Hospitals, Medical Groups Start To Worry About Skills Of Older Doctors
Our top story, the image of the older doctor whose skills are enhanced by experience who can correct the impulsive errors of young physicians is one that Americans have grown up with in popular culture. Old is equal good when it comes to the medical profession. Now the American Medical Association says it is not always the case. The AMA recently proposed the development of guidelines and screening to assess the skills of senior, late career doctors. KPBS is news partner is looking into the effort to screen older doctors, is a controversial topic that San Diego healthcare facilitators -- this lease are pushing into the ways. Joining me today, Cheryl Clark, freelance journalist and Dr. David Bazzo, professor, UC San Diego's School of Medicine. Welcome. Show, why is there concern now about the skills of older doctors? Other more older doctors than there used to be? There are a lot of older doctors practicing now. According to the AMA, 242,000 doctors are over the age of 65. About one in four practicing into their 70s and 80s. In California, there's about 36 In California, there's about 36,000 physicians with active licenses according to the medical Board of California who graduated from medical school before 1981. About 14,000 of those are over the age of 70. There's a concern about the legal liability reasons have allowed doctors are practicing on their own, so the practice is not going into the hospital anymore. What should they be doing to make sure these doctors are not harming patients? Dr. Basel, which in particular is a concern about physicians working beyond retirement age? I think physicians are two different than the general population of money talk about general health issues. Some of the things we could you to older aging are things such as cognition may be slowly down, perhaps the ability to think novelty they be decreased. For diagnosis? Yes. Related to that is are the analytical skills needed. People's dexterity surgeons who need to use their hands, sometimes speed matters so we slow down a little bits. Positions are not a special group. They are just like everyone else in the same conditions I go along with agent for the general population applies to them as well. Other instances you know upper age-related problems did affect patient care? Yes. We have expense of the program we ran here called the position assessment and clinical education or pace program where we have evaluated physicians who were referred to as specifically after a condition was identified or issue was identified perhaps an error occurred. In our evaluation of these physicians, looking at multiple facets of their ability to practice, including their health and well-being, we were able to find in some cases, cognitive issues were discovered, technical perhaps health issues impacting their ability to practice safely. The AMA House of delegates is pushing for guidelines for senior doctors. Do we know what kind of guidelines they have in my? We really don't. There using the phrase senior, late career physicians. The AMA is very vague about that sort of policy. The fact is today, policies are over the map, there's no consistency. What is going on at Stanford is different than UCSD. Is different from going on in Virginia etc. It's all over the map. I think there's an effort led by Dr. Jim hay admits he is an organization called see TPH. To propose some guidelines to keep within a legal framework so you are not running afoul of as a discrimination must. These were target hospital staff positions so exchange for staff privileges, the medical executive committee in each hospital with set some sort of uniform framework and the idea is that you want sharp and scripts and everybody would be on the same page. Dr., I doctors already required to maintain board certification, take required courses, why isn't that enough? Let's take a step back because all doctors are required to relicense every two years in California. That involves making a statement that you have done your continued education which for a licensing standpoint is about 25 credits per year. If you are board certified which not all positions are. There are things that are above beyond the licensing requirements the. Maintenance of certification is the latest movement has come about. Basically what is board-certified, they are required to do more continuing education hours. You're also required to take a test every so often and that can be about every 10 years and required to do other things to maintain your skills and mostly it's a knowledge based activities that you do as opposed to improving your skills procedurally. That's a proxy to maintaining its. Yes, that is one mechanism that is currently in place. Unfortunately not part of that is a health and wellness screening. When I talk about physician help, I'm talking about how the broadest terms, talk about physical health, mental health, we can talk about substance abuse, we can talk about some of the things that go along with agent like cognition decline, etc. I was just going to mention that of the doctors in the nation are board certified, 289,000 of them have lifetime certificates. That means they took a first board exam whenever that particular board had unlimited certificate. They give it to her lifetime. So you don't have to rename. So for American Board of internal medicine, the cutoff was 1990. If you take your first exam before 1990, you weren't required to take it again. You can volunteer to take the test but it's not a requirement. This very controversial and understand its influx right now. There's concern that beyond that cutoff point, the doctor beyond that, the continuing education courses requirement very state-by-state. Of the epic -- you have educational upkeep over the map. Cheryl, you spoke with older physicians, are they receptive to this? The responses were ranging from the grudgingly accepting to very adverse. Some doctors say I know a guy who should be practicing anymore, but it's not me. I hope that when my time comes, I will no when it's time to go. I think the other thing that really resonated for me and most of the interviews is that doctors admit in their patients -- the patience of the last to know when they start to fail but they don't translate that to themselves necessarily. We have a clip from someone