Aging Physicians in Your Practice: Handling Competency Issues
Aging Physicians in Your Practice: Handling Competency Issues
There have been several articles in the news recently about the need for oversight of older physicians to assure competency. An article in the Washington Post in collaboration with Kaiser Health News gave examples of impaired physicians, such as a vascular specialist in his 80s who performed surgery and then went on vacation, forgetting he had patients in the hospital. One patient, who had no doctor managing his care, later died. Another example cited was a physician who suffered a stroke and got lost in his own office going between exam rooms.
Although these are extreme examples, they are possible scenarios facing physicians as they age. It’s estimated by the AMA that about 42 percent of the nation’s one million physicians are older than 55 and 21 percent are older than 65, according to The Post. This means that physician impairment due to physical and cognitive medical issues is a growing concern.
To address the issues of aging physicians, some hospitals now require doctors over a certain age (usually starting between ages 70 and 75) to undergo periodic physical and cognitive exams as a condition of renewing their privileges. It’s likely many physicians will retire rather than undergo forced competency testing, while others will be obliged to acknowledge medical concerns. Whether voluntary or forced retirement under one hospital’s program will become a reportable event that affects licensure or privileges at other institutions is not yet clear.
From the perspective of a physician practice, this trend might be a positive one. As discussed in an earlier blog, many practices find themselves in the difficult position of trying to address medical issues affecting physician colleagues. Because impaired physician typically cannot (or will not) admit impairment, others are often forced to hide their colleague’s errors, fix mistakes, or otherwise make excuses for the impaired physician.
While confronting impaired physicians directly is advisable, it can be awkward or badly received. At the same time, most practices are aware that postponing action can result in potential harm to patients, malpractice cases against the impaired physician (and the practice), or loss of the impaired physician’s license; a devastating result for a proud practitioner.
Other frequent concerns I hear about older physicians include resistance to new technology and a preference for “outdated” medical techniques (with which they are more comfortable), even though the preferred approach may pose higher risks or offer lower success rates. Other physicians continue to perform procedures even when observed as lacking the strength or exhibiting shakiness or uncertainty.
Most practices have no formal written approach to confronting physicians with medical issues, including deteriorating hearing, vision or motor coordination, or impairments such as dementia.
To address these possible issues in your practice, consider the following:
1. In the event there appears to be reasonable evidence of a physician deficit that could impact patient care, the practice should formally meet with the physician and require a visit with a third-party physician selected by the practice for evaluation. For larger practices, different voting requirements can be considered to demand this evaluation.
2. If a physician refuses to be evaluated, the practice’s documents should require such a visit as a continuing condition of employment/partnership. It’s important to tailor any such provision to comply with state and federal laws.
3. Based on the particular situation, practice documents can allow for a program of limited duties, reassignment to particular roles or other reorganization to accommodate a physician’s continued medical practice, if possible. For example, while hearing aids might completely resolve all issues, shaky hands might require surgery to be curtailed.
4. The practice should talk with counsel about the correct combination of benefits and compensation that might be needed to address competency issues in advance, as well as the creation of a retirement program that might encourage a “disabled” physician to feel he or she can retire with dignity.
Talk to the physicians in your practice about how prepared you are to handle a physician that exhibits a competency issue. Plan well in advance for this possible scenario and think about how you would want and expect to be treated. With an aging population of physicians, it’s likely to become an issue sooner than you think.
I wonder if a physician can collect workman's compensation benefits if a medical staff claims they are no longer competent to treat patients.
At age 78, I realize that I run the risk of cognitive deficits. Realizing that I might be unaware of deficits in myself, I have told several trusted physicians to advise me if they see signs that I am slipping. I would much rather they quietly suggest I retire, rather than present an embarrassing management problem to my colleagues.
I am not against periodic cognitive exams in principle, but I question how much has been done in correlating such exams with what is actually required in the various medical specialties. We don't want the bar set too low OR too high.
I appreciate your comments and I think the health care community is only at the start of developing methodologies for examining physician competency as it relates to aging. There are certainly many factors to take into account, such as the differences between specialties, the amount of patient contact and whether the issues is physical or cognitive.
