This is the second in a MedPage Today series on the controversial but growing trend among healthcare institutions to require physicians of a certain age to undergo testing for thinking skills and physical dexterity. The first installment examined how, why, and where these requirements are being rolled out. Here we discuss the reaction among physicians and others.
Pediatrician Georges E. Argoud, MD, sees newborns at Scripps Hospital in Chula Vista and helps others take care of children of asylum seekers at the border. Although now partially retired at age 92, he takes care of other pediatricians’ patients when they go on vacation.
But recently, Argoud heard he might be required to undergo cognitive testing at Scripps Health, the 3,000-physician hospital network in San Diego within which he works. Scripps is preparing to launch a system-wide cognitive screening program for all physicians age 70 years and older, though he just paid his $500 two-year recredentialing fee. Officials at Scripps and elsewhere say such testing is needed to ensure that their aging clinical workforce remains competent to provide safe patient care.
But for Argoud, it’s an uncomfortable development, an awkward sense that now he and his older colleagues would come under such scrutiny. There’s no national standard to do this for all physicians, he reasoned, nor is there a requirement that politicians undergo it, and maybe they — as well as those in other life-sensitive professions — should too.
Any final decision about whether he could continue to practice should be made by a committee of his peers, those who know him, and have watched him provide care, not some computer test, he said.
Many physicians said much the same in comments on MedPage Today‘s first story on this topic.
Arbitrary age cutoff?
Nielufar Varjavand, MD, a program director for the Drexel University School of Medicine Physician Refresher/Re-Entry Course, which helps physicians return to practice after taking time away — perhaps because of illness, another career, or state agency’s disciplinary order — was also skeptical about setting an age for cognitive screening of doctors.
“Is it fair to make a cutoff point?” she asked rhetorically. “Is 64 or 69 okay, but 70 and 74 not okay? There may be statistics behind this, but who decides the age cutoff? And who determines whatever assessment is used is the appropriate assessment tool? I would just like to know what the evidence is. It seems so arbitrary to me.”
At Pomona Valley Hospital Medical Center in California, Kenneth Nakamoto, MD, vice president of medical affairs, acknowledged the problem that the growing number of aging physicians may present for hospitals, and increasing pressure on organizations to develop policies. But there’s no mandate from any organization yet, although some are starting to grapple with the issue. For example, the Federation of State Medical Boards and the Federation of State Physician Health Programs will hold a forum on “The Aging Physician in America: What will be the Impact on Patient Care” at their meeting next month in Fort Worth, Texas. Also, the Coalition for Physician Enhancement will hold a two-day meeting in Chicago on aging and fitness for duty Oct. 3 and 4 in Chicago, in collaboration with the American Medical Association.
For the time being, Nakamoto said, Pomona Valley is holding off instituting any policy to screen the aging physician.
Pushback in Provo
At Intermountain Healthcare in Utah, the question of what to do with senior physicians came to a head about seven years ago because bylaws for the 5,000-physician system mandated retirement at age 72. Many clinicians didn’t want to quit and obtained extensions, said Kelly Garrett, PhD, clinical neuropsychologist for IHC’s Late Career Physician (LCP) program.
“We had quality data, some peer review data, but really no program that was evidence based, reliable, and valid to keep the professionalism that we want,” she said.
A year-long deliberation resulted in a policy, set in 2012, to replace mandatory retirement with screening at age 72. Intermountain used the MicroCog, a computer-based test that scores processing speed and accuracy using questions, some of which deal with simple math and the ability to recall elements of a short story. Like with PAPA (an assessment program developed at the University of California, San Diego), those physicians who fail must submit to a more comprehensive assessment that includes more intense testing and evaluation, both physical and mental. The MicroCog test is just a preliminary screening tool.
But many physicians were upset such a test could lead to a review that would end their careers and with help from the Utah Medical Association fought back. That effort resulted in a Utah state law that took effect last September banning age-based physician screening by medical groups, hospitals, or health plans.
The bill’s sponsor, state Sen. Lyle Hillyard, said physicians complained that the test didn’t assess medical competency. “They felt it was just a tool being used by Intermountain to get some of the more well-paid doctors out of the hospitals and bring younger doctors in to take their place,” Hillyard told MedPage Today. “I was told that doctors [ages] 45 and 50 had taken it … just to find out, and they flunked.”
That ended Intermountain’s program. But apparently not for long.
Back in business?
Garrett and others defended their screening program as a way to see which physicians need more careful review, and testified this month in support of a new bill overturning last year’s prohibition.
It passed on March 14 and awaits Utah Gov. Gary Herbert’s signature. Garrett wrote in an email to colleagues “we are back in business.” She said she expects the program to resume as long as the screening tests that Intermountain uses are based on principles of medical evidence and tests for “cognitive changes associated with aging that are relevant to physician performance,” which she is sure they will.
Garrett said over the program’s nearly seven-year operation, the LCP screened 97 physicians, some up to four times (screening is repeated every two years). For those physicians who took it the first time, the failure rate was 11%; for repeat tests it was 13%, she said.
The screening had some surprising benefits, she said. One physician’s results revealed cognitive deficits which, upon further evaluation and physical exams, turned out to be due to a correctable medical issue.