you spoke with, Dr. Paul . His 75. Still working full-time. I asked my associates to keep an eye on me. Let me know if they think I'm getting out of hand. I hope it's not too soon because I really enjoy what I do. Do physicians hope their colleagues would let them know? I think part of being a professional is you monitor your own and hopefully say something and take care of your colleague Nancy. Unfortunately, that's not what we always see. In fact, there's a study I can point us to the side while 96% of positions believe we should monitor and look after others and would be willing to do that for colleagues, when asked if they would witness a report something, that number drops to 45%. I think it's one of those things, there's two issues. Number one is its very difficult to report a colleague especially if you're not quite sure. Has so goes up and you don't want to make a person's life miserable without reasonable cause. On the other side, is the insight available. Cheryl had alluded to this. Not only with the general pop is it -- population but with physicians, we see ourselves as doing better than we are. Unfortunately, some of the stories and participants, the case that got you into trouble, he should have stopped one before that. We just don't have the insight to be able to do that in many circumstances. At the program, what's the process like? So That is a larger program that does for cause a valuation. The screening we started is one of the newer programs we run which is just a small slice of what we do. We have done so screening of physicians. We contracted with their medical group and they had decided by themselves that age 70 was a cutoff of them. When it comes time to renew privileging, the positions will come to our program and we will initiate our screening. That tries to look at health cognitive related issues. Part of our battery includes a full history and physical examination of the participant looking at their vacations, past history, any medical conditions they had. We do to screening exams for their cognitive skills. We use a certain tool that is a general screening tool then we use a more specified test which is called Michael cart. That's was usually specifically develop for physicians. It's now more broadly applied and what we do with that is if they can Peter-based cognitive test, generally takes an hour to perform. Were able to compare physicians not only versus Asia but it gets the general population of physicians. We get an idea of where they fall. It's important to compare the two age groups because number one, you want to see how they are doing relative to other ¬72. In being a physician you really want someone who is competent compared to all positions. It's important to make that comparison across the board of all positions because they may look very good against other people of the same age. You compare them to the court there may be issues that raise concern. There are health court -- healthcare organizations that can get around these issues by having clear-cut retirement ages. Spoke with anesthesia group in town that a firm retirement age of 70, how is that working out? I think it's working very well, according to their General Counsel. Everyone knows going in the that's going to be the end of the line for them. Although, I think some of the doctors are grumpy about a. This is anesthesiology. These are people who have to be called upon in the middle of the night to deliver babies. They have to assist in administering anesthesia during long surgical procedures. For somebody of that age, that's a lot to ask. It becomes a stamina issue. I think for them, it's worked out fine. The physician I interviewed who got sort of kicked out was taking it very well. He went on a cruise to console himself. I have point I think it's important to interject. We're talking about a spy want to be very clear that age is but one risk factor that is involved with physician competence and ability. We're talking about safety for the patient first and foremost. There are many other things that can impact safety. Health standpoint. We have a pace of a fitness for duty evaluation which is a full cause a valuation when someone has a health issue. Our youngest participants had been in their late 30s. We had all ages. I want to make their age is but one issue but it's an issue we can grab and hold onto and we can look at what's happening in the general population the dexterity is coming down. That's one aspect. The idea is to give information to the physician in a safe environment that will help their decision on when it's time to retire a little more clear to them. Some doctors I talked to, especially some of the people up at Stanford say we should screen all doctors because most patient harm is done at the hands of younger physicians, not older. I don't know whether that's accurate are valid, it's certainly a point to be raised that this could happen all over the place. You can find the story on older doctors on our webpage@KPBS.org. I've been speaking with Cheryl Clark, freelance journalist and Dr. David Bazzo, professor, UC San Diego's School of Medicine.
Every weekday at the crack of dawn and usually on weekends too, Dr. Paul Speckart backs his dark blue 1986 Volvo down his Mission Hills driveway, carefully avoiding the gateposts.
He drives 18 blocks to Scripps Mercy Hospital in Hillcrest to examine his patients treated there, and writes orders for their drugs or tests.
Then he goes to the Bankers Hill practice he shares with his four partners to see an additional 20 or so patients. Then at 6 p.m., he's back in the Volvo to make hospital rounds again, lucky to make it home by 8:30. On Saturdays he often makes house calls and visits nursing homes.
Speckart turned 75 in late June. It's an age when many doctors might retire. But after nearly four decades of this routine, the internist and endocrine specialist has no plan to call it quits. He keeps up with relevant journals, maintains his board certifications and takes required courses. He said his patients assure him they still have high confidence in his skills.
“At some point, I'm going to have to get thrown out of the office,” he quipped. But with the shortage of new doctors choosing primary care, he asked, “Who would be left to see my patients?” Younger doctors don't want to work as hard as those in his generation, he said.
