Credentialing the aging practitioner
Last week, I was asked to assist a medical staff in addressing resistance to its recently adopted policy on reappointing aging practitioners. I offered to meet with any physicians concerned about the new policy, and a number of physicians signed up to meet with me. As we assembled for the meeting, a stooped, white haired gentleman approached me and, in a loud voice, asked, “Would you mind terribly putting this around your neck when you talk?! I’m a bit hard of hearing, and this gadget will feed your voice directly into my hearing aids!” Somehow, it felt like the perfect way to kick off this meeting.
As I looked around the room, I that noted almost all the participants met my idea of the aging practitioner. (I have to be careful about this because I am now 57, and every year my cutoff point for who qualifies as an aging practitioner gets a little older.) Later, I confirmed that all the participants who were not medical executive committee members were 70 years or older.
I opened the meeting by asking why they were concerned about the aging practitioner policy. For years, this medical staff had required a physical examination at reappointment for all physicians regardless of age because the state Department of Public Health required them to do so. The medical staff’s new policy had added to this requirement a mandatory mini mental status examination by a physician approved for this purpose by the credentials committee. If the physician wanted this examination paid for by the hospital, this meant undergoing an examination by a neurologist who had agreed to provide this service. The neurologist’s mini mental status examination was required at biannual reappointment beginning at age 70 and annually starting at age 75.
Some of the physicians expressed in the strongest of words that they felt this requirement was disrespectful and discriminatory, and they threatened to sue the hospital for age discrimination. Some said the peer review program should be adequate to determine whether they were practicing at the generally recognized standard of care. If the peer review program found no problem with their performance, what right did the medical staff have to impose this policy that treated them differently than their peers? Others argued that physicians should be the judge of when they should retire and that the policy wrongly implied that physicians would not themselves recognize when it was time to retire. The physicians made yet another argument that the mini mental status examination provided only an insensitive screening for dementia and was the wrong procedure for a fit-for-duty assessment for most physicians.
Some physicians were not afraid to raise their indignant voices, but for the most part, the meeting participants engaged in a thoughtful discussion of their key concerns. Eventually, they agreed the peer review program was a relatively insensitive tool for detecting a practitioner’s medical conditions that might place patients at risk. Examples of high-profile athletes who had played beyond when they should have retired, embarrassing themselves and hurting their teams, provided enough evidence that some physicians were at risk of doing the same.
When the group began discussing the validity of the mini mental status exam, one participant helpfully suggested that all of the identified concerns could be parsed into two categories. One category involves the principle of whether it is right to treat physicians above a particular age differently at reappointment than younger physicians. Eventually, everyone agreed that the likelihood of a medical condition that might adversely affect a physician’s capacity to carry out his or her privileges between the ages of 95 and 97 is higher than between 45 and 47. The same held true for between 85 and 87, to a lesser extent for between 75 and 77, and to a still lesser extent between 65 and 67. Once the group agreed to this idea, it became clear that if the hospital and medical staff are to fulfill their duty to only grant privileges to practitioners who are both competent to and capable of carrying out those privileges, then at some age, it is appropriate to treat older physicians differently at reappointment than younger ones. The moment the group reached consensus on this point, most of the heat went out of the argument. With the contention out of the air, the group acknowledged the second category of concerns, which involved how to design and implement the treatment older physicians would receive. Parsing the issues into these two categories allowed for legitimate disagreement regarding the sensitivity or effectiveness of the mini mental status examination as a screening tool, the appropriate age at which to initiate a higher level of medical assessment at reappointment and how best to establish which physician(s) should be authorized to perform the fit-for-duty assessment.
By the end of the meeting, the group had made progress. The physicians summarized their concerns regarding the “how” of the policy and passed that summary on to the credentials committee and medical executive committee so that the policy might be tweaked to be more fair and effective. Although they shared these concerns, the group had come to agreement on the principle that it was fair and appropriate to conduct some additional fit-for-duty assessment linked to privileges requested at some age.
As the meeting broke up and the white haired gentleman approached me to collect his hearing apparatus, I inquired about his specialty. “Internal medicine and rheumatology,” came the loud reply. Curiosity got the best of me, and I couldn’t resist asking his age. “I’m 90 years old and practice three days a week!”
“That’s a personal record for me,” I replied. His hunched frame straightened a little as he beamed a dentured smile at me. I walked away grateful that the medical staff had adopted an aging practitioner policy.
Richard A. Sheff, MD, CMSL, is chair and executive director of The Greeley Company, a division of HCPro, Inc., in Danvers, MA.