Late-Career Physicians: Ethical Considerations and Patient Safety Strategies
CME Information
Sponsored by: The NORCAL Group of companies includes NORCAL Mutual Insurance Company, along with its subsidiary companies Medicus Insurance Company, FD Insurance Company, NORCAL Specialty Insurance Company and its affiliate Preferred Physicians Medical RRG.
NORCAL Mutual Insurance Company is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
For questions, please call the Risk Management Department at 855.882.3412.
Method and Medium
To obtain CME credit, read the article then take the quiz and fill out the evaluation form. You can print or email your CME certificate from this application.
Please complete and submit the online quiz by the expiration date indicated below:
Original Release Date: March 15, 2018
Expiration Date: April 1, 2020
Learning Objectives
By reviewing medical professional liability claims and/or emerging topics in healthcare risk management, this enduring material series will support your ability to:
Assess your practice for risk exposures.
Apply risk management best practices that increase patient safety and reduce medical professional liability claims.
Target Audience
All physicians, clinicians, staff and healthcare administrators.
Credit Designation Statement
NORCAL Mutual Insurance Company designates this enduring material for a maximum of 1 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Disclosure Policy
As an ACCME accredited provider, NORCAL Mutual Insurance Company requires planners, reviewers or authors who influence or control the content of a CME activity to disclose financial relationships (of any amount) they have had with commercial interests associated with this CME activity during the year preceding publication of the content.
Any identified conflicts of interest are resolved prior to the commencement of the activity.
Disclosures
Individuals involved in the planning, reviewing or execution of this activity have indicated they have no relevant financial relationships to disclose.
Editor
Mary-Lynn Ryan
Risk Management Specialist, NORCAL Mutual
Content Advisors
Sandra L. Beretta, MD
Chair, NORCAL Mutual, FD Insurance, Medicus and Preferred Physicians Medical RRG
Patricia A. Dailey, MD
Director, NORCAL Mutual, FD Insurance, Medicus and Preferred Physicians Medical RRG
Cognitive and physical changes are a normal aspect of aging,1 but in medical practice they can increase the risk of patient injuries and complicate the defense of medical malpractice claims.2,3 Various functions that are important for the safe practice of medicine deteriorate with age, including sequential processing, attention, logical analysis, hand-eye coordination, verbal and non-verbal learning, visual-spatial ability, inductive reasoning and verbal memory.3,4,5 Sustained attention and ability to perform among distractions and in the presence of multiple visual, auditory, or other stimuli can also deteriorate along with vision, hearing, stamina, strength and fine-motor skills.1,3 In addition to physical and cognitive decline, patient safety may be negatively impacted by other factors affecting the late-career physician: unwillingness to adopt new therapies and practices that promote safe patient care; ineffective continuing education; and intergenerational communication disconnects.3
Many different issues complicate the task of systematically managing the patient safety risks associated with age-related cognitive and physical decline in physicians; for example:1,2,6,7
The rate and extent of decline varies significantly from person to person.
Clinical performance is affected by many issues other than age, including practicing outside the scope of training, clinical volume, fatigue, stress, burnout, health issues, systems problems and practice setting.
Different specialties and practice arrangements have different physical and cognitive demands.
Physicians suffering from cognitive impairment may not notice it.
It may be difficult to conduct peer review of impaired physicians in solo practice, physicians practicing in rural areas, or physicians who have limited caseloads.
Late-career physicians, family, colleagues and institutions may inadvertently or intentionally collude to extend a physician's practice career past the point of safety; for example:
Physicians who don't want to retire may minimize or deny suspected impairment.
Physician family members may avoid discussing suspected impairment out of embarrassment, respect, or reliance on the physician's income.
Colleagues may compensate for the dyscompetence of older physicians out of a sense of loyalty.
Colleagues and staff may be reluctant to confront older physicians in authority positions.
Practice partners may delay discussing retirement for fear of loss of goodwill.
