"We are overly protective of our own. We need to step back and say, ‘No, we’re about protecting our patients.’" – A call to action for healthcare professionals to prioritize patient safety over collegial deference when observing potential cognitive decline in physicians, particularly as the medical workforce ages.
As the demographics of the medical profession shift towards an older population, a critical challenge emerges: ensuring the continued competence of experienced physicians while safeguarding patient well-being. This article delves into the complex issue of cognitive decline in late-career physicians, exploring the growing need for robust screening programs, the hurdles these initiatives face, and potential pathways forward to maintain high standards of medical care. The experiences of physicians undergoing evaluation, alongside the perspectives of experts and data from implemented programs, paint a nuanced picture of a profession grappling with its own aging workforce.
The subtle, yet significant, signs of cognitive impairment can manifest even in the most skilled medical professionals. A case in point is a 78-year-old surgical oncologist, a respected practitioner in a Southern city, whose colleagues began observing a troubling pattern of hesitation during complex surgical procedures. Mark Katlic, director of the Aging Surgeon Program at Sinai Hospital in Baltimore, recounted how this physician would appear "hesitant, not sure of how to go on to the next step without being prompted" by his assistants. This growing concern for the doctor’s cognitive acuity led the chief of surgery to mandate an evaluation as a condition for credential renewal.
This situation is not isolated. Since 2015, Sinai Hospital has been at the forefront with its comprehensive two-day physical and cognitive assessment program for surgeons aged 75 and older. Approximately 30 physicians nationwide have voluntarily undergone this rigorous evaluation. The surgeon in question, while not initially seeking the assessment, ultimately participated. The tests revealed mild cognitive impairment, a condition that, while not always a precursor to full-blown dementia, can significantly impact an individual’s ability to perform demanding tasks. A neuropsychologist’s report concluded that the surgeon’s difficulties were "likely to impact his ability to practice medicine as he is doing presently, e.g. conducting complex surgical procedures."
Importantly, such a diagnosis does not automatically necessitate retirement. The report acknowledged that the surgeon retained a "lifetime of knowledge that had not been impacted by cognitive changes." Consequently, the hospital implemented accommodations, transitioning the physician from the operating room to a clinic-based role where he continued to see patients. This approach highlights a crucial aspect of late-career physician management: adapting roles to leverage retained expertise while mitigating risks associated with diminished cognitive capacity.
The implications of such cases are set to become more prevalent as America’s physician workforce continues to age. In 2005, over 11% of practicing physicians were 65 or older, a figure that surged to 22.4% last year, representing nearly 203,000 older practitioners, according to the American Medical Association. This demographic shift occurs against a backdrop of physician shortages, particularly in rural areas and critical specialties like primary care. The desire to retain the invaluable skills and experience of veteran doctors is paramount, yet the imperative to ensure patient safety cannot be compromised.
Research has begun to document a discernible "gradual decline in physicians’ cognitive abilities starting in their mid-60s," according to Thomas Gallagher, an internist and bioethicist at the University of Washington who studies late-career trajectories. While cognitive scores exhibit considerable variability among individuals, with some maintaining peak performance well into their later years and others experiencing significant challenges, the general trend suggests a need for proactive monitoring. Factors such as slowed reaction times and the potential for knowledge to become outdated are considerations in this evolving landscape.
In response to these emerging realities, a few health organizations have proactively established late-career practitioner programs. These initiatives often mandate cognitive and physical screenings for older physicians. UVA Health at the University of Virginia, for instance, initiated its program in 2011 and has since screened approximately 200 practitioners. Notably, in only four cases did the screening results lead to significant changes in a doctor’s practice or privileges. Stanford Health Care and Penn Medicine at the University of Pennsylvania also launched similar programs the following year.
Estimates suggest that as many as 200 such programs may exist nationwide, though a comprehensive count remains elusive. Gallagher estimates that these programs represent "a vast minority" of the more than 6,000 hospitals in the United States. The momentum behind these initiatives may have even waned in recent years, influenced by a federal lawsuit and the medical profession’s inherent resistance to stringent oversight.
