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THERE has been a long-held expectation and obligation within the medical profession to take responsibility in identifying and managing predictable risks to patient safety in the deliverance of clinical care. Across the health sector, there has been increasingly rigorous debate regarding revalidation systems to ensure continued professional development (CPD) and clinical competence of medical practitioners.
The premise of this has been that evidence-based approaches to CPD drive clinical practice improvement and better patient outcomes, notwithstanding the dispute of whether CPD compliance alone is in fact sufficient to ensure ongoing competence.
Under the Health Practitioner Regulation National Law, which governs the operations of the National Boards and the Australian Health Practitioner Regulation Agency (AHPRA), there are currently strict requirements in Australia mandating health services’ adherence to appropriate credentialing and CPD practices in making decisions related to the appointment and re-appointment of individual medical practitioners.
The Medical Board of Australia has developed a Professional Performance Framework to design and conduct screening and remediation approaches to a number of risk factors identified in literature as markers of poor clinical performance. Of these, the evidence for age-related risk of poor performance is particularly strong (here, here, here and here). For practitioners of an advanced age, potential age-related cognitive decline presents a greater level of individual risk with respect to their ability to continue professional practice. Within the five pillars of the Framework, the second pillar of “active assurance of safe practice” highlights increasing age as a known risk factor for poor performance. The Board “plans to propose” requiring targeted screening of practitioners over the age of 70 years and above, who are providing clinical care, to have regular health checks and formal peer reviews. These checks are designed to assure patients, individual practitioners, employers and regulators of doctors’ continuing ability to provide safe clinical care.
Age-related risk to clinical practice is a bitter reality that we all will eventually face as our careers grow and mature. The most learned clinicians, the most adept surgeons and the most ambitious of professionals will all be faced with acknowledging an eventual decline in function, and will be required to exercise a high level of insight and judgement in modifying their clinical (or non-clinical) practices in response. Interestingly, multiple studies looking at cognitive performance data appear to indicate that self-perceived cognitive changes in memory does not in fact align with objectively demonstrated cognitive outcomes (here, here and here).
While most clinicians practise safely and are suitably self-aware to retire and/or reduce their clinical practice scope at the appropriate point, there is a minority of individuals who may be either unaware of their deficits or in denial of them.
While the Medical Board’s Professional Performance Framework itself is rather non-committal in its language of the proposal for targeted screening of advanced age doctors, there is mention of embedding this requirement in a new registration standard. As the new standard is yet to be “informed by legal advice, and subject to extensive consultation and regulatory processes”, it unfortunately does not provide any substantial direction and guidance for health services and medical leaders in supporting and managing advanced age practitioners at the present time.
Helping medical practitioners through this transition of their careers is perhaps one of the most daunting discussions for medical leaders to undertake. This is particularly the case for new and junior consultants in the field of medical management.
Medical leaders will invariably face this scenario at a time when a senior doctor is not only be confronting their own mortality, but are also faced with having to prove their professional functional competence. This is a dangerous cocktail with the potential to generate an emotionally charged situation of extreme sensitivity and hyper-vigilance in safeguarding the individual’s self. Medical leaders charged with ensuring safe clinical practice and the wellbeing of the medical workforce within health services and hospitals must therefore approach any discussions, with respect to revalidation, credentialing and scope of clinical practice delineation reviews of these doctors, with an abundance of caution and a great deal of empathy.
In fact, in their submission to the consultation on revalidation that was undertaken by the Medical Board of Australia, the Royal Australasian College of Surgeons wrote “there is now irrefutable evidence that demonstrates that cognitive and technical skills decline with age, at a time when they may be under less scrutiny by clinical governance processes or undertaking locum work across a number of hospitals. However, there is a deficit nationally in guidance on how to approach the issue of ageing and surgical performance”.
In facing this challenge from the perspective of a large metropolitan health service, we undertook a rational and sensitive approach to reach a decisive stance on this issue.
The first step was to bring the issue to the attention of and enable senior clinicians and peak governance committees to seriously consider the question of competence assurance of advanced age practitioners. Hospital medical advisory committees (or equivalent) proved an ideal platform for the initial debates, discussions and challenging of opinions. An interesting observation during this process was the somewhat widespread unwillingness or inability of discussion participants to commit to any one or other position on the issue. This was undoubtedly due to the contentious, highly sensitive nature of the topic and the current absence of any definitive regulation or direction to follow. However, it was unanimously agreed that it was an issue in dire need of an immediate solution.