I would hope that any program that is developed will be compliant with ADA, which requires that an employer try to accomodate a physician's disabilities. This may mean evaluating what role a physician can continue to play in the practice of medicine, if any, based on whatever limitations may exist. It can be very hard for a physician, like any other person, to recognize (or accept) that they have changed and aged and cannot do what they once did. This means that any discussion on this topic is likely to be emotional.
Physicians should question any such exam program and have an active voice in the methods used and how the exam results are interpreted. I think both patients and physicians will benefit from an active discussion on these issues.
It's also important for physician practices to think about these issues and plan ahead, from a contractual, management and compensation/benefits perspective.
Good Article, but I have been looking for one that gives me guidance, as if I don't already know the avenues within which to pursue... But one that openly discusses THE ISSUE of Physician Competency when one finds that another doctor fails to refer, admit, diagnose, treat, test, etc. appropriately, IAW std of care, and pursuant to M&Ms. I am also looking for sources on which to cite and blog as I teach, answer questions, & present online within my own specialty... thereby providing guidance to peers and younger providers in my field on this very key topic of epic gravity.
I have seen several highly competent, even renowned surgeons in my field bow out gracefully at a certain point, and then revert to clinic practice only... I think that is quite an elegant tack. It takes the the proper amount of humility, of knowing when to say when, and avoiding the human error of "false pride" as I have seen some be guilty of-- which only leads to the embarassment of being asked to leave to O.R. if not practice altogether... and hopefully in disgrace (by means of mistakes, mis-steps, poor judgment, or malpractice suits, all to ruination). We, as a young country, and of the baby boom generation (the 46ers to 64ers), of which I'm at the very, very end [Dec'64], still have a long, long way to go before we accept this whole aging & dying thing gracefully. Yes, I too am not willing to go quitely into the night, and get things on this old retired soldier's, turned doc-surgeon, now in civilian practice, body fixed so that I can stay as active in as many athletic activities as I ever was... But, we still refuse to turn off the machines or let our kids do it for us, or even our doctors... dare I say it without setting off an S-storm- like they do in the Netherlands... I'm not saying that's what we should do, but we can't even give in to hospice; no, we have to bankrupt the system w/ 100's of k's of $'s of last minute heroics when it's time to just let the angels take us. C'mon people and doctors already: circle of life and all that... this western romantic idealistic thought or notion that we've been sold or are selling is what? Modern technology and medicine is gonna make us live forever? And that's why I've paid all these premiums, worked so hard, etc., etc. Bologna. It's a bill of goods. Sometimes I think patients come in for a consultation looking for a star trek device, laser surgery, or some new miracle pill that doesn't exist (yet)... and won't for a 100 yrs or so!! But because of blu-ray & ipods, and hi health insurance premiums, they think it does! Think about it. No? Wanna bet? I've got some pts who would tell you they thought otherwise. And yours are just too embarassed upon leaving the clinic to tell you they thought otherwise too, and you failed to talk at their level to get it outa them... see, on my C.V. (it's 5pp long), I've done every job you can do in this life, and know how to talk at just about every level, and I get stuff outa them; I'm no stuffed shirt in clinic w/ MY pts. 'Sides, conversation is the spice of life. Merry Xmas, and rem'ber J.C. was born in the summertime, and crucified in the fall. --WG
William and others:
I'd recommend you read Ericka's previous post on how your medical practice should handle an impaired physician. It's an excellent read and provides great insight:
http://www.physicianspractice.com/blog/how-should-your-medical-practice-...
This is clearly NOT a benefit to physician practices and to say so is disingenuous at best and a patent falsehood at worst.
This constant chipping away of the professionalism and privilege that should be the reward of physicians is counterproductive for the profession, adversely impacting the ability to attract the best and brightest into medicine and driving good, competent physicians into early departures due to a constant negative barrage about the profession.
These issues have always been issues, have been dealt with on an individual, compassionate basis and should continue to be dealt with this way.