Performance Assessment of Late Career Practitioners: On the Horizon? Or Already Here?

Dr Ellison holds the Swank Foundation Endowed Chair in Memory Care and Geriatrics, Christiana Care Health System, Wilmington, DE, and is Professor of Psychiatry and Human Behavior, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA.

Did you know that FBI agents are required to retire at age 57? And that commercial pilots, national park rangers, and air traffic controllers face mandatory retirement at an age that many physicians consider prime years of professional fitness? In India, Central Health Service doctors must retire at age 65.¹ In the US, physicians are not subject to a mandatory retirement age, but public opinion and accumulating evidence of the effects of aging on professional performance have instigated development of “Late Career Practitioner Assessment” policies at many US health care institutions.

An aging physician workforce

Our physician workforce is indisputably aging. At present, more than a quarter of US physicians are 65 or older.² Unlike many other professions in which retirement is earlier, medical practitioners often wish to continue working into their later years. Medical practice in later adulthood is sometimes a consequence of financial pressure in our era of increased life expectancy. In addition, many physicians avoid relinquishing some of the rewards associated with full participation in professional life.

Age itself does not detract from the quality of a physician’s performance; in fact, age is often associated with greater stress tolerance, resilience, and wisdom. But aging has also been linked with changes in physical and cognitive functioning that can directly affect skills required to carry out clinical work.

The American College of Surgeons (ACS) has been proactive in its recognition of the effects of physical and cognitive aging on performance. Currently, the ACS recommends that surgeons undergo periodic voluntary physical examination, eye examination, and cognitive screening beginning as early as age 65.³ While the relationship of visual and motor function to the performance of medical and surgical procedures is readily appreciated, the link between cognitive aging and changes in physician performance presents more subtle challenges for assessment and elicits greater resistance among the professional community.

Age-related cognitive changes

Physicians’ cognitive decline has been claimed to lag behind that of the general population, ostensibly because of high baseline ability and cognitive reserve reinforced through years of intellectual activity.⁴ Cognitive faculties known to change even with typical aging, however, are integral to excellent professional performance. Complex attention is required to sustain the intake of auditory and visual information while attending to the multiple tasks that constitute a clinical encounter. Intact working and short-term memory support the integration of novel information for use in decision-making. Executive function assists in the recognition of unexpected data, the correction of errors, and the development of an optimal treatment plan. Aging is often accompanied by greater reliance on pattern-based cognitive processing, which can lack flexibility, and decrements in working memory and processing speed that support complex attention and executive function.⁵

Short of an actual neurocognitive disorder, the significance of age-associated changes in physician performance remains controversial, but growing evidence suggests there is reason for concern. Aging of physicians and time since graduation have been correlated with decrements in history taking, physical examination, record keeping, and problem solving⁶ as well as higher mortality with some complex surgical procedures.⁷ An analysis of 62 studies evaluated the relationship of quality of medical care to age or number of years in practice and showed a negative correlation in more than half of the studies reviewed.⁸

Screening for fitness based on age represents a clear departure from the most prevalent current practice, which is to evaluate only when this is suggested by patient complaints or peer concerns. Interestingly, data from comprehensive evaluations of older physicians referred for assessment on the basis of such concerns have typically documented a high rate of cognitive performance issues among the referred individuals.⁹ Unfortunately, physicians are not necessarily good judges of their own performance,¹⁰ and reliance on reports from peers has not proved sufficient.¹¹

Aging, of course, is only one of many factors that affect physician performance. Patient volume and population characteristics, support resources and work environment, documentation requirements, adoption of electronic health records, and professional burnout are among other important influences on the quality of care provided.