Hospital leadership may tolerate a physician's dyscompetence because of the revenue the physician generates or because the hospital has difficulty recruiting new physicians.
Late-career physicians may file age or disability discrimination lawsuits.
Appropriately responding to suspected age-related disability is challenging on many different levels for all parties involved. The patient safety and medical liability risks associated with age-related disability must be carefully balanced against the risk of violating the aging physician's right to continue practicing.8 Colleagues, family members and administrators should be aware of personal ageist biases, recognizing that age-related disabilities can often be accommodated.1 With accommodation, late-career physicians present a workforce opportunity that can be leveraged in a time when physician shortages are also threatening patient safety.9 However, it is important for late-career physicians to heed Hippocrates's admonition, "first do no harm," and exit practice when it is appropriate.
NORCAL Closed Claims Data Key Points
NORCAL data showed that late-career physicians' claims were more likely to pay indemnity, more likely to settle and less likely to be dismissed. In other areas, NORCAL claims data for late-career physicians did not differ appreciably from claims data for other physicians.
NORCAL data showed that late-career physicians' claims were more likely to pay indemnity, more likely to settle and less likely to be dismissed. In other areas, NORCAL claims data for late-career physicians did not differ appreciably from claims data for other physicians.
Physician Age
Physician Count
% of Total Physicians
<30
18,023
1.9%
30-39
208,799
21.9%
40-49
227,953
23.9%
50-59
214,422
22.5%
60-69
183,870
19.3%
>70
94,969
10.0%
Age Unknown
5,659
0.6%
Total Physicans: 953,695
Reference
Young A, et al. A Census of Actively Licensed Physicians in the United States, 2016. Journal of Medical Regulation. 2016;103(1):7-21. Available at: www.fsmb.org/... (accessed 1/19/18).
Discrimination Against Late-Career Physicians
Requiring physicians over a certain age to participate in job-qualifying or requalifying activities as a stipulation for continuing to treat patients can be - and has been - challenged as discriminatory. Employment laws such as the Age Discrimination in Employment Act (ADEA) specifically prohibit employers from discriminating against their employees on the basis of age.1,10 Although the ADEA arguably does not apply to independent contractor physicians,11 courts look for ways to apply it to independent contractors.12 Additionally, age-based discrimination against a late-career independent contractor physician may support a lawsuit for restraint of trade, violations of anti-trust laws and unfair interference with competition.11 Therefore, privileging/credentialing or employment decisions based solely on age should be avoided.
The Americans with Disabilities Act (ADA) and state disability anti-discrimination laws would protect physicians who have age-related disabilities, as they protect other disabled individuals.13 And, like other disabled individuals, disabled physicians have a right to reasonable accommodations. (Courts have held that ADA anti-discrimination protections apply to non-employee medical staff members.14) Sometimes in an ADA analysis involving a late-career physician, the foreseeable threat to patient safety will be too great and accommodations will not be possible.15 However, in many circumstances, late-career physicians with age-related disabilities can continue to work safely and successfully.
On the flipside, if a physician's age-related disabilities cause a patient injury and a healthcare entity knew or should have known about the physician's dyscompetence, the entity can be found liable for negligent credentialing.16 Healthcare entities may also be found vicariously liable for injuries caused by employed or contracted physicians.16 The question of how to determine whether a late-career physician is competent and qualified to safely treat patients is complicated; however, bylaws and policies should be in place that effectively monitor, review, audit and evaluate all physicians' performance. A physician's age-related disabilities should not come to the attention of administrators for the first time during the investigation of an unanticipated outcome. Having a system in place that tracks physician competence is essential in making determinations as to whether late-career physicians are meeting the same expected standards as any other physicians, and, if not, how and whether accommodation will allow them to do so.
