Health Equity

Nuanced approach needed to assure senior physician competency

Timothy M. Smith , Contributing News Writer

The growing number of seniors in the physician workforce and increasing expectations for physician accountability are bringing attention to the question of whether age-based competency screening may be necessary to assure safe and effective practice. A recent article in the Journal of Continuing Education in the Health Professions (JCEHP) notes several challenges to establishing a national screening standard. These include designing an evidence-based screening process, determining the appropriate body to administer the screening and striking the right balance between patient protection and fairness to senior physicians.

The article, “Ensuring Competent Care by Senior Physicians,” notes that the number of U.S. physicians 65 and older more than quadrupled between 1975 and 2013. Seniors now make up almost one-quarter of the physician workforce nationwide, and nearly 40 percent are actively engaged in patient care.

Research suggests there is an increased risk for competence and practice-performance decline with increasing years in practice, but the effect of age on individual physicians’ competency is highly variable. Other factors, such as one’s practice environment, can also affect a physician’s clinical performance. 

Moreover, the article notes, aging itself does not cause cognitive impairment. In addition, “some attributes needed to deliver quality health care—such as wisdom, resilience, compassion and tolerance of stress—may increase with aging.” Older physicians, the authors add, have a valuable place in clinical environments and arbitrary retirement or unnecessary restrictions could have a negative impact on patients’ access to care.

Still, in the aggregate, increases in age and time since graduation do predict poorer performance, and the decline is not limited to cognitive function. Manual dexterity and visuospatial ability also drop with age. Taken together, this all suggests steps should be considered to protect patients, support delivery of high-quality care throughout doctors’ careers and maintain the physician workforce, says the JCEHP article. The article, published over the summer, was co-written by AMA Medical Education Outcomes Vice President Richard E. Hawkins, MD, and colleagues at the AMA, the University of Massachusetts Medical School, Worcester, Duke University School of Medicine and University of Texas Health Northeast.

The article’s authors say competency screening of some form should be considered, but many challenges arise in the effort to fairly implement such screening. For example, the question of who should oversee senior physicians’ competency is a troublesome one for licensing authorities, certifying bodies, hospitals, clinical directors and even insurers.

Some hospitals and health systems already require physicians to undergo physical and cognitive exams once they reach a certain age as a condition of privilege renewal. Many other health care organizations oppose such a policy, ostensibly because evidence does not support a specific age threshold. A growing number have policies requiring age-triggered assessments of practice patterns and abilities to practice safely, but the screening ages and intervals of testing are variable.

Another unsettled question is which screening tools are most effective. Peer reporting, while generally viewed as a key mechanism for identifying physicians with compromised competence, is “not reliable,” the article says. A national survey found nearly half of practicing physicians with direct knowledge of a colleague who was impaired or incompetent failed to report that physician.

Peer review, on the other hand, is a more formal quality oversight process, but significant variability exists across institutions in their mechanisms, methods, criteria and perceptions of quality.

Maintenance of Certification (MOC) programs might seem to be the logical way to assess competency, but these too have limited applicability. Many senior physicians are exempt from MOC requirements because of “grandfather” rules. In addition, MOC does not apply to physicians who are not board certified.

Not to be lost in the discussion are the effects—both positive and negative—that screening can have on senior physicians affected by cognitive decline.

“When competency to practice safely is in question, the strategy to address it must be individualized,” the article’s authors write, noting that in some situations state medical boards may intervene and revoke a physician’s license. “If the condition is potentially reversible, or the deficit potentially remediable, state medical boards and hospitals may refer physicians to specialized programs for competency and practice assessments and remediation.”

Some affected physicians may delay retirement by altering their practice environment or by engaging in tailored continuing professional development activities to help mitigate the effects of age-associated cognitive changes.

“Shifting away from procedural work, allocating more time per individual patient, using memory aids, and seeking input from professional colleagues may help physicians successfully adjust to the cognitive changes that accompany aging,” the authors say.

In light of the challenges of using cognitive assessments to predict quality of care by senior physicians and the highly individualized nature of effectively addressing cognitive decline, the authors recommend that regulators and policy makers consider:

  • Developing an evidence-based screening process that addresses the influence of patient and practice variables
  • Eschewing policies that mandate age-specific retirement
  • Establishing consistent quality standards that are applied equitably to all physicians throughout their practice careers

In the absence of such standards, the authors write, “physician organizations should consider whether guidelines for monitoring and assessing the competence and performance of senior physicians fulfills our professional obligation to our patients and what additional evidence is necessary to inform such guidelines.”

A recent AMA Journal of Ethics poll asked website visitors and Twitter followers:

An elderly and esteemed surgeon needs assistance to safely complete his or her cases. How should his or her colleagues respond?

  • 5 percent of respondents said they should report the surgeon to the licensure board
  • 48 percent said they should bring the issue to the attention of the department chair
  • 38 percent said they should confront the surgeon directly and privately
  • 9 percent said they should place a call to the organization’s patient safety hotline

Share your answer on the AMA Journal of Ethics website, and explore a case posing more of the critical ethical and clinical questions surrounding aging physicians with diminished capacities in the October issue of the AMA Journal of Ethics.