“It turned out this doctor was in kidney failure, and he was then able to get that addressed so his cognitive abilities improved.”
“Some argue that doctors are smart. They’ll know when to retire, right?” Kelly said during a committee hearing on the latest bill. “Well, that might be true of some, but the data don’t really support that … and we have evidence published in JAMA that support the idea that doctors tend to think that ‘I’m about the same as I ever was’ when that simply isn’t the case.”
A review in JAMA Surgery in October 2017 noted that voluntary approaches are politically feasible “but share the fatal flaw of relying either on physicans to self-refer or clinicians to report an aging colleague to such programs. Despite physicians’ commitments to professionalism, compelling data suggests neither is likely to occur.”
But some Utah physicians still oppose the screening.
Though Salt Lake City pediatrician Louis Borgenicht, MD, now 76, passed it twice before retiring six months ago, he didn’t think it useful. “You read a story at the beginning, don’t think about it until the end when they ask for details, like was the furniture Baroque or classic? And there were word associations, like is this shape similar to this shape?”
Particularly irksome, he said, was the part that — as he recalled it — asked him “to multiply 576 by 354. … That was a difficult and unfair thing; you can’t do those things in your head.” However, sources familiar with the MicroCog said the test doesn’t require computations that complex, and that people with some college education should pass it.
Stanford University in 2012 launched a screening policy with the MicroCog for faculty who reached age 74.5 years, but had to rescind it after some physicians loudly complained of age discrimination. Stanford replaced its policy with peer assessment, history, and physical exams, minus the MicroCog.
A task force “determined that while there was no convincing evidence for using a cognitive screen in older physicians to determine their ability to practice safely (likely because this was a new concept and it had not yet been tested broadly enough)… there was evidence that rigorous peer review was a useful tool to accomplish that goal,” explained Ann Weinacker, MD, Stanford’s vice chair of medicine. Of 74 physicians screened, follow-up reviews were warranted in about six, she said.
Frank Stockdale, MD, 83, a Stanford breast cancer oncologist who led the fight against Stanford’s initial policy, stressed that use of a certain age to prompt special screening “is arbitrary” and that routine cognitive testing is not currently supported by high quality evidence.
“In my view, patients are best protected from harm when medical competency is evaluated with a rigorous, uniform method for all,” he said. Organizational focus on age, he added, “is distracting our profession from formulating the best approach to protect patients.”
Medical groups police their own
It isn’t just acute-care systems that want to test older doctors’ thinking skills.
Sharp Rees-Stealy Medical Group (SRSMG), with 577 physicians in San Diego, is among the large medical groups that have begun age-based testing. Like Intermountain in Utah, it started screening all doctors at age 70 in 2016 as a way to replace a mandatory retirement age of 70, allowed specifically for medical groups under California law. Also like Intermountain, the group had allowed exceptions to the mandatory retirement.
“The question was how do we make exceptions in a safe way,” said SRSMG’s chief medical officer, Steven Green, MD. “We had physicians who were 70 or more and going strong, providing great care. … We came up with the idea of using PAPA to assure people were safe to practice.”
Garrett said when screening began in Utah, Intermountain made staffing decisions estimating a certain number of its senior doctors would just retire rather than take the test. They were surprised that twice as many as expected dropped out — either retired or moved elsewhere — although Intermountain had also adopted a new EMR system at the same time, which may have played a role.
In an effort to alleviate physician apprehension, Intermountain’s system is set up so that physicians can pay the cost of initial screening, and then decide whether or not to share the results with the credentialing committee, they could. “If the physician, upon reviewing results, wishes to retire, that’s an option too,” she said.
Several clinicians acknowledged a fear factor loomed large. How embarrassing would it be if they failed, and key colleagues learned their results?
“Some physicians said, well, I don’t mind doing the test, but if it’s abnormal, I want the choice of deciding what happens to it,” said SRSMG’s Green.
“I’m not going to tell you this stuff is easy,” Green said. “This is not an issue without controversy, and some people are very upset by the fact that we would screen based on age. … These are hard conversations to have with physicians. But at the end of the day, I don’t think I’ve yet had a physician not agree with the idea that if they knew that they were not safe to practice, none of them would want to practice.”
The cost is considerable, however.
David Bazzo, MD, director of PAPA, says the testing program costs from $1,100 to $2,200, depending on how many doctors an institution sends. If areas of concern are seen, PAPA will recommend the follow-up “fitness for duty” review. That would include a general medical physical and consult with a neurologist, a psychiatrist, or psychologist — if the physician chooses to press ahead with recredentialing, that is.
That costs $12,000 to $15,000 but could go as high as $20,000, Bazzo said. Who pays — the medical group or the hospital medical executive committee — may vary among organizations.
Jerrold Glassman, MD, an interventional cardiologist with San Diego’s Scripps Health, believes screening is the right thing to do and “a great goal.” But he noted, “the devil is in the details” on how it will roll out for Scripps’ 3,000 clinicians. Just to be sure, as a leader of Scripps Mercy Hospital’s bylaws committee, he and some colleagues plan to take the test this summer on their own, to see what it’s like, before recommending it to their peers.