Age-based screening spurs debate

National policies for age-based screening of physical and cognitive status of physicians are already an accepted part of medical practice in Canada, Australia, New Zealand, and other countries. In the United States, by contrast, policies are springing up locally and their requirements are inconsistent. Based on the groundbreaking work of California Public Protection and Physician Health, Inc., the typical requirements of an age-based assessment are the medical history, physical examination including motor and visual evaluation, performance review by various approaches, and cognitive examination-but there is much latitude in the performance and interpretation of these measures.¹² The cognitive examination has been especially controversial. The medical staff of the Stanford Hospitals, for example, was successful in eliminating it from the late career practitioner policy now in effect.¹³ A lively ongoing debate is examining the ethics and legality of age-based evaluation of clinicians, exploring whether physician age can be regarded as a “bona fide occupational requirement” subject to use as a trigger for performance assessment, as permitted under the Age Discrimination in Employment Act, or whether the use of age in this way constitutes age discrimination.¹⁴

At the 2019 Annual Meeting of the American Psychiatric Association, a matched pair of symposia will address the issues surrounding the development and spreading phenomenon of age-based practitioner assessment policies. Entitled “Health Care Systems, Malpractice Insurers, and Aging Physicians: Emerging Age-Based Assessment Practices Part 1/Part 2,” these sessions are scheduled for Wednesday, May 22, in Room 154 of the Upper Mezzanine at Moscone Convention Center South. Part 1 will take place from 10:00 AM to 11:30 AM, and part 2 from 1:00 PM to 2:30 PM. A diverse panel will present current information on the evolving demographics of the US physician workforce and the evidence linking age or years of practice with changes in performance issues; the ongoing issues raised by adoption of late career practitioner policies; the concerns that malpractice insurers have about performance of aging practitioners; and the characteristics of a model policy. Please plan to attend and to join in the lively discussion that is certain to occur.

References:

1. Kaul R. Retirement age of central government doctors raised to 65 years. Hindustan Times. September 27, 2017. https://www.hindustantimes.com/india-news/retirement-age-of-central-government-doctors-raised-to-65-years/story-nEFFoxDCLSujIyeITJ3HjN.html. Accessed April 28, 2019.

2. Young A, Chaudhry HJ, Pei X, et al. A census of actively licensed physicians in the United States, 2016. J Medical Regulation. 2017;103:7-21.

3. American College of Surgeons (ACS). Statement on the Aging Surgeon. ACS website. https://www.facs.org/about-acs/statements/80aging-surgeon. Published January 1, 2016. Accessed April 28, 2019.

4. Powell DH, Whitla DA. Profiles in Cognitive Aging. Boston, MA: Harvard University Press; 1994.

5. Eva KW. The aging physician: changes in cognitive processing and their impact on medical practice. Acad Med. 2002;77:S1-S6

6. Caulford PG, Lamb SB, Kaigas TB, et al. Physician incompetence: specific problems and predictors. Acad Med. 1994;69(10 Suppl):S16-S18.

7. Waljee JF, Greenfield LJ, Dimick JB, et al. Surgeon age and operative mortality in the United States. Ann Surg. 2006;244:353-362.

8. Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care. Ann Intern Med. 2005;142:260-273.

9. Korinek LL, Thompson LL, McRae C, Korinek E. Do physicians referred for competency evaluations have underlying cognitive problems?Acad Med. 2009;84:1015-1021.

10. Davis DA, Mazmanian PE, Fordis M, et al. Accuracy of physician self-assessment compared with observed measures of competence: a systematic review. JAMA. 2006;296:1094-1102.

11. DesRoches CM, Rao SR, Fromson JA, et al. Physicians’ perceptions, preparedness for reporting, and experiences related to impaired and incompetent colleagues. JAMA. 2010;304:187-193.

12. California Public Protection and Physician Health, Inc. Assessing Late Career Practitioners: Policies and Procedures for Age-based Screening. https://www.cppph.org/wp-content/uploads/2015/07/assessing-late-career-practitioners-adopted-by-cppph-changes-6-10-151.pdf. June 10, 2015. Accessed April 28, 2019.

13. Krieger LM. Stanford doctors fight age-related test of fitness to practice. The Mercury News. June 8, 2015. http://www.mercurynews.com/2015/06/08/Stanford-doctors-fight-age-related-test-of-fitness-to-practice. Accessed April 28, 2019.

14. U.S. Equal Employment Opportunity Commission. The Age Discrimination in Employment Act of 1967. https://www.eeoc.gov/laws/statutes/adea.cfm. Accessed April 28, 2019.