The aging physician: Balancing safety, respect, and dignity

Physicians often enter their 60s practicing medicine full time, but as they inch their way toward 70, many start making significant adjustments to their schedules and scope of practice. Most of us acknowledge the affect aging has on our cognitive and motor skills, with the help of some not-so-subtle hints from our colleagues and loved ones. For some, it’s no big deal—there are so many ways to earn a livelihood inside and outside the healthcare profession that it seems fruitless to hold onto things that may no longer fit our professional goals, such as inpatient privileges. They gladly move into the ambulatory setting and are often relieved to enter a different phase of their professional lives. For others, however, this transition is not easy, and it may require the guidance and support of peers. For this reason, it is important for medical staff leaders to understand how to support and respect long serving colleagues while ensuring that patients are not inadvertently placed in jeopardy.

When I entered the practice of emergency medicine 30 years ago, there were always one or two physicians in their 80s who refused to give up their practices. More than once, I followed a physician suffering from dementia on his or her on rounds to discretely modify orders at the request and relief of the nursing staff. Some of the orders required minimal modification and some were lethal doses of inappropriate agents that the nursing staff had no intent of carrying out. This was our tradition—to support our loyal colleagues who had served their communities for decades, despite that we all knew this was not the right thing to do.

Flash forward to 1990 when the American with Disabilities Act was passed. The act serves two purposes: it protects the rights of disabled individuals to work with a “reasonable accommodation” (if feasible and not a burden to an organization) and it obligates organizations to address potential impairment. As a result, older practitioners became subject to ad hoc investigations if their clinical performance indicated a potential impairment or inability to exercise their requested clinical privileges. Medical staffs watched vigilantly for signs that physicians’ clinical performance may not meet professional expectations and dealt with issues retrospectively based on less–than-adequate quality outcomes.

Today, medical staffs are looking for a more constructive and proactive approach to assessing aging practitioners in a manner that balances patient safety with the rights and dignity of our loyal colleagues. The following represents a contemporary approach that I hope you will consider:

1. Draft a policy and procedure that addresses aging practitioners in a constructive and proactive way. The airline industry has done this for years by requiring aging pilots to participate in simulation exercises every six months and creating a mandatory retirement age (65).
2. Choose an age (e.g., 70) at which the medical staff will begin to more closely monitor a physician’s performance. This may include decreasing the reappointment period from two years to one year and requiring a more detailed evaluation of a practitioners “capacity to practice” and ability to safely exercise their requested clinical privileges.
3. Request a fitness for work evaluation. This evaluation is not a history and physical, but rather a vocational examination based on requested privileges. It should be performed by an individual who is familiar with the clinical privileges related to that specialty and who is directly accountable to the medical executive and credentials Committee. The hospital may need to pay for this evaluation.
4. Create co-management privileges to enable physicians to make a dignified transition from independent privileges to refer-and-follow privileges (ambulatory-based privileges that allow physicians to refer patients to the hospital, order ancillary studies from an outpatient setting, and follow their patients in the hospital.)
   5. Require mandatory refer-and-follow privileges at a pre-determined age (e.g., 85) unless waived by the MEC and governing board in extraordinary situations.

Our older colleagues deserve to be treated with dignity. The above approach does so while enabling medical staff leaders to assure the governing board that both physicians and the patients they treat will be respected and protected from potential harm. This is a better approach than the damage control of yesteryear or the “bad apples” impairment evaluation approach that is used by many medical staffs today.

I hope that this article stimulates a thoughtful discussion at your next medical staff meeting. Please contact me at jburroughs@greeley.com or any member of the Greeley Company if you would like an example of an aging physician policy and procedure.

Jon Burroughs, MD, MBA, CMSL is a senior consultant with The Greeley Company, a division of HCPro, Inc. in Marblehead, MA.