Last week, I was watching the second of the televised Democratic presidential candidate debates with my father-in-law. The exchange between Congressman Swalwell and Vice President Biden generated a good conversation between me and my father-in-law. I was somewhat disappointed by the cheap jab made by Swalwell at Biden but it did raise the important question of when experience and wisdom cross over into decline that could create challenges and even danger in a demanding job like President of the United States.
In fact several of the top tier candidates as well as our current President are 70 years old and above. It’s hard work being the leader of the free world and national or international disasters that require urgent attention do not keep “banker’s hours”. Conversely, youth which does come with energy and new ideas (“rookie smarts) also has its drawbacks. We are all continuous learners in the school of life and those accumulated experiences help us tackle current and future challenges that a more youthful person may never have encountered. Mentorship can help address some of those gaps but in a job like President of the United States, the ultimate decision must be made by the person who was elected to that office or risk undermining the integrity of the position.
There is of course, no easy answer to this question and ultimately it will be up to voters to decide how young is too young or how old is too old to be the leader of the free world. However, this issue did hit close to home.
Many organizations are struggling with how to manage aging physicians. While the electronic medical record forced many doctors into early retirement, the current demographics of physicians approximate that of the general population and there are plenty of doctors who are still practicing well into their 70s and occasional 80s. I don’t need to go into too much detail here because a number of media organizations have written on this subject. Yet despite public awareness and acknowledgement by both health systems and professional organizations, this issue has been difficult to address.
Like President, experience means something no matter what type of specialty we practice. Sure, there is an added dimension of physical ability for surgeons and proceduralists but often the medical decision making prior to an intervention influences outcomes more than the technical aspects. And experience can often outweigh slight technical declines. The role of surgical volume on outcomes is well established. The ability through experience to anticipate problems and avoid or mitigate them wins out over the technical ability to correct an error when it happens.
But aging has its drawbacks and medicine can be physically and mentally demanding. Long days, being woken up in the middle of the night on call, medical conditions and medications can impact anyone’s ability to perform but for a doctor, these can become life or death factors for a patient.
We have an adequate mechanism by which young doctors gain expertise and experience. Sure the process is long- medical school followed by residency training and often fellowship. This often can occupy a decade of a young person’s life. Of course, safeguards remain in place once a doctor completes their training in many circumstances. While there is much to criticize about specialty boards, they do create some type of baseline that physicians must cross in terms of medical knowledge to be recognized by their specialty. And formally or informally, most practices do have focused professional practice evaluation (FPPE) for new colleagues that often includes case review, assisting with care or surgeries, and tracking of outcomes. I was supported in this way when I completed my fellowship by my senior partners and I continue to do the same now after 12 years with my new partners assisting them with surgeries, reviewing cases, and helping them hone their skills and expertise. They get my accumulated experience and I, in return, get exposed to new ideas and techniques that prevent me from becoming a dinosaur.
But we are failing on the other side of the spectrum. As an Associate Chief of Staff for my Health System, I am called upon to lead peer reviews when faculty are found to have quality or behavioral gaps that impact patient care. These cases escalate to us from Departments when local processes are not working, from staff or other colleagues that raise concern, from patients, or from internal and external reports of patient risk.
While not all of these involve older physicians, my sense is that we are in the midst of period where we are going to be forced to develop a systematic approach to help physicians more as they evolve through their career. In truth, we are all aging physicians and if we could develop a just and kind solution to a problem that currently creates distress to colleagues who have dedicated their lives to caring for others, it would help all of us in the future. It’s easy to say that we’ll know when to stop practicing but the reality is that many of us continue to practice beyond our shelf life because we don’t know a better way to spend our time, have continue financial commitments that prevent us from retiring, or simply still find joy in what we do. Because of these factors, it is incumbent upon all of us to develop a pathway that can be used as people enter the later part of their career.
This challenge is not only due to demographics and aging. In fact, I believe a major contributor is related to the increased expectations for performance (RVUs) and the associated scrutiny that comes with expecting all of us to increase our clinical activity. Couple this with the era of increased metrics and data and we have created a recipe for disaster for our more senior colleagues. It’s funny because I used to see medicine as a pyramid scheme. Senior partners or faculty could slow down and still accumulate a healthy income while new hires and junior members of the group would “hump” it indirectly paying for their more senior partners. This worked only if those at the bottom of the food chain were able to make their way to the top. All that is gone now and while it might seem fair to expect everyone to pull their weight and cover their salary, it has left us with the unintended consequence of expecting senior faculty and partners to function at a pace that they are no longer used to maintain their income. This risks patient harm and quality concerns. Ongoing professional practice evaluation (OPPE) is, of course, designed to spot outliers and trends in physician practice. The problem is that often the data we collect has a greater emphasis on process which is easier to collect than actual outcomes that matter to us and our patients. When we get a real outlier signal, it is likely that we are already too late in protecting our colleagues from error and patients from harm. We need to be able to see the signal in real-time and react before it’s too late.
