In many professions in which mental and physical acuity are vital to safety and effectiveness, industries have established mandatory retirement ages and requirements for additional testing. Airline pilots must retire at age 65 years, air traffic controllers at age 56 years, and FBI agents at age 57 years.

There is no mandatory retirement age for physicians, but there is good reason to consider how aging may affect their abilities to safely and effectively practice medicine, especially for surgeons. Some healthcare organizations are addressing those concerns with programs that provide additional monitoring and testing for physicians as they age.

As of 2017, 44.1% of all active U.S. physicians were age 55 years or older, according to data from the American Association of Medical Colleges (AAMC).1 Some states with a relatively low number of aging physicians still have more than a quarter who are 60 or older. The AAMC reports that the states with the highest percentage of physicians 60 or older are New Mexico (37%), Hawaii (35.5%), New Jersey (35%), Montana (35%), and Maine (34.6%).2

Particular Concern for Surgeons

Surgeons are a particular concern because their work requires such precise execution, says Mark R. Katlic, MD, MMM, FACS, chair of the department of surgery at Sinai Hospital of Baltimore. He also is director of the Sinai Center for Geriatric Surgery.

Katlic notes older surgeons often are well respected. However, like anyone else who is aging, they can experience subtle cognitive and physical changes that affect their ability to operate safely.

For that reason, Katlic developed the Aging Surgeon Program at LifeBridge Health in Baltimore, which evaluates the physical and cognitive function of older surgeons. Katlic says the program was designed to identify conditions that could affect physician performance. In many cases, the treatments could address those problems. (Editor’s Note: Much more information on the Aging Surgeon program is available online at: https://bit.ly/2wd7lWL.)

Rather than taking punitive action or trying to force doctors out before they need to retire, Katlic says the program can protect a physician’s rights and professional reputation. Data from the program can shield physicians from arbitrary decisions based on their chronologic age and lower the liability risk of credentialing hospitals, he says.

Many surgeons continue operating well into their 70s without any difficulty. Each surgeon’s abilities must be evaluated on a case-by-case basis, Katlic stresses. Arbitrary cutoffs based solely on age will force many surgeons into retirement long before they develop any performance deficiencies, while at the same time allowing some doctors with early symptoms of aging to continue caring for patients, he says.

The American College of Surgeons (ACS) has advocated for the evaluation of older surgeons’ physical and cognitive function since 1992. Currently, ACS recommends voluntary physical examination, eye examination, and online screening tests of cognition for surgeons age 65 to 70 years.3 However, Katlic says there are no data showing how often this happens. Some hospitals have adopted a late career practitioner policy in their medical staff bylaws, which Katlic says typically require physicians age 70 years and older to undergo the ASC-recommended screening.

Katlic developed the LifeBridge program four years ago after watching chiefs of surgery and chief medical officers making difficult decisions about older surgeons without any objective evidence. They had to base their decisions largely on hearsay of nurses and fellow physicians, he says.

“I’ve been practicing general thoracic surgery for more than 35 years and been chief of surgery at a number of institutions. I’ve encountered some older surgeons who should have stopped operating before they did,” Katlic says. “We’re all human, and our cognitive and physical abilities decrease with age. That’s just a fact.”

The evaluation program is open to physicians from any facility, not just Sinai Hospital. The Aging Surgeon Program is a two-day, multidisciplinary evaluation of a surgeon’s physical and cognitive function that includes neurologic and ophthalmologic examinations, in addition to neuropsychological, physical, and occupational tests.

“They typically come in the night before the evaluation. On the first day, they undergo a physical exam, a neurology exam, and then a couple hours of physical and occupational therapy testing that assess hand-eye coordination, fine motor skills, and balance,” Katlic explains. “Then, they have a nice lunch and an entire afternoon of neurocognitive testing. The standardized tests were selected for individuals with high education levels and high executive functioning.” The second day of testing includes more neurocognitive testing and a complete eye exam. Each specialty area in the program prepares a detailed report on the physician’s results. The team meets at the end of the week to develop a summary report. The program provides a confidential, encrypted report to the hospital or medical group that commissioned the evaluation. The hospital credentialing committee and physician leadership use that information to decide what action is necessary, if any.

