Assessing the Competency of Older Physicians

The number of older physicians is on the rise, presenting a potential conflict practice managers could have to face in the coming years - how to fairly and legally assess aging physicians.

In a recent meeting, the AMA stated that the number of physicians older than 65 has quadrupled since 1975 and now accounts for one out of every four physicians. Armed with this information, in June 2015, the AMA decided they needed to develop guidelines and methods to screen and assess older physicians, to ensure they are competent in providing care to patients. The organization is currently in the planning stages of implementing this policy, saying it will gather perspectives from different stakeholder representatives before moving forward.

AMA backed this decision with research from its Council on Medical Education, which claims that past the age of 60, there are "differences in performance" that "may become apparent." The largest physician organization in the country also says that older physicians are less likely to acquire knowledge over time. While the AMA says age is not the only factor that determines whether or not a physician is capable of practicing medicine to the fullest extent, the report summarized recommendations from various sources that cognitive and physical screening should begin between ages 65-70.

"Physicians are professionally obligated to ensure that they are providing high-quality care to their patients and to continually assess their own physical and mental health, even though there is no national standard for screening physicians who have reached a certain age. A number of regulators and policymakers are considering some form of age-based competency screening, and some hospitals and health systems already require such screenings," Rich Hawkins, the physician vice president of medical education outcomes at AMA, said in an e-mail to Physicians Practice.

Yet, not everyone is onboard with the AMA's edict. Jane Orient, a general internal medicine physician and head of the Association of American Physicians and Surgeons, says that the actions of the AMA are an example of "blatant discrimination" and a money grab.

"Someone has a vested interest in making a lot of money from the [screening and assessment] tests that they'll sell to you," says Orient. "I think it's unfair because while capacities do change with age, to assume the older physicians are not as capable as younger ones is dangerous … when I'm looking for a physician, I want an older physician. His years of experience and early basic training count for a lot more than any slowing down he may have experienced."

Some physicians, like David Norris, an anesthesiologist with Wichita Anesthesiology Chartered, based in Wichita, Kan., and the owner of a physician-based training organization, the Center for Professional Business Development, wrestle with the idea of judging of older physicians, especially when it comes to people who may have mentored or hired him. "Who am I to say you are not a good doctor? Telling someone, 'You've been practicing for so long and now I don't know if you have the skills,' that's the hard thing," he says.

STICKY SITUATION

Norris faced a difficult situation in his medical group a few years back, which speaks to just how hard this kind of scenario can be. In his case, the doctor's age wasn't the reason for his retirement, but rather an injury.

"We had a [doctor] who suffered a closed head injury and was in the [intensive care unit] for quite some time. When he came back to practice, things weren't quite right," says Norris. "He was having issues with clinical judgment and it was clear he wasn't the same person from before."

At first, the doctor wouldn't admit to any deficiencies. Eventually, after prodding from others within the practice, he acquiesced and took a competency test from an outside organization. The results showed what everyone had suspected: He was impaired enough that practicing anesthesia everyday would be a challenge. With those results, the doctor admitted that objectively speaking, it was time to retire.

For Norris, this situation went about as smoothly as he could've hoped. For other physicians, it's not always that easy when asking their peers to take a competency test, for whatever reason - be it injury, age, or something else.

Indeed, while many older physicians are happy to scale back operations past the age of 60, others, like a pair of surgeons Norris works with, continue to practice in their 70s. Some doctors even continue into their 80s. This becomes a problem if their skills are diminished. Phil Zarone, a partner at Horty, Springer & Mattern, P.C., which deals exclusively with healthcare law, says in the last few years he has seen more clients ask how they could legally and fairly assess an older physician. "I am not sure if it's because more baby boomers are reaching the retirement age, and some want to keep practicing, whether it's for a financial [reason] or they just enjoy practice…that may be one reason," he says.

WHAT TO DO

Fair or not, the increasing number of older physicians makes it likely that a given practice will face this potentially combustible issue in the coming years. If they do, the first thing these practices should do with the older physician is hash it out, says David Bazzo, a family medicine physician who is an associate director of the University of California San Diego Health System's Physician Assessment and Clinical Education (PACE) program. Bazzo says being hands-on will help practices avoid problems later.

"Have your medical staff debate the issue and then come to some kind of consensus. This is one of those things that will become inevitable. This is a perfect example where physicians can take the lead and be proactive and have control over it," Bazzo says.

The PACE program, or a similar competency assessment course, could be another route for practices to take. The program, which is the largest of its kind in North America, evaluates the physical and mental capabilities of a physician, with the elements in the assessment catered to the specific area of practice. While it doesn't always look at older physicians, Bazzo says some practices make passing its assessments a requirement for physicians over a certain age.

One thing practices don't want to do is make a brash decision that will get them in legal trouble. Thomas Baeur, a cancer surgeon in York, Maine, and Tim Hanlon, a cardiologist in Bend, Ore., both claimed they were dismissed from their medical groups for no reason other than age. They sued their medical groups, both of which were publicized in local newspapers.

For obvious reasons, practices want to avoid those kinds of headlines and headaches. Zarone says practices can get in potential hot water for taking abrupt action on an older physician or practitioner. His advice for practices is to be as cautious as possible.

"If they have a concern about someone … the first thing when doing peer review is to get your facts straight and get all of the data available. Don't jump to conclusions. Be sure you know the scope and nature of what any problem might be. Once you have that data, when trying to work with an individual … keep it as collegial as possible. Work with the person, rather than give the impression that peer review is a punitive process," Zarone says.

Zarone stresses thoroughness when going through this process and consider hiring a third-party organization to do an assessment for you. In terms of creating a policy that would mandate a re-assessment of older physicians, he says to document the rationale behind this decision.

EMOTIONAL ASPECT

Bazzo empathizes with those who say this might be ageist. Still, he notes that objectively speaking, age is a risk factor due to declining physical and cognitive ability. Physicians need to look at it from this kind of impartial standpoint.

The emotions of this encounter are a hard thing to separate, however. Norris notes that the physicians in question will almost always feel as if they are under attack and take it personally. He says there is just no way around it, especially if they gave you your job.

"It's a hard thing to do, but you have to do it if you are going to be as a leader," Norris says, with some closing advice for physicians. "Be fair … never walk in [a meeting with an older physician] with assumptions. Come in as if you know nothing [on why they are being assessed.] Make sure you ask the right questions."

Gabriel Pernais the managing editor for Physicians Practice. He can be reached at gabriel.perna@ubm.com.

This article was originally published in the February 2016 issue of Physicians Practice.

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