He was a surgical oncologist at a hospital in a Southern city, a 78-year-old whose colleagues had begun noticing troubling behavior in the operating room.
During procedures, he seemed 鈥渉esitant, not sure of how to go on to the next step without being prompted鈥 by assistants, said Mark Katlic, director of the Aging Surgeon Program at Sinai Hospital in Baltimore.
The chief of surgery, concerned about the doctor鈥檚 cognition, 鈥渨ould not sign off on his credentials to practice surgery unless he went through an evaluation,鈥 Katlic said.
Since 2015, when Sinai inaugurated a screening program for surgeons 75 and older, about 30 from around the country have undergone its comprehensive two-day physical and cognitive assessment. This surgeon 鈥渄id not come of his own accord,鈥 Katlic recalled.
But he came. The tests revealed mild cognitive impairment, often but not necessarily a precursor to dementia. The neuropsychologist鈥檚 report advised that the surgeon鈥檚 difficulties were 鈥渓ikely to impact his ability to practice medicine as he is doing presently, e.g. conducting complex surgical procedures.鈥
That didn鈥檛 mean the surgeon had to retire; a variety of accommodations would allow him to continue in other roles. 鈥淗e retained a lifetime of knowledge that had not been impacted by cognitive changes,鈥 Katlic said. The hospital 鈥渢ook him out of the OR, but he continued to see patients in the clinic.鈥
Such incidents are likely to become more common as America鈥檚 physician workforce ages rapidly. In 2005, more than 11% of doctors who were seeing patients were 65 or older, the American Medical Association said. Last year, the proportion reached 22.4%, with nearly 203,000 older practitioners.
Given physician shortages, especially in rural areas and key specialties like primary care, nobody wants to drive out veteran doctors with skills and experience.
Yet researchers have documented 鈥渁 starting in their mid-60s,鈥 said Thomas Gallagher, an internist and bioethicist at the University of Washington who has studied late-career trajectories.
At older ages, reaction times slow; knowledge can become outdated. Cognitive scores vary greatly, however. 鈥淪ome practitioners continue to do as well as they did in their 40s and 50s, and others really start to struggle,鈥 Gallagher said.
A few health organizations have responded by establishing mandating that older doctors be screened for cognitive and physical deficits.
UVA Health at the University of Virginia began its program in 2011 and has screened about 200 older practitioners. Only in four cases did the results significantly change a doctor鈥檚 practice or privileges.
Stanford Health Care launched its late-career program the following year. Penn Medicine at the University of Pennsylvania also put in place a testing program.
Nobody has tracked how many exist; Gallagher guesstimated as many as 200. But given that the United States has more than 6,000 hospitals, those with late-career programs constitute 鈥渁 vast minority,鈥 he said.
The number may actually have shrunk. A federal lawsuit, along with the profession鈥檚 lingering reluctance, appears to have put the effort to regularly assess older doctors鈥 abilities in limbo.
Late-career programs typically require those 70 and older to be evaluated before their privileges and credentials are renewed, with confirmatory testing for those whose initial results indicate problems. Thereafter, older doctors undergo regular rescreening, usually every year or two.
It鈥檚 fair to say such efforts proved unpopular among their intended targets. Doctors frequently insist that 鈥溾業鈥檒l know when it鈥檚 time to stand down,鈥欌 said Rocco Orlando, senior strategic adviser to Hartford HealthCare, which operates eight Connecticut hospitals and began its late-career practitioner program in 2018. 鈥淚t turns out not to be true.鈥
When Hartford HealthCare published data from the first two years of its late-career program, it reported that of the 160 practitioners 70 and older who were screened, .
That mirrored results from Yale New Haven Hospital, which instituted mandatory cognitive screening for medical staff members starting at age 70. Among the first 141 Yale clinicians who underwent testing, that were likely to impair their ability to practice medicine independently,鈥 a study reported.
Proponents of late-career screening argued that such programs could prevent harm to patients while steering impaired doctors to less demanding assignments or, in some cases, toward retirement.
鈥淚 thought as we got the word out nationally, this would be something we could encourage across the country,鈥 Orlando said, noting that Hartford鈥檚 program cost only $50,000 to $60,000 a year.
Instead, he has seen 鈥渮ero progress鈥 in recent years. 鈥淧robably we鈥檝e gone backward,鈥 he said.
A key reason: In 2020, the federal over its testing efforts, charging age and disability discrimination. The legal action continues (the EEOC declined to comment on its status), as does the hospital鈥檚 late-career program.
But the suit led several other organizations to pause or shut down their programs, including those at Hartford HealthCare and at Driscoll Children鈥檚 Hospital in Corpus Christi, Texas, while few new ones have emerged.
鈥淚t made lots of organizations uncomfortable about sticking their necks out,鈥 Gallagher said.
Instituting later-career programs has always been an uphill effort. 鈥淒octors don鈥檛 like to be regulated,鈥 Katlic acknowledged. Late-career programs have 鈥渋n some cases been very controversial, and they鈥檝e been blocked by influential physicians,鈥 he said.
As health systems wait to see what happens in federal court, most national medical organizations have recommended only voluntary screening and peer reporting.
鈥淣either works very well at all,鈥 Gallagher said. 鈥淧hysicians are hesitant to share their concerns about their colleagues,鈥 which can involve 鈥渃hallenging power dynamics.鈥
As for voluntary evaluation, since cognitive decline can affect doctors鈥 (or anyone鈥檚) self-awareness, 鈥渢hey鈥檙e the last to know that they鈥檙e not themselves,鈥 he added.
In a recent , Gallagher and his co-authors recommended procedural policies to promote fairness in late-career screening, based on an analysis of such programs and interviews with their leaders.
鈥淗ow can we design these programs in a way that鈥檚 fair and that therefore physicians are more apt to participate in?鈥 he said. The authors emphasized the need for confidentiality and safeguards, such as an appeals process.
鈥淭here are all sorts of accommodations鈥 for doctors whose assessments indicate the need for different roles, Gallagher noted. They could adopt less onerous schedules or handle routine procedures while leaving complex six-hour surgeries to their colleagues. They might transition to teaching, mentoring, and consulting.
Yet a substantial number of older doctors head for the exits and retire rather than face a mandated evaluation, he said.
The future, therefore, might involve programs that regularly screen every practitioner. That would be inefficient (few doctors in their 40s will flunk a cognitive test) and, with current tests, time-consuming and consequently expensive. But it would avoid charges of age discrimination.
Faster reliable cognitive tests, reportedly in the research pipeline, may be one way to proceed. In the meantime, Orlando said, changing the culture of health care organizations requires encouraging peer reporting and commending 鈥渢he people who have the courage to speak up.鈥
鈥淚f you see something, say something,鈥 he continued, referring to health care professionals who witness doctors (of any age) faltering. 鈥淲e are overly protective of our own. We need to step back and say, 鈥楴o, we鈥檙e about protecting our patients.鈥欌
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