"We are overly protective of our own. We need to step back and say, ‘No, we’re about protecting our patients.’" This sentiment underscores the critical challenge of ensuring patient safety when physicians, particularly those in demanding surgical roles, experience age-related cognitive changes. The article delves into the increasing prevalence of this issue as the physician workforce ages, exploring the ethical dilemmas, practical challenges, and nascent solutions aimed at balancing the invaluable experience of senior doctors with the paramount need for patient well-being.
The aging of America’s physician workforce presents a growing and complex challenge, particularly within the high-stakes environment of surgery. As doctors continue to practice at older ages, concerns about potential cognitive decline and its impact on patient care are becoming more pronounced. While the vast experience and accumulated knowledge of senior physicians are undeniable assets, the subtle, and sometimes not-so-subtle, shifts in cognitive function that can accompany aging necessitate careful consideration and proactive measures. The case of a 78-year-old surgical oncologist, whose hesitations in the operating room led to mandatory evaluation, serves as a poignant illustration of this unfolding issue. His experience, while leading to a diagnosis of mild cognitive impairment and a subsequent shift in his practice, also highlights the potential for effective interventions and accommodations that allow experienced physicians to continue contributing their expertise in modified roles.
The medical profession, like many others, is witnessing a significant demographic shift. In 2005, over 11% of practicing physicians were aged 65 or older. By last year, this figure had surged to 22.4%, representing nearly 203,000 seasoned practitioners. This trend is particularly acute in areas facing physician shortages, such as rural communities and critical specialties like primary care. The desire to retain these experienced doctors, who possess invaluable skills and institutional knowledge, is strong. However, this demographic reality is also accompanied by research indicating a gradual decline in cognitive abilities starting in the mid-60s for some physicians, as noted by Dr. Thomas Gallagher, an internist and bioethicist at the University of Washington. This decline can manifest as slower reaction times and knowledge that may become outdated, though cognitive function varies widely among individuals. Some practitioners maintain peak performance well into their later years, while others begin to struggle.
In response to these concerns, a growing number of health organizations have begun implementing late-career practitioner programs. These initiatives typically involve comprehensive two-day physical and cognitive assessments for surgeons and other physicians aged 75 and older. Sinai Hospital in Baltimore, for example, inaugurated its screening program in 2015, and since then, approximately 30 physicians nationwide have undergone its rigorous evaluation. Mark Katlic, director of the Aging Surgeon Program at Sinai Hospital, recounted the instance of the 78-year-old surgeon who, under pressure from his chief of surgery, agreed to an evaluation. The tests 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.
The diagnosis did not necessitate immediate retirement. Instead, the focus shifted to identifying appropriate accommodations. "He retained a lifetime of knowledge that had not been impacted by cognitive changes," Katlic emphasized. Consequently, the surgeon was transitioned out of the operating room but continued to see patients in the clinic, a solution that preserves his expertise while mitigating risks associated with his cognitive status. This approach exemplifies the potential for a nuanced strategy that prioritizes both patient safety and the continued professional engagement of experienced physicians.
Beyond Sinai, other institutions have established similar programs. UVA Health at the University of Virginia initiated its screening program in 2011 and has evaluated around 200 older practitioners. In only four cases did the assessments lead to significant changes in a doctor’s practice or privileges. Stanford Health Care and Penn Medicine at the University of Pennsylvania also launched their late-career programs around the same time. Dr. Gallagher estimates that as many as 200 such programs may exist across the country. However, he cautions that given the more than 6,000 hospitals in the United States, those with established late-career programs constitute "a vast minority."
The progress in implementing these programs has, regrettably, stalled and potentially reversed in recent years. A federal lawsuit filed by the Equal Employment Opportunity Commission (EEOC) against Yale New Haven Hospital in 2020, alleging age and disability discrimination in its mandatory cognitive screening for medical staff, has cast a long shadow. While the lawsuit continues and Yale New Haven Hospital maintains its program, the legal action has prompted several other organizations, including Hartford HealthCare and Driscoll Children’s Hospital in Texas, to pause or discontinue their own initiatives. "It made lots of organizations uncomfortable about sticking their necks out," Gallagher observed.
