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ΕίσοδοςAbout eight years ago, at the age of 78, a vascular surgeon in California operated on a woman who then developed a pulmonary embolism. The surgeon did not respond to urgent calls from the nurses, and the woman died.
Even after the hospital reported the doctor to the Medical Board of California, he continued to perform operations for four years until the board finally referred him for a competency assessment at the University of California, San Diego.
“We did a neuropsychological exam, and it was very abnormal,” said Dr. William Norcross, director of the physician assessment program there, who did not identify the surgeon. “This surgeon had visual-spatial abnormalities, could not do fine motor movements, could not retain information, and his verbal I.Q. was much lower than you’d expect.”
Yet “no one knew he had a cognitive deficit, and he did not think he had a problem,” Dr. Norcross continued. The surgeon was asked to surrender his medical license.
A fifth of the nation’s physicians are over 65, and that proportion is expected to rise. As doctors in the baby boom generation reach 65, many are under increasing financial pressures that make them reluctant to retire.
Many doctors, of course, retain their skills and sharpness of mind into their 70s and beyond. But physicians are hardly immune to dementia, Parkinson’s disease, stroke and other ills of aging. And some experts warn that there are too few safeguards to protect patients against those who should no longer be practicing. “My guess is that John Q. Public thinks there is some fail-safe mechanism to protect him from incompetent physicians,” Dr. Norcross said. “There is not.”
Often the mechanism does not kick in until a state medical board has found it necessary to discipline a physician. A 2005 study found that the rate of disciplinary action was 6.6 percent for doctors out of medical school 40 years, compared with 1.3 percent for those out only 10 years.
In 2006, a study found that in complicated operations, patients’ mortality rates were higher when the surgeon was 60 or older, though there was no difference between younger and older doctors in routine operations.
Patient advocates note that commercial pilots, who are also responsible for the safety of others, must retire at age 65 and must undergo physical and mental exams every six months starting at 40. Yet “the profession of medicine has never really had an organized way to measure physician competency,” said Diane Pinakiewicz, president of the nonprofit National Patient Safety Foundation. “We need to be systematically and comprehensively evaluating physicians on some sort of periodic basis.”
Some experts are calling for regular cognitive and physical screening once doctors reach 65 or 70, and a small cadre of hospitals have instituted screening for older physicians. Some specialty boards already require physicians to renew their certification every 7 to 10 years and have toughened recertification requirements. But such policies have met resistance from rank-and-file doctors.
“I do not believe that diminished competence attributable solely to age is a significant factor in the underperformance of most poor-performing physicians,” Dr. Henry Homburger, 64, professor of laboratory medicine at the Mayo Clinic, said by e-mail. Mental illness like depression, substance abuse and a “failure to maintain competence through continuing education far outweigh age as causes of poor performance, in my opinion,” he wrote.
Others doubt that a single type of exam can be used to assess the performance of doctors from a variety of specialties. “More research is needed for us to define what combination of cognitive and motor issues are important,” said Dr. Stuart Green, a member of the ethics committee of the American Academy of Orthopaedic Surgeons.
Physicians do have to meet minimal requirements to continue to practice. To renew a medical license in most states, doctors must complete a certain number of hours of continuing medical education every year or two.
This does not impress experts like Dr. Norcross. “You can be asleep during those courses and no one would know,” he said.
Even the tougher new policies of specialty boards do not usually apply to older physicians, who, because of “grandfather” clauses, are not required to renew their certification — an expensive, time-consuming process.
They are being encouraged to do so voluntarily, but few do — less than 1 percent of the 69,000 so-called grandfathered members of the American Board of Internal Medicine, for example.
Doctors with mild cognitive impairment may not be aware they have a problem or their performance is flagging. Changes are often subtle at first: a person may not be able to recall words, learn new material, apply knowledge to solving problems or multitask.
These deficits can make it hard to carry out the latest recommendations for diagnosis and treatment, learn new computer-based technology, remember prescribing details about medications, or function well in a stressful environment like the emergency room.
Only when a doctor’s behavior starts to become odd are other physicians, nurses and patients likely to take notice.
Medical professionals are supposed to report colleagues’ unsafe practices and bad behavior. But doctors are reluctant to confront their fellow physicians, especially their seniors, who may have trained them. “Sometimes we empathize too much and have difficulty making the hard calls when we need to,” Dr. Norcross said.
Doctors often cover for physicians who are becoming less sharp, by having another surgeon in the operating room or by regularly reviewing their cases, Dr. Green said.
Dr. John Fromson, associate director of postgraduate medical education at Massachusetts General Hospital, cited a case at another medical center in New England, where physicians noticed cognitive changes in the 77-year-old chairman of internal medicine.
He was highly respected and had trained most of the physicians at the center, so they were reluctant to confront him. Instead, they gave him a retirement party, hoping he would take the hint. “But he didn’t,” Dr. Fromson said. “He kept on working.”
Dr. Fromson staged an intervention, at which four or five of the doctor’s close colleagues confronted him as compassionately as they could. “We reaffirmed our concern and caring for him, and asked him to hand over his medical license,” he said. “He became quite tearful, but he did.”
To lift this burden from peers while protecting patients, 5 percent to 10 percent of hospitals around the country have begun to address the issue of aging physicians more systematically, said Dr. Jonathan Burroughs, a consultant with the Greeley Company, which advises hospitals and health care companies.
“The other 90 to 95 percent are not willing to take this on,” he said. In some instances, their efforts have been squashed by a vocal medical staff.
At Driscoll Children’s Hospital in Corpus Christi, Tex., Dr. Karl Serrao, the credentials chairman, decided to move slowly and enlisted the staff’s help in drafting a policy for aging physicians. The staff expressed concerns about age discrimination, losing the valuable experience of older physicians and invasion of privacy. Now the hospital’s policy states that when doctors 70 and older are up for reappointment, they must undergo cognitive and physical exams that assess skills specific to their specialty.
Dr. Burroughs says that screening physicians may be a more compassionate route than doctors think. “By identifying the issue early enough, it enhances their chance of being able to practice longer,” he said. When a cognitive deficit is discussed openly, the physician’s practice can be simplified, he can reduce his patient load, and his partners can regularly monitor and assess his work.
“But once something bad happens,” Dr. Burroughs said, “he’ll get his license taken away.”
This article has been revised to reflect the following correction:
Correction: February 3, 2011
An article on Jan. 25 about aging doctors, using a figure supplied by the American Medical Association, overstated the number of physicians in the United States who were over 65 as of 2008. It was 20.3 percent, not “one-third.”
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6 Απριλίου 2008, 20:48:31