"The medical profession, while fiercely protective of its own, must prioritize patient safety above all else, even when it means confronting the difficult reality of cognitive decline in experienced physicians."
As the medical field grapples with an aging physician workforce, a growing concern emerges: ensuring patient safety when senior doctors experience cognitive decline. While experience and knowledge are invaluable, the physical and cognitive demands of medicine, particularly surgery, necessitate a proactive approach to assessment and accommodation, even as legal and cultural hurdles complicate these efforts.
The story of a 78-year-old surgical oncologist in a Southern city serves as a poignant case study of this complex issue. His colleagues observed a discernible hesitation and uncertainty during surgical procedures, often requiring prompts from assistants to proceed. This trend, noted Mark Katlic, director of the Aging Surgeon Program at Sinai Hospital in Baltimore, prompted concern from the chief of surgery regarding the doctor’s cognitive fitness. To continue practicing, the surgeon was required to undergo a comprehensive evaluation.
This evaluation was not voluntary. Since 2015, Sinai Hospital has implemented a rigorous two-day physical and cognitive assessment for surgeons aged 75 and older. Approximately 30 such physicians from across the nation have undergone this screening. The assessment revealed that the Southern oncologist had mild cognitive impairment, a condition that, while not always progressing to dementia, can significantly impact one’s ability to perform complex tasks. The neuropsychologist’s report unequivocally 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."
However, this diagnosis did not necessitate immediate retirement. The report acknowledged the surgeon’s "lifetime of knowledge that had not been impacted by cognitive changes." Consequently, instead of a complete cessation of practice, accommodations were made. He was removed from the operating room but continued to see patients in a clinical setting, a testament to the possibility of adapting roles to leverage retained expertise while mitigating risks.
This scenario is poised to become increasingly prevalent. The American physician workforce is aging rapidly. In 2005, over 11% of practicing physicians were 65 or older. By last year, this figure had climbed to 22.4%, representing nearly 203,000 older practitioners. This demographic shift, coupled with existing physician shortages, particularly in rural areas and critical specialties like primary care, creates a delicate balancing act. The desire to retain the invaluable experience of veteran doctors clashes with the imperative of patient safety.
Research has documented a "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 medical professionals. While reaction times may slow and knowledge may become less current, the extent of cognitive decline varies significantly. Some practitioners maintain peak cognitive function well into their later years, while others experience more pronounced challenges.
In response to these emerging realities, a handful of health organizations have pioneered late-career practitioner programs. These initiatives typically mandate regular screenings for cognitive and physical deficits among older physicians. UVA Health at the University of Virginia initiated its program in 2011, assessing approximately 200 older practitioners. In a majority of these cases, the assessments did not lead to significant changes in practice or privileges. Stanford Health Care and Penn Medicine at the University of Pennsylvania also established similar programs around the same time.
While the exact number of such programs nationwide is unquantified, Gallagher estimates it could be as high as 200. However, given the more than 6,000 hospitals in the United States, this constitutes a "vast minority." Furthermore, the trend may be reversing. A federal lawsuit and a persistent cultural reluctance within the medical profession have cast a shadow over the ongoing efforts to regularly assess the abilities of older physicians.
Traditionally, these late-career programs require physicians aged 70 and above to undergo evaluations for credential and privilege renewal, with further testing for those whose initial results raise concerns. Subsequent rescreenings are typically conducted annually or biennially.
These mandatory evaluations have often been met with resistance from their intended beneficiaries. Rocco Orlando, senior strategic advisor at Hartford HealthCare, notes that doctors frequently assert, "’I’ll know when it’s time to stand down,’… It turns out not to be true." Hartford HealthCare, which launched its program in 2018, found that of 160 practitioners aged 70 and older screened in its initial two years, 14.4% exhibited some degree of cognitive impairment.
Similar findings emerged from Yale New Haven Hospital. After instituting mandatory cognitive screening for medical staff members starting at age 70, a study reported that 12.7% of the first 141 clinicians tested "demonstrated cognitive deficits that were likely to impair their ability to practice medicine independently."
Proponents of these screening programs argue they are crucial for preventing patient harm and for guiding physicians with cognitive impairments toward less demanding roles or, when necessary, towards retirement. Orlando expressed his initial hope that these programs would be widely adopted nationally, highlighting that Hartford’s program had a modest annual cost of $50,000 to $60,000.
However, Orlando has observed a disheartening lack of progress in recent years, stating, "Probably we’ve gone backward." A significant contributing factor 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 related to its testing efforts. While the legal action remains ongoing, and the EEOC declined to comment on its status, the lawsuit prompted several other organizations, including Hartford HealthCare and Driscoll Children’s Hospital in Texas, to pause or discontinue their own programs. Consequently, few new initiatives have emerged.
"It made lots of organizations uncomfortable about sticking their necks out," Gallagher commented, underscoring the chilling effect of the legal action.
Implementing late-career programs has always presented challenges. "Doctors don’t like to be regulated," Katlic acknowledged, adding that these programs have "in some cases been very controversial, and they’ve been blocked by influential physicians." As health systems await legal resolutions, most national medical organizations continue to advocate for voluntary screening and peer reporting, approaches that Gallagher deems largely ineffective.
"Physicians are hesitant to share their concerns about their colleagues," Gallagher explained, citing the inherent "challenging power dynamics." Furthermore, he pointed out the inherent lack of self-awareness that can accompany cognitive decline: "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 designed to foster fairness in late-career screening. Their recommendations, informed by an analysis of existing programs and interviews with their leaders, aim to create a framework that encourages physician participation by emphasizing confidentiality and robust safeguards, including an appeals process.
Gallagher highlighted the availability of "all sorts of accommodations" for physicians whose assessments indicate a need for modified roles. These can range from less demanding schedules and the management of routine procedures to transitions into teaching, mentoring, and consulting roles, allowing complex surgeries to be handled by colleagues. Despite these options, a substantial number of older doctors opt for retirement rather than face mandated evaluations.
Looking ahead, a potential solution could involve universally applied screening programs for all practitioners. While this might be perceived as inefficient given the low likelihood of cognitive impairment in younger doctors and could be time-consuming and costly with current testing methods, it would effectively circumvent allegations of age discrimination. The development of faster, more reliable cognitive tests currently in the research pipeline may offer a path forward. In the interim, Orlando advocates for a cultural shift within healthcare organizations, promoting peer reporting and recognizing "the people who have the courage to speak up."
His message is clear: "If you see something, say something." This sentiment extends to all healthcare professionals who observe any physician, regardless of age, experiencing difficulties. "We are overly protective of our own," he stated, emphasizing the critical need to reframe priorities. "We need to step back and say, ‘No, we’re about protecting our patients.’"