Late-career programs typically mandate evaluations for practitioners aged 70 and older before the renewal of their privileges and credentials. Initial screenings identify potential issues, triggering confirmatory testing. Older doctors are then usually subject to regular rescreening, often annually or biennially. These programs, however, have historically faced resistance from the very physicians they are designed to assess. Rocco Orlando, senior strategic adviser to Hartford HealthCare, noted the common sentiment among doctors: "’I’ll know when it’s time to stand down,’ It turns out not to be true."
Data from implemented programs underscore the necessity of such assessments. Hartford HealthCare’s program, initiated in 2018, reported that among 160 practitioners aged 70 and older screened in its first two years, 14.4% exhibited some degree of cognitive impairment. Similarly, Yale New Haven Hospital’s mandatory screening for staff members starting at age 70 found that 12.7% of the first 141 clinicians tested "demonstrated cognitive deficits that were likely to impair their ability to practice medicine independently." These findings suggest that a significant minority of older physicians may indeed require adjustments to their practice.
Proponents of late-career screening argue that these programs serve a dual purpose: protecting patients from potential harm and guiding physicians with cognitive impairments toward less demanding roles or, when necessary, toward retirement. Orlando expressed initial optimism that the model could be adopted nationwide, noting the relatively low cost of Hartford’s program, estimated at $50,000 to $60,000 annually. However, he has witnessed "zero progress" in recent years, stating, "Probably we’ve gone backward."
The reluctance to implement mandatory screening is multifaceted. Beyond the legal challenges, there is a deeply ingrained cultural resistance within the medical profession to external regulation. "Doctors don’t like to be regulated," Katlic acknowledged. Late-career programs have "in some cases been very controversial, and they’ve been blocked by influential physicians," he added.
In the absence of widespread mandatory programs, most national medical organizations currently recommend voluntary screening and peer reporting. However, Gallagher is skeptical of their efficacy. "Neither works very well at all," he stated. Physicians are often hesitant to report concerns about colleagues, a reluctance that stems from complex power dynamics within the profession. Furthermore, impaired self-awareness can be a consequence of cognitive decline, meaning affected doctors are often "the last to know that they’re not themselves."
Recognizing the need for more equitable and effective approaches, Gallagher and his co-authors recently published a commentary in The New England Journal of Medicine. Their analysis, based on interviews with leaders of late-career programs, proposes procedural policies to promote fairness and encourage physician participation. Key recommendations include ensuring confidentiality and establishing safeguards such as an appeals process. The goal is to design programs that are perceived as fair, thereby increasing physician buy-in.
The concept of accommodations for older physicians is central to these discussions. Gallagher points out that a range of options exist, from adjusting schedules to reducing the complexity of procedures. Physicians might transition to roles focused on teaching, mentoring, or consulting. However, a substantial number of older doctors opt for retirement rather than face a mandated evaluation.
Looking ahead, a potential solution to the age discrimination concerns could involve regularly screening every practitioner, regardless of age. While this approach might be inefficient for younger doctors who are unlikely to exhibit cognitive decline, and potentially time-consuming and expensive with current testing methods, it would eliminate the appearance of age-based discrimination. The development of faster, more reliable cognitive tests, currently in research phases, could pave the way for such universal screening.
In the interim, fostering a cultural shift within healthcare organizations is paramount. Orlando emphasizes the importance of encouraging peer reporting and commending "the people who have the courage to speak up." The principle of "If you see something, say something" should extend to all healthcare professionals witnessing faltering performance, regardless of the practitioner’s age. As Orlando compellingly stated, "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 for ensuring the highest standards of patient care in an era of an aging medical workforce.