The Quandary of Competency Testing for Senior Doctors

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The term test, in and of itself, invokes a sense of dread as it produces memories of sitting for exams that seemed to have no end. The word can imply a certain starkness in definition such as passing or failing, excellent or poor. That word can conjure up a mixture of emotions that may invoke negative visceral responses in many, but here I am referencing physicians in particular.

At the American Medical Association s (AMA) annual meeting this year, officials based their decision to develop competency guidelines for aging physicians on results from a study that specifically dealt with the issue of effectiveness.

This is a hot button topic, not only due to the vociferous opposition or advocacy for further testing, but also because about a quarter of all physicians (240,000) are baby-boomers aged 65 or older, a four-fold increase from 1975. In 2010, there were 64,000 licensed physicians in their 70 s. Guidelines that make competency testing mandatory will impact a significant number of doctors, and perhaps also contribute to a looming physician shortage.

For many doctors, this is a very emotional and sensitive topic to broach, considering their very identity depends on their profession. When most of the waking hours are spent in a hospital (or clinic) requiring significant personal sacrifices, their job becomes what they know. It would be difficult to not identify that way, thus making it particularly challenging to walk away, especially if that decision is being made for them.

Implementing guidelines comes with its own set of quandaries. At what age would it be appropriate to initiate age-based screening? What test will be used to assess cognition? How can you effectively test surgical skills? How expensive will this be to implement? Who should bear the burden of cost?

Most hospitals that have enacted their own age-based testing policies have recommended 70 as the cutoff. In California, a coalition called the California Public Protection and Physician Health, issued a guideline that called for assessments to include physical exams, peer assessments and a test of cognitive functions. Testing cognitive function becomes problematic because, there are insufficient data at present to support cognitive screening of late-career physicians, according to Ann Weinacker, MD, a Stanford Medical Center quality improvement expert.

Mark R. Katlic, MD, chief of surgery at Sinai Hospital in Baltimore, has developed a program that tests surgical skills and perceptual testing. Its major drawback is that it costs $17,000 for two days of physical and cognitive testing. Mandating requirements could subject physicians to continued fleecing by programs that offer skills testing. These tests may be valid, however, they are costly and no sufficient data exist to support their use.

Jonathan Burroughs, MD, a healthcare consultant in Maryland, believes the test should be performed by a vocational specialist, in a manner similar to assessments of airline pilots, and evaluations should cover cognitive, metabolic, psychological, and physical domains. He estimates that the initial cost would be about $300 - $500 and that hospitals should cover it. And when "impaired" physicians are identified, steps would then be taken, such as recommending they not take an overnight call, reducing hours spent in surgery, or not working long shifts.

At Stanford, and at the College of Physicians and Surgeons of Ontario, the requirements are peer based. Who better to evaluate a physician other than people who know and work with them? Some physicians prefer peer-based assessments, and are reluctant to take cognitive tests. Some of these tests have been able to determine that 80 percent of physicians with mild cognitive impairment will develop dementia within six years. That can trigger anxiety in a population of people that are already contending with the shame of aging.

Clearly, this is delicate issue. To impose another hoop for physicians to jump through in order to maintain their credibility seems excessive. It can be humiliating to some degree to be scrutinized, and be made to have a sense of deficiency simply because of age. While it may seem insensitive, another important factor, of course, is that physicians treat people. When each took their oath, doctors vowed to do right by their patients. Ultimately, patient safety must come first -- do no harm.