"The medical profession is grappling with a growing challenge: how to ensure patient safety as a significant portion of its workforce ages, potentially experiencing cognitive decline. While veteran doctors possess invaluable experience, their later careers may necessitate careful evaluation and thoughtful accommodations to balance their continued contribution with the paramount need for patient well-being."
As the American physician workforce rapidly ages, healthcare systems face an increasingly complex challenge: ensuring patient safety while accommodating the needs of experienced, yet potentially aging, medical professionals. A growing number of doctors are continuing to practice into their 70s and beyond, bringing a wealth of knowledge and expertise. However, this demographic shift also raises concerns about potential age-related cognitive and physical decline, prompting a national conversation about the necessity and implementation of late-career practitioner programs.
The issue came into sharp focus with the case of a 78-year-old surgical oncologist in a Southern city. His colleagues began to notice a troubling hesitancy during surgical procedures, a lack of decisiveness that required constant prompting from his assistants. 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 abilities, mandated an evaluation before re-credentialing him. This physician, like many others, did not voluntarily seek assessment; it was a condition for continued practice.
The comprehensive two-day physical and cognitive assessment at Sinai, a program established in 2015 for surgeons 75 and older, revealed that the oncologist had mild cognitive impairment. This condition, while not always a precursor to dementia, was deemed significant enough by the neuropsychologist to likely impact his ability to perform complex surgical procedures. However, the diagnosis did not necessitate immediate retirement. As Katlic emphasized, the surgeon retained a lifetime of knowledge unaffected by his cognitive changes. The hospital adapted by removing him from the operating room but allowing him to continue seeing patients in a clinical setting, a testament to the potential for accommodating experienced physicians in modified roles.
This scenario is not isolated. In 2005, over 11% of practicing physicians in the United States were 65 or older, according to the American Medical Association. By last year, that figure had climbed to 22.4%, representing nearly 203,000 older practitioners. This trend is particularly acute in areas facing physician shortages, such as rural communities and critical specialties like primary care, making the idea of driving out seasoned doctors seem counterproductive.
Yet, research indicates a gradual decline in physicians’ cognitive abilities can begin in their mid-60s. Thomas Gallagher, an internist and bioethicist at the University of Washington who studies late-career trajectories, notes that while reaction times slow and knowledge can become outdated, cognitive scores vary significantly. Some physicians maintain high levels of performance well into their later years, while others experience notable struggles.
In response to these emerging concerns, a handful of health organizations have proactively established late-career practitioner programs. These programs typically mandate regular screenings for cognitive and physical deficits in older physicians. UVA Health at the University of Virginia pioneered such an initiative in 2011, screening approximately 200 older practitioners. In the majority of cases, the assessments did not lead to significant changes in practice or privileges. Stanford Health Care and Penn Medicine at the University of Pennsylvania followed suit with similar programs.
While the exact number of these programs nationwide is difficult to ascertain, Gallagher estimates there may be as many as 200. However, considering the over 6,000 hospitals in the U.S., those with formal late-career programs represent "a vast minority." Furthermore, the landscape for such initiatives may have contracted. A federal lawsuit and a persistent reluctance within the medical profession have cast a shadow over the regular assessment of older doctors’ abilities.
Typically, late-career programs require physicians aged 70 and above to undergo evaluations for credential renewal. Initial findings indicating potential issues trigger confirmatory testing, followed by regular rescreening, often annually or biennially. These programs, however, have frequently been met with resistance from their intended beneficiaries. Rocco Orlando, senior strategic adviser at Hartford HealthCare, which launched its late-career program in 2018, observed that doctors often believe they will recognize when it’s time to step down, a belief that research suggests is often inaccurate.
Data from early implementations of these programs supports this concern. Hartford HealthCare’s initial findings from 160 practitioners aged 70 and older revealed that 14.4% exhibited some degree of cognitive impairment. Similar results emerged from Yale New Haven Hospital, which mandated cognitive screenings for medical staff starting at age 70. A study of the first 141 Yale clinicians found that 12.7% demonstrated cognitive deficits likely to impede their independent practice.
Proponents of these screening programs argue they are crucial for preventing patient harm and can guide impaired physicians toward less demanding roles or retirement. Orlando, who initially believed such programs could be widely adopted, expressed disappointment at the lack of progress, stating, "Probably we’ve gone backward."
A significant impediment to the broader 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 in its screening efforts. While the lawsuit is ongoing and the EEOC declined to comment on its status, the legal action prompted other organizations, including Hartford HealthCare and Driscoll Children’s Hospital, to pause or discontinue their programs. This reluctance to "stick their necks out" has created a chilling effect, discouraging the establishment of new initiatives.
The inherent challenges in implementing late-career programs are multifaceted. As Katlic noted, "Doctors don’t like to be regulated." These programs have often been controversial and, at times, have faced opposition from influential physicians. With legal proceedings pending, many health systems are adopting a wait-and-see approach, and most national medical organizations currently recommend only voluntary screening and peer reporting.
However, these voluntary measures have proven largely ineffective. Gallagher pointed out that physicians are often hesitant to voice concerns about their colleagues due to complex power dynamics. Furthermore, the lack of self-awareness that can accompany cognitive decline means that impaired doctors are often the last to recognize their own struggles.
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, emphasize the importance of designing programs that physicians are more likely to participate in, stressing confidentiality and safeguards such as an appeals process.
Gallagher highlighted that numerous accommodations exist for doctors whose assessments indicate a need for modified roles. These can include adjusting schedules, delegating complex procedures to colleagues, or transitioning into teaching, mentoring, or consulting roles. Despite these options, a substantial number of older doctors opt for retirement rather than undergo mandated evaluations.
Looking ahead, a potential solution involves implementing universal screening for all practitioners, regardless of age. While this approach might be inefficient and costly with current testing methods, it could circumvent allegations of age discrimination. The development of faster, more reliable cognitive tests currently in research pipelines could offer a path forward. In the interim, Orlando stressed the need for a cultural shift within healthcare organizations, encouraging peer reporting and commending those who bravely speak up. The mantra, he urged, should be: "If you see something, say something." He concluded by emphasizing that while healthcare professionals are often protective of their own, the ultimate priority must be patient safety, requiring a willingness to address potential issues even among esteemed colleagues.