Policies Targeted Toward Aging Physicians May Keep Doctors Working Longer, Smarter by Kim Krisberg
Orthopedic surgeon, Ralph Blasier, M.D., J.D., has voluntarily set an end date for his time in the operating room--age 65, about three years from now. “I want to make sure I stop before I lose my skills,” said Blasier, who works in private practice in ... Michigan. “The surgery is what I really enjoy, so if I’m going to stop surgery, I might as well stop seeing patients.”
Aging physicians and their ability to continue practicing safely and effectively has been on Blasier’s mind for years. In 2009, he published an article, “The Problem of the Aging Surgeon: When Surgeon Age Becomes a Surgical Risk Factor,” in the journal Clinical Orthopaedics and Related Research. In the article, he referenced true events, such as a surgeon in his late 80s who had to depend regularly on younger colleagues to finish his operations. He wrote that the issue has attracted “only scant interest and little study” despite the changes in physical and cognitive abilities that come with age being especially pertinent to medicine. It is a complicated and sensitive issue, Blasier said, noting that many physicians may not welcome such a discussion. “I think [these discussions] are the wave of the future and it probably should go that way.”
Some hospitals and health care systems are starting to wade into these waters, adopting official policies that require physicians to undergo health assessments upon reaching a certain age. Such policies may not only benefit patient safety, they also may help physicians who want to practice longer do so safely. According to recent data from the American Medical Association, more than 40 percent of practicing U.S. physicians are older than 55 and almost 21 percent are older than 65.
A Comprehensive Approach
At the University of Virginia Health System, a new policy requires all physicians and licensed independent practitioners, such as psychologists and nurse practitioners, to undergo physical, cognitive, and psychological assessment once they reach 70. They are assessed again at 75, and every two years thereafter to coincide with credential renewal, said John Schorling, M.D., M.P.H., a professor of medicine and public health sciences at the University of Virginia School of Medicine and director of its Physician Wellness Program.
“This wasn’t in reaction to any event in particular,” Schorling said. “We wanted to take a closer look at practice patterns and physician abilities to practice safely. This was an outgrowth of [patient safety] in general.”
Put into effect in 2011, the assessment evaluates issues such as immediate memory, delayed memory, visualspatial abilities, and attention span. It also zeroes in on the specific procedures a practitioner wants to continue offering. Schorling and the practitioner review the results of the assessment, together discussing next steps. While Schorling reports his recommendations back to the hospital’s credentialing committee, the group is not privy to detailed results. In the policy’s first year, 28 physicians older than 70 were due for reappointment; of those, 20 underwent evaluation and the rest retired, Schorling reported.
Schorling said that in light of current physician shortages, such policies have the potential to encourage doctors who have experienced no impairments to practice longer. He noted that one physician who was planning to retire passed the evaluation with flying colors, gained a renewed sense of confidence, and decided to continue practicing. “This can provide reinforcement for doctors ...that they do still have the cognitive ability to be good doctors,” he said.
Of the hundreds of physicians referred to the Physician Assessment and Clinical Education Program at the University of California, San Diego, School of Medicine (UCSD), about 10 to 15 percent have an issue related to aging that adversely affects their ability to practice, said William Norcross, M.D., founder and executive director. The program, which began in 1996 and has conducted about 1,500 physician assessments to date, offers comprehensive competency evaluations for physicians from around the country.
“To be honest, it’s an idea whose time has come, “ Norcross said. “We apply the same sort of assessment and remediation that we use for students and residents. There’s nothing magical or different about what we do that hasn’t been done somewhere in some American medical school.”
Norcross explained that the majority of physicians referred to him for age-related reasons are found to be safe, though they may benefit from learning “better ways to practice.” For example, he described one 78-yearold obstetrician referred to the program after a few suboptimal patient outcomes came to light. Evaluators at the UCSD program found his cognitive abilities were superior--”he was one of the fittest people you’d ever see,” Norcross said. But evaluators did discover he was falling behind in his knowledge base. In response, they were able to recommend training to get him fully up to date on the latest competencies.
“We can help doctors practice longer with a higher quality of care,” Norcross said. “I would stop doing this if I didn’t have that hope.”
David Bazzo, M.D., director of Fitness for Duty within the UCSD program, said it tailors evaluations to a doctor’s specific needs and can offer suggestions, such as getting more rest between shifts or working under heightened supervision, so they can continue to practice safely.
“When they’re here, we not only do an assessment, but we also try to impart some education as well,” said Bazzo, who also serves as a clinical professor of family medicine at UCSD. “Many physicians may be unhappy about it or disgruntled when they come in, but then view the process as fair and objective once they’ve walked out the door.”
Bazzo and Norcross also are involved in a new effort to bring physicians out of retirement and into primary care. The initiative, led by a new organization outside of UCSD and set to launch in early spring, will provide a 15-module online education course in primary care. After physicians finish the course, they will travel to San Diego to complete an in-person exam that includes working with actors portraying standardized patients. Bazzo said the effort is being driven, in large part, by current shortages in primary care.
“Given the Affordable Care Act and considering projections that we’ll be well shy of the number of primary care physicians needed to take care of all the people who will now be insured, there are many physicians who may be interested in returning to practice, maybe part time and maybe working in under-served areas where they can give back, “ Bazzo said.
As for policies that require physician evaluation, Bazzo noted that he supports such screenings, though he said it’s hard to say at what age they should begin. However, he added that as more health care institutions move in that direction, the evidence base will begin to grow.
“I do believe these policies can be effective,” Norcross said. “What I’m afraid of is that they’re coming off as punishment, as intimidation, and I’d like them to come across as a way that a doctor can show his or her commitment to professionalism. The simple fact is that with age, the incidence of disease increases, and we cannot change that. We need to do what’s best for our patients.”
As of March 2010 at Driscoll Children’s Hospital in Texas, medical staff must undergo physical and cognitive evaluation once they reach 70, continuing every two years thereafter at the time of reappointment. The policy was driven and formulated by medical staff to ensure it was fair and equitable, said Donna Quinn, M.S., vice president of operations and quality at the hospital. Quinn said that the policy has been embraced among staff. She also noted that she regularly receives requests for advice from fellow hospitals and health care institutions considering a similar policy.
“There’s definitely a movement toward this,” she said. “We recognized that there was no national consensus concerning the best approach to the issue to aging practitioners, which is why we were so sensitive to the policy and development. We want it to be a dignified process.”
2013 The Reporter April 2013. Association of American Medical Colleges. All rights reserved. Reproduced with permission.