"The medical profession is facing a growing challenge as its workforce ages, with a significant increase in physicians over 65. While experience is invaluable, cognitive abilities can change with age, necessitating careful consideration of how to maintain patient safety without prematurely sidelining seasoned practitioners."
The landscape of American medicine is undergoing a profound demographic shift. As the nation’s population ages, so too does its physician workforce. This demographic trend presents a complex challenge: how to harness the invaluable experience and knowledge of older physicians while ensuring the continued safety and quality of patient care. A growing number of healthcare institutions are grappling with the need to implement programs that assess the cognitive and physical capabilities of their senior medical staff, a necessity driven by documented age-related changes in cognitive function that can, in some cases, impact a physician’s ability to practice medicine.
Consider the case of a 78-year-old surgical oncologist in a Southern city. His colleagues had begun to observe a subtle but concerning shift in his performance during surgical procedures. Mark Katlic, director of the Aging Surgeon Program at Sinai Hospital in Baltimore, described how the physician would appear "hesitant, not sure of how to go on to the next step without being prompted" by his assistants. This observation, coupled with a chief of surgery’s concern about the doctor’s cognitive status, led to a mandate for a formal evaluation before his credentials could be renewed.
This situation is not isolated. Since 2015, Sinai Hospital has operated a comprehensive two-day physical and cognitive assessment program for surgeons aged 75 and older. Approximately 30 physicians from across the country have participated in this rigorous screening. The 78-year-old oncologist, who did not initially seek out the evaluation voluntarily, underwent the assessment. The tests revealed mild cognitive impairment, a condition that, while not necessarily a precursor to full-blown dementia, was deemed likely to impact his ability to perform complex surgical procedures.
Importantly, a diagnosis of mild cognitive impairment does not automatically necessitate retirement. The neuropsychologist’s report highlighted that the surgeon’s extensive lifetime of knowledge remained intact. Instead of a complete cessation of practice, accommodations were proposed. The hospital successfully transitioned the physician out of the operating room, allowing him to continue seeing patients in an outpatient clinic setting, leveraging his experience in a role that aligned with his current capabilities.
The increasing prevalence of such scenarios is intrinsically linked to the rapid aging of the physician workforce. Data from the American Medical Association reveals a significant uptick in the proportion of practicing physicians aged 65 and older. In 2005, this demographic accounted for just over 11% of patient-seeing doctors. By last year, that figure had climbed to 22.4%, representing nearly 203,000 experienced practitioners. This trend is particularly acute in rural areas and critical specialties like primary care, where physician shortages are already a pressing concern. The desire to retain the skills and experience of these veteran doctors is strong, creating a delicate balance between leveraging their expertise and ensuring patient safety.
Research has documented a gradual decline in cognitive abilities among physicians starting in their mid-60s. Thomas Gallagher, an internist and bioethicist at the University of Washington, who has extensively studied late-career physician trajectories, notes that while reaction times may slow and knowledge can become outdated, cognitive scores exhibit significant variability. "Some practitioners continue to do as well as they did in their 40s and 50s, and others really start to struggle," Gallagher explains, underscoring the individual nature of cognitive aging.
In response to these trends, a growing number of health organizations have proactively established late-career practitioner programs. These initiatives typically mandate comprehensive screenings for cognitive and physical deficits in older physicians. UVA Health at the University of Virginia pioneered such a program in 2011 and has since screened approximately 200 older practitioners. In a small fraction of these cases, the assessments led to significant adjustments in a doctor’s practice or privileges. Stanford Health Care and Penn Medicine have also implemented similar programs, recognizing the importance of systematic evaluation.
Estimates suggest that as many as 200 such programs may exist nationwide, though a definitive count remains elusive. However, given the sheer number of hospitals in the United States – over 6,000 – those with dedicated late-career programs represent "a vast minority," according to Gallagher. The number of these programs may have even contracted in recent years. A federal lawsuit, coupled with an ingrained reluctance within the medical profession to confront issues of aging physician competency, has cast a shadow over efforts to regularly assess older doctors’ abilities.
Typically, late-career programs require physicians aged 70 and above to undergo evaluations prior to the renewal of their privileges and credentials. Initial screenings that indicate potential issues trigger more in-depth confirmatory testing. Subsequently, older doctors are usually subject to rescreening at regular intervals, often annually or biennially.
These mandatory evaluations have often proven unpopular with their intended recipients. Physicians frequently express the sentiment, "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." Hartford HealthCare, which launched its late-career practitioner program in 2018, published data from its initial two years, revealing that 14.4% of the 160 practitioners aged 70 and older screened showed some degree of cognitive impairment.
Similar findings emerged from Yale New Haven Hospital, which implemented mandatory cognitive screening for medical staff members starting at age 70. A study of the first 141 Yale clinicians tested indicated that 12.7% "demonstrated cognitive deficits" that were likely to impede their independent practice of medicine.
Proponents of late-career screening programs advocate for their role in preventing patient harm and facilitating smoother transitions for impaired physicians, whether through modified roles or, when necessary, retirement. Orlando expressed optimism that national awareness would foster broader adoption of such programs, highlighting the relatively modest annual cost of Hartford’s initiative, estimated at $50,000 to $60,000. However, he laments the lack of progress and even a perceived regression in recent years.
A significant impediment to the widespread adoption 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 in its testing efforts. While the lawsuit remains ongoing, and the EEOC declined to comment on its status, the legal action prompted several other organizations, including Hartford HealthCare and Driscoll Children’s Hospital in Texas, to pause or discontinue their programs. Few new initiatives have been launched in its wake. Gallagher notes that the lawsuit made "lots of organizations uncomfortable about sticking their necks out."
The establishment of late-career programs has always faced significant hurdles. As Katlic acknowledges, "Doctors don’t like to be regulated." These programs have, in some instances, been "very controversial and they’ve been blocked by influential physicians," he adds.
While health systems await the resolution of federal legal challenges, most national medical organizations continue to recommend only voluntary screening and peer reporting. However, Gallagher contends that "neither works very well at all." He explains that physicians are often hesitant to voice concerns about their colleagues due to "challenging power dynamics." Furthermore, the inherent nature of cognitive decline can impair self-awareness, leading individuals to be "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 promote fairness in late-career screening. Their recommendations, derived from an analysis of existing programs and interviews with their leaders, focus on designing these initiatives in a manner that fosters physician participation. Key to their approach are robust confidentiality measures and safeguards, including a formal appeals process.
Gallagher emphasizes that a variety of accommodations can be made for physicians whose assessments indicate a need for role adjustments. These might include reduced work schedules, a focus on routine procedures while delegating complex surgeries to colleagues, or a transition to roles in teaching, mentoring, and consulting. However, he also notes that a substantial number of older doctors opt for retirement rather than undergo mandatory evaluations.
Looking ahead, a potential future model involves the regular screening of all practitioners, regardless of age. While this approach might be considered inefficient, as few physicians in their 40s would likely fail a cognitive test, it could mitigate allegations of age discrimination. The development of faster, reliable cognitive tests currently in the research pipeline may offer a more practical solution. In the interim, Orlando suggests that fostering a culture of open communication is paramount. This includes encouraging peer reporting and commending "the people who have the courage to speak up." He advocates for a paradigm shift where healthcare professionals, regardless of age, prioritize patient well-being over protecting colleagues when concerns arise. "If you see something, say something," Orlando urges, reminding practitioners that the ultimate responsibility lies in safeguarding patients.