As clinicians age, many questions arise about how to protect their well-being and that of their patients through the aging process. Research reveals that declines in cognition are clearly associated with the aging process across all populations, including clinicians.
The issues surrounding aging clinicians are complex as physicians with potential cognitive impairments must be carefully evaluated to ensure that both their rights and the rights of their patients are safeguarded. The potential for age discrimination is also very real.
The rise of aging physicians aligns with the overall population; older doctors must care for older and sicker patients with complex medical problems. These trends occur at a time when physician demand is outstripping supply. The Association of American Medical Colleges predicts a shortage of up to 122,000 physicians by 2032.1
Current practices around clinicians of any age who may be impaired—including late-career clinicians—are reactive rather than proactive. Typically, impaired physicians are referred to Physician Health Programs, which are organized and run by the Federation of State Physician Health Programs. While these programs are necessary to help clinicians with problems, proactive programs could offer support to clinicians at all phases of their careers focused on their wellbeing and health.
Such programs would help clinicians avoid burnout and addiction as well as mental and physical health problems by promoting work-life balance, exercise, and healthy eating. Medical professional liability insurers are interested, not only in limiting liability related to late-career clinicians, but also in fostering the well-being and health of physicians of all ages, which contributes to better patient outcomes.
Scope of the challenge
In a webinar hosted by MPL Association, Late-career Clinicians— Promoting Wellbeing While Managing Risk, Christopher Bundy, MD, MPH, executive medical director with Washington Physicians Health Program, and Edward Manning, PhD, clinical psychologist, University of Mississippi Medical Center, discussed how to create an appropriate climate for supporting impaired physicians while ensuring that patients are protected from harm.
With the aging of the American population and the clinician population combined with a forecast shortage of physicians, it’s important that the supply of clinicians align with the demand to the greatest extent possible. That means supporting physicians who want to extend their careers into their late 60s, 70s, and beyond.
Although there is a direct correlation between aging and cognitive decline, there is significant individual variation. That means there is no one-size-fits-all method for determining which late-career clinicians can continue to practice safely and which ones can’t.
“There are major questions as to how we can assure that doctors practice safely and competently as they get older so that we can keep as many in the workforce as we can.” Bundy said. “We want to encourage older doctors who want to continue to practice to do so and avoid unnecessary barriers to discourage them from practicing when they are able. At the same time, we need to make sure that they have the ability to meet the standards of care of good medical practice.”
While most doctors surveyed agreed that they would report an impaired colleague, when actually confronted with this situation, many don’t. In fact, 45% of those surveyed reported encountering an impaired physician and not following through in reporting.3 That creates a gap that can result in adverse patient outcomes and potential liability.
Current practices
Current best practice involves referring physicians about whom there are concerns to Physician Health Programs, which are coordinated by the Federation of State Physician Health Programs, a nonprofit, independent organization. These 48 organizations in most cases are nonprofits led by physicians, designed as a therapeutic alternative to discipline for doctoral level health professionals.
These organizations provide a number of services, including:
- Confidential assessment
- Evaluation referral
- Treatment referral
- Ongoing monitoring of impairing health conditions
The goals of these organizations are public safety, rehabilitation, and confidentiality with a goal that early intervention translates into less overall risk. While these programs are effective, they address problems that are already occurring instead of preventing them.
To succeed, these programs must be tailored to a clinician population. Concerns are typically confirmed based on cognitive screening, rather than age alone or clinical interviews. In-depth neuropsychological screening establishes cognitive impairment; more basic assessments are only guidelines rather than sole determinants.
Such exams can take three to five hours to conduct in addition to scoring, integrating, and generating reports, Manning noted. There’s less potential for error in more comprehensive testing protocols, although every clinician is likely to generate some abnormal scores because everyone has isolated difficulties of one type or another, according to Manning.
To ensure optimal results, assessments should include skill-specific tests that relate to the individual clinician’s specialty. “Physicians may demonstrate cognitive deficiencies in a more generalized short assessment, but in a skill-specific test, those deficiencies may not be in evidence,” said Manning. Initial findings may be incorrect due to factors such as test anxiety or doctors may be able to compensate for deficits through the knowledge and skills they’ve acquired over years of practice. Clinicians may also compensate through looking up more information and relying on support systems.
