Aging Physicians Present Both Issues and Opportunities by Betsy White Williams, Ph.D., M.P.H.

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Aging Physicians Present Both Issues and Opportunities by Betsy White Williams, Ph.D., M.P.H.

A combination of demographic and economic forces combined with changes in health and longevity suggest a probable increase in the number of physicians practicing well into old age. Over the next 20 years the number of older physicians as well as the proportion of older physicians in the workplace is projected to rise significantly. There are two causes of this trend: first the United States population has aged and grown causing an increased demand for physicians’ services; second, there are a greater number and proportion of older physicians in an increasingly tight market for all physician(Bureau of Health Professions, 2008), although there is some controversy on this conclusion (see, for example, Staiger, Auerbach, & Buerhaus, 2009).

This trend poses a number of important and complex issues. Central to these issues are the changes that occur as part of normal aging. These changes, many positive, some negative have important implications for the effective utilization of older physicians in the medical labor force. One of the most robust findings in the field of gerontology is the increase in heterogeneity of performance across the lifespan.

A number of researchers have reported increases of performance with age and experience as well as relative stability across the lifespan (Gerstorf, Smith, & Baltes, 2006). For example, wisdom and expertise increase with time in many fields such as music, chess and medicine (Jastrzembski, Charness, & Vasyukova, 2006; Schmidt & Rikers, 2007). Within the field of medicine, these findings are also consistent with the practical observation that many roles are consistently offered in considerably greater frequency to older and more experienced physicians. It is commonly reported that it takes a physician a minimum of ten years in practice to move from the level of novice to expert (Ericsson, 2004). The findings are also consistent with language used to describe older individuals, i.e. seasoned, tried, experienced, etc.

Understanding of these characteristics may prove key in leveraging the potential workforce represented by the current cohort of aging physicians. The areas most often cited as either increasing or stable in performance with age are: complex procedural problems; complex diagnostic problems; making initial diagnoses, and complex management or departmental integration problems. Data suggest that older doctors are superior at tasks such as making initial diagnoses because they tend to rely on non-analytic diagnostic strategies thus relying on their years of experience (Bordage, 2007).

However, the literature also suggests decreases in performance with age and with increasing years after medical school and residency. The research shows a consistent finding that age or years post licensure is a risk factor for decreased quality of care as well as increased licensure issues (Williams, 2006). In addition, the gerontology literature has demonstrated that there are a number of decrements in cognitive performance and sensory functioning that occur as a function of advancing age. Within the medical and medical education literature, data support a number of specific age related performance declines: a decrease in the quality of medical knowledge (Norcini, Lipner, Benson, & Webster, 1985), a decrease in the speed and accuracy of medical reasoning (Norman & Eva, 2005), a decrease in the speed and precision of medical procedures (Choudhry, Fletcher, & Soumerai, 2005; Waljee, Greenfield, Dimick, & Birkmeyer, 2006), a decrease in productivity as well as an increased tendency towards premature closure (Eva & Cunnington, 2006) (deciding on a diagnosis before all of the information is in hand).

Eva (Eva, 2002, 2003) in his excellent and comprehensive reviews discussed the changes in cognition that occur as a function of age. He then relates these changes to medical practice as well as continuing medical education. He provides an overview of the well-known and substantiated differences in memory, reasoning and problem solving that occur as a function of normal aging and discusses them in the context of analytic and non-analytic problem solving methods used in medicine. Analytic problem solving is effortful and requires a conscious and deliberate process whereas non-analytic problem solving is largely effortless, experienced based, automatic and recognition based. In a fascinating study, Elstad and colleagues (Elstad, et al., 2010) investigated attributes of clinical practice including how physicians conceptualize and describe the meaning of their clinical experience, and how they use their experience in clinical practice. Their results suggest that what physicians actually gain over time is complex social, behavioral and intuitive wisdom as well as the ability to compare the present day patient against similar past patients. Thus, the relationship between age and physician performance is complex.

What is clear is that with increased utilization of and reliance on an older physician workforce, it will be important to ensure that the strengths aging physicians bring to the medical profession are appropriately recognized, valued and employed to maximize both the benefit of their continued participation as well as their willingness to do so. Simultaneously, it will be important to ensure that the older physician is able to perform the services required at a level that provides quality care to the patient. This tension implies that the roles these providers fill must be designed in an appropriate way and that ongoing professional performance evaluations are necessary to ensure quality of medical care.

Roles most suited for the aging physician include roles that make the greatest use of their acquired knowledge and expertise including supervision, oversight, and facilitation in medical and clinical settings. These roles can include provision of departmental interface and interdepartmental quality functions. The competencies which aging physicians are most likely to excel include communications and interpersonal skill, systembased practice, and the processes involved in practice based learning. These are likely also the skills with which young physicians are least comfortable. A useful approach that maximizes the skills of both younger and more novice clinicians with those of older physicians and more experienced clinicians is the creation of mixed-aged practices (Collier, 2008). Roles for which the aging physician is least suited are ones that require fast yet routine judgments, quickly changing technical or procedural skills, or have a requirement for a high level of physical stamina.

Facilities employing older physicians should consider the need for effective, evidence and performance based continuing medical education. Performance based continuing medical education will ensure that the aging physician maintains their currency and is able to provide quality medical care. The design and implementation of continuing education activities that are relevant and delivered in a way that recognizes the cognitive changes and increased clinical experiences that occur as a function of normal aging and expertise will also be of critical importance in assuring that older physicians are delivering the most current and highest quality health care (Eva, 2003).

