I recently read with interest an article by Laurie Tarkan at the New York Times that highlighted the case of a 78-year old surgeon who lost a patient post-operatively. The routine investigation that followed revealed that the surgeon himself was showing obvious signs of age-related cognitive dysfunction – no one had noticed.
My immediate reaction was to feel compassion for the doctor, who lacked any insight into his own deterioration and clearly intended no harm. However, the case does highlight the significant (even ultimate) risk faced by patients of impaired doctors of any age.
I am not aware of any medical registration bodies that place specific emphasis on age-related evaluation of fitness to practice, yet there is no doubt that ageing brings with it a predictable list of associated cognitive and motor skill impairments. The airline industry is certainly aware of this - commercial airline pilots must submit to physical and medical assessments every 6 months from 40 years old to re-certify and must retire at 65.
It seems remarkable that doctors manage to avoid the same level of scrutiny given that their actions have such a significant impact on the well being of their patients. Whilst disciplinary matters are handled proactively, subtle variations in competence brought on by ageing can fly under the radar. It is much harder to notice, or have the courage to report, a problem with a much-revered senior doctor with a distinguished and unblemished career than it is to raise concerns about a young upstart with a known poor track record.
So how should registration bodies and employers handle this issue? What constitutes “too old to practice” and should different standards be applied to different disciplines?
Psychiatrists often work well into their 80’s where the accumulated wisdom of a long career can be applied to a discipline that does not change much from one decade to the next. A younger surgeon, on the other hand, may well be challenged on currency of knowledge, technique or dexterity when wielding the scalpel. Surgical practice requires stamina and fine motor skills, plus techniques change constantly and those learned a decade ago could quickly become obsolete.
There is much debate around this subject and a number of potential solutions have been proposed, but this will undoubtedly remain controversial unless universal guidelines can be implemented. Some of the ideas I have come across include:
Regular assessment for fitness to practice - The General Medical Council in the UK is considering wholesale assessment of all doctors for re-validation of their licenses. It will be interesting to see if their recommendations include any variations based on age.
New registration category - Prof Philip Morris at the ANZMHA suggests a new step-down registration category that recognizes the skills and wisdom of senior doctors and the contribution that they can make in the workforce. Areas such as training, mentor-ship, research and professional representation immediately spring to mind.
Peer supervision - Overseas doctors in Australia are subjected to a period of peer supervision to ensure that their practice is of appropriate standing. Perhaps a similar system could be conditional after a certain age.
Employer driven assessment – Individual employers may take matters into their own hands if regulatory bodies do not provide a safety net. One hospital in the US, Driscoll Children’s Hospital in Texas, already insists on cognitive and physical assessment as a condition for renewal of contract for doctors over 70 years old.
Alternative to Discipline - When concerns do arise perhaps a different, more compassionate inquiry process can be undertaken so as not to stigmatize those being assessed with a “disciplinary” process. This would increase the likelihood of reporting as well as spare doctors with an otherwise exemplary record from the humiliation and shame of “de-registration”.
None of the above address the problem in its entirety but perhaps mandatory skills assessments for all doctors would sweep aside the age question and raise the bar for all when it comes to maintaining high standards.
Medical registration bodies ultimately have a duty of responsibility to protect the public and age per se is not the problem. Incompetence and poor character most certainly are, and these are not age-dependent. I wait with interest the results of the GMC consultation process on re-validation but that’s a whole other topic.
Written by Dr. John Bethell, Director of Wavelength International