Monday, November 2, 2015

Aging physicians 2

(My confession:  January 18, 2016, would be my 65th birthday.)

Should older physicians be forced to stop practicing once they begin to slow down? Some experts in competency testing are calling for doctors to be evaluated as early as age 65, arguing that that's when physical and mental disabilities start to become apparent.

A few hospitals have already started evaluating physicians in their 70s for competency. When results show significant impairment, these physicians are required to get remediation, submit to limitations of their privileges, or retire completely, depending on the severity of the impairment.

Some experts argue that the cutoff age for these exams should be 65 years, which would have a huge impact on America's doctors. Owing to the baby boom, 240,000 doctors are now in that age group—a fourfold increase since 1975, according to the American Medical Association (AMA)...

Proponents of age-based testing say it's no longer permissible to simply allow aging physicians to determine when they should retire, because many of them stay on after impairment sets in. But critics assert that younger physicians are just as likely to be impaired, and targeting older physicians is unnecessarily humiliating.

Doctors in their 70s are taking leading roles on both sides of the debate.

Dr Wolfe says there are several reasons why age-based testing is needed. "Unfortunately, older physicians don't always know when to quit practicing," she says, and "it's very difficult to get physicians to identify impaired colleagues" and convince them to quit.

She says older physicians who aren't impaired should be allowed to practice no matter how old they are. Even when impairments are identified, every effort should be made to help physicians alter their practice without ending their careers, she says. But if they have serious impairments, such as dementia, they'll need to resign.

Although he's slowing down physically, Dr Stockdale says he has learned to adjust. "My memory isn't as good as it used to be and I don't play basketball anymore, but that doesn't mean I'm not competent to practice medicine," he says. "You learn to compensate." Older physicians tend to see fewer patients; focus on patients with less acuity; and spend more time with them, which patients like, he says...

  • A 2005 study showed a much higher rate of disciplinary actions against doctors out of medical school for 40 years compared with those out of school 10 years.
  • Another study, also from 2005, indicated that performance on a range of outcomes declined as physicians' years in practice increased.
  • A 2008 study found "no notable relationship" between older physicians' own assessment of their cognitive skills and objective cognitive measures, indicating that the physicians may be unaware of their impairments....

  • But even the most convincing studies show that a significant percentage of older physicians have no serious competency problems, even when they're at an advanced age. For example, a 2010 study found that one third of surgeons in their 70s still matched younger surgeons in competence on a variety of tasks.

    However, Dr Stockdale disputes that loss of cognitive ability is the main reason why physicians make mistakes. "The major reason for errors," he says, "is not cognitive problems but behavioral ones," such as alcoholism, substance abuse, and failure to document, which occur more frequently in younger physicians. "The mid-career is a more risky time for physicians," he asserts. "These doctors are 15 years or more beyond training, and what they learned has started to wane."...

    Consider the case of Warren Guntheroth, MD, a cardiologist at the University of Washington (UW) Medical School, as reported by the Seattle Times.

    In 2006, when Dr Guntheroth was 79, the medical center started to investigate his skills after he was accused of becoming isolated from other doctors, writing inappropriately short assessments of patients, and misreading cardiology tests.

    Three outside doctors appointed to assess Dr Guntheroth concluded that only his clinical documentation was poor. As a result, UW decided to restrict his privileges. His patient records were monitored, he was limited on where he could practice, and he was required to attend sessions on cardiology topics.

    Dr Guntheroth claimed he was being retaliated against for publicly criticizing the medical school on several policy issues, and he reported the medical school to the EEOC. UW insisted that it wasn't engaging in age discrimination because none of the 14 other on-staff physicians older than 70 were under review.

    In 2008, the EEOC concluded that Dr Guntheroth had not "engaged in misconduct which would warrant the adverse treatment" he received, and there was "reasonable cause" to believe that he'd been discriminated against. Nevertheless, the EEOC didn't take any further action. To force UW to revoke its action against Dr Guntheroth, the EEOC would have had to sue the university, and the agency rarely brings lawsuits, the Times reported.


    1. University of Washington doctor Warren Guntheroth didn’t mince words when the UW’s medical centers paid a record $35 million penalty in 2004 for overbilling Medicare and Medicaid. He publicly blamed the dean of the medical school for the scandal.