Accommodating Normal Age-Related Cognitive Changes
Research suggests that late-career physicians have a tendency to compensate for cognitive changes that interfere with processing new information by relying on matching patient symptoms to a vast mental database of medical knowledge accumulated through many years of practice (crystalized knowledge).3 By pattern matching, aging physicians can reach a correct initial diagnosis about 60 percent of the time - a higher percentage than their younger colleagues. However, aging physicians are less likely than younger physicians to explore an alternative diagnosis. In the remaining 40 percent of cases in which late-career physicians come to an incorrect initial diagnosis, this tendency towards "premature closure" can result in misdiagnosis and patient injury.1,17,18 Premature closure may be partially impacted by over-confidence in medical decision-making among late-career physicians.19 Also, various combinations of patient factors and practice pressures can increase an older physician's tendency towards premature closure. For example, short appointment times, new computer systems and atypical presentations can all increase the risk of an older physician more heavily relying on crystalized knowledge, settling on a preliminary diagnosis and avoiding time-consuming, analytic processing when it is necessary to reach a correct diagnosis.20,19
The following two cases involve the same 75-year-old surgeon, who, within the same month, misidentified patients' cystic ducts and arteries and instead dissected their hepatic and bile ducts and arteries. He had been a general surgeon for many years and had begun doing laparoscopic procedures in the 1990s, when the surgical approach became widespread and popular. Laparoscopic cholecystectomies and hernia repairs were the "bread and butter" of his practice. He was very experienced.
Research indicates the majority of bile duct injuries during laparoscopic cholecystectomies occur because of compelling anatomic illusions - the surgeon purposefully dissects a bile duct because he or she perceives it is the cystic duct. Experience, knowledge and technical skill do not appear to affect the chance of misidentification.21 However, studies indicate that surgeons with better situational awareness make fewer of these errors during laparoscopic cholecystectomy.22 Situational awareness, which impacts myriad aspects of medical practice, has been defined as the "perception of the elements in the environment within a volume of space and time, the comprehension of their meaning and the projection of their status in the near future."23 Non-rational cognitive processes that affect physicians of all ages - like premature closure - can diminish situational awareness.24 Although late-career physicians may have expertise in the performance of laparoscopic cholecystectomies from performing hundreds of them over the course of their careers, normal age-related cognitive changes may make it more difficult to make correct decisions when confronted with inflammation or otherwise unusual anatomy. (For further information on situational awareness, see the March 2018 edition of the Claims Rx, The Impact of Anesthesiologist Situational Awareness on Patient Safety and Liability Risk).
In the following case, there was no evidence that the surgeon was suffering from dementia. However, he practiced in a manner that increased the risk that age-related cognitive changes could result in patient injuries. Consider the possible roles age-related cognitive changes, cognitive bias and diminished situational awareness played in the following two cases.
Case One
Allegation:
Negligent misidentification of the cystic duct and artery, and delayed diagnosis of the surgical error, resulted in permanent patient disability.
Patient 1 presented for a laparoscopic cholecystectomy. According to the surgeon's operative note, Patient 1's gallbladder was somewhat swollen and was deeply seated and attached to the bed of the liver. There were no other abnormalities and no inflammation, stones or ductal dilatation. While dissecting the gallbladder out of the liver bed, the surgeon noted a smaller duct structure, which he believed to be a smaller vessel off of the hepatic artery. He documented that he dissected the cystic duct and the cystic artery. (However, he had dissected and clipped the common bile duct and dissected the common hepatic duct, which he left opened and draining.) The surgeon did not realize his mistake, and the errors were not discovered until 10 days following surgery. Due to the surgical error and delayed diagnosis, Patient 1 was expected to require multiple additional procedures throughout her lifetime. She filed a malpractice lawsuit against the surgeon.
