"We are overly protective of our own. We need to step back and say, ‘No, we’re about protecting our patients.’" This poignant statement encapsulates the central ethical dilemma facing the medical profession as its ranks age: how to ensure patient safety without unfairly penalizing experienced physicians, especially in an era of critical workforce shortages. The growing number of older doctors presents both invaluable expertise and potential challenges, prompting a critical examination of assessment programs and the culture surrounding peer accountability.
The landscape of American medicine is undergoing a significant demographic shift. As the nation’s physician workforce ages rapidly, a growing percentage of practicing doctors are well into their careers, bringing decades of experience but also facing the natural cognitive changes that can accompany advanced age. This trend, highlighted by the increasing proportion of physicians aged 65 and older, necessitates a proactive approach to maintaining high standards of patient care. While the desire to retain seasoned professionals is strong, particularly in underserved areas and crucial specialties, the imperative to safeguard patients from potential harm due to declining cognitive abilities has never been more urgent. This evolving situation has spurred the development of late-career practitioner programs, designed to assess and manage the capabilities of older physicians, yet these initiatives are fraught with ethical, legal, and professional challenges.
A poignant case study illustrates the delicate balance involved. A 78-year-old surgical oncologist in a Southern city found himself under scrutiny due to observed hesitancy and a reliance on prompts from assistants during surgical procedures. Mark Katlic, director of the Aging Surgeon Program at Sinai Hospital in Baltimore, recounted how the chief of surgery, concerned about the doctor’s cognitive function, required an evaluation before re-credentialing. This doctor, like approximately 30 others from across the country since 2015, participated in Sinai’s comprehensive two-day physical and cognitive assessment, a program initiated for surgeons aged 75 and older. The assessment revealed mild cognitive impairment, a condition that, while not necessarily a precursor to dementia, was deemed likely to impact his ability to perform complex surgical procedures.
Importantly, the diagnosis did not mandate immediate retirement. The assessment provided a pathway for continued contribution, recognizing that the surgeon’s lifetime of knowledge remained intact. As Katlic explained, the hospital transitioned him out of the operating room, allowing him to continue seeing patients in a clinical setting. This scenario underscores the potential for adaptive strategies, allowing experienced physicians to transition to roles that leverage their expertise without compromising patient safety.
The implications of this demographic trend are substantial. In 2005, over 11% of patient-seeing physicians were 65 or older, according to the American Medical Association. By last year, this figure had climbed to 22.4%, representing nearly 203,000 older practitioners. This surge in senior physicians occurs against a backdrop of widespread physician shortages, particularly in rural areas and critical specialties such as primary care. The challenge, therefore, is to create systems that can identify and address cognitive decline without alienating or forcing out valuable, experienced doctors who are essential to the healthcare system.
Research has documented a gradual decline in cognitive abilities starting in the mid-60s, as noted by Thomas Gallagher, an internist and bioethicist at the University of Washington who studies late-career physician trajectories. This decline can manifest as slower reaction times and the potential for knowledge to become outdated. However, cognitive scores exhibit significant variability; some practitioners maintain peak performance well into their later years, while others experience more pronounced difficulties.
In response to these concerns, a growing number of health organizations have established late-career practitioner programs. These programs typically mandate cognitive and physical screenings for older doctors. UVA Health at the University of Virginia, for instance, initiated its program in 2011 and has since screened approximately 200 older practitioners. In most cases, these screenings have not led to significant changes in practice or privileges, with only four instances requiring such adjustments. Stanford Health Care and Penn Medicine at the University of Pennsylvania also implemented similar programs in the years that followed.
While the exact number of such programs remains unquantified, Gallagher estimates there could be as many as 200 nationwide. However, given the sheer volume of hospitals in the United States—over 6,000—this represents a "vast minority," indicating a significant gap in widespread implementation. Furthermore, the number of active programs may have actually decreased. A federal lawsuit and the medical profession’s inherent resistance to external regulation have cast a shadow over the ongoing efforts to regularly assess the abilities of older doctors.
