"We are overly protective of our own. We need to step back and say, ‘No, we’re about protecting our patients.’"
The aging of America’s physician workforce presents a growing challenge for healthcare systems: ensuring patient safety while retaining the invaluable experience of seasoned medical professionals. As doctors increasingly practice into their later years, concerns about cognitive decline and its potential impact on surgical precision and diagnostic acumen are prompting institutions to re-evaluate credentialing and performance monitoring. This complex issue necessitates a delicate balance between supporting senior physicians and upholding the highest standards of patient care, a balance complicated by legal considerations and the inherent reluctance of many doctors to acknowledge their own potential limitations.
The operating room is a high-stakes environment where split-second decisions and flawless execution are paramount. For a 78-year-old surgical oncologist in a Southern city, these critical faculties began to show signs of strain. His colleagues observed him becoming hesitant during procedures, requiring prompts from assistants to navigate the next step. This observed change in performance triggered concern among hospital leadership, culminating in the chief of surgery requiring a comprehensive evaluation before re-credentialing him to practice.
This scenario, while specific, is indicative of a broader trend. Mark Katlic, director of the Aging Surgeon Program at Sinai Hospital in Baltimore, noted that the surgeon in question "did not come of his own accord." This suggests that, like many in the profession, he was resistant to the idea of assessment. However, the hospital’s policy, implemented in 2015 for surgeons 75 and older, mandated such evaluations. Sinai’s program involves a rigorous two-day physical and cognitive assessment, designed to identify potential impairments that could affect a physician’s ability to practice safely.
The evaluation of the 78-year-old oncologist revealed mild cognitive impairment, a condition that, while not always leading to dementia, can significantly affect performance. A neuropsychologist’s report explicitly stated 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." This finding did not necessarily mandate immediate retirement. Instead, it opened the door for accommodations. Katlic emphasized that the surgeon "retained a lifetime of knowledge that had not been impacted by cognitive changes." Consequently, he was transitioned out of the operating room but continued to see patients in a clinical setting, a common strategy to leverage experience while mitigating risk.
The demographic shift in the medical field underscores the increasing relevance of such programs. In 2005, over 11% of practicing physicians in the United States 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 aging physician population is particularly significant given existing physician shortages, especially in rural areas and critical specialties like primary care. The desire to retain experienced doctors, who possess invaluable knowledge and skills, is strong, creating a tension between the need for rigorous oversight and the imperative to avoid losing seasoned professionals.
Research has documented a gradual decline in cognitive abilities starting in the mid-60s for some physicians, 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 slowed reaction times or outdated knowledge. However, cognitive abilities vary greatly; some practitioners maintain peak performance well into their later years, while others experience significant challenges.
In response to these concerns, a handful of health organizations have established "late-career practitioner programs." These programs often mandate periodic screening for cognitive and physical deficits in older physicians. UVA Health at the University of Virginia pioneered such an initiative in 2011, assessing approximately 200 older practitioners. In only four instances did the results lead to significant changes in a doctor’s practice or privileges. Stanford Health Care and Penn Medicine at the University of Pennsylvania launched similar programs shortly thereafter.
Despite these efforts, the widespread adoption of such programs remains limited. Gallagher estimates that perhaps 200 such programs exist nationally, a "vast minority" considering the over 6,000 hospitals in the United States. The number may have even contracted due to a federal lawsuit and a persistent reluctance within the medical profession to implement mandatory assessments for older doctors.
Late-career programs typically require physicians aged 70 and older to undergo evaluations before the renewal of their credentials and privileges. Initial screenings might trigger more in-depth testing for those showing signs of impairment, followed by regular rescreening, often annually or biennially.
These programs, however, have faced considerable opposition from their intended beneficiaries. Rocco Orlando, senior strategic adviser to Hartford HealthCare, which implemented its program in 2018, observed that doctors often believe, "’I’ll know when it’s time to stand down,’… It turns out not to be true." Hartford HealthCare’s initial data from its program revealed that 14.4% of 160 screened practitioners aged 70 and older exhibited some degree of cognitive impairment. Similar findings emerged from Yale New Haven Hospital, where 12.7% of the first 141 clinicians tested at age 70 demonstrated cognitive deficits likely to impair their independent practice.
Proponents argue that these screenings are crucial for preventing patient harm and for guiding physicians toward less demanding roles or retirement when necessary. Orlando expressed his initial hope that such programs would be encouraged nationwide, noting that Hartford’s initiative was relatively inexpensive, costing $50,000 to $60,000 annually. However, he has witnessed "zero progress" in recent years, with the movement potentially regressing.
A significant factor contributing to this stagnation is a 2020 lawsuit filed by the federal Equal Employment Opportunity Commission (EEOC) against Yale New Haven Hospital, alleging age and disability discrimination based on its testing program. While the lawsuit is ongoing, the legal action prompted several other organizations, including Hartford HealthCare and Driscoll Children’s Hospital, to pause or discontinue their programs. This hesitancy, as Gallagher noted, made many organizations "uncomfortable about sticking their necks out."
Instituting late-career programs has always been an uphill battle, complicated by physicians’ inherent aversion to regulation. Katlic acknowledged that these programs have been "very controversial" and at times "blocked by influential physicians." As health systems await the outcome of legal challenges, most national medical organizations continue to recommend only voluntary screening and peer reporting.
However, these voluntary measures have proven largely ineffective. Gallagher stated, "Neither works very well at all." He cited physicians’ reluctance to report concerns about colleagues due to "challenging power dynamics" and the inherent lack of self-awareness that can accompany cognitive decline, making affected doctors "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 designed to ensure fairness in late-career screening. They emphasized the need for confidentiality, safeguards, and an appeals process to encourage physician participation. Accommodations for impaired physicians can include adjusted schedules, focusing on routine procedures, or transitioning to roles in teaching, mentoring, and consulting. However, a substantial number of older doctors opt for retirement rather than face mandatory evaluations.
Looking ahead, a potential solution could involve regularly screening all practitioners, regardless of age. While this approach might be inefficient and costly with current testing methods, it would circumvent accusations of age discrimination. The development of faster, more reliable cognitive tests currently in research could pave the way for such widespread screening. In the interim, fostering a culture of open communication is crucial. Orlando advocates for encouraging peer reporting and commending those who have the courage to speak up. The principle of "If you see something, say something" extends to healthcare professionals witnessing any doctor, regardless of age, faltering. This requires a shift in perspective, moving from an instinct to protect colleagues to a primary commitment to patient safety.