The surgeon testified he was a proponent of the "critical view of safety" (CVS) method of identification of the cystic duct and cystic artery during laparoscopic cholecystectomy. However, according to experts, if he had used the CVS, the error would not have occurred. One plaintiff's expert noted that some "older surgeons" do a modified version of the CVS and they are "lucky," as most patients have normal anatomy. Because Patient 1's pre-operative imaging suggested normal anatomy and she was considered low-risk, experts surmised the surgeon may have relaxed his vigilance toward a complete and careful dissection of the hepatocystic triangle. Because of the relaxed vigilance, he trusted his assumption that the first structures he encountered off the infundibulum were the cystic duct and artery, rather than verifying he had identified them correctly before dissecting. Additionally, experts noted the surgeon was using the most "old-fashioned" scope available (a rigid, zero-degree scope). This may have contributed to his inability to correctly identify the cystic duct and artery. Modern scopes are angled and offer a much greater view of the operative site.
Although the surgeon testified that it was his practice to use a cholangiogram intraoperatively if there were more than two vessels or structures in his surgical site, he did not do this, despite identifying an additional vessel. Additionally, experts believed the diameter of the bile duct and the absence of a commonly found lymph node should have prompted the surgeon to pause and perform an intraoperative cholangiogram to determine the true anatomy. During the repair surgery many days later, it was discovered that he had clipped four different ducts, which additionally should have alerted him to something being dramatically wrong.
Case Two
Allegation:
Negligent misidentification of the cystic duct and artery, and delayed diagnosis of the surgical error, resulted in permanent patient disability.
Patient 2 presented for a laparoscopic cholecystectomy. According to the surgeon's operative note, Patient 2's gallbladder was chronically inflamed and indurated. The surgeon believed he conservatively followed the neck of the gallbladder down and dissected the cystic duct closer to the gallbladder than usual. (However, he dissected the common bile duct well below the takeoff of the cystic duct and transected the right hepatic artery.) Thinking they were the cystic duct and artery, he placed clips on the common bile duct and on the right hepatic artery. He did not realize the mistake and concluded the surgery. Patient 2 suffered permanent liver damage. He filed a malpractice lawsuit against the surgeon.
According to experts, the surgeon should have converted to an open procedure, performed a cholangiogram and obtained assistance when the inflammation made identification of the cystic duct and artery difficult. The surgeon defended his surgical plan by opining that the inflammation was so severe, that visualization of the operative area would not have been improved by cholangiogram, converting to an open procedure or obtaining the second opinion of a colleague.
In both of these cases, the surgeon was at a loss to explain how or why he had misidentified the cystic duct and artery. Lack of insight into why medical errors are occurring may be a sign of diminishing cognition.
If dementia is causing a physician's dyscompetence, accommodation efforts might be futile.1 On the other hand, if a physician's faulty decision-making stems from the natural effects of aging, he or she may benefit from training and accommodation.1 With the late-career physician remaining longer in practice, the ability to evaluate their skills becomes more urgent. Having systems in place to evaluate physician competence and provide individualized accommodation is paramount to facilitating a late-career physician's safe practice.
Late-Career Physician Recommendations
Age-related changes may affect many different aspects of medical practice. Although there is no national standard for screening physicians who have reached a certain age, physicians are professionally and ethically obligated to continually assess their own physical and mental health, and adjust their practice accordingly.15 Consider the following strategies:3,6,25,26,27,28,29
Question overconfidence in initial diagnoses.
Ask a colleague for advice or a second opinion to reframe an unusual situation.
Increase communication with medical team members.
Obtain training to improve situational awareness.
Obtain retraining and updates on out-of-date techniques.
Use surgical and medical equipment that increases perceptual input; for example, use an angled scope that utilizes ultrasound to compensate for the loss of haptic sense during laparoscopic operations.
Use checklists and other standardized safety protocols.
Be open to competency assessment. Neuropsychological assessment can tease out whether medical decision-making and/or performance are being affected by a neuropsychological/neurological condition, primary health condition, personality traits or stress reactions.
Work with a personal physician to take care of mental and physical health.
Don't ignore vision and hearing impairment.
Address problems associated with sleep deprivation and fatigue, and adjust your schedule accordingly.