But now, hospitals and medical groups including the American Medical Association are starting to worry about “senior/late career” doctors like Speckart, and whether they are still up to snuff. One in four of the national physician workforce is at least 65 today, quadruple the number we saw in the 1970s.
Doctors are like anyone else. They can become forgetful as they grow old, develop illnesses, tremors or behavioral problems, and lose their sight and hearing. Is it safe to let them maintain hospital privileges, prescribe drugs, interpret test results for reliable diagnoses, and perform surgery, when a mistake could cost a life?
In San Diego County, 1,282 physicians, or 20.2 percent with active state licenses, graduated from medical school before 1981, making them at least 60 years of age. Of those, 423 are over 70, and 66 are over 80, according to statistics from the Medical Board of California. It is not known how many are still practicing.
In a 21-page report, the AMA House of Delegates in June advocated development of “guidelines and methods of screening and assessment to assure that senior/late career physicians remain able to provide safe and effective care for patients.”
“People don’t know when they’re beginning to fail,” said Dr. Claire Wolfe, who is 71 and a member of the governing council of the AMA's senior physicians section. The council represents 65,000 doctors who have turned 65, and it strongly urged the AMA delegates to approve the report.
“If you’re impaired, you’re the last person to notice,” Wolfe said. “Denial is a strong self-protective mechanism for everyone.”
Wolfe, a physiatrist and rehabilitation medicine expert in Columbus, Ohio, said that when the resolution to tackle the issue came up a year ago, AMA members objected.
“There was incredible debate, and people said we shouldn't discuss this because it was ageism; we were picking on senior doctors, and we need these doctors because there's a physician shortage," said Wolfe.
“But here we were, the entire senior physician council, saying, ‘No, no. We do. You can't put your head in the sand.’”
The AMA report referenced dozens of studies linking age with declines in skills doctors need, such as working memory, the ability to store and process information, mental speed, visual acuity, hearing and manual dexterity. With aging, the report said, “mental efficiency decreases,” potentially leading to diagnostic errors, and “a compromise in the ability to care for more complex patients.”
The AMA report may influence more hospitals and medical groups to institute such screening policies, said Dr. James Hay, 68, a family doctor in Encinitas who was president of both the California Medical Association and the San Diego County Medical Society.
“There's a trend, at least as shown in the AMA report, that at least leadership now understands there's an issue, and because of that I think more organizations will use screening (of older doctors) throughout the country,” he said. “As that happens, there will be an accumulation of data that (will answer the question) whether it does make a difference to patient safety.”
Hay believes the issue is so important, he and other members of California Public Protection and Physician Health Inc. helped produce guidelines for hospitals seeking to screen older doctors without running afoul of anti-discrimination laws. The report was co-authored by members of the CMA, the California Hospital Association and San Diego healthcare lawyer Richard Barton.
A screening test every year or two might help find doctors who could be putting patients at risk, Hay said. “But it can't be too onerous, or no one will want to do it.”
Another problem is how to evaluate doctors who may be showing problems but who now practice only in their offices. Most doctors no longer visit their hospitalized patients, like Speckart does, because hospitalists — doctors who just treat hospitalized patients — have largely taken over that role.
Many community physicians no longer even request hospital privileges, and thus, would not come under their hospital's required two-year review.
Dr. Ira Levine, a San Diego surgeon who retired at age 70 in 2011, said blanket screening of older doctors isn't the right way to do it. “It's going to find so few individuals that need to be reprimanded or stopped from practicing. It's going to put a lot of burden on everybody to weed out a few.”
If screening for cognitive or physical impairment begins, Levine suggested that it should be done “for people in their 40s, 50s and 60s too, just to make sure people stay sharp.”
The University of California San Diego’s Physician Assessment and Clinical Education program, or PACE, is a leading national assessment and remediation effort for health-care professionals. It evaluates doctors who are referred by medical groups, medical boards and hospitals after problems or concerns have emerged about their performance.
Concerns about whether older doctors have maintained competency to practice has prompted PACE to launch a program to screen doctors after they reach their 65th, 70th or 75th birthdays.
It's called PAPA, or PACE Aging Physician Assessment, said Dr. David Bazzo, PAPA's director. Bazzo said the idea is that an independent panel not connected to the provider group can offer a more objective, systematic and scientific review of older doctors than the doctors' work colleagues.
Several hospitals have launched their own screening programs, including Stanford hospitals, which four years ago began mandating physical exams on all doctors when they turn 75 as a condition of staff privilege.