Another cause of the current aging physician challenge is a change in culture. Increased transparency is leading patients to expect better outcomes and health systems are responding by focusing on safety and quality. Whether in the form of process improvement, high reliability, or another management tool, those who deliver health care are being held to a higher standards. This has the effect of breaking down the “old guard” mentality that might protect a physician of inferior quality or dwindling function from scrutiny. No longer can someone slide by with bad outcomes just because they have been at an institution “forever” or the Dean, CEO, or other health system leader thinks they’re a good “guy” because their kids went to school together or they socialize outside of work. While this cultural shift is long overdue, it again comes with secondary consequences that some of our senior colleagues are not equipped to handle. Judging someone’s career on today’s standards lacks nuance and risks devaluing the many contributions of a person that made our current care possible.
Current solutions have been met with resistance. Some health systems have tried to implement cognitive and medical evaluations starting at a particular age. Identifying a medical or mental health issue that can be improved is a critical part of peer review and providing our colleagues with respect and due process. For example if someone has sleep apnea and a CPAP helps with their memory and function, then this allows someone to continue practice. Additionally, identifying substance abuse or disability gives us a chance to return a colleague to well being.
The problem is that current efforts and tools are imperfect. Neuro-psych testing often fails to identify a problem in a doctor who performs better than the standard population even if there is decline. In addition, standard medical evaluation is not sophisticated enough to reliably isolate impairment that can impact performance. While more robust evaluation tools exist for physicians, these are often very costly, require specific expertise and as such can not be used as a tool for all aging physicians.
The biggest barrier to the recognition of decline is often the physician themself. Often, doctors come to the attention of health systems due to a lack of insight into how they are physically/mentally changing and how that impacts their performance. Instead, they choose to see themselves as their best selves when they were at the top of their game even if that was 20 years ago.
But data is hard to ignore and we are fortunate to live in an era where data could give us a proactive mechanism to help provide guidance as we all age in our careers. This might have more of a slant toward surgeons or proceduralists but I believe that with some minor adjustments, it could be applied to doctors of any specialty.
First, we can use administrative data such as Commercial or public claims data to compare an individual physician to their colleagues. In particular, for surgeons, looking at volume, readmission, and morbidity/mortality could be used to help a surgeon with insight into their own practice compared to others. We are fortunate at Michigan Medicine because we participate in a number of continuous quality improvement collaboratives with Blue Cross Blue Shield of Michigan that provide real time data on outcomes that are fed back, adjusted and compared to peers. While the intention is for improvement, this data could also be used to identify gradual decline which could be used to adjust an individuals practice before quality or safety are compromised.
In addition, other data can be used to help identify a career roadmap as a physician in a particular specialty ages. While recertification and MOC have become dirty words, most specialties require case logs be submitted to allow someone to sit for a recertification exam. These logs could be reviewed and aggregated harnessing the “wisdom of the crowds” to understand what cases are being performed and at what volume in someone’s 1st, 2nd, and 3rd decades of practice. Sure it would need to be adjusted by subspecialty and other practice factors but the data could provide individual guidance about when to stop particular aspects of a practice. Similarly, many specialty societies now collect census data on their members and this could add granularity to when certain procedures fade out of a clinicians practice. It can also offer insight into what other peers start to do as they evolve in their career ( more office based procedures, for example). Together, these sources of data could be used to help a physician as they consider how to evolve their career over its lifetime.
Of course, this concept would need to be tested to understand its value but it presents the aging physician ( which is all of us) with a mix of objective data and peer comparison that would be hard to ignore even for those who lack the insight to know when to stop doing certain things. While more difficult to implement for more cognitive specialties, even starting with surgeons could help our colleagues maintain dignity throughout their career and protect patients.
Using age alone to determine fitness for duty is discrimination whether someone is running for President or caring for patients. While voters can decide the issue of the age for our highest office, we can’t put everyone’s retirement up for a vote. The ability to evolve in our careers, shift focus from more physically/mentally demanding tasks to other non-direct clinical activities and more straightforward clinical activities means that we can be useful for sometimes longer than in other careers. However, our personal interest and ego must never supersede the interests of our patients and thoughtful application of existing data can help.