During this initial process of engaging clinicians and hospital leaders, the importance of presenting a ready-made proposal for the group to then consider became clear. Facilitating consequent discussions about the advantages and disadvantages of adopting this proposal proved far more productive than merely requesting the group to provide the answer to the problem from first principles. This also helped to circumvent some of the inherent decision-making inertia that was observed.
An internal position statement necessitating annual “reviews” for reappointments and recredentialing of all doctors over the age of 70 years was developed and presented to the peak clinician group for debate. The position was modified in response to feedback from craft group consultations, peak credentialing and appointments committees and senior clinicians. An ongoing process of consultation further allowed for peer review and peer support structures to be considered and incorporated within the position statement.
The position statement was underpinned by a strong commitment to provide a non-discriminatory, individualised and procedurally fair approach in supporting all advanced age medical practitioners to continue to deliver safe clinical care where possible. Key parameters aligned to the organisation’s values and by-laws were then developed as part of the position statement.
These parameters included considerations of individual medical practitioners’:
- planned volume of clinical activity and/or proposed modifications to scope of clinical practice;
- annual and total procedural and consulting activity since the start of their first accreditation at the organisation;
- annual and total procedural and consulting activity external to the organisation;
- clinical outcomes including mortality rates, complications and/or any incident reports;
- hospital outcomes, including unexpected readmissions, return to theatre rates and prolonged length of stay;
- staff and patient feedback and complaints; and
- participation in continuing professional development and/or peer review activities in alignment with the requirements of the specialist medical colleges.
The position statement further stipulated that the above parameters be reconsidered at least every 12 months for medical practitioners aged 70 years and above. An appeals process was also set up supporting any medical practitioners’ right to appeal decisions made on the basis of these parameters. This was in alignment with the initial commitment that was made to ensure a procedurally fair approach, and helped strengthen the position.
The next challenge was the practical implementation and impact management of this relatively bold position statement. Consistency, transparency and fairness of the process, and allowing for consideration of individual and contextual circumstances, respecting the individual and their inherent degrees of sensitivity to the issue were crucial and were continually upheld. Respect and understanding of senior doctors in each instance are essential, as (in most situations) it may fall to medical leaders who are relatively junior to them to conduct these difficult discussions and competency assessments.
To aid this task and ensure a reliable standard was upheld, a segmented guideline outlining key behavioural, practice and cognitive components relevant in competence assessments was then developed. The guidelines encompassed a self-reflective component that the medical practitioner in question would be encouraged to contemplate, as well as a checklist of key points to guide the discussion. Key components of this guideline are outlined in Table 1.
| Table 1: Discussion checklist (self-reflection to be encouraged at each point) | |
| Medical practitioner’s planned volume of clinical activity | Does this represent a decrease in activity compared with recent/current activity levels? |
| Current and/or intended participation in an on-call roster | What is the plan for managing this? |
| Intention to modify scope of clinical practice | Reflective capacity |
| Medical practitioner’s annual and total procedural/consulting activity | Within and external to an organisation |
| Clinical outcomes (including mortality rates, complications, incident reports) | Comparisons with colleagues |
| Hospital outcomes (including unexpected readmissions, return to theatre rates, operating time and prolonged length of stay) | Comparisons with colleagues/peer organisations |
| Staff/patient feedback and complaints | Further inquiry as indicated if relevant |
| Continuing professional development (CPD) plans | Alignment with specialty college CPD requirements |
| Approach to navigating new/emerging medical advances/clinical practices | Particularly any that may replace or enhance components of their current practice |
| Intended involvement in teaching and research | Continue and/or modify? |
| Wellbeing and health checks | General practitioner support? Medical care support? |
| Retirement plans | Insight and judgement |
The art of discussion
While checklists and questionnaires certainly have a place in aiding consistency and comprehensiveness of such discussions, the true art of engaging doctors in sensitive issues such as this cannot be replaced or overlooked.
