Should older doctors be examined, tested or forced to retire?

(Reuters Health) - At 81, Dr. Frank Stockdale continues to see breast cancer patients and believes he offers them the wisdom and knowledge from his more than 50 years of oncology practice.

But a new review of the literature on aging physicians questions the competency to practice of older physicians like Stockdale. The report in JAMA Surgery recommends that healthcare organizations develop protocols for testing doctors of a certain - though undetermined - age for health and competence.

“This is clearly a discriminatory policy if you pick an age to test,” said Stockdale, a professor at the Stanford University School of Medicine in Stanford, California, who was not involved in the review.

Lead author Dr. E. Patchen Dellinger, professor of surgery at the University of Washington in Seattle, does not know what age is the right age to begin testing doctors, he said in a phone interview. But the 73-year-old surgeon believes he and other doctors should willingly submit to physical examinations and cognitive testing. And he has.

“The point is you need to have good cognitive function to practice,” he said. “There’s a lot of resistance to being tested. And yet we accept it. Pilots accept it. As pilots control the fates of their passengers, surgeons control the fate of their patients.”

The medical community has grappled with the question of whether to test aging physicians, particularly surgeons, for two decades, if not longer. But the graying of the nation’s physicians has energized the debate over their health and competence.

During the past four decades, the number of practicing U.S. doctors who were at least 65 years old more than quadrupled. By 2015, nearly one in four physicians were 65 or older, the authors write.

Dr. Paul Schenarts, a trauma surgeon and professor at the University of Nebraska College of Medicine in Omaha, agrees with the authors of the review that a program for testing aging physicians should be implemented.

“Something new and different should be done,” Schenarts, who was not involved with the review, said in an email. “It is a well-known paradox that the surgeon with the greatest experience may be the one putting patients at the greatest risk.”

Though federal law prohibits age discrimination, commercial pilots are required to retire before 65, and starting at 40, they must submit to more-frequent medical examinations than younger pilots.

Previous studies of a possible link between doctors’ ages and clinical performance found mixed results. While some showed patients more likely to die from cardiovascular procedures performed by older surgeons, others showed patients were more vulnerable at the hands of younger surgeons.

Using a cognition test called a MicroCog, one prior study examined doctors alongside people outside the profession. Doctors scored better than others, but cognition scores for everyone in the study declined with age. Researchers found significant variability in older physicians’ scores, with some demonstrating fully intact cognitive ability and others showing dramatic declines.

Stockdale discounted the MicroCog as incapable of judging a physician’s ability to practice and said he knew of no test that could appropriately examine a doctor’s cognitive ability to practice medicine.

“The major problem is what is the test for cognition,” he said in a phone interview. “You have to have an instrument that’s been shown to correlate with our work task.”

In 2012, Stanford, where Stockdale practices, proposed cognitive testing for doctors 74.5 years and older. Stockdale protested the policy, which was tabled.

But that doesn’t mean Stanford isn’t monitoring its physicians, he said. They, along with physicians in hospitals throughout the nation, are evaluated every six to nine months and constantly subjected to the scrutiny of their coworkers, patients and oversight committees, he said.

“If I were demented, I can tell you I’d last about a week before every nurse and medical student noticed,” Stockdale said.

“Physicians of all ages are injuring patients,” he said. “We should be testing everybody at all ages for their competence. It shouldn’t be because you’re 65.”

Appealing though all-age testing might be, Schenarts called it “completely impractical” and said he too did not know at what age to start.

A 78-year-old doctor might be fully functioning, he said, whereas a 62-year-old might be in decline.

Ideally, an independent third party from outside the area would conduct testing and peer review, he said.

“The difficulty with local peer review is that there is the possibility that a group of young surgeons may have an incentive to declare an older surgeon is no longer capable,” Schenarts said. “While I personally feel this is unlikely, the potential is a real concern for older surgeons.”

SOURCE: JAMA Surgery, online July 19, 2017.