Late-career programs typically require physicians aged 70 and older to undergo evaluations for credential renewal. Initial assessments that flag concerns trigger further, confirmatory testing. Subsequently, older physicians usually undergo rescreening annually or biennially. These programs, however, have often been met with resistance from their intended participants. Rocco Orlando, senior strategic adviser to Hartford HealthCare, which launched its late-career program in 2018, observed that doctors frequently assert, "I’ll know when it’s time to stand down," a sentiment he asserts is often untrue.
Data from early implementations provide compelling evidence for the necessity of such programs. Hartford HealthCare’s initial findings from its program revealed that 14.4% of 160 screened practitioners aged 70 and older exhibited some degree of cognitive impairment. Similarly, Yale New Haven Hospital’s mandatory cognitive screening for staff members starting at age 70 found that 12.7% of the first 141 clinicians tested demonstrated cognitive deficits likely to impair their independent practice.
Advocates for late-career screening argue that these programs are crucial for preventing patient harm and for guiding physicians with impairments toward less demanding roles or retirement. Orlando expressed his initial optimism that such programs could be adopted nationwide, noting that Hartford’s initiative was relatively cost-effective, ranging from $50,000 to $60,000 annually. However, he has witnessed a disheartening lack of progress in recent years, suggesting a regression in these efforts.
A significant impediment to the widespread adoption and continuation of these programs emerged in 2020 when the federal Equal Employment Opportunity Commission (EEOC) filed a lawsuit against Yale New Haven Hospital, alleging age and disability discrimination based on its testing efforts. Although the EEOC declined to comment on the lawsuit’s status, and Yale New Haven’s program persists, the legal action prompted several other organizations, including Hartford HealthCare and Driscoll Children’s Hospital in Texas, to pause or discontinue their programs. This hesitancy has stifled the emergence of new initiatives, with Gallagher noting that such legal challenges have made many organizations "uncomfortable about sticking their necks out."
The implementation of late-career programs has always been an arduous undertaking. "Doctors don’t like to be regulated," acknowledged Katlic, adding that these programs have sometimes faced significant controversy and opposition from influential physicians. As health systems await the outcome of federal legal proceedings, most national medical organizations continue to recommend only voluntary screening and peer reporting.
However, these voluntary measures have proven largely ineffective. Gallagher states that physicians are often reluctant to report concerns about their colleagues due to complex power dynamics. Furthermore, cognitive decline can diminish a person’s self-awareness, making them "the last to know that they’re not themselves."
In a recent commentary published in The New England Journal of Medicine, Gallagher and his co-authors proposed procedural policies designed to ensure fairness in late-career screening. Their recommendations, based on an analysis of existing programs and interviews with their leaders, aim to create a framework that fosters physician participation. Key to their proposal are the principles of confidentiality and robust safeguards, including an appeals process, to ensure equitable treatment.
Gallagher also emphasized that numerous accommodations exist for doctors whose assessments indicate a need for modified roles. These can include reduced work schedules, focusing on routine procedures while delegating complex surgeries, or transitioning into teaching, mentoring, and consulting roles. Despite these possibilities, a substantial number of older physicians opt for retirement rather than undergo mandated evaluations.
Looking ahead, the future may involve universal screening for all practitioners. While this approach might seem inefficient, particularly for younger doctors who are unlikely to exhibit cognitive decline, it could circumvent accusations of age discrimination. The development of faster, reliable cognitive tests currently in research pipelines could offer a more practical solution. In the interim, Orlando suggests that fostering a culture of open communication within healthcare organizations is paramount. This involves encouraging peer reporting and commending those who demonstrate the courage to voice concerns about faltering colleagues, regardless of age. "If you see something, say something," he urges, underscoring the primary responsibility of healthcare professionals: patient safety above all else.