DOs gauge risks of cognitive decline in older physicians

Headlined “As Doctors Age, Worries About Their Ability Grow,” an article in The New York Times in late January has drawn much attention online, having been cited by other news media, health policy websites and personal injury blogs. Leading with a grim anecdote about a 78-year-old vascular surgeon whose negligence likely caused a patient to die from a pulmonary embolism—a surgeon later determined to have severe age-related cognitive deficits—the article emphasizes that current recertification and relicensure requirements and hospital-based peer reviews do not sufficiently weed out impaired elderly physicians still in practice.

Noting that commercial airline pilots must retire at age 65 and submit to cognitive and physical examinations every six months beginning at age 40, the article quotes several MDs who recommend that practicing physicians undergo systematic assessment after reaching a certain age, such as 70.

Most physicians retire voluntarily when their health and faculties fade or are nudged into retirement by family members and colleagues, acknowledges health care consultant Jonathan Burroughs, MD, who was among those quoted. But some older physicians who show signs of dementia refuse to give up practicing, he observes, noting that it can be difficult for physicians to address potential and undiagnosed impairments with their older colleagues, whom they may revere as mentors. In addition, cognitive deficits that can have an impact on medical abilities are not always obvious to others, Dr. Burroughs says.

While a correlation exists between aging and the eventual decline of mental and physical abilities, age alone is a poor predictor of physician competence, argue a number of osteopathic physicians.

“Impairment can occur at any age,” asserts Robert P. Fedor, DO, a family physician in Madeira Beach, Fla., and a former chairman of the Florida Board of Osteopathic Medicine. Depression, substance abuse, medication, neurological disorders, early-onset Alzheimer disease and numerous other afflictions—as well as personality traits such as complacency and arrogance—can adversely affect a physician’s performance long before he or she reaches age 65, he says.

“Age improves some people and diminishes others,” Dr. Fedor says, noting that he has seen incompetent residents, middle-aged physicians who have failed to keep up with changes in medicine, and physicians with more than 40 years of experience who are among the best-informed, most highly skilled specialists in their fields.

“I have lived long enough to bear witness to physicians dropping out of practice at every age because of cognitive defects, emotional and psychological problems, physical problems and medical problems,” notes 90-year-old pediatrician Arnold Melnick, DO, who retired from college administration at age 78 but continues to write books, articles and columns. “Age should not be used as a regulatory criterion because there are a myriad of cognitive states, emotional situations and competencies within any age group,” says the founding dean of the Nova Southeastern University College of Osteopathic Medicine in Fort Lauderdale, Fla.

Because individuals age so differently, geriatrician Janice A. Knebl, DO, similarly objects to any notion that a mandatory retirement age or rigid age-based system of practice restrictions and assessments be imposed on physicians. Assuring physicians’ ongoing fitness to practice is an issue that specialty-certifying boards, state medical boards and international regulatory authorities are currently addressing, says Dr. Knebl, a professor of internal medicine at the University of North Texas Health Science Center—Texas College of Osteopathic Medicine (UNTHSC/TCOM) in Fort Worth. “The challenge is not age-related decline but ensuring competency throughout a physician’s life.”

“The focus should be on physician competence, which can be an issue at any age,” agrees AOA President Karen J. Nichols, DO, offering her personal opinion since the AOA does not have a policy on age-related cognitive impairment. Physicians should be expected to demonstrate competence throughout their careers through outcomes measures established by hospitals, state licensing boards and specialty certifying boards, she says.

Dr. Nichols notes that because the practice of medicine requires a high level of concentration, stresses that can occur at any time during one’s career, such as a divorce or a diagnosis of cancer, can impair a physician’s performance. Thus, age should not be the main trigger for additional scrutiny and precautionary interventions, she says.

But some osteopathic physicians do acknowledge concerns about the aging of the physician workforce. One-fifth of all physicians are at least 65 years old—a proportion that is increasing as baby boomers age—and more and more physicians are deferring retirement for financial reasons.