Listen carefully to concerns expressed by colleagues, family and friends indicating potential cognitive changes, and appropriately pursue diagnosis, treatment and accommodation.
Reduce aspects of practice that require rapid cognitive processing.
Think about when and how to begin to wind down your practice. Retirement planning can reduce anxiety.
Develop interest in activities outside the practice of medicine.
Late-Career Physician Resources
AMA Senior Physician Section
Information available at: www.ama-assn.org/... (accessed 2/2/2018).
Administrator Recommendations
Some physicians will not self-select out of customary practice when cognitive deficits begin affecting their ability to safely treat patients. However, the skills of older physicians who can practice with accommodation complement those of younger colleagues. With many areas of the country experiencing physician shortages, the creation of mixed-aged practices can benefit all parties.28 For smaller practices with a late-career solo physician, succession planning should be in place well in advance of anticipated retirement.
Policy Development Strategies
Language in policies and procedures, as well as employment and partnership agreements, should facilitate planning for, assessing and accommodating physician aging. Practices should strive to minimize the risk of age discrimination, while reasonably protecting patients from foreseeable injuries;30 therefore, gather input from attorneys and group/practice/staff physicians of different ages. Consider the following: 6,15,26,31,32,33
Define competent practice.
Describe how competent practice will be assessed in a way that accurately evaluates the physician's capacity to perform the duties currently held or requested. For example:
When will physicians be referred for assessment?
By age?
When requesting recredentialing?
By time period?
By request of the administration?
When the frequency of poor outcomes or near misses over a short period of time increases?
What will be tested?
Physical and cognitive capacity?
How will competence be tested?
Will proctoring be required?
Who sets the scope and duration?
Will simulation sessions be used?
Who will conduct evaluations?
Will evaluators be chosen by the physician or the administration?
Who will arrange and pay for the evaluations?
Include language in employment/partnership agreements that sets the stage for age-related assessment; for example, "Partners and employees will be subject to review for impairment due to matters including, but not limited to. . .age-related physical and/or mental conditions."
Describe a process for implementing assessment findings.
Describe the pathway for accommodation.
With whom will the physician coordinate accommodation?
The CEO, COO, managing partner, human resources department, department chair?
Describe the means for accommodation.
What equipment/schedule changes are contemplated?
Describe an appeal process for competency determinations.
Include language that assures the ability of staff and clinicians to anonymously report suspicions of cognitive/physical impairment without fear of retribution or dismissal.
Reach out to physicians who may soon be impacted by any policy changes. For example, while a new late-career physician policy is being developed, leadership could personally contact physicians who would be affected and engage them in review and feedback sessions.
Impairment Report Response Strategies
Administrators should be prepared to respond to reports of age-related impairment. Many practices will already have policies/procedures for responding to physician impairment due to other causes. Existing strategies for other types of impairment (e.g., substance abuse) can be helpful; however, a report of age-related impairment may call for more delicacy as the potential for a full return to practice could be limited. Consider the following recommendations:30
Arrange a meeting with the physician alone or with other physicians in the practice to provide support and share concerns.
Obtain assistance and guidance from an affiliated physician wellness committee.
Consider having a neutral party present who can help everyone stay focused on being supportive.
Plan to present options for assessment and accommodation.
Plan for the potential of the physician refusing to discuss the subject and refusing to cooperate with recommendations.
Carefully consider confidentiality issues associated with the process of evaluating competency.
Consistently enforce policies - don't make exceptions. If exceptions are regularly being made, consider changing the policies, as they may not be realistic.
