By Joy Daughtery Dickinson, Executive Editor
An 82-year-old surgeon had a career spanning 50 years in a large, prestigious suburban hospital and had an excellent reputation. Over the previous two years his surgical complication rate, especially the length of time of procedures and the infection rate, began to climb and was greater than that of his colleagues. His colleagues volunteered more often to “assist” him with surgery and help him with difficult cases.
His problems culminated one weekend when he left on vacation with several seriously ill postoperative patients in the hospital, one of whom subsequently died. He did not sign out to a covering surgeon, and no one in his department was aware of his plans for vacation. When he returned, he was horrified, and he admitted that he had forgotten to obtain coverage during his vacation.
The surgeon was referred to a physician assessment and clinical education (PACE) program. These programs perform intensive competency evaluations of doctors referred by state medical boards or healthcare facilities. The PACE program determined he had a markedly poor performance on the screening exam for cognitive functioning, which triggered a neuropsychological examination that revealed major deficits in memory; the ability to assimilate new information; executive function, including the ability to deal with novel or unexpected situations; and visuospatial processing. When presented with the results, the surgeon voluntarily surrendered his medical license. The real-life scenario was shared by William A. Norcross, MD, clinical professor of family medicine and director of the University of California, San Diego (UCSD) PACE Education Program, in the Department of Family and Preventive Medicine, UCSD School of Medicine.
“Same-day surgery managers should respond to older physicians with impairment in the same manner they should respond to physicians who are impaired for any other reason: substance abuse, general incompetence, etc.,” Norcross says. “The same-day surgery manager should be guided by the following concern: What is best for the patient?” Norcross evaluates 100-150 physicians annually. He estimates, based on accepted prevalence data, that about 8,000 currently practicing physicians suffer from significant cognitive deficits, including various types of dementia.
Often, staff members have a “code of silence,” sources say. While commercial airline pilots have to undergo regular health screenings at age 40 and retire at age 65, such rules don’t exist for physicians. Unfortunately, it sometimes takes a catastrophic event with a patient before the surgeon’s impairment is addressed, sources say. Such an event can bring liability or loss of the physician’s license, however. There is some research supporting declining abilities among older surgeons, including a 2006 study that found surgeons older than age 60 had more patient mortality in complex operations than their younger colleagues did.1
Some hospitals are implementing policies that require doctors over a specific age, such as 70 or 75, to have periodic physical and cognitive exams before they can renew their privileges.2
The issue is not going to go away. According to the American Medical Association, one in five licensed physicians in the United States is older than age 65.3 Additionally, the recession has changed physicians’ retirement plans, about 52% reported this change in one recent survey by Jackson & Coker, a physician staffing agency in Alpharetta, GA.3
In some cases, medical malpractice insurance companies limit what an aging physician can do, says Stephen Trosty, JD, MHA, CPHRM, ARM, president of Risk Management Consulting Corp., in Haslett, MI. “Some won’t write a policy after a certain age, such as 75 or 80,” Trosty says. Others limit a physician’s work, especially as it pertains to certain physical skills such as outpatient surgery or minor procedures, he says. “Some insurance companies will require a test both in terms of physical ability and sometimes even mental acuity,” Trosty says.
Are surgeons up to date with technology?
Outpatient surgery managers must address this issue, particularly considering how much technology and methods are changing in the field, sources say.
“Every decade or two, there are entirely new operations to learn,” says Marty Makary, MD, MPH, a Johns Hopkins Medicine surgeon and author of The New York Times bestseller “Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care.” The doctors need retraining on these procedures, Makary says. “There are older doctors who nicely keep up and up to date, and there are others that have not,” he says. That issue is “poorly tracked and measured,” Makary says.
The focus should not on the surgeon’s age solely, says Ray Grundman, MSN, FNP-BC, CASC, senior director of external relations and surveyor, Accreditation Association of Ambulatory Health Care (AAAHC). “Aging per se is not the issue,” Grundman says. “It’s maintaining competence.” (See more on accreditation and Medicare requirements, below.)