Scott A. Steingard, DO, the president of the Arizona Board of Osteopathic Examiners, worries about the many physicians in Arizona who are returning to practice during their retirement years because of the economic recession. “Many of these doctors have not practiced in several years, so there is the added weight of the changes in medicine since they were in practice and the potential of medical morbidity intervening in their skill set,” says Dr. Steingard, who serves on the Board of Directors of the Federation of State Medical Boards of the United States (FSMB).

Nevertheless, the problem in Arizona is more one of potential than of urgency. When an elderly DO is reported to Arizona’s osteopathic board, “the possibility of organic brain disease causing cognitive decline is an area we consider,” Dr. Steingard says. “We are currently adjudicating a case involving an elderly DO in which cognitive decline may be the deciding factor, but I can’t recall any previous such cases.”

Dr. Fedor points out that Florida has already experienced the problem of retired surgeons from other parts of the country moving to the Sunshine State and setting up practice in specialties for which they have been inadequately trained. But the resulting concerns and complaints have had more to do with these physicians lacking the requisite training and experience than with senility, he says.

Ill-informed, poorly performing physicians of any age pose a hazard to patients, Dr. Fedor insists. This is why the FSMB has developed guidelines for more robust maintenance-of-licensure requirements, which medical and osteopathic licensing boards are expected to roll out in the next few years.

Because the New York Times article on aging physicians makes no mention of the plan for states to strengthen relicensure requirements, the FSMB’s president and chief executive officer, Humayun J. Chaudhry, DO, sent the newspaper a letter to the editor.

“The Federation of State Medical Boards has proposed a system in which physicians would be expected to demonstrate their continued professional development every few years to qualify for license renewal,” Dr. Chaudhry wrote in the published letter. “We believe this new approach will help address many of the issues raised in your story.”

Fitness for practice

A literature review article in the June 2009 issue of the American Journal of Geriatric Psychiatry, however, dismisses arguments that age-related cognitive impairment should be treated no differently from other forms of impairment. “It may be argued that physicians with depression, drug addiction, alcoholism, and stressful life events may also manifest impaired functioning [and thereby perhaps be most in need of early intervention], but the difference is that these conditions are treatable and may be time-limited, whereas dementia manifests an irreversible downward course,” states the article titled “The Aging Physician With Cognitive Impairment: Approaches to Oversight, Prevention, and Remediation.”

“Although professional development and experience may have a positive effect on a physician’s abilities, it is undeniable that free recall, encoding, retrieval, visuospatial abilities, abstraction, and mental flexibility decline with age,” write the researchers, led by Sheila M. LoboPrabhu, MD. While concluding that competence rather than age “should be the deciding factor regarding whether physicians should be able to continue their practice,” the authors nonetheless suggest that age may be a risk factor that merits special attention. “Either age-related screening for cognitive impairment should be initiated or rigorous evaluation after lapses in standard of care should be the norm regardless of age,” the authors recommend.

Dr. Burroughs takes a stronger stance in support of age-triggered cognitive and physical screenings for physicians. Proactively preventing potentially fatal medical errors from occurring is far better for both patients and physicians than retrospectively addressing dire outcomes, he points out.

Dr. Burroughs advises hospitals to implement annual specialty-specific “fitness for work” assessments of physicians beginning at age 70. After this age, reappointments should be limited to one year rather than the typical two years, he recommends. Up to 10% of U.S. hospitals have started implementing cognitive screenings and other policies to systematically address the competence of physicians above a certain age, Dr. Burroughs notes. He expects this percentage to grow.

Fears of being forced to retire early deter physicians from confronting head-on the issue of age-related cognitive impairment, Dr. Burroughs maintains. “As I emphasize with clients, our goal is not to shorten physicians’ careers,” he says. “We want to extend physicians’ careers by matching their cognitive and physical abilities with responsibilities they can handle well and with new vocations.”

Most important, Dr. Burroughs asserts, fitness-for-work assessments help prevent long careers from ending ignominiously with license revocations and malpractice lawsuits.

“Plenty of physicians practice competently into their 60s, 70s and 80s,” Dr. Burroughs acknowledges. “I do not advocate that physicians give up their clinical careers at a certain age but rather appropriately adjust their scope of privileges to match their current clinical competence and professional issues and desire.”