Accommodation Strategies
A physician wellness committee may have helpful insight into determining how age-related disability can be accommodated and when the risk of patient injury is too great for accommodation. For practices without a physician wellness committee, strategies for managing age-related disabilities may already be in place within existing strategies for managing disabilities caused by other issues. Potential accommodations include:6,28,34,35,26
Proactive training, such as surgical coaching, to improve technical and non-technical skills
Reduced night call, shortened schedules or shortened work weeks to lessen the effects of sleep deprivation and fatigue
Assignment to lower-acuity cases that do not require rapid cognitive processing
Longer appointment times for patients with complex medical problems
Assistance from other physicians, residents, advanced practice professionals or staff, as appropriate
Training on effective communication with younger colleagues - different generations communicate differently
Late-Career Physician Policy Development Resources
The following resources can provide guidance in developing a late-career physician evaluation program.
California Public Protection and Physician Health
"Assessing Late Career Practitioners: Policies and Procedures for Age-based Screening"
Available at: www.procopio.com/... (accessed 2/1/2018)
Stanford Health Care
Late Career Practitioner Policy
Available at: stanfordhealthcare.org/... (accessed 2/1/2018)
University of San Diego PACE Program
PACE Aging Physician Assessment (PAPA)
Information available at: www.paceprogram.ucsd.edu/... (accessed 2/1/2018)
Dealing with Dementia
According to the Alzheimer's Foundation, in 2016, an estimated one in every 10 people over the age of 65 had Alzheimer's dementia.36 In 2016, almost 95,000 of the nation's licensed physicians were 70 years or older.37 Conservatively extrapolating from the data, 9,500 physicians with dementia may be treating patients.
Dementia in a physician can be difficult to identify; often there are only clues. For example, signs of dementia may include:1,38
Increase in prescription errors
Irrational business decisions
Loss of skills
Slower speed of task performance
Increase in patient dissatisfaction
Unsatisfactory peer review
Increase in the frequency of poor outcomes or near misses over a short period of time
Irritability
Depression
Repeating stories without realizing it
Forgetting events and conversations
Difficulty retrieving words and names
Losing track of time
Not recognizing memory problems
In the following case, the physician's dementia likely affected her treatment decisions, which were later questioned by experts. Like many NORCAL claims that involve physician dyscompetence, the fact of a physician's impairment - coupled with the potential of it having caused the patient injury - complicated the physician's defense and the defense of her employer, who arguably should have restricted her practice at an earlier time.
Case Three
Issue:
Hysterectomy caused the patient's cancer to spread.
A 48-year-old patient presented to an OB/GYN as a new patient requesting a hysterectomy. She reported daily abnormal vaginal bleeding. Conservative treatment had not been successful. Although the patient's cervix appeared grossly distorted with multiple bleeding lacerations, cervical cancer was not in the OB/GYN's differential. She scheduled the patient for a laparoscopic hysterectomy the following week. Alternative surgical options were not discussed. Prior to the hysterectomy, she did not do a cervical biopsy or obtain any of the patient's records from previous OB/GYNs. The next week, the OB/GYN excised the uterus into pieces for extraction and completed the procedure without apparent complications. Pathology revealed the patient had cervical cancer.
The patient filed a malpractice lawsuit against the OB/GYN claiming the hysterectomy seeded the cancer and significantly diminished her chance of survival, which was estimated at 5%. She also sued the hospital for negligent credentialing.
Around the time of the hysterectomy, there was discussion among administrators at the hospital in which the OB/GYN had surgical privileges about proctoring her because colleagues had raised competency concerns. In fact, during litigation, the OB/GYN was diagnosed with early Alzheimer's disease. Although the physician seemed fairly normal in regular conversation, during the litigation process she could not remember or answer questions about the patient or why she chose the surgical approach. She could not explain why she had not obtained medical records, why she did not biopsy the patient's cervix or why cervical cancer was not in her differential. Her medical records provided no assistance in this regard. The OB/GYN was not expected to be able to provide effective testimony for her own defense.
While there were no overt signs of the OB/GYN's cognitive impairment in the medical records, it is reasonable to infer, based on the recent onset of her apparent dyscompetence and prior distinguished career, that dementia had affected her decision-making. For example, consider the opinions of experts, who were mostly in agreement:
The OB/GYN should not have performed a hysterectomy without determining whether the patient's symptoms were being caused by cervical cancer.