Late-career programs typically require physicians aged 70 and above to undergo evaluations before the renewal of their privileges and credentials. Initial screenings may trigger confirmatory testing for those indicating potential issues, followed by regular rescreening, usually biennially. These programs, while designed to protect patients, have often been met with resistance from their intended beneficiaries. Physicians frequently express the sentiment that "I’ll know when it’s time to stand down," a belief that, as Rocco Orlando, senior strategic adviser to Hartford HealthCare, points out, "turns out not to be true."
Data from implemented programs underscore the prevalence of cognitive impairment in older physicians. Hartford HealthCare’s late-career practitioner program, established in 2018, reported that among the first 160 practitioners aged 70 and older screened, 14.4% exhibited some degree of cognitive impairment. Similar findings emerged from Yale New Haven Hospital, which instituted mandatory cognitive screening for medical staff starting at age 70. A study of the first 141 Yale clinicians tested revealed that 12.7% "demonstrated cognitive deficits that were likely to impair their ability to practice medicine independently."
Advocates for late-career screening argue that these programs can prevent patient harm by identifying physicians who may benefit from less demanding roles or, in some instances, retirement. Orlando expressed initial optimism that such programs could be adopted nationwide, noting the relatively low annual cost of Hartford’s initiative, estimated at $50,000 to $60,000. However, he has observed "zero progress" in recent years, with a perceived regression in efforts to implement these screenings.
A significant impediment to the widespread adoption and continuation of these programs has been legal challenges. In 2020, the federal Equal Employment Opportunity Commission (EEOC) filed a lawsuit against Yale New Haven Hospital, alleging age and disability discrimination based on its mandatory testing efforts. While the lawsuit is ongoing and the EEOC declined to comment on its status, the legal action has prompted other organizations, including Hartford HealthCare and Driscoll Children’s Hospital in Texas, to pause or discontinue their programs. The lawsuit has created a climate of discomfort, making "lots of organizations uncomfortable about sticking their necks out," according to Gallagher.
The implementation of late-career programs has always been an uphill battle, partly due to physicians’ inherent aversion to regulation. Katlic acknowledges that these programs have been "very controversial" and, in some cases, "blocked by influential physicians." As health systems await the outcome of federal legal proceedings, most national medical organizations continue to recommend voluntary screening and peer reporting.
However, both voluntary screening and peer reporting have proven to be largely ineffective. Gallagher notes that "physicians are hesitant to share their concerns about their colleagues," a reluctance often rooted in "challenging power dynamics" within the profession. Furthermore, the nature of cognitive decline can impair self-awareness, meaning that "they’re the last to know that they’re not themselves."
In a recent commentary in The New England Journal of Medicine, Gallagher and his co-authors proposed procedural policies to ensure fairness in late-career screening, based on their analysis of existing programs and interviews with their leaders. The core question they sought to address is, "How can we design these programs in a way that’s fair and that therefore physicians are more apt to participate in?" Their recommendations emphasize the critical importance of confidentiality and robust safeguards, including an appeals process.
For physicians whose assessments indicate a need for altered roles, a range of accommodations are available. These can include adopting less demanding schedules, focusing on routine procedures while delegating complex surgeries to colleagues, or transitioning into teaching, mentoring, and consulting roles. Despite these options, a substantial number of older physicians opt for retirement rather than undergo mandatory evaluations.
The future of ensuring physician competence in later years may lie in universal screening programs that evaluate every practitioner, regardless of age. While this approach might be inefficient, particularly for younger physicians less likely to exhibit cognitive decline, and potentially time-consuming and costly with current testing methodologies, it would circumvent allegations of age discrimination. The development of faster, reliable cognitive tests currently in the research pipeline could offer a more practical solution.
In the interim, fostering a cultural shift within healthcare organizations is crucial. Orlando advocates for encouraging peer reporting and commending "the people who have the courage to speak up." The sentiment, "If you see something, say something," extends to all healthcare professionals who witness a colleague, regardless of age, faltering. As Orlando emphasizes, "We are overly protective of our own. We need to step back and say, ‘No, we’re about protecting our patients.’" This fundamental reorientation of priorities is essential to navigate the complex challenges of an aging physician workforce and uphold the paramount commitment to patient safety.