It requires a great deal of emotional intelligence and reflective capacity on the part of medical directors/administrators who are facilitating these discussions. One must be able to continuously modify and adapt their approach, style of conversation, and demeanour. Careful observation and attention to body language, tone of voice, unintended posturing, choice of vocabulary, and emotional undertones of the individual being questioned or assessed are a crucial aspect of what will determine the success or failure of this method.
Adequate time and opportunity for the doctors to self-reflect and judge their capacity for themselves must be allowed for during each interaction. Acknowledging any apparent sensitivities from the outset and actively exploring those emotions and/or even reluctance to participate any such discussions will help neutralise tension and unintended emotional bearings. Splitting the discussion into manageable blocks and conducting them over a number of days is another technique that may be preferred by some. This will be particularly useful if any serious concerns are flagged which may hinder our ability to reach a mutually agreed outcome with the medical practitioner.
No doubt we will see progressive developments, additional research, and regulatory guidance in this area as well as in the broader medical practitioner revalidation approach in the coming years. While these changes will be greatly welcomed and adopted into our daily administrative practices, this article has attempted to outline an experience of a practical and standardised approach that perhaps may prove helpful to medical administrators in the interim.
Dr Sidney Chandrasiri is Group Director (Academic and Medical Services) and Deputy Chief Medical Officer at Epworth HealthCare.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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I just want to say thank you for this great forum. I found a solution here on insightplus.mja.com.au for my issue.
I have practised in a surgical specialty both in a public hospital and in private practice to the age of 65 and was also involved in hospital administration. Retirement from hospital appointments used to be compulsory at 65 and I consider that there is still a strong case of this. I have seen cases which caused considerable difficulty when the consultant over the age of 65 would not retire. If a consultant over the age of 65 still has appropriate ability he or she can then be usefully reemployed on a recurring temporary basis or can practice in private in some less demanding capacity such as performing medicolegal assessments, teaching, assessing medical records or assisting in medical administration. In my own case I performed part-time medicolegal work for another 20 years
Dr Chandrasiri must be horrified to see Mr Biden given a 4 year employment contract, at his age! Especially as his predecessors have shown dubious mental health screening, narcotic addiction, chronic subdurals…
As an intern one of my bosses was incensed that he was being sacked from the public hospital when he turned 65 later in the month, despite being at the height of his skills (and with a thriving private practice). Subsequently litigation by an anaesthetist in NSW led to this age-related discrimination being banned. So I am surprised that the type of overt age discrimination detailed here has been exempted.
The problem for surgery, rather than cognitive-based disciplines like non-procedural medicine, is that it is a psychomotor task. We know from activities which involve complex motor functions like playing a musical instrument or driving a car, that there is a bimodal age distribution of poor performance, with the older group having cognitive or physical impairment, but the younger group having inexperience.
Clearly a better approach than discriminating against people on the grounds of age arbitrarily, is to require some sort of competency testing of all doctors, set against some sort of objective standard. How does 72 year old Dr Methuselah compare in morbidity/mortality figures with 29 year old Dr Neophyte? Is each safer than the minimum Australian standard of Dr Bolam Goodenough?
This is by no means easy, because apart from anything else the senior surgeon is likely to be referred the complex cases, whereas the junior just starting out acquires simple ones, and can ‘refer up’ to the seniors.
The elephant in the room, is that in my experience many hypocompetent older surgeons are working because they have to, not because they want to. Many years at cheap rates in the public hospital, an ill-advised tax-minimising investment, a divorce that cleaned out the super, an adult child needing support – I have seen all these as reasons why older surgeons strap their weary bones into a theatre gown.
Perhaps the single best intervention Dr Chandrasiri could implement, if she wants to avoid having older incompetent surgeons, is to advise all the young surgeons to charge the AMA fees, and plan to retire by 55. That way they can choose to work on if they are confident of their competency, but not be compelled to work on when they know they are past it.
Ron Pirola says “The issue is cognitive decline, not age.” and “Age should not be considered at all.” The problem with that approach is that cognitive decline is very strongly linked with age (though not exclusively). Of course other factors like head trauma and alcohol also have an effect – but these further amplify the age effect.
It makes no sense not to screen people with a strong predisposing factor for the condition. For that reason, we do mental state examinations frequently on people over 85, but not on people under 40 (for example).
There is good evidence that increasing age is associated with declines in cognitive processing. Here is a relevant reference: Academic Medicine Oct 2002: The Aging Physician Changes in Cognitive Processing and Their Impact on Medical Practice.