More than a dozen physicians, including oncologist Dr. Frank Stockdale, have filed formal objections to the program. Stockdale said there are many other mechanisms in the peer review process to stop problem doctors, “and actually, if one looks at the data, most patient harms come from physicians in mid-career, not late career. Picking on doctors at a certain age doesn't prevent anything.”
The University of Virginia Health System requires doctors to take physical and cognitive screening tests after their 70th birthday.
The College of Physicians and Surgeons of Ontario, Canada (CPSO), the equivalent to the Medical Board of California that licenses doctors, requires its 38,503 physicians to undergo peer assessment of their ability to practice after their 70th birthday. In 2013, 202 were assessed and 37 had to undergo “remediation,” said CPSO spokeswoman Kathryn Clarke. She couldn't say how many had their practices curtailed.
To avoid screening, some medical groups have established bright line retirement cutoffs, after which physicians must leave or resign from full partnerships.
At Anesthesia Service Medical Group Inc. (ASMG), which employs 240 anesthesiologists and dispatches them to 11 hospitals and eight outpatient surgery centers in San Diego County, doctors who reach their 70th birthday, must leave.
That's what happened to Dr. Alexander Pue when he turned 70 last year, after working for ASMG since 1989. He had to leave, and consoled himself with an Alaska cruise.
“I completely understood why they have this policy,” Pue said, recalling that the policy was implemented because years ago, some anesthesiologists “weren't doing a very good job, caused some problems, and the group couldn't get rid of them.”
Now Pue is working part time in outpatient surgery at UCSD Medical Center, on a schedule he says is not nearly as stressful and on cases that are usually shorter.
“Doing night call, which is what I was doing before, was rough,” he said. Going without sleep “ruins the day before and the day after, throws off your whole wake-sleep cycle.”
Glenn Buberl, general counsel for ASMG, which is self-insured, said the anesthesia group established the policy in 1990, in part because “people tend to slow down,” but also because the alternative — evaluating people on a case-by-case basis if there's a concern — would mean that if a problem was discovered, state law requires that “you have to report that to the medical board.”
Southern California Permanente Medical Group, a 6,500-member partnership of doctors who treat Kaiser patients in six California counties including San Diego, also has an age cutoff. At the end of the year they turn 65, SCPMG doctors can continue on a contract or a per diem basis, but they do have to resign from the partnership.
That means they lose certain benefits, such as distributions from the partnership, vacation and sick time, and dental coverage, said Dr. Albert Ray, a San Diego family physician who turned 65 last year but continues to practice. “Most doctors retire and not work,” he said.
Now 72, Dr. Stony Anderson, a SCPMG gastroenterologist, still practices at Kaiser three days a week, “an extremely flexible schedule.”
“It's a very complicated thing measuring competency, and a lot of that has to do with how hard the person is willing to work,” he said. “And if you do establish a (screening policy), you have to have some basis for it in the literature, and then you have to establish it for everyone.”
Asked if medical groups might cause problems for other practices by forcing older doctors to leave after a certain birthday, Buberl said he doesn’t think so.
“What you can do on your own is different than what you do in a group. We don’t have a way to let people work in hospitals part time. Dr. Pue, for example, is figuring it out, picking up a little here and there, and as he said, there’s less stress for him," said Buberl.
“The other thing to keep this in context, is that the majority of people don’t make it to 70, (but retire much earlier). It’s not like we’re just turning truckloads of people out. And we’re not saying they’re dangerous. We just have a bright line; that’s where we end. And we hope people will be fine with that.”
Patients should have the right to know when an older doctor may start having problems, said Marian Hollingsworth, a patient safety advocate in La Mesa. And while screening older doctors “is a step in the right direction” to protect patients, she said, if screening reveals a possible problem — such as a doctor's failing memory or poor medical record keeping — patients should be informed before receiving that doctor's care.
Of course, not all older doctors will have problems associated with aging, said Hollingsworth, a volunteer with the Consumers Union Safe Patient Project. “You could have a doctor who is 70 and razor-sharp.” But some doctors as they age fail to keep up with the latest medical protocols, as she discovered when she was interviewing pediatricians for her child.
Speckart, who sits on his hospital's medical executive committee, which decides which physicians can have staff privileges, knows it can take years to force a problem doctor out, a costly and emotionally devastating process for everyone.
“It's a terribly, terribly difficult situation. You do have people who age, and are no longer as good, and shouldn't be practicing anymore. But who makes the determination of who's competent? And do you do that by checking with his peers, or by formal testing, and what kind of tests are really valid?”
For himself, Speckart asks his colleagues “to personally let me know if my standards are off the mark, or if I need to take corrective action or leave. I think most physicians are responsible enough to let their colleagues know when it's time.”
An earlier version of this story incorrectly stated that Claire Wolfe is a psychiatrist.