      Since then, Guntheroth claimed, medical-school officials have retaliated, trying to force him out. They questioned his competence as a cardiologist, hired outsiders to assess how he treated heart patients, and ordered other UW doctors to review his work, government records show.

      “This was humiliation and harassment,” Guntheroth said.

      He complained to the federal Equal Employment Opportunity Commission (EEOC) in 2006, alleging age discrimination. Guntheroth, a faculty member for 50 years, turned 80 last July.

      Most complaints filed with the EEOC are dismissed or settled before the agency has to rule. Over the past decade, only 4 percent to 10 percent of those who filed each year obtained a favorable ruling.

      Late last year, the EEOC ruled in Guntheroth’s favor, although a cloud remains over him because the UW has failed to recognize the finding.

      Guntheroth, one of the first doctors in the country to urge parents to place babies on their backs to avoid sudden infant death syndrome, only recently revealed the dispute to The Seattle Times...

      As a doctor, Guntheroth has taken unpopular stands, such as opposing insurance-industry efforts to curb medical-malpractice suits. During the UW billing scandal, he was one of just a few medical-faculty members to speak out.

      He publicly chastised UW officials in 2002 when the university agreed to pay up to $3.7 million to prominent neurosurgeon H. Richard Winn to leave the UW after Winn, a tenured professor, pleaded guilty to obstructing a federal criminal investigation into the overbilling.

      “The effect on the university is bad,” Guntheroth said at the time. “How can we teach our students that crime doesn’t pay?”...

      Last summer, the EEOC told the UW it did not find evidence to show that Guntheroth had “engaged in misconduct which would warrant the adverse treatment and conditions of employment … imposed on him.”

      In September, the agency officially said it found “reasonable cause” to conclude he had been the victim of harassment and discrimination.

      The EEOC then urged the UW and Guntheroth to resolve the matter.

      The agency proposed that medical officials provide better training about age discrimination; post a notice informing employees how to raise concerns about the subject; and not retaliate against Guntheroth. He asked for an apology from the dean, EEOC documents show.

      UW officials declined to participate. And Guntheroth said the restrictions on him remain in place.

      The EEOC cannot force an employer to resolve a case, although the agency can sue to enforce remedies. But the EEOC sues in only a fraction of cases, using its limited resources to bring suits with wide implications, such as class-action cases.

      Otherwise, the EEOC advises people they can file suit on their own.

      Guntheroth said this is what happened in his case. But at his age, he said, “I am not too interested in long, drawn-out battles.”

    2. Since 2011, the University of Virginia Health System has required physicians to undergo neurocognitive and physical exams when they reach the age of 70, adding an extra step to renewing their hospital privileges. They have to repeat the exam at age 75 and every time they renew their privileges thereafter; the director of the physician wellness program has to sign off on it. Syverud says the exam takes about 4 hours, and costs about $2,000 apiece. The physicians' clinical departments cover the cost. "It only takes one bad outcome with a patient to make the entire program worthwhile."

      That's because a bad outcome is sometimes the first indication of a clinicians' impairment.

      "If we didn't have this policy, the traditional way that this happens with physicians is that something happens in their practice," Syverud says. "It's career-ending, and it's a public end to the career. It's not good for the physician, and more importantly, it's not good for the patient." Neither is it good for the hospital or health system.

      About 50 clinicians have gone through the evaluation since the policy was established. The results are confidential and they determine what action is taken. For some clinicians, a clean bill of a health is a source of pride, and maybe also validation. If a weakness is detected, the "policy offers them a confidential way to discuss that," Syverud says. "I suspect that would be a relief for many people."...

      Munson Medical Center adopted a similar policy in 2014, requiring physicians at age 70 and every 2 years thereafter to undergo a physical exam, a hearing screen, and the Montreal Cognitive Assessment. The program is voluntary at age 65. If a physician hasn't taken the exam within 30 days of being notified to do so, he or she will be considered as having voluntarily relinquished their privileges.

      Speirs says there was some resistance to the policy when it was first adopted.

      "Some of the pushback was that they didn't feel that it was right to take a test, that they would know when they weren't able to practice medicine," she says. But, "the argument does not stand up. Even with signs of mild dementia, you cannot tell in yourself, many times. You may be the last to know."