Re: Rupert Sherwood.
Thank you for your commentary and reasoning, and thank you for the supporting evidence.
The problem of ‘practitioner competence’ is clearly complex and multifactorial. However quality of care and patient safety are on the line.
‘Something must be done’.
Complex problems typically require complex solutions. I agree, age is not a good discriminator, although it’s axiomatic that both the incidence and prevalence of cognitive impairment increase with increasing age (what is the absolute risk of cognitive impairment at 60, 70, 80?). Sensitivity and specificity of age for cognitive impairment? Not terribly good. There must be an abundance of practitioners in their 70s and 80s who are cognitively intact, and who practise competently and safely. Conversely, there will be practitioners in their 50s and 60s who are cognitively impaired, who are neither clinically competent nor safe. As Rupert Sherwood has indicated, there will be practitioners who have reversible conditions that may temporarily affect competence for clinical practice. They need to be identified and supported – and not ‘written off’.
So multi-source feedback will be part of any solution. Feedback through participation in CPD, feedback from peers, feedback from patients, feedback from any trainees/students, feedback from reception staff.
Formal neuropsychological testing will be difficult to organise, and it will be potentially confronting and humiliating for a senior practitioner to have to do a ‘mental test’. Also, neuropsychological testing is only an indirect test of clinical competence. As has been said, there are no ideal ways of assessing competence for medical students, trainees, or others.
I certainly do not have The Answer, other than to recommend that we have ongoing discussions about what to do and how to do it. But doing nothing is not an option.
Unsurprisingly, this opinion piece by Dr Chandrasiri has drawn a wide range of responses with varying opinions on the very vexed issue of the ageing doctor. Disappointingly the references did not include a recent paper published in the BMJ (Sherwood R, Bismark M. BMJ Qual Saf 2019;0:1–9. doi:10.1136/bmjqs-2019-009596) which reported on interviews with 50 leaders across 4 countries who participated in a semi-structured interview on this topic, and the possible solutions. Needless to say, there is no simple answer, but most importantly, using age as a single identifier will not be the solution. Competence and performance as a doctor are lifelong and continuously variable metrics, and should be treated as such. Some influences temporary and reversible – depression, life stresses or recovery from substance abuse. Others, such as cognitive decline, loss of sensory capability, motor skills and ability to recover from fatigue are inevitable but vary enormously across individuals. The answer is likely to lie in a career-long regular (and mandatory) assessment of all these domains, screening initially and then targeted detailed review of identified deficiencies. AHPRA and the MBA should only be one player, with doctors, employers, MDOs and colleges all actively engaged.
Get out when you are at the top of your game. Sound advice for sportspeople, politicians – and doctors.
During the 1990s and 2000s, when I was working in a rural area, three GP colleagues developed dementia. They were all over 75. They continued to work until a series of crises occurred in each case.
These GPs had all worked for nigh on 50 years in their rural communities. They had worked exceptionally hard. They were highly skilled in rural medicine. They were greatly respected by patients, their communities, and their colleagues.
Unfortunately, their legacies became their dementia and the mistakes that occurred during their periods of cognitive decline.
Patients and communities remembered wistfully ‘what they had been like in the old days’, but patients and communities were scathing and negatively judgmental about the GPs’ clinical performance at the end of their careers.
They are now remembered as ‘dangerous and doddery’, not as practitioners who had provided exemplary service to their communities over long and committed careers.
My younger GP colleagues and I failed to take any action. We did not report the GPs to the Medical Board. We did not take the GPs aside to suggest that they should see a GP/get help/stop working. We covered up for their mistakes. We checked their work.
They were senior and respected colleagues. They were the bosses. We were junior colleagues – junior in age and in status.
Reminds me of the First Officer of the KLM 747 who did not speak up to prevent his Captain taking off without clearance at Tenerife in 1977. The KLM 747 crashed into a Pan-Am 747 which was on the runway. 583 fatalities – the worst disaster in aviation history. If the First Officer had been assertive, he could have stopped the Captain from going ahead with take-off. But it seems that the First Officer – who knew that clearance had not been given – did not speak up. We will never know for sure. Nobody on the KLM 747 survived.
