A distinguished vascular specialist in his 80s performs surgery, then goes on vacation, forgetting he has patients in the hospital; one subsequently dies because no doctor was overseeing his care. An internist who suffered a stroke gets lost going from one exam room to another in his own office. A beloved general surgeon with Alzheimer's disease continues to assist in operations because hospital officials don't have the heart to tell him to retire.
About 42 percent of the nation's 1 million physicians are older than 55 and 21 percent are older than 65, according to the American Medical Association, up from 35 percent and 18 percent, respectively, in 2006. Their ranks are expected to increase as many work past the traditional retirement age of 65, for reasons both personal and financial.
Many older doctors remain sharp, their skills up-to-date and their judgment honed by years of experience. Peter Carmel, the AMA's immediate past president, a 75-year-old pediatric neurosurgeon in New Jersey, recently wrote about "going full tilt."
Unlike commercial airline pilots, who by law must undergo regular health screenings starting at age 40 and must retire at 65 – or FBI agents, whose mandatory retirement age is 57 – there are no such rules for doctors. Nor are any formal evaluations required to ensure the continued competence of physicians, many of whom trained decades ago. Most states require continuing education credits to retain a medical license, but, as Ann Weinacker, chief of the medical staff at Stanford Hospital and Clinics in California, observed, "you can sleep through a session, and if you sign your name, you'll get credit."
"The public thinks that physicians' health and competence is being vigorously monitored and assessed. It isn't," said geriatrician William Norcross, 64, founding director of a program at the University of California at San Diego that performs intensive competency evaluations of doctors referred by state medical boards or hospitals. The program – known as PACE, for Physician Assessment and Clinical Education – is one of about 10 around the country.
Norcross, who evaluates 100 to 150 physicians annually, estimates that about 8,000 doctors with full-blown dementia are practicing medicine. (Between 3 and 11 percent of Americans older than 65 have dementia.) Studies have found, Norcross noted, that approximately one-third of doctors don't even have a personal physician, who might be on the lookout for deteriorating hearing, vision or motor coordination, or the cognitive impairment that precedes dementia.
WHAT HAPPENS TO SKILLS OVER TIME?
"Doctors are not immune to the effects of aging," Norcross said, adding that the onset of dementia is often insidious and gradual. Too often, he said, health problems become impossible to ignore after a catastrophic event, such as the death of a patient. "Doctors with cognitive and neurological problems almost never have insight into their problems," he said, and many deny that anything is wrong.
While few experts would argue that age alone should control who can continue to practice, some studies suggest that doctors' skills tend to deteriorate over time. A 2006 report found that patient mortality in complex operations was higher among surgeons older than 60 than among their younger colleagues.
To address the problem in a systematic way, a small but growing number of hospitals, including the University of Virginia Health System, Stanford Hospital and Clinics, and Driscoll Children's Hospital in Corpus Christi, Texas, have recently adopted policies requiring doctors over a certain age – 70 at U-Va. and Driscoll, 75 at Stanford – to undergo periodic physical and cognitive exams as a condition of renewing their privileges.
Diane Pinakiewicz, former president of the National Patient Safety Foundation, a Boston-based information and advocacy group, calls the policies "a fabulous idea" that is long overdue. "Without a rule, it's left to someone's personal decision" to self-monitor.
New Hampshire health-care consultant Jonathan Burroughs, who has worked with hospitals seeking to implement testing policies for older physicians, estimates that roughly 5 to 10 percent of institutions have adopted them and that interest is growing.
"Colleagues have a code of silence," said Burroughs, who spent 30 years as an emergency department physician. During his career, Burroughs said he followed several elderly doctors around, quietly correcting their orders to prevent mistakes. Such experiences, he said, are nearly universal in medicine. "Most medical staffs look the other way, thinking, 'There but for the grace of God.' This person has been a good doctor, and we're not going to betray them," Burroughs said.
But that kindness can backfire, he added, subjecting patients to potentially disastrous consequences such as serious injury or death, and the faltering physician to a malpractice suit or the loss of a medical license. John Schorling, a professor of medicine who heads U-Va.'s Physician Wellness Program, said the policy adopted last year was prompted by "general concerns" about patient safety and is modeled on aviation industry practices. "Pilots have people's lives in their hands, and so do doctors," he said.
'FRED FLINTSTONE' CARE
But some hospital administrators dispute the need for such testing. Fitness to practice, they maintain, is already paramount in decisions that hospitals make every two years or so to renew a physician's privileges. And that process, they say, has gotten more stringent in the past decade with the proliferation of performance data on doctors.