "Surgeons are in a more of a task-oriented specialty, and they may need different competency exams than general physicians," Sanchez said.

For surgeon Goldfarb, self-monitoring is key. "Anyone my age who is still operating, every day you should assess, should I be doing this?" If there are issues, "you address it: You self-limit. You stop doing certain kinds of operations." And you make sure you do cases with someone else who's competent, "someone who can see your hands are still working and things are going smoothly."

Comment