The OB/GYN should have biopsied the cervix prior to the surgery. Had she biopsied the cervix, she most likely would have discovered the cancer, which would have been treated with a combination of radiation and radical hysterectomy.
Even without a biopsy, the OB/GYN should have had cancer in her differential based on her examination findings. The defendant admitted that she would not have performed the surgery and would have referred the patient to an oncologist if she had known the patient had cancer.
The OB/GYN should have obtained the patient's prior treatment records. If she had done so, she would have realized the patient had never had a biopsy, despite the history of abnormal vaginal bleeding.
The surgery took close to three hours, which was excessive.
Many of the strategies in the prior discussion on normal age-related cognitive changes can be applied to physicians with dementia. Because individuals with dementia may be unaware of the extent of their disability, the following strategies are focused on physician colleagues and administrators.
Strategies for Colleagues and Co-Workers of Physicians with Suspected Age-Related Cognitive Impairment
Members of the healthcare team have an ethical and often legal duty to report impaired or incompetent colleagues. Prior to making reports to a medical board, individuals can obtain guidance from their physician wellness committee, credentials committee, medical executive committee, risk managers or other designated administrators.15 Consider the following recommendations:39,40
Recognize subtle clues of dementia.
Approach a colleague who appears to be struggling and genuinely ask, "How are you doing?" Actively listen to and evaluate the answer.
Seek out continuing medical education (CME) coursework in the area of ethics and promoting skills for "difficult conversations."
If your practice does not have policies and procedures for approaching and managing physicians with dementia, refer to and adapt existing strategies for approaching physicians with other types of impairments that put patients at risk.
Document your concerns.
Research and become familiar with impaired physician reporting requirements in your state, within your hospital or within your group. For example, review the website of your state's Physician Health Program (PHP) and become familiar with the process for reporting an impaired colleague to the medical staff physician wellness committee.
A list of state PHPs is available from the Federation of State Physician Health Programs at: www.fsphp.org/... (accessed 1/17/2018).
Information for California Physicians is available at: www.CPPPH.org (accessed 1/17/2018).
If a physician with dementia who poses a risk to patients cannot be convinced to retire, put the matter into the hands of the state medical board.
Understand that while reporting an impaired colleague may be difficult, failing to report could threaten the welfare of patients and of your colleague.
Recognize that being in a situation in which you have a duty to report an impaired colleague may cause you to feel stress and may create emotional conflict.
Strategies for Administrators
Hospitals and other healthcare entities have an obligation to patients to maintain only competent physicians on staff. Physicians must be credentialed fairly, but the needs of the physician must be balanced with the duty to ensure patient safety. Competency evaluation is an ongoing duty. Ideally, the onset of dementia should be recognized and addressed before physicians can no longer practice safely. Consider the following recommendations:10,16
Be prepared with a strategy for dealing with a physician with dementia who has not self-selected out of active practice.
When appropriate, engage the physician's family to facilitate retirement.
Provide medical staff members with due process and a fair hearing when denying or restricting privileges.
Studies indicate that with aging, certain cognitive and physical abilities begin to diminish.3 Many declining capacities directly affect a physician's ability to safely treat patients. However, there is no consensus by physicians, medical boards, regulatory agencies and professional societies on how to balance the needs of late-career physicians with patient safety. It is a delicate process that can be partially managed through well-crafted employment/medical staff and partnership agreements, policies and robust cooperation and communication among various stakeholders.1 Although age-related changes in physical and cognitive abilities can raise challenges for late-career physicians and administrators, with optimal accommodation, many physicians can continue to work safely and successfully - up to a point. Both physicians and administrators should agree on that point prior to its arrival.
The NORCAL documents referenced in this article, along with many other Risk Management Resource documents and past editions of the Claims Rx, are available in the Risk Solutions area of MyACCOUNT, or by policyholder request at 855.882.3412.
