Physician quality: What’s age got to do with it?

Slowly, but surely, Norman Dunitz, MD, discovered the limitations that age placed on his ability to safely practice as an orthopedic surgeon in Tulsa, Okla. As he neared 70, he took fewer cases as a lead surgeon and started assisting on more procedures led by his colleagues.

In his later 70s, Dr. Dunitz gave up surgery entirely due to the physical toll it took.

“My eyesight, my coordination was not as good. I felt pretty good, but I felt the time had come to stop,” he said.

“Surgery was harder in the sense that we’d operate into the late afternoon,” he said. “I’d be more tired in the evening and have muscle cramps after being on my feet all day. I was just obviously not as physically able as I was 10 years before. & It was a warning to me that I was trying to do too much.”

Dr. Dunitz spent the last few years delivering patient care solely in the office, treating patients’ orthopedic problems with medication, injections, physical rehabilitation orders and referrals for surgery. And in July, he retired from patient care at the age of 84. While Dr. Dunitz’s body told him when it was time to cut back, physicians are sometimes the last to notice or acknowledge when age has impaired their ability to deliver high-quality care.

The aging U.S. doctor population raises patient safety concerns, say experts on geriatric psychiatry, neuropsychology and physician assessment. Virtually no one agrees with the idea of mandating physician retirement at a certain age, as is done with airline pilots who turn 65. And physicians and patient safety experts agree that many doctors deliver excellent care well into their golden years.

But now there is a call for the medical profession to address the delicate subject of when and how to monitor older physicians to assure patient safety.

“This is genuinely a problem,” said James W. Lomax II, MD, senior author of a June 2009 American Journal of Geriatric Psychiatry article on how to oversee, prevent and remediate cognitive impairment among elderly physicians. “We need a broad scope to look at safety in providing patient care, and how to ensure safe provision of care to the public. Our goal is to increase awareness and to help stimulate interest across the country, both in medical societies as well as hospital entities and health care systems looking at this issue and taking it into account and making sure it’s addressed.”

How cognitive functioning fades

Physicians, like everyone else, are at greater risk for a broad range of medical problems as they grow older. Sometimes the issues are self-evident: a hand tremor that poses dangers during surgery; macular degeneration that makes reading a medical chart impossible; or full-blown dementia that renders even household chores a challenge. Other times, the problem is more subtle — a mild decline in cognitive functioning that can affect a physician’s ability to react to novel patient presentations or recall important factors when making a diagnosis.

Between 3% and 11% of seniors develop dementia, and the early signs can be easy to miss, said the article co-written by Dr. Lomax, associate chair in the Menninger Dept. of Psychiatry and Behavioral Sciences at Baylor College of Medicine in Houston. Cognitive abilities also gradually decline with age, with adults in their 70s taking twice as long to process the same mental tasks as people in their 20s, according to a Journal of Continuing Education in the Health Professions study from the summer of 2010.

A Feb. 15, 2005, Annals of Internal Medicine systematic review of 62 studies found that 52% of those studies demonstrated a decline in physicians’ quality linked to advancing age and the passage of years since their medical school and residency training.

Many of the doctors referred for competency evaluations by state medical boards and physician wellness committees are in their late 50s and early 60s, said William Norcross, MD, a geriatrician and executive director of the Physician Assessment and Clinical Education Program at the University of California, San Diego. PACE is one of six centers nationwide where potentially impaired doctors are sent for evaluation.

A study of 267 physicians referred to another doctor-assessment center in Denver found that 24% of them showed evidence of “cognitive difficulty” requiring further neuropsychological evaluation. In a control group of 68 physicians who took the same test, none had scores suggesting cognitive problems, according to the August 2009 study in Academic Medicine.

About 5% of hospitals already have age-based medical-staff policies in place, according to Jonathan H. Burroughs, MD, president and CEO of The Burroughs Healthcare Consulting Network in New Hampshire. He recommends that hospitals make annual renewal of privileges for physicians older than 70 contingent on their securing a fitness-for-duty evaluation from a doctor who specializes in vocational or occupational medicine. The assessment may include a computer-based neuropsychological test of cognitive functioning that also is used to evaluate airline pilots and screen for Alzheimer’s disease.

“When there’s a potential impairment that’s not caused anyone harm, the solution too often is to turn the other way and hope nothing bad happens,” said Dr. Burroughs, a former emergency department medical director. “I’m trying to get physicians to look at this in a more proactive way. If someone’s starting to struggle, why not reach out to them and help them? Paradoxically, you can help extend the life of their practice & instead of allowing someone to fail and foreshorten their career.”