Dr. Burroughs, who is in his 60s, points out that he retired from emergency medicine in his 50s, like many emergency physicians do, because this high-stress specialty requires an extremely high level of stamina and mental flexibility. After earning his MBA, he began a second career in health care management consulting. For those physicians who retire from the clinical practice of medicine, “there is so much they can do in their 60s, 70s and 80s that doesn’t involve taking care of patients,” Dr. Burroughs says, noting that options range from academic positions to jobs in the insurance and pharmaceutical industries. “Physicians can parlay what they’ve learned in health care into a new career.”

In his late 70s, Phoenix gastroenterologist Murray Harvey Cohen, DO, still practices five days a week, performs endoscopies in a hospital setting and interacts with referring primary care physicians and other specialists on an ongoing basis. He senses and accepts that he is more closely scrutinized by his colleagues in an informal way because of his age but takes issue with the argument that reaching a particular age is a significant risk factor for medical errors warranting the imposition of systematic screenings and practice restrictions.

“The biggest safety problem is not aging physicians—it is diminished surveillance of staff because hospitals are more concerned about financial statements than levels of care,” Dr. Cohen contends. Residents often are insufficiently supervised, and more and more nurse practitioners and physician assistants are being hired to replace physicians who are retiring, he explains. And physicians of every age in solo practice who are not affiliated with hospitals tend to have inadequate oversight, he says.

Dr. Cohen advises all physicians to keep up with the transformational changes in medicine that occur every 10 years or so and to take continuing medical education seriously. That way, the depth of education and experience older physicians bring remains an asset to patient care, he says. “In many ways, age diminishes stress, which is known to adversely affect performance,” Dr. Cohen adds, citing the example that the challenges of raising children often distract younger physicians.

Cognition screenings

AOA Trustee William S. Mayo, DO, the president of the Mississippi State Board of Medical Licensure, can recall just two physicians with age-related dementia coming before his state’s licensing board in the past 4.5 years. In one case, the physician forgot to make his rounds in the hospital. In the other case, the physician was so physically incapacitated that he had office assistants—not nurse practitioners, registered nurses or physician assistants—performing his physical exams. “When we saw him, we realized that he also had cognitive issues,” Dr. Mayo remembers.

This doesn’t mean that dementia in practicing physicians is extremely rare, but the problem is generally dealt with discreetly, without the need for disciplinary action, according to Dr. Mayo. “Dementia issues are typically handled locally,” he says. For example, a colleague who observes a physician making a series of baffling mistakes in judgment might file a complaint with the hospital. If suspected of having cognitive impairment, the DO or MD typically would be required to take a physician competency examination. “If the physician does poorly on the exam, he or she would likely be told, ‘You have had 40 or 50 or 60 great years of service; it is better to retire now.’ Most of the time, that is what these physicians end up doing,” Dr. Mayo says.

The majority of physicians who are referred for competency evaluations are between 40 and 60 years old, notes geriatrician and family physician Joel L. Dickerman, DO, a clinical evaluator for the Center for Personalized Education for Physicians (CPEP) in Denver and a former member of the organization’s Board of Directors. Assessing and remediating physicians from around the country, who are referred by licensing boards and hospitals primarily due to quality-of-care concerns, CPEP does evaluate a fair number of physicians age 60 and older, Dr. Dickerman says—approximately 16% of the referred physicians. Every physician regardless of age receives a neuropsychological screening designed for physicians, is tested on clinical knowledge, undergoes structured clinical interviews conducted by specialist peers, and participates in videotaped interactions with simulated patients.

A study published in the August 2009 issue of Academic Medicine showed a strong correlation between competency referrals and cognitive impairment. The research, however, did not show a similarly strong correlation between age and significant cognitive impairment among physicians in the control group. “That’s why I don’t think it’s necessary for every physician above a certain age to undergo a neuropsychological screening,” Dr. Dickerman says, noting that such testing also wouldn’t be feasible due to the costs and time involved. Moreover, unless baseline measurements are obtained for individual physicians when they are young, neuropsychological screening will not reveal the rate or extent of physicians’ cognitive decline.

