The cognitive decline and reluctance to retire from medical practice will become increasingly relevant as the physician population ages.
Screening aging physicians for cognitive impairment is a practical approach, but its applicability is limited in those over 60 due to ethical concerns about age discrimination.
Implementing mandatory baseline cognitive screening in mid-adulthood may garner more acceptance within the medical community while safeguarding patient well-being.
Dementia rates are rising. Data from a recent UK study showed that 42% more people than previously forecast will be diagnosed with some form of the disease by 2040. And physicians are just as much at risk as the general population.
An argument for cognitive screenings
An article in Clinical Ethics presents the compelling report of an 80-year-old pulmonologist. This physician, who had multiple comorbidities and past depression, presented with troubling symptoms of short-term memory impairment. After serial cognitive assessments, he was presumptively diagnosed with senile dementia of the Alzheimer's type.
Despite recommendations to retire due to his condition, the resolute physician adamantly refused to step down voluntarily.
This intriguing case sparks a critical dialogue: Are physicians (along with the general population) aging well, and what implications does this have for patient care?
An aging physician population
Recent projections by an AAMC report indicate that over the next decade, more than 2 out of 5 currently active physicians will reach age 65 or older.
The Clinical Ethics authors noted that while non-analytic knowledge tends to stay consistent with age, the ability for analytical processing tends to diminish.
Studies have also found evidence supporting a decline in physician performance as they age, challenging the notion that accumulated experience compensates for cognitive decline.
Doctors' abilities may initially deteriorate in terms of strength, followed by vision, dexterity, and cognition. Impairment manifests earlier in surgeons, whose necessary competencies include physical prowess, visual acuity, and manual dexterity.
Let's look at the numbers here:
Around 28% of the approximately 95,000 actively licensed US physicians aged 70 and above have some form of mild cognitive impairment (21%) or dementia (7%), according to a report in Neurology Clinical Practice.
An article in the NEJM reported that roughly 11,000 have amnestic mild cognitive impairment (MCI), a precursor to Alzheimer's, while 9,400 have non-amnestic MCI, a precursor to cognitive disorders affecting areas other than memory. Additionally, approximately 7% of physicians enrolled in New York's physician health program annually receive referrals for cognitive issues. Most of them are allowed to continue working under restrictions and supervision.
Recently, a study found that after age 70, the incidence of dementia in physicians reached 20.2% (compared with 17.5% in the general population).
Factors affecting retirement age
The AAMC report cites burnout as a key reason for physicians to expedite their retirement.
However, counterbalancing influences, like economic uncertainties and negative effects of retirement on their own financial well-being, could lead them to delay their retirement plans.
In contrast to countries such as Finland, Japan, China, and India, there is no obligatory retirement age for physicians in the United States. This means that some doctors may continue practicing despite cognitive decline. Potential issues, such as misdiagnoses, medication errors, or reduced care quality, could impact patient safety and well-being.
According to the Clinical Ethics authors, research has shown that physicians have limited ability to evaluate their own competency. Interestingly, while most physicians endorse their ethical responsibility to report colleagues' impairment, many fail when they themselves are faced with these situations.
The common method for detecting cognitive issues in doctors is reactive evaluation, which only takes action after an error or a report from someone like an institution, patient, or coworker. This approach misses many impaired doctors and can lead them to conceal their issues.
Younger doctors often hesitate to report issues in older doctors because of the hierarchical apprenticeship model. In a US survey, more than one-third of physicians didn’t believe it was their duty to report impaired colleagues. Another third felt unprepared to deal with such colleagues.
The AMA suggests that doctors aged 70 or older should get regular neurocognitive tests.
In 2019, most surgical chairs (67%) supported tests for surgeons over 65, and the American College of Surgeons had earlier recommended assessments starting at 65–70, with self-assessment as an option. Despite these calls, there are no established guidelines for competency.
One solution is establishing a standardized test for surgeons' physical skills and for cognitive assessments for all physicians. The American Academy of Surgeons suggests surgeons undergo confidential physical and visual tests and regular re-evaluations between 65 and 70.
Some health systems are introducing age-based cognitive tests, ranging from simple assessments, like the Mini-Mental State Examination, to more extensive neurocognitive evaluations.
A simplified, multi-domain approach has been proposed by the authors writing in Neurology Clinical Practice. It suggests starting cognitive screening at age 65, with further evaluation triggered when a doctor scores at least two standard deviations below the mean. Those scoring within one standard deviation should be retested every 5 years, and those between one and two standard deviations below the mean might require testing every 2 years.
However, resistance from older doctors and legal concerns related to the Age Discrimination Act of 1975 could limit the effectiveness of such protocols. An alternative approach could involve screening doctors in mid-adulthood, well before expected dementia onset, addressing age discrimination concerns.
What this means for you
Ethical responsibilities within the medical profession demand that physicians confront cognitive impairment in themselves and their colleagues. Proactive assessments of physicians' fitness to practice should prioritize their well-being. Once potentially compromised physicians are identified, impartial third parties can oversee evaluations and maintain confidentiality. Doctors who can't do clinical work can still contribute through teaching, mentoring, administrative roles, patient advocacy, or leadership.
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