During his time as an ED medical director, Dr. Burroughs and colleagues noticed that a senior physician who joined the department at age 65 began to make mistakes toward the end of his shifts, such as missing obvious findings on x-rays. During more than a decade, the otherwise excellent physician agreed to cut back his shifts from 12 hours to 10 to 6. At the end of his career, the emergency doctor agreed to work only daytime shifts.

“He actually retired in good standing earlier this year,” Dr. Burroughs said. “That’s a happy ending. He didn’t hurt anybody, and he retired when he wanted to and retired with dignity and respect instead of shame and humiliation.”

More doctors delaying retirement

Physician groups and hospital credentialing committees are likely to face difficult calls over aging colleagues’ competence with increasing frequency. One in five licensed U.S. doctors is older than 65, according to 2010 data from the AMA. Many of those doctors continue to practice for the love of medicine and often because retirement is financially out of reach.

Fifty-two percent of physicians said they changed their retirement plans due to the 2007-09 recession, according to survey of 522 U.S. doctors released Aug. 2, 2011, by Jackson & Coker, an Alpharetta, Ga.-based physician staffing agency. A third of these physicians planned to work part time, and 26% wanted to keep going at their current pace.

“A lot of people have expenses like their kids’ weddings and college tuitions, and they don’t know how to deal with them any other way than working,” said Kenneth H. Cohn, MD, a locum tenens general surgeon and physician-hospital relations consultant who lives in Amesbury, Mass. “Especially over the last 10 years, with two recessions, many of us have seen our 401(k)s shrink to less than 201(k)s, so to speak.”

Concern about declining quality among older physicians is part of what prompted the maintenance-of-certification programs offered by 24 boards that compose the American Board of Medical Specialties. Many boards are moving to require more frequent recertification exams and continuing practice-improvement modules. Yet officials at ABMS and the American Board of Internal Medicine acknowledge that these programs are not designed to detect the cognitive decline that can come with age.

Moreover, many physicians in their mid-50s or older earned their initial board certification prior to 1990 and are exempted from the MOC requirements. About a quarter of ABIM-certified internists are “grandfathered,” said Eric Holmboe, MD, the board’s chief medical officer and senior vice president. For physicians who are subject to maintenance of certification, failure on recertification exams could certainly be a red flag, but how that would be acted upon to protect patients remains unclear.

“This is a challenge. Given the voluntary nature of maintenance of certification, the boards are probably not in the best position to act on it,” Dr. Holmboe said. “If they recognize someone hasn’t passed, it’s not like they’re going to be right there with them in the institution. With an impaired physician — whether it’s due to aging, cognitive decline or something else — it’s still heavily dependent on the local environment to identify the problem and intervene.”

About half of hospitals do not require maintenance of certification as a condition of medical staff appointment, Dr. Holmboe said. Hospitals in underserved areas are likelier to credential doctors who are not board certified, he added.

Age discrimination?

The idea of requiring screening after a doctor turns 65 or 70 could discriminate against older physicians who have a lot to offer, said Harris R. Clearfield, MD, a 78-year-old Philadelphia gastroenterologist who works nine hours a day and sees about 70 patients a week.

“I’m really concerned that somebody’s going to come up with a list of memory tests or psychometrics or whatever to see whether you’re good enough to practice,” said Dr. Clearfield, who gave up performing endoscopies and colonoscopies nearly a decade ago to let younger colleagues do the diagnostic procedures. Dr. Clearfield said he feels mentally and physically strong and has never heard an age-related concern from a colleague or a patient.

“Medicine for me is not a job, it’s a life,” he said. “I don’t have a deadline to retire, like at 80 I’m out. I kind of assume that at some point my body or my mind will tell me it’s time.”

Older physicians and experts interviewed for this article recommended that senior doctors visit a personal physician at least once annually and ask trusted colleagues to let them know if they spot signs of slipping care quality.

Dr. Dunitz, the recently retired orthopedic surgeon, said monitoring senior physicians to assure they are still mentally and physically capable is better than arbitrarily pushing them into retirement. He continues to engage in quality improvement initiatives at Tulsa Bone & Joint Associates and is an alternate delegate to the AMA’s House of Delegates for the American Assn. of Hip and Knee Surgeons.

“I realize that you have to protect the public,” Dr. Dunitz said. “Eventually, we have to come to grips with this. We’re living longer. There are people who are 88 or 90 who are still pretty sharp people who can do things in medicine. They may not be able to stand up in surgery all day, but they’re still pretty sharp.”