Katlic says the results of the examinations can lead to several outcomes. The hospital may continue granting the surgeon full privileges or revoke all privileges. Perhaps the hospital removes only operating privileges, or allows operating privileges if assisted by another surgeon. The surgeon may be restricted to only routine cases or only assistant privileges. Further, the surgeon may be subjected to a focused review of cases, or could wind up working fewer hours.

“Most of the physicians we’ve seen came here kicking and screaming. They would have not elected to come to our program on their own,” Katlic says. “Most have come reluctantly because their chief of surgery, someone at the hospital, or their state medical society made them come. However, to a person, every one of them who has gone through the evaluation admitted at the end that it was a fair evaluation and they were treated with great respect.” Two participants have become spokesmen for the program and the potential difficulties of aging physicians. Katlic also says Sinai Hospital’s late career practitioner policy can be a model for other institutions. (Editor’s Note: See the sidebar story later in this issue to read more about the Sinai policy.)

“Ours says that whenever any practitioner, which includes doctors, nurse practitioners, and physician assistants, comes up for recredentialing, and they are 75 or older, they must have a physical exam, an eye exam, and a neurocognitive screening evaluation. That information is given to our credentials committee,” Katlic reports. “Our medical executive committee unanimously passed that policy, and so did our hospital board of directors. That policy has worked well, and we’ve had not a single complaint about it.”

Possible Legal Issues

Yale New Haven Hospital recently reported on the results from its mandatory testing policy, which requires evaluations at age 70 years. The hospital found that almost one in eight clinicians tested exhibited cognitive deficits that were likely to affect their performance and patient safety.4

Fifty-seven percent of 141 physicians and practitioners who applied for renewal of hospital privileges at Yale New Haven Hospital demonstrated no cause for concern.

The rest were required to undergo yearly recredentialing or further testing, which could then lead to proctored medical practice, resignation, or retirement. In all, 12.8% of clinicians tested exhibited cognitive deficits considered serious enough to warrant concern over their ability to practice independently, the hospital reported, but none of them had been the subject of any reports to their peer review committees or hospital leadership about their abilities.

Late career practitioner policies may be challenged as discriminatory and illegal. On Feb. 11, the U.S. Equal Employment Opportunity Commission (EEOC) filed suit against Yale New Haven Hospital over its policy. (Editor’s Note: See sidebar story later in the issue for more details about the case.)

Katlic says he hopes the EEOC’s lawsuit will not be successful because labor law provides an exception for bona fide occupational qualification exemption, which allows employers to require specific abilities necessary for the job. He expects the hospital to argue that the policy is reasonable because physical and cognitive abilities required for the job are known to diminish with age. “The patient safety issue may outweigh the age discrimination issue when it comes to doctors being qualified to take care of patients,” Katlic offers.

REFERENCES

  1. Association of American Medical Colleges. 2018 Physician Specialty Data Report. Executive Summary. Available at: http://bit.ly/3cw0wAu.
  2. Association of American Medical Colleges. 2017 State Physician Workforce Data Report. Available at: http://bit.ly/2TA1kLN.
  3. American College of Surgeons. Statement on the aging surgeon, Jan. 1, 2016. Available at: http://bit.ly/2Tkm9vQ.
  4. Cooney L, Balcezak T. Cognitive testing of older clinicians prior to recredentialing. JAMA 2020;323:179-180.

SOURCE

  • Mark R. Katlic, MD, MMM, FACS, Chair, Department of Surgery, Director, Aging Surgeon Program, Sinai Hospital of Baltimore. Phone: (410) 601-5843.