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Cognitive screening of older physicians: What’s fair?


 

FROM JAMA

Cognitive screening of 141 clinicians 70 years or older at Yale New Haven (Conn.) Hospital identified 18 with cognitive deficits likely to impair their ability to practice medicine. Six retired and 12 agreed to limit their practice to closely proctored environments, according to a report in JAMA.

It was part of a program to screen all practitioners 70 years or older who apply for reappointment to the medical staff, and every 2 years thereafter, due to “concerns about the potentially compromised ability of older clinicians,” said the authors, Yale rheumatologist and geriatrician Leo M. Cooney Jr., MD, and Thomas Balcezak, MD, Yale New Haven’s chief medical officer.

Yale is not alone. Intermountain Healthcare, Stanford Hospitals and Clinics, Scripps Health Care, Penn Medicine, and the University of California, San Diego, are among the institutions with similar programs.

The move is being driven by the aging of the medical community. About 15% of U.S. physicians are over 65 years old, a tripling from 23,000 in 1980 to 73,000 in 2012-2016, and the number is growing, according to an editorial by Jeffrey L. Saver, MD, professor of neurology and senior associate vice president of neurology at the University of California, Los Angeles.

Dr. Jeffrey L. Saver, professor of neurology and senior associate vice president of neurology at the University of California, Los Angele Mitchel L. Zoler/MDedge News

Dr. Jeffrey L. Saver

Given the trend, “it is not surprising that the issue of screening aging physicians for cognitive deficits has gained attention over the last decade,” Katrina Armstrong, MD, chair of the department of medicine at Massachusetts General Hospital, Boston, and Eileen E. Reynolds, MD, associate professor of medicine at Beth Israel Deaconess Medical Center, Boston, noted in a second editorial.

“Cognitive decline often accompanies aging, and the prevalence of dementia increases rapidly after age 70 years,” they said.

The data on whether older clinicians pose a risk to patients is limited and somewhat mixed. An analysis of 736,537 Medicare hospitalizations found no association between physician age and 30-day patient mortality among physicians 60 years or older with more than 201 admissions per year, but higher mortality among older physicians with lower volumes.

A meta-analysis of 62 studies showed that “older physicians have less factual knowledge, are less likely to adhere to appropriate standards of care, and may also have poorer patient outcomes.”

The new Yale data, meanwhile, suggests that “approximately 13% [18 of 141] of physicians and other clinicians older than 70 years should not be practicing independently,” Dr. Armstrong and Dr. Reynolds said in their editorial.

There is support for screening efforts. “As a profession that deals with human life, medical practitioners must obviously have the cognitive capacity to safely practice medicine. I applaud the approach taken by Yale New Haven Hospital in that cognitive abilities themselves, and not simply funds of knowledge, are assessed,” said Richard J. Caselli, MD, professor of neurology at the Mayo Clinic Arizona, Scottsdale, and a leader of the Alzheimer’s disease program there.

Dr. Richard J. Caselli, professor of neurology at the Mayo Clinic in Scottsdale, Ariz., and associate director and clinical core director of Mayo’s Alzheimer’s Disease Center.

Dr. Richard J. Caselli

However, it’s not hard to imagine highly competent but older physicians taking umbrage at cognitive screening, and there’s been pushback. Stanford was considering a Yale-like approach but opted instead for peer review after opposition. Objections from the Utah Medical Association led Utah to enact a law banning age-based physician screening. In 2015, the American Medical Association issued a report calling for the development of guidelines and standards for assessing competency in aging physicians, but the AMA House of Delegates shelved it pending further study.

There are concerns about age discrimination, discounting the accumulated wisdom of long-practicing physicians, and misclassifying competent physicians, particularly those who provide quality care in rural and other underserved areas. Indeed, 8 of 14 clinicians who screened positive at Yale and underwent more extensive testing were allowed to recredential, “suggesting that the false-positive screening rate could be as high as 57%,” Dr. Armstrong and Dr. Reynolds noted.

The consensus seems to be that there probably is a need for some sort of screening, but it must be both sound and fair. Rather than a piecemeal institutional approach, perhaps there is “an important opportunity for other groups, including specialty boards and state licensing boards” to standardize the process, they said.

Among other things, assessments could focus less on test scores and more on the practice of medicine. For instance, fine motor skill/motor planning assessments for surgeons, and intermediate results could trigger a more extensive assessment of actual clinical performance, perhaps even direct observation, Dr. Saver said in his editorial.

As far as clinical performance goes, none of the 18 clinicians at Yale had previous performance problems. “Was this a failure of the system to report impaired physicians or were these physicians compensating sufficiently to avoid detection?” In either case, “cognitive testing should be a red flag that triggers other clinical assessments,” said Carl I. Cohen, MD, professor and director of the division of geriatric psychiatry at the State University of New York, Brooklyn.

Dr. Carl I. Cohen, professor and director of the division of geriatric psychiatry at the State University of New York, Brooklyn

Dr. Carl I. Cohen

The original plan at Yale was for neurologic and ophthalmologic examinations beginning at age 70, but ultimately it was decided to go with a battery of 16 tests to assess visual scanning and psychomotor efficiency, processing speed under pressure, concentration, and working memory, among other things. Testing takes about 50-90 minutes, and is graded by single neuropsychologist to ensure consistency. Results were compared with normative scores from both older and younger clinicians.

To prevent clinicians from preparing for it, Yale isn’t releasing its test battery.

Suboptimal performance triggered additional evaluations, including in-depth assessment of intellectual, memory, and executive function. Final reviews and recommendations were made by a committee that included a geriatrician, the clinician’s section or department chair, and current and past chief medical officers.

Photographee.eu

Among the 18 providers who demonstrated deficits impairing their ability to practice medicine, 5 were 70-74 years old; 4 were 75-79; and 9 were 80 years or older. Minor abnormalities were found in 34 other candidates (24.1%); they were allowed to recredential but were scheduled for rescreening at 1-year intervals, instead of every 2 years.

The mean age among the 141 screened clinicians was 74.3 years and ranged from 69 to 92 years; 86% were men. Applicants included 125 physicians (88.7%) as well as 5 advanced practice registered nurses; 4 dentists; 3 psychologists; 2 podiatrists; 1 physician associate; and 1 midwife.

The authors had no relevant disclosures.

SOURCE: Cooney L et al. JAMA. 2020 Jan 14;323(2):179-80.

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