LoboPrabhu SM, et al. The aging physician with cognitive impairment: approaches to oversight, prevention, and remediation. American Journal for Geriatric Psychiatry. 2009;17(6):445-454.
Kaups KL. Competence not Age Determines Ability to Practice: Ethical Considerations about Sensorimotor Agility, Dexterity, and Cognitive Capacity. AMA Journal of Ethics. 2016;18(10): 1017-1024. Available at: journalofethics.ama-assn.org/... (accessed 2/5/2018).
Moutier CY, Bazzo DE, Norcross WA. Approaching the Issue of the Aging Physician Population. JMR. 2013; 99(1)10-19. Available at: jmr.fsmb.org/... (accessed 2/5/2018).
Gostlow H, et al. Non-technical skills of surgical trainees and experienced surgeons. Br J Surg. 2017;104:777–785.
Diekema C. Issues Regarding the Aging Physician. 2013. Available at: www.youtube.com/... (accessed 2/5/2018).
AMA. Competency and retirement: Evaluating the senior physician. AMA Wire. 2015. Available at: wire.ama-assn.org/... (accessed 2/5/2018).
Hyer R. Cognitive Impairment in Older Physicians May Be Widespread. 2006. Medscape Business of Medicine. Available at: medscape.com/... (accessed 2/5/2018).
The Greeley Company. 10 "Aging Physicians" Issues Hospitals Are Facing. The Greeley Company Website. Available at: greeley.com/... (accessed 2/5/2018).
Bjelland MJ at al. Age and Disability Employment Discrimination: Occupational Rehabilitation Implications. Journal of Occupational Rehabilitation. 2010;20(4):456-471. Available at: www.ncbi.nlm.nih.gov/... (accessed 2/5/2018).
West JC. Age Discrimination and the Older Medical Staff Member. West Consulting Services Website. Available at: westconsultingservicesllc.com/... (accessed 2/5/2018).
Chase-Lubitz J. Legal Issues and the Aging Physician. 2017. Barrett & Singal Website. Available at: barrettsingal.com/... (accessed 2/5/2018).
Snelson EA. (MentorHealth) Problems with Aging Physicians. 1/25/2018.
Barton RD. Late Career Practitioners or Difficult Behavior: How Medical Staff Policies and Procedures Can Help
You or Hurt You. 2017. Western Health Care Leadership Academy website. Available at: www.westernleadershipacademy.com/... (accessed 2/5/2018), referencing Menkowitz v. Pottstown Memorial Medical Center, 154 F.3d 113 (1998).
Barton RD. Late Career Practitioners or Difficult Behavior: How Medical Staff Policies and Procedures Can Help You or Hurt You. 2017. Western Health Care Leadership Academy website. Available at: www.westernleadershipacademy.com/... (accessed 2/5/2018).
Matzka K. Credentialing, Recredentialing, and Privileging: The Basics and Beyond. National Association of Medical Staff Services website. Available at: www.namss.org/... and Matzka K. Credentialing, Recredentialing, and Privileging Basics. 2017. National Association of Medical Staff Services website Available at: https://www.youtube.com/... (accessed 2/5/2018).
Harada CN, at al. Normal Cognitive Aging. Clinics in geriatric medicine. 2013;29(4):737-752. Available at:
www.ncbi.nlm.nih.gov/... (accessed 2/5/2018).
Durning SJ, et al. Ageing and cognitive performance: Challenges and implications for physicians practicing in the 21st century. Journal of Continuing Education in the Health Professions 2010;30:153-160.
Salem-Shatz SR, Avorn J, Soumerai SB. Influence of clinical knowledge, organizational context, and practice style on transfusion decision making. JAMA. 1990; 264:471-475.
Eva KW, Cunnington JP. The difficulty with experience: Does practice increase susceptibility to premature closure? J Contin Educ Health Prof. 2006;26:192-198.
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