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What’s New in the Patient Safety World

February 2020

The Older Physician: A Practical Approach?

 

 

No organization or individual wants to be accused of age discrimination. Yet, we have an obligation to our patients to police ourselves and ensure the competency of our clinicians to provide safe and effective care. The reality is that the incidence of both dementia and mild cognitive impairment (MCI) increase substantially after the age of 65. Prevalence rates for mild cognitive impairment and dementia in those ≥65 years old in the general population have been estimated to be up to 20% and 13%, respectively. While we know of no study that looked at such rates in the physician population, there is no reason to suspect that the rates in physicians differ from that of the general population. And the physician population over the age of 65 continues to increase.

 

In 2 of our previous columns we discussed some approaches to the issue of how to deal with the issue of credentialing and privileging of older physicians (see our Patient Safety Tips of the Week for July 7, 2015 “Medical Staff Risk Issues” and May 28, 2019 “The Older Physician”).

 

Recently, Yale New Haven Hospital developed a very practical process for dealing with this issue (Cooney 2020). In their process, physicians age 70 and older undergo a screening cognitive test developed by a neuropsychologist. The Cooney paper does not publish the actual test, noting that the test questions remain confidential so that prospective test takers cannot practice for it. But the article describes the general content of the test.

 

The screening battery used consisted of 16 brief tests including rudimentary information processing (2 tests), visual scanning and psychomotor efficiency (2 tests), processing speed and accuracy under decision load (1 test), concentration and working memory (1 test), visual analysis and reasoning (2 tests), verbal fluency (2 tests), memory (1 visual test and 1 verbal test), “prefrontal” self-regulation (1 test), and executive functioning (3 tests).

 

A Medical Staff Review Committee (MSRC) consisting of the previous and current chief medical officers of the hospital, a faculty geriatrician, and the neuropsychologist performing the examinations, review the results of this testing and make recommendations to the medical staff’s credentialing committee. Where concerns were raised, the committee reviews the case with the section chief or departmental chair. This review outlines the scope of the clinician’s practice and any concerns that his or her supervisor had about the candidate’s capabilities.

 

Practitioners with global scores considered within normal limits are allowed to proceed with the regular medical credentialing process. Those individuals are to be rescreened at subsequent recredentialing at 2-year intervals. Practitioners with somewhat lower global scores or who demonstrated relative weakness but not deficits in 1 or 2 abilities proceed with the credentialing process but are scheduled for rescreening in 1 year. Practitioners whose profiles indicate some weaknesses with possible implications for unsafe practices are requested to undergo a comprehensive neuropsychological examination, which involves an in-depth assessment of intellectual, memory, and executive function.

 

If, at the end of the review, the committee decides that an individual did not have adequate cognitive abilities to practice medicine, the chief medical officer, often with the assistance of another committee member, meets with the clinician to discuss options, including working in a highly structured proctored clinical environment or retirement from clinical practice. These individuals are offered assistance in evaluating medical conditions that may have contributed to their poor examination performance.

 

The Cooney paper described the results of the new process on a total of 141 clinicians aged 70 years or older. 88.7% were physicians, and the remainder included advanced practice registered nurses, dentists, psychologists, podiatrists, physician associates, and a midwife. 57.4% completed the screening test requirements and proceeded with the regular credentialing process. They were to be retested at 2 years at the time of the regular reappointment cycle. 24.1% proceeded with the credentialing process but were scheduled for rescreening in 1 year because of minor abnormalities on the screening test results. 5% had limitations in domains such as memory, executive function, processing speed, or constructional skills that could impair their capacity to practice medicine. These clinicians were asked to undergo a comprehensive assessment. At the completion of this assessment, 4 of the individuals were determined to be capable of continuing with the recredentialing process. Three clinicians were determined to have significant problems and either retired or resigned from the active medical staff.

 

Nineteen clinicians (13.4%) were identified as performing substantially less well than their colleagues on the global score of the screening neuropsychological assessment. Twelve of these had such substantial problems on their screening tests that discussions were undertaken with these clinicians to determine how to address these problems. Following those discussions, these clinicians either entered a proctored setting for their practice or retired from medical practice. The other 7 of these 19 clinicians were asked to undergo a full neuropsychological evaluation. At the conclusion of these tests, 4 individuals were allowed to proceed with the recredentialing process and 3 individuals were asked to limit their practice or retire.

 

After completion of screening and/or full neuropsychological testing, the MSRC determined that 18 clinicians (12.7%) demonstrated cognitive deficits that were likely to impair their ability to practice medicine independently. Of interest, none of these 18 clinicians had previously been brought to the attention of medical staff leadership because of performance problems. These 18 clinicians elected to discontinue their practice or moved into a closely proctored environment. All of these practitioners agreed to make changes in their practice voluntarily.

 

Two editorials accompanying the Cooney paper (Saver 2020, Armstrong 2020) describe programs utilized at some other organizations and discuss the many challenges in addressing the problem.

 

Of particular concern, but not surprising to us, was the fact that none of the 18 clinicians in the Yale New Haven experience who had cognitive deficits likely to impair their ability to practice independently had previously been brought to the attention of medical staff leadership because of performance problems. In our two previous columns dealing with the aging physician we described some of the barriers to raising concerns. The physician is often a very well liked and respected physician who has practiced at the hospital and community for many years. But he/she may not be aware of any decline and everyone is afraid to confront him/her about it. Most of his/her patients still love him/her and the board members are his/her friends or have long interacted with him/her in community activities. You may hear whispers amongst staff about their concerns regarding this physician. They all know that sooner or later he/she is going to do something that might result in patient harm. But they are not willing to come forward with specific examples. Medical directors and medical executive committees are often handcuffed when no one is willing to formally come forward with negative information on such physicians. Having a formal process, such as the Yale New Haven one, is one way to bring problems forward without appearing discriminatory toward any one clinician.

 

We think the process developed at Yale New Haven is both practical and considerate of the individual’s status. It adds an element of objectivity to processes that have often been purely subjective in the past. It can serve as a model to replicate in your organizations.

 

 

Our prior columns dealing with the issue of the aging physician:

 

 

 

References:

 

 

Cooney L, Balcezak T. Cognitive Testing of Older Clinicians Prior to Recredentialing. JAMA 2020; 323(2): 179-180

https://jamanetwork.com/journals/jama/article-abstract/2758602

 

 

Armstrong KA, Reynolds EE. Opportunities and Challenges in Valuing and Evaluating Aging Physicians. JAMA 2020; 323(2): 125-126

https://jamanetwork.com/journals/jama/article-abstract/2758580

 

 

Saver JL. Best Practices in Assessing Aging Physicians for Professional Competency. JAMA 2020; 323(2): 127-129

https://jamanetwork.com/journals/jama/article-abstract/2758581

 

 

 

 

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