Ralph Blasier, MD, JD, orthopedic surgeon at OSF Saint Francis, Escanaba, MI, says physical and cognition tests are available, “but no one agrees who should administer them or how.”
So what’s an outpatient surgery manager to do? Consider these tips:
• Establish a policy.
“Ideally, there should be a policy, process, and protocol in place that allows for immediate intervention in cases where patients are at immediate risk,” Norcross says.
If the physician’s perform is in a “gray area,” the policy should allow reporting the physician confidentially “and subsequently assessing his competence to perform surgeries and provide quality of care in the privileges that he/she has requested,” he says. “Physicians should be referred for competency evaluations whenever there is a reasonable concern that a competency issue exists”
Healthcare facilities increasing are having requirements to determine if their elderly physicians are still coherent and physical capable, Makary says. “That way if someone is strong and capable, providing good care, even into their 80s, there is validation that there is safety,” he says. Many of these centers have said that an evaluation is mandatory when a physician turns 70, and the annual physical examinations are used to support their credentialing or privileges, Makary says.
• Consider the alternatives.
One alternative is for aging physicians to limit their practice. Blasier, age 62, took this step himself. “I gave up doing total hip, total knees, knee arthroscopy, and I limited the shoulder arthroscopy I do — the more difficult ones,” he says. “I’m trying to make sure I’m not persisting in doing things when I think I’m OK, but I’m old.” Blasier plans to give up practicing medicine at age 65, or sooner if he has problems.
Blasier suggest physicians ask a trusted colleague younger than themselves to tell them when it’s time to quit, and not argue.
Makary says other alternatives include suggesting a second surgeon to assist with operations, along with physical and cognitive examinations for certain competencies for memory loss, vision, hearing and tremors, “rather than dealing with this issue by being draconian.”
Small instruments often need fine motor coordination, Grundman says. “When that starts to go, they still have the ability to help others do procedures,” he says. Also, a mentoring role “can be an important role in the final years of their careers,” Grundman says.
• Have physician evaluated.
One option is that limited competency evaluations can be performed by a hospital’s chief of staff or the Physician Wellbeing Committee, Norcross says. “However, when a larger scale, detailed and objective assessment is required, I would recommend a referral to one of the member organizations of the Coalition for Physician Enhancement,” he says. The UC San Diego PACE Program evaluates physicians and surgeons of all specialties, Norcross says. (For more information on these programs, see Resources at end of this article.)
“I do support age-based medical staff screening policies, but of course, the devil is in the details,” Norcross says.
A number of diseases can impair physicians’ abilities to provide quality care, and they increase with age, he says. In general, a screening process should have these criteria, he says:
• It should be confidential.
• It should be evidence-based and reliable in detecting deficiencies in competence.
• Ideally, it should be local, quick, and inexpensive.
• Most importantly, the goal of this process at all times should be optimal, safe, and high-quality patient care. (See Norcross’ recommendation for screening, below.)
Because of the nature of surgery, in terms of it being a referral-based business, avoid the appearance of age discrimination by having elderly physicians undergo independent examinations, such as ones by independent primary care physicians, Makary says.
“Having independent examinations makes the process objective and less subject to the bias of local politics,” he says.
- Waljee JF, Greenfield LJ, Dimick JB, et al. Surgeon age and operative mortality in the United States. Ann Surg 2006; 244(3): 353–362. Accessed at http://1.usa.gov/Zpxhqp.
- Boodman SG. Aging doctors face greater scrutiny. Kaiser Health News. Dec. 10, 2012. Accessed at http://bit.ly/RZVa4V.
- O’Reilly KB. Physician quality: What’s age got to do with it? July 30, 2012.Accessed at http://bit.ly/MNWUf8.