A focus on wellness that recognizes the need to identify and compensate for relative weaknesses will also be of critical importance to the functioning of older physicians. Thus use of user-friendly physician electronic aides, training in the use of such aides, and pacing of tasks that are sensitive to changes in cognitive function is appropriate. Other accommodations might include the use of checklists to promote cueing, scheduling that recognizes changes in sleep patterns, lowering distractions (such as decreasing interruptions or background noise), and enhancing contrast on scans.

Policies that assist physicians of all ages in recognizing the need for self-care and wellness are also of critical importance, particularly in light of the literature that suggests that doctors are often reluctant to seek professional assistance for medical issues (Kay, Mitchell, & Del Mar, 2004). This reinforces the need for self care and wellness activities including the assessment of medical, psychological, and clinical skills over the course of one’s career. This prospective screening approach is important since many individuals with cognitive impairment or professional performance gaps lack insight into their problem and may minimize or deny the degree of their impairment. Thus it is unlikely that they will self-refer for assessment, treatment, and/or remediation.

Helping physicians feel comfortable in discussing concerns about a colleague’s health and/or performance is of critical importance in ensuring the health and safety of the colleague as well as the public at large. Providing feedback to a colleague about health or performance concerns is a task that is often difficult, uncomfortable and unfamiliar to physicians. In a national survey of physicians, only 45% of respondents indicated that they had notified the state licensing board of a colleague they felt was impaired or incompetent, yet almost all (96%) indicated that these individuals should be reported (Campbell, Regan, Gruen, & Ferris, 2007). Making sure that physicians are aware of the importance of a timely response in these types of situations as well as resources available within the workplace (such as Employee Assistance Programs, Physician Wellbeing Committees) and their state (e.g. the State Physician Health Program) is critical.

Finally it is important that when older professionals ultimately choose to or must retire, that the transition is managed in an appropriate and compassionate manner. Counseling and mentorship of physicians prior to, during, and after retirement is an important social support for physicians. Many physicians have provided years of selfless service and have few interests outside of medicine. Supporting them in this transition is an important support as they move from active care provider to retired physician (Peisah, Adler, & Williams, 2007).


 

References

Bordage, G. (2007). Prototypes and semantic qualifiers: from past to present. Medical education, 41(12), 1117-1121. Bureau of Health Professions. (2008). The Physician Workforce: Projections and Research into Current Issues Affecting Supply and Demand. Retrieved from http://bhpr.hrsa.gov/ healthworkforce/reports/physicianworkforce/ default.htm.

Campbell, E. G., Regan, S., Gruen, R. L., & Ferris, T. G. (2007). Professionalism in medicine: results of a national survey of physicians.

Ann Intern Med. Choudhry, N. K., Fletcher, R. H., & Soumerai, S. B. (2005).

Systematic review: the relationship between clinical experience and quality of health care. Ann Intern Med, 142(4), 260-273. Collier, R. (2008). Diagnosing the aging physician. CMAJ, 178(9), 1121-1123.

Elstad, E. A., Lutfey, K. E., Marceau, L. D., Campbell, S. M., Von Dem Knesebeck, O., & Mckinlay, J. B. (2010). What do physicians gain (and lose) with experience? Qualitative results from a cross-national study of diabetes.

Social science & medicine (1982), 70(11), 1728-1736. Ericsson, K. A. (2004). Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains.

Academic medicine : journal of the Association of American Medical Colleges, 79(10 Suppl), S70-81. Eva, K. W. (2002).

The aging physician: changes in cognitive processing and their impact on medical practice. Academic medicine : journal of the Association of American Medical Colleges, 77(10 Suppl), S1-6. Eva, K. W. (2003).

Stemming the tide: cognitive aging theories and their implications for continuing education in the health professions. The Journal of continuing education in the health professions, 23(3), 133-140. Eva, K. W., & Cunnington, J. P. (2006). The difficulty with experience: does practice increase susceptibility to premature closure? The Journal of continuing education in the health professions, 26(3), 192-198.

Gerstorf, D., Smith, J., & Baltes, P. B. (2006). A systemicwholistic approach to differential aging: longitudinal findings from the Berlin Aging Study. Psychology and aging, 21(4), 645-663.

Jastrzembski, T. S., Charness, N., & Vasyukova, C. (2006). Expertise and Age Effects on Knowledge Activation in Chess.

Psychology and aging, 21(2), 401-405. Kay, M. P., Mitchell, G. K., & Del Mar, C. B. (2004). Doctors do not adequately look after their own physical health.

Medical Journal of Australia, 181(7), 368-370. Norcini, J., Lipner, R., Benson, J., & Webster, G. (1985). An analysis of the knowledge base of practicing internists as measured by the 1980 recertification examination. Annals of Internal Medicine, 102, 385-389.

Norman, G. R., & Eva, K. W. (2005). Does clinical experience make up for failure to keep up to date? Evidence Based Medicine, 10(4), 66-68.

Peisah, C., Adler, R. G., & Williams, B. W. (2007). Australian pathways and solutions for dealing with older impaired doctors: a prevention model. Intern Med J, 37(12), 826-831.

Schmidt, H. G., & Rikers, R. M. J. P. (2007). How expertise develops in medicine: knowledge encapsulation and illness script formation. Medical education, 41(12), 1133-1139.

Staiger, D. O., Auerbach, D. I., & Buerhaus, P. I. (2009). Comparison of physician workforce estimates and supply projections. JAMA: The Journal of the American Medical Association, 302(15), 1674-1680.

Waljee, J., Greenfield, L., Dimick, J., & Birkmeyer, J. (2006). Surgeon Age and Operative Mortality in the United States. Transactions of the ... Meeting of the American Surgical Association, 124, 19-28.

Williams, B. W. (2006). The prevalence and special educational requirements of dyscompetent physicians. The Journal of continuing education in the health professions, 26(3), 173-191.

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