The Impact of Aging on Physician Clinical Performance and Quality of Care

The Coalition for Physician Enhancement (CPE) recently presented an innovative and enlightening program, “Practicing Medicine Longer: The Impact of Aging on Physician Clinical Performance and Quality of Care,” which expands thinking about physicians and retirement and has academic and clinical implications. For many, especially physicians, aging is objectionable, but our professional responsibility to our patients and to the profession necessitates reliable methods of assessment and treatment of competency as aging occurs. One of the few but well-regarded programs in the United States that offers solutions to these problems is the U.C. San Diego Physician Assessment and Clinical Education (PACE) Program. In this conference, PACE and CPE have joined to review the current literature and research on aging and physician competence. Topics covered in this meeting, all dealing with physicians’ aging, included education, remediation, competency evaluations, fitness for duty evaluations, performance, impairment, aging, and leadership. International experts in medicine, law, and public policy were brought together to discuss this controversial area of healthcare: the multifaceted impact of aging on physician clinical performance and quality of care.

In order to consider the many topics relative to physician aging, it was necessary to lay out the demographic data. Peter Boal, associate director of the PACE Program, presented two credible sources: AMA’s Physician Master File and the U.S. Census. AMA has been reporting and studying physician competence with aging since the 1980s and currently surveys one-third of the MD population annually as to major clinical activity and other nonclinical work. Both AMA and the U.S. Census agree that the general population is aging, as is the practicing physician population. Many studies also report that the growing over-65 population of physicians often coexists with a shortage of physicians overall.

Working professionals are continuing their careers well after the standard retirement age, and doctors are no exception. While an experienced physician is certainly prized, there are some risks concerning the optimal and safe delivery of care to the patient that are associated with aging. Currently, there are very few healthcare systems with age-based screening policies. However, some opponents of this grading might consider any age-based screening to be ageist and unethical. In one workshop session, Jill Silverman, president of CMA’s Institute for Medical Quality, took the side of the physicians and enumerated some of the challenges inherent in age-based screening; for instance, data collection relevant to aging and competency is often unreliable. The Honorable Steven Adler, California administrative law judge, argued for the public that there is ample evidence of increased risk of cognitive decline and health-related impairment with advancing age. Nevertheless, in the mid ’90s the Coalition for Physician Enhancement formed to study the concerns of the medical community about the relationship between competence and quality of care. Along with CPE, the PACE program is dedicated to the education of physicians and other healthcare professionals; the detection, evaluation, and remediation of deficiencies in medical practice; and assisting the medical profession in its quest to deliver the highest quality of healthcare to the people of the United States.

This conference demonstrated the sophistication of study in the areas of physician quality of care and educational needs at any age. But the meeting focused on the measurement of aging, the various components of aging available to derive the most complete and valid picture of the aging physician. For example, Dilip Jeste, MD (SDCMS-CMA member since 2011), distinguished professor of psychiatry and neurosciences at UC San Diego Health System, presented the topic of “healthful” aging and strategies to improve the likelihood of successful aging in the physician population. He described current definitions of successful aging that include the concepts of wisdom, social cognition, and optimal decision-making, areas beyond general physical and mental health. He provided scientific data that demonstrated the neuroplasticity of the human brain, and gave evidence-based strategies for increasing the likelihood of aging successfully for all of us.

Another perspective was presented by William Perry, PhD, associate director of the neuropsychiatry and behavioral medicine service at UC San Diego Health System. He presented neuropsychological research linking aging to cognitive changes, and explored the link between cognition and occupational performance in physicians. Of great interest was his discussion of a well-supported theory that many older physicians draw from “crystallized knowledge” and rely more heavily on non-analytic cognitive processes in their clinical practice. Additionally, he explained the distinction between a neuropsychodiagnostic assessment and a fitness for duty evaluation, such as is offered at the PACE Program. He ended on a bright note by introducing the idea that doctors can accommodate to cognitive decline and how they can mitigate against the results of aging.

Stephen Miller, MD (retired SDCMS-CMA member), UC San Diego Health System clinical professor of plastic surgery and faculty in the PACE Program, showed the need for regular evaluations of clinical skills in the medical profession by comparing the aviation and medical fields, showing the differences between the regulatory standards for each. Besides describing areas where clinical competency would be beneficial, he noted that physicians endorse the old tenet of the profession that would require reporting an impaired colleague, but few have actually done so when it would have been appropriate. Dr. Miller ended by making a case for regular evaluations of mental and physical health throughout a physician’s life cycle, and suggested other important ways to ensure competency for physicians of all ages.

Finally Andre Jacques, MD, director of the Medical College of Quebec, and William McCauley, MD, president of CPE, described the differences in testing and treatment utilized in Quebec and Ontario, Canada, where systems are in place to assess all physicians as they age. This testing is run by the physician boards of each province, not by external sources as in the United States.

“Practicing Medicine Longer” is an eye-opening lesson in the close relationship between the individual physician’s abilities and quality of care. Many aspects of this ever-widening subject were presented by world experts with convincing data and conclusions. There was an optimistic air throughout because of the quality of the work presented and the many intriguing and achievable solutions. Physicians should be individually evaluated regularly and educated to remain in practice as long as safely possible.

Acknowledgements: I am especially appreciative of the contributions of all the speakers, but I would like to recognize Dr. William Norcross and Dr. David Bazzo for their leadership in this exciting expansion of a field of medicine invaluable yet intimidating to physicians, and inseparable from dedication to high quality of care of the profession. For their help in educating me and guiding my writing, I am very grateful.