- Coalition for Physician Enhancement. Web: http://www.physicianenhancement.org.
- The University of California, San Diego Physician Assessment and Clinical Education (PACE) Program evaluates physicians and surgeons of all specialties. Web: http://www.paceprogram.ucsd.edu.
Recommendations for optimal screening
There are many factors to consider when setting up a screening process for aging surgeons. William A. Norcross, MD, clinical professor of family medicine and director of the University of California, San Diego (UCSD) Physician Assessment and Clinical Education (PACE) Education Program, in the Department of Family and Preventive Medicine, UCSD School of Medicine, says his “best vision” for a screening process would include the following:
• Screening would begin at age 65 for male physicians and age 70 for female physicians. It also might be triggered by certain serious events such as stroke, myocardial infarction, or hospitalization for any serious illness, including mental illness.
• The interval for repeat assessment would be in the range of 3-5 years, depending on clinical circumstances.
• The initial assessment would include the following:
o a complete history and physical examination, and appropriate lab and imaging tests as indicated, performed by an independent physician (i.e., not a friend or colleague of the physician);
o neurocognitive screening via the MicroCog created originally at Harvard but now owned by PyschCorp. It is a reliable and quick, computer-based cognitive screening test that is relatively inexpensive, Norcross says. (For more information, go to http://bit.ly/VtKkUv.);
o screening for depression, substance abuse, and perhaps other psychiatric diseases using simple, inexpensive, yet objectively studied, paper-and-pencil screening instruments. “I would specifically not recommend routine urine drug screening, although I have colleagues who would dispute this,” Norcross says;
o results of a confidential 360 degree assessment that would also be done at routine intervals for all of the physician and staff members of the clinical unit. “We use the PULSE Program in Florida, but many instruments can be used,” Norcross says. (For more information, go to http://physiciansdevelopmentprogram.com.)
Accreditation and Medicare requirements
When it comes to aging physicians, the Accreditation Association for Ambulatory Health Care (AAAHC) trusts healthcare practitioners will assess their skills or others will assess their skills to ensure they’re maintaining their competence, says Ray Grundman, MSN, FNP-BC, CASC, senior director of external relations and surveyor.
In terms of credentialing, AAAHC expected facilities to have the medical staff go through complete recredentialing and reprivileging at least every three years, but some states require that process more frequently.
Peer review is an important part of the process, Grundman says. “We ask organization to have an active, ongoing process for evaluating significantly the competence of the care they deliver,” he says.
The process should go beyond generic peer review criteria, such as looking at 10 charts every quarter to see if physicians signed the operative report and orders, Grundman says. “That’s stuff they’re expected to do,” he says. “But what we’re looking for: What are the key outcomes for the care they provide?”
For example, with cataract surgery, there is about a 2% rate among the best surgeons for a capsule tear. If your surgeons’ rate goes above 2%, examine what is happening, Grundman advises. “It may be symptom of someone not able to physically keep up,” he says. Managers might need to curtail or remove privileges if physicians can’t maintain that level of proficiency, Grundman says.
“The way we guard patient safety is with credentialing and privileges that goes on every 2-3 years and an ongoing process of peer view to evaluate each other and hold each other to highest level of performance,” Grundman says.
Medicare rules for hospitals and ambulatory surgery centers (ASCs) require facilities to review and periodically re-review the qualifications of the medical staff, including records of any performance duties. A spokesperson for the Centers for Medicare and Medicaid Services (CMS), who spoke on condition of anonymity under department policy, says, “In the case of any ASC that is owned by a surgeon who is the only person performing surgery, this is a more challenging process, but the ASC is still expected to document the evidence that supports the privileging decision.”
Joint Commission addresses aging
The Joint Commission has several standards that address concerns related to the provision of safe quality care, practitioner performance, or practitioner health or behavior, for which investigation might determine that age has impacted the practitioner’s ability to perform the privileges or the practitioner’s behavior. These include: