Physician Assessments: Ageist or Necessary?

Should clinicians of a certain be assessed to ensure competence, or does that just foster stigma and stereotypes?

CONFERENCE REPORTER

Should older physicians be required to undergo occasional screening and assessment if they want to keep practicing into their 70s? Susan Lehmann, MD, associate professor of Psychiatry and Behavioral Sciences at Johns Hopkins Medicine, proposed this question at an American Association of Geriatric Psychiatry Annual Meeting panel on aging. The online annual meeting was held March 15 to 19.

“I think age testing is going to increase in coming years,” Lehmann told her audience. The question, she continued, will be “are these programs fair to practitioners? [Or] are they examples of age discrimination?”

“In many ways,” she explained, “these are not really new concerns at all.” According to Lehmann, Sir William Osler, MD, CM, a founder of modern American medicine, told the Johns Hopkins University medical faculty that physicians should retire at age 60. He reportedly said, “We should miss the energies of some young-old men, but on the whole be of greater service to the sexagenarii themselves.”

The issue is more pressing now ever, because physicians population is aging. In 2010, 16.3% licensed physicians were aged 60 to 69, and 8.9% were aged 70 years or older. By 2016, those numbers had risen. 19.3% were aged 60 to 69, and 10.0% were over the age of 70.1

Cognitive decline is part of aging, and Lehmann cited several troubling studies on its clinical consequences. Older physicians were found to have less factual knowledge, worse adherence to standards of care, and their patients have worse outcomes.2 In addition, she said older physicians are less likely to adopt new approaches,3 and patients with older physicians had higher mortality rates than patients with younger physicians.4

Even more troubling, older physicians may not recognize their own impairment, Lehmann added. They may lack insight into their conditions, or they may want to minimize or deny their impairments. The stigma surrounding age-based decline may prevent them from asking for help, and colleagues may keep quiet out of fear of offending them.

Medical organizations have already broached the issue of age-based assessments, Lehmann told attendees. In 2015, the American Medical Association’s (AMA) Council on Medical Education recommended that the AMA develop voluntary screening procedures for physicians aged 70 years or older. But its proposed “guiding principles” were voted down in 2018 by a narrow margin of 282 to 222. Those who objected to the AMA’s guidelines cited ageism as a major concern. “I think it’s a really slippery slope to start doing that to any group of people, especially our colleagues,” one voter said at the time.5

Similarly, Lehmann reported that the Society of Surgical Chairs (SSC) has begun developing recommendations, including mandatory cognitive and motor tests after the age of 65.6

The SSC has recognized the need to create modified roles for senior surgeons as well as the importance of discussing career transition and retirement earlier in surgeons’ careers.

Lehmann seconded this sentiment, noting “the transition from an active and productive work life to retirement is a difficult one.” She shared the story of a colleague who lamented that after retirement he had gone from “Who’s Who” to “Who’s he”? By creating new roles for older physicians, Lehmann hopes medicine can ease the tension between ageism and the need to maintain high clinical standards.

References

1. Young A, Chaudhry HJ, Pei X, et al. A census of actively licensed physicians in the United States, 2016. Journal of Medical Regulation. 2017;103(2):7-21.

2. Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care. Ann Intern Med. 2005 Feb 15;142(4):260-73.

3. Hawkins RE, Welcher CM, Elliott VS, Pieters RS, Puscas L, Pick PH. Ensuring competent care by senior physicians. JCEHP. 2016;36:226-231.

4. Tsugawa Y, Newhouse JP, Zaslavsky AM, et al. Physician age and outcomes in elderly patients in hospital in the US: observational study. BMJ. 2017;357:j1797.

5. Firth S. How can competency be measured in older docs? AMAcouncil guidance for testing fails to win over delegates. Medpage Today. November, 14, 2018. Accessed March 23, 2021. https://www.medpagetoday.com/meetingcoverage/ama/76334

6. Rosengart TK, Doherty G, Higgins R, et al. Transition planning for the senior surgeon: guidance and recommendations from the society of surgical chairs. JAMA Surg. 2019;154(7):647-653.

What do you think? Should there be mandatory testing or retirement for clinicians?