Yale’s experience with age-based testing
Some hospitals require clinicians over a certain age to take cognitive tests as part of the re-credentialing process. Yale began such a process in 2016, including physicians, nurses, dentists, psychologists, and other medical professionals age 70 and older.4 Yale published a report on its experience in the Journal of the American Medical Association.
In the report, authors Leo Cooney, a geriatrician at the Yale School of Medicine, and Thomas Balcezak, chief hospital medical officer, reported that 12.7% of those screened exhibited cognitive impairment “likely to impair their ability to practice medicine independently.”5 None of these physicians had previously had any reported impairments or performance problems.
As a result of the testing, 57% passed the screening and were scheduled for retesting in two years. Nearly 25% had minor problems and were rescreened in a year. The rest underwent more comprehensive testing and received counseling about next steps.6
Yale declined to release information about the exact specifics of the assessments, which included a battery of 16 tests designed to assess processing speed under pressure, visual scanning and psychomotor efficiency, concentration, working memory, and other factors.7
Model for the future
When considering an ideal model for dealing with a potentially impaired physician, ideas emerge around supporting clinicians’ wellness throughout their careers, beginning in medical school. Encouraging clinicians need for work-life balance, as well as physical, emotional, and mental health is likely to lead to improved outcomes, avoiding impairment.
Such a model must protect patients, ensure confidentiality, and support clinicians experiencing difficulties leading to impairment. A holistic proactive model, Bundy noted, promotes early intervention, which leads to less risk for patients and clinicians. “When addressed early, potential impairment issues can be more easily remediated, resulting in less damage to the physician and patients, facilitating the ability for clinicians to remain safely in practice,” he said.
When dealing with age-related impairment, there are factors that need to be taken into consideration in screening due to potential age discrimination claims. Some insurers require cognitive testing for clinicians over 80. To guard against discrimination charges, cognitive testing might have to be embraced on a broader level. However, how to staff and pay for testing and how to ensure that everyone is tested are questions that would need answering.
For insurers grappling with this issue from the risk perspective, Manning and Bundy noted that consulting with the closest state Physician Health Program is the best practice. “I suggest getting to know your Physician Health Program medical directors as most of us have an educational and outreach mission,” said Bundy. “We consider this part of our job to handle consultative roles such as this and can refer you to reliable and credible experts to conduct any screening.”
References
1 “New Findings Confirm Predictions on Physician Shortage.” Association of American Medical Colleges, April 23, 2019. https://www.aamc.org/newsinsights/press-releases/new-findings-confirm-predictions-physician-shortage.
2 Jeffrey L. Saver. Best Practices in Assessing Aging Physicians for Professional Competency. J Am Med Assoc, Jan. 14, 2020. https://jamanetwork.com/journals/ jama/article-abstract/2758581. Accessed Mar 17, 2020.
3 Eric G. Campbell, et al. Professionalism in Medicine: Results of a National Survey of Physicians. Ann Int Med, Dec 2007. https://annals.org/aim/articleabstract/737856.
4 Stacey Burling. Yale required cognitive testing for older physicians. Here’s how many passed the test. The Philadelphia Inquirer, Jan. 17, 2020. https://www.inquirer.com/health/older-physicians-dementia-testing-cognitive-changes-safety-yalepenn-20200117.html.
5 Stacey Burling. Yale required cognitive testing for older physicians. Here’s how many passed the test. The Philadelphia Inquirer, Jan. 17, 2020. https://www.inquirer.com/health/older-physicians-dementia-testing-cognitive-changes-safety-yalepenn-20200117.html.
6 Stacey Burling. Yale required cognitive testing for older physicians. Here’s how many passed the test.” The Philadelphia Inquirer, Jan. 17, 2020. https://www.inquirer.com/health/older-physicians-dementia-testing-cognitivechanges-safety-yale-penn-20200117.html.
7 M. Alexander Otto. Cognitive screening of older physicians: What’s fair? The -Hospitalist.org, Jan 17, 2020. https://www.the-hospitalist.org/hospitalist/ article/215751/business-medicine/cognitive-screening-older-physicianswhats-fair.