key: cord-0981813-z8lnfqpd
authors: Khine, Albert H.
title: Evaluating the toll for elderly physicians
date: 2020-07-16
journal: Am J Med
DOI: 10.1016/j.amjmed.2020.06.016
sha: 590f6fc6962a399d0ea10a5311bcd135b458d3a8
doc_id: 981813
cord_uid: z8lnfqpd

nan

I knew Mike before he was bald. Mike was the gynecologist in my multi-specialty group with glaring white hair and a soft gravel voice. Though 30 years my senior, he stayed in better shape than I had at any age.

He often strode into the office accoutered in neon bib shorts, after a weekend of cycling even more miles than his normal bike commute. When I first saw him without hair a couple years ago, he was quick to reassure me it was by his choice. "It is the best thing I've done," he proclaimed. Whether that meant not fiddling with thinning hair or getting a better aerodynamic fit under his helmet, I didn't know. His characteristic unbridled enthusiasm was proof enough.

When Mike turned 70, he was asked to leave our practice. It was not due to poor patient care or personal conflicts. Section II, paragraph 1 of our partner agreement mandated resignation at that age. Once he reached that milestone, he didn't readily leave his patients and practice of almost 20 years. He sensed his competence unchanged from a few years earlier when he was voted one of the top gynecologists in the city.

Like the populace at large, American doctors are getting older. They are healthier and staying active longer than in previous generations. About 15% of the physician workforce is over 65. When this contract was written decades ago, someone foresaw the aging physician as a liability. They knew an older mind has slower reaction times and assumed it would be one with higher mistake rates.

Outcome data comparing whippersnappers to old hands, however, is inconclusive. In one study of hospital patients, 30-day mortality was highest among patients treated by physicians aged 60 and above.

In closer analysis, experience appeared more important. Older doctors with high level of admissions procured the same patient mortality rates as their younger equivalents. Physicians under age 40 with a low volume of admissions had worse outcomes than elderly doctors with even a median level of admissions. (1) "Older" is arbitrary and has been defined anywhere from >55 to >75 years old. My father, Henry, recently retired from anesthesiology while in his 80s. He could have been deemed "old" 30 years ago. As a doctor, he saw the birth of CT scans, HIV, HMOs, EMRs and Covid-19. His hospital staff knew him as the go-to doctor to get a difficult IV start, not only because of years of practice, but because newer doctors If neurologic testing is a proven barometer for outcomes, then it should be used broadly at all ages.

There are hundreds of factors that might effect neurologic testing and medical competency. Doctors with depression, at risk for psychomotor slowing, may need assessment. Physicians who are parents of newborns are typically sleep-deprived and may test lower than their peers.

As opposed to most other fields, physicians have a system that evaluates competence for all-comers. We have regular board examinations and maintenance of certification programs. These tests are a source of ire due to cost, stress and productivity loss. These burdens are doubled if cognitive testing is added separately. At Yale, beyond the first round of tests, 60 of the providers (43.6%) did not pass without impediment. These physicians had to undergo additional testing and/or evaluations with the Medical Executive Committee. If cognitive testing has a place, it should be incorporated into medicine's established ordeals of accreditation.

The main tenet inherited from Hippocrates is to do no harm. To do this, we need good data to assess if patients will benefit from any intervention. Unfocused and unproven neurologic testing not only harms the accused providers, but all the patients that may have benefited from their care.

If we cut short the careers of enduring physicians, we ignore valuable information about the practice of medicine. Reports of physician burnout are rampant in professional and academic articles. Little has been published about the counterpoint to that phenomenon, doctors like my father that stayed everlasting flames. What makes those men and women different? Perhaps they represent a different reaction to burnout, when their occupation consumes their identity completely, making retirement unthinkable. Or maybe they represent a different era that emphasized grit and stability over ingenuity and lifestyle.

Understanding the people that can metabolize the vicissitudes of the medical profession can shed light on those that succumb.

There is much to learn from and about our predecessors. At age 70, my colleague Mike had enough chutzpah to start his own independent practice. My partnership later unanimously ratified a new contract that eliminated the age mandate. Before any notion of primum non nocere, the first vow of the Hippocratic oath is to respect our teachers and to hold them with as much regard as our parents. My father Henry feels we should treat them even better, and treat them with the same compassion and academic rigor that we use with our patients. In both ancient Greece and modern times, how we treat our elderly colleagues is fundamental to the art of medicine.

Physician age and outcomes in elderly patients in hospital in the US: observational study

Cognitive testing of older clinicians prior to recredentialing