How old is too old to practice?

For years, a debate has raged: At what point does a physician’s age begin to affect his or her ability to practice medicine competently? The question comes down to patient safety. As we age, many of us lose certain faculties, which increases the likelihood of mistakes. But aging doesn’t affect everyone uniformly. So, how can healthcare ensure that all physicians can do their job properly?

Before we get to that question, it’s worth noting that this issue is becoming more urgent. According to an editorial published in JAMA, the number and proportion of aging physicians in the United States have presented “a unique challenge of the current medical era.” Of note, 43% of all doctors are over the age of 55, and 15% are over 65. In fact, the number of physicians 65 years or older across the country tripled between 1980-2016, from 23,000 to 73,000. And each year, 20,000 more doctors turn 65. 

But how many of these physicians should be thinking about retirement? Does the wisdom and experience gained outweigh the biological deterioration of aging? And how has the pandemic’s call for doctors to return to the workplace shifted the equation? 

To address this, here’s a rundown of some of the latest research regarding age and competency, along with details on what some institutions are doing to tackle the issue. 

Evidence of a link between age and competency

A case study published in Clinical Ethics epitomizes the problem posed by an aging physician population. A practicing pulmonologist, age 80, began to present symptoms of short-term memory impairment. After under-scoring on mental status tests, he started taking donepezil to improve mental function. But 6 months later, after his mental status scores declined, he still refused to retire, despite a presumptive diagnosis of senile dementia.

The authors cited various reviews and analyses that indicate the case above isn’t an outlier. One study found that while non-analytic knowledge appears to remain constant as doctors age, analytic processing tends to decline. Likewise, one review concluded that physician performance decreases with increasing age. 

However, other studies have found that this isn’t a black-and-white situation. One study tested the cognitive functioning of a cohort of 1,002 physicians and 581 non-physicians. Researchers found that each group tended to exhibit decreased cognition as they aged, but there was far more variability among the doctors compared with the other group. In fact, some of the physicians retained their full cognitive abilities despite their age. 

Authors of the Clinical Ethics case study point out that declines in faculties occur in different ways for different people. For some, it may be a decline in strength; for others, eyesight; others still, cognition. As such, physicians in certain specialties may be perfectly fine to continue their practice.

The question then becomes: How and when do we assess physicians' abilities as they age? Research suggests that doctors have “limited capacity to assess their own competency.” Physicians also tend to harbor a reluctance to report their impaired colleagues, partially as a result of a culture that presents elders as mentors. The authors of the Clinical Ethics case study conclude that cognitive screening should be applied, but the framework remains a subject of debate.

An ongoing call for screenings

In 2015, the AMA Council on Medical Education released a report which urged institutions and policymakers to create “guidelines/standards for monitoring and assessing both their own and their colleagues’ competency.” The council followed up with a report published in 2018 that once again cited evidence indicating physical health and some cognitive abilities decline with aging, which can put patient safety at risk. 

However, while the report restated the need to screen for competency and even provided some guidance for how to craft related policy, it didn’t offer any formal guidance on how or when these screenings should be applied. To date, there remains no national standard. 

As a result, some organizations now implement screenings of their own. 

What hospitals are doing 

Among the healthcare organizations that now assess the competency of their clinical staff is Yale New Haven Hospital. As noted in an article published in JAMA, the hospital’s medical executive committee voted to introduce a neurologic and ophthalmologic exam for any applicant for reappointment over the age of 70. Data collected from 141 test results showed that nearly 13% of these applicants had “cognitive deficits that were likely to impair their ability to practice medicine independently.”

Similarly, a review published in the World Journal of Orthopedics in April analyzed nine policies designed to assess the competency of practicing surgeons. All these policies included a medical exam featuring general health, cognition, vision, and hearing testing. The authors concluded that forced retirement after a certain age wasn’t necessary for all surgeons—and that competency testing was effective at showing who requires remediation or retirement.

As noted by the AMA Council on Medical Education, without a mandated national standard, it’s on physicians to push for administrations to develop evidence-based standards for monitoring and personal competency tests.

How COVID-19 plays into the equation

Early in the pandemic, governments across the country put out calls for retired doctors to return to the workplace to help handle the steep influx of patients. In many cases, physicians answered. In New York, for example, more than 50,000 retired healthcare professionals responded to the state’s plea for more workers.

This, of course, raised an important question—one asked by the authors of an article published in International Psychogeriatrics: Will these retired physicians lack the competencies to practice safely, without putting patients at risk? The article cited research that found aging is associated with changes in physical and cognitive functioning that affect skills germane to clinical work.

The authors, however, concluded that bolstering staffing was vital early in the pandemic. As such, the researchers offered guidance on precautions to take when hiring once-retired healthcare workers:

• Require retired clinicians to work with an actively licensed supervising professional to ensure competency levels are up to snuff.

• Deploy returning doctors not to the frontline, but to leadership, supervision, consultation, public relations, mentorship, teaching, and research roles.

The flipside of COVID’s impact is that it prompted many other physicians to consider calling it a career. According to the findings of a survey published in September 2020, 19% of clinicians decided or were planning to retire early because of COVID-19. Another survey published at that time—this one conducted by Medscape—found that 25% of US physicians were considering early retirement as a result of the pandemic.

While the evidence is unclear, COVID-19’s risks to the elderly might have pushed older doctors away from the clinic.

Indicators that doctors are past their prime

An important first step in tackling the issue is to learn to recognize signs of age-related decline in yourself and colleagues. Some of these signs appeared in a Washington Post article written by Jonathon Maltz, MD.

Maltz writes that physicians should pay attention to memory lapses. If a colleague forgets someone they’ve met frequently or mistakes them for someone else, this could be a red flag. It’s also worth picking up on changes in personality or demeanor, including an increase in impatience or dismissiveness. Other clear signs that something may be amiss include: general forgetfulness, difficulties in hearing or seeing, motor issues including shaking, and a proclivity to refer patients to other professionals for any and every medical problem that arises.