Should older doctors be tested for competency?

There's no question about it: The US physician workforce is aging. More than 2 of every 5 active physicians in the US will be 65 or older within the next decade, with a large portion nearing traditional retirement age, according to data from a 2021 report published by the Association of American Medical Colleges.

But along with aging comes a gradual decline in physical and mental capabilities. In light of this fact of life, US air traffic controllers have a mandatory retirement age (56 years old), as do national park rangers (57 years old), military officers (64 years old), and pilots (65 years old).

This begs the question: Why isn’t there a mandatory retirement age for physicians? 

The question of cognitive testing

Controversy over this age-old question has been reignited due to an article in JAMA.^[] The paper describes how the executive medical committee at Yale New Haven Hospital, New Haven, CT, decided to implement cognitive testing for all medical staff aged 70 years or older “because of concerns about the potentially compromised ability of older clinicians.” 

The cognitive screening battery, developed by a neuropsychologist, consisted of 16 objective tests that assessed rudimentary information processing, visual scanning and psychomotor efficiency, processing speed and accuracy under decision load, concentration and working memory, visual analysis and reasoning, verbal fluency, memory, “prefrontal” self-regulation, and executive functioning.

Of the 141 clinicians aged 70 years and older (average age: 74.3 years) who were assessed, 18 clinicians (12.7%) demonstrated cognitive deficits. 

None of these clinicians had previously been brought to the attention of staff managers for performance problems. Nevertheless, these physicians voluntarily chose to discontinue their practice or move into “a closely proctored environment,” according to the authors of the JAMA article.

Does older age mean worse outcomes? 

But, is such testing appropriate, or even valid? 

In an "accompanying editorial in JAMA Katrina A. Armstrong, MD, MSCE, physician-in-chief of the Department of Medicine at Massachusetts General Hospital, and Eileen E. Reynolds, MD, chief of the Division of General Internal Medicine at Beth Israel Deaconess Medical Center, Boston, MA, suggested that assessing cognitive impairment isn’t the only method—or even the best one—to determine a physician’s competency.^[] 

“Although cognitive impairment increases with age, the evidence that increasing clinician age is associated with worse patient outcomes is weak at best,” they wrote.

Still, several healthcare institutions—including Intermountain Healthcare, Stanford Hospitals and Clinics, Scripps Health Care, and Penn Medicine—have implemented similar programs for assessing older doctors, Dr. Armstrong and Dr. Reynolds pointed out. 

Indeed, Dr. Armstrong and Dr. Reynolds don’t make the case against testing older doctors per se, but against the methods currently used for testing. 

“As challenging as it is to have initiated the difficult conversation concerning physician competency, patients deserve competent physicians and physicians deserve a clinically valid, confidential, and respectful process for determining competency,” they wrote. “Reaching this goal will take time, investment, engagement, and professionalism.”

Not if, but when and how

With the publication of this JAMA article, the conversation seems to be changing. It no longer appears to be a matter of whether to assess physicians for competency, but rather how such an assessment should be done. Consider that the American Medical Association’s Council on Medical Education called for the development of guidelines for screening and assessing aging physicians back in 2015. 

William B. Barr, PhD, director of neuropsychology and associate professor of neurology and psychiatry at NYU Langone Health, New York, NY, supports cognitive testing for assessing older doctors. It’s the only scientifically validated way to address the issue of cognitive functioning in these individuals, he says. 

“This JAMA article brings to light the important role that neuropsychologists have been playing over the years at numerous medical centers in evaluation of cognitive functioning in older physician colleagues,” Dr. Barr told MDLinx.com. 

He pointed to another published study in which researchers used cognitive and motor tests to identify neurocognitively impaired physicians. In that study, nearly half of the clinically referred physicians who were assessed demonstrated impairment on standardized testing.^[] 

“Continued utilization of neuropsychologists in the role of identifying ‘neurocognitively impaired’ physicians will provide a means of ensuring the public’s safety and their ability to receive quality care from physicians who choose to continue medical careers beyond the traditional retirement age,” wrote Dr. Barr, who was not involved in either this study or the JAMA article. 

For now, it’s important to remember that even though 13% of the 70- and 80-something clinicians at Yale New Haven Hospital were considered cognitively impaired, nearly all of the rest of those senior physicians were OK’d to continue to practice. Clearly, age alone isn’t a mandate to retire.