“If we were to subject all older doctors to neuropsychological screening or testing, what results would make the doctor a threat?” retired pediatrician Dr. Melnick wonders. “Would the physician need to fail in just one domain, across all domains or something in between?”

Some degree of cognitive decline occurs with normal aging, but that may be offset by experience in many cases, Dr. Melnick asserts. “I’d rather pick a surgeon who has performed the surgery I need 1,000 times than one who has done it only 50 times,” Dr. Melnick says. “And I’d rather have a surgeon who says, ‘Oh, that’s a different pathology. I saw one like this in 1992, and here’s what happened’ than one who has to say, ‘Oh, that’s a different pathology. I wonder what it is and how to approach it.’ ”

But as they age, surgeons and other physicians tend to continue doing what has worked well for them in the past and may ignore later advances, sometimes persisting with outmoded procedures and treatments, Dr. Melnick acknowledges.

Inconclusive research

The New York Times article on aging physicians cites two studies that purport to show the negative effects of physicians aging on patient care, but these are inconclusive, Dr. Melnick says. Published in July 2005 in the American Journal of Medicine, one of these studies reviewed data on physicians disciplined by the Oklahoma Board of Medical Licensure and Supervision and found that the proportion of physicians disciplined increases with each successive 10-year interval after first licensure. However, a similar review of data on physicians disciplined in Ohio, published in the February 2003 issue of JAOA—The Journal of the American Osteopathic Association, found that those disciplined were significantly more likely to have been in practice 20 or fewer years.

Dr. Fedor notes that medical liability insurance rates do increase with the length of time a physician is in practice, but this is due to the statistically greater likelihood of being sued as practice duration increases. Medical liability insurance rates are not tied to age, he says. A 60-year-old physician in practice 10 years will pay lower rates than a 50-year-old physician in practice 20 years.

Dr. Melnick points out that the New York Times article oversimplified the results of the other cited study, published in the September 2006 issue of the Annals of Surgery. This study indicated an increase in mortality for three out of eight surgical procedures for physicians older than 60, observing that the older surgeons performed worse on more complicated procedures. But the study stated that “the overall magnitude of this difference was small, and the effect of surgeon age was largely restricted to surgeons with low procedure volumes.” The study further stated, “Although there are many theories regarding the effect of surgeon age on patient outcomes, these remain largely speculative. Explication of the effect of physician age on operative outcomes must await additional study.”

Promoting competence

Cardiothoracic surgeon Albert H. O-Yurvati, DO, the chairman of the American Osteopathic Board of Surgery, notes that research has shown that surgical competence correlates most strongly with ongoing professional development and the quality of CME—not with the age of a surgeon. “It is the mid-career surgeons, in fact, who sometimes have a level of cockiness that adversely affects their performance,” says Dr. O-Yurvati, UNTHSC/TCOM’s chairman of surgery.

Osteopathic continuous certification and its allopathic counterpart, maintenance of certification, recognize that lifelong learning is crucial to physicians, Dr. O-Yurvati says. Intended to ensure that board-certified osteopathic physicians stay current and competent to practice in their fields, osteopathic continuous certification will require DOs to pass practice performance and clinical knowledge assessments, as well as complete 50 CME credits in their specialty in each three-year CME cycle.

Beyond recertification, stronger relicensure requirements to be implemented by state medical and osteopathic boards will help ensure that the many MDs and DOs who are not board certified are competent to practice, notes AOA President Dr. Nichols.

Approximately 7 to 10% of physicians practicing in the United States are impaired, studies indicate. This includes impairment from dementia, as well as from substance abuse, depression and other conditions. When a physician observes that a colleague is exhibiting unusually poor performance, “it is incumbent upon that physician to seek help for the impaired colleague,” Dr. Nichols emphasizes. “Don’t blow it off or try to cover for the physician.” As she observes, informal scrutiny by peers will remain a key way to identify dysfunctional physicians of any age.