What me! No not me. Surely you’re not referring to me. I have been practicing for 60 years and have got my head around all this bureaucratic interference. My patients love me and are terrified of me going. Let yer know when I’m ready to go….
While I’m only aged 82 I have in fact recognised my slow but steady decline and adapted to it. I have in the past tended to practice at the forefront of innovative medicine from being a pioneer of laparoscopic surgery through mid trimester abortion to transmedicine in the midst of the controversy surrounding the use of testosterone. As I progressed along this aging metamorphosis I recognised my only chance of becoming a butterfly from a humble larva was a reductio but not quite ad absurdem. I am now left with a narrow sliver of practice that I know in depth. My question is when I come up to peer review, who will be qualified to review me? I am still licensed to practice the whole breadth of my specialty but there are huge chunks that are entirely consigned to history. Does that disqualify me from practicing what I continue to offer…and who is to judge when there are so few to make the judgment? Peer review for me holds a certain horror mixed with bemusement that could could well cause me throw up my hands and leave my ‘special’ cohort stranded without competent help.
They already do. Most are involved in college CPD programs. Is this writer actually stating that these are grossly inadequate? What evidence do they present for this? The colleges may take a different view.
How about a sort of ‘reverse mentorship’ program? Linking doctors aged 70 and over with a nominated and trained younger doctor as mentor. The mentor would be in the same specialty as the older doctor. The mentor would have a duty to report to the Medical Board any concerns about the doctor’s clinical performance, professionalism, and cognitive state. The mentor can assess this using multi-source feedback, eg interview, case analysis, and feedback from patients. Once reported, it would be up to the Medical Board to investigate.
The issue is cognitive decline, not age. Therefore, what needs to be tested is cognitive decline. That is incomparably easier to monitor than decline in professional competence for an individual’s practice.
Age should not be considered at all. After all, a number of factors such as alcohol excess and vascular disease or previous concussions from sports can impair brain function and these can start impacting one’s practice long before 70. A relatively simple clinical fitness screening annually should help to exclude much of this and those in doubt could have more formal cognitive testing.
Any other form of testing of professional competence should be undertaken not only by the target group but by the assessors as well. However, even then, it is likely to have little relevance to many styles of practice undertaken by experienced clinicians who might have restricted themselves to particular fields of special interest.
Even in a major teaching hospital specialist under age 65 can become clinically impaired and it is very hard to dislodge a young specialist in a teaching hospital. Once over 65 you are being constantly monitored for poor performance.
If the over 70 need revalidation so should be the younger ones as I found that some of the younger appointees skills are deceptively lacking.
In general practice revalidations are much harder and considerations had to be given for familiarity and relationship with their long-standing patients and perhaps that can work as registrars in reverse in general practice
Perusal of the references supplied by Dr Chandrasiri reveals that they don’t really support the points she is making. It is scarcely surprising that older doctors are more prone than younger ones to physical and cognitive degeneration. What is surprising is how few of them continue to practise, not how many. The articles all emphasise a sympathetic, collegial response to cognitive and physical difficulty and look for a continuing, but limited and appropriate role for those found to have a significant disability.
Some points for reflection.
Can a bureaucracy really develop a method of detecting cognitive decline which is sufficiently sensitive to detect all those who should limit or withdraw from practice, while being sufficiently sensitive that it does not unjustly limit the practice of doctors who are still practising to an acceptable standard?
Why are disabled old male doctors not eligible for the same sympathy, respect and assistance to practice to the limits of their ability which is afforded to all other disabled doctors?
Given that cognitive impairment is not limited purely to male doctors over 70, how can this process aim at old male doctors exclusively and not be ageist and sexist?
And finally, why is it necessary to create a new process? Meaningful annual reassessment would be onerous and humiliating in the extreme, and would likely result in the withdrawal from practice of many healthy old men who are continuing to make an excellent contribution. Where is the evidence that a new process would be any more effective than the existing safeguards?
Sometimes deteriorating cognitive competency is obvious but this is usually once “the horse has bolted”. Most often it is an insidious deterioration and I doubt that we will find a reliable way of determining exactly the point when the risk from cognitive decline outweighs the benefit of years of clinical experience. We have not yet perfected the tools to determine competency at the beginning of a medical career (medical student and specialist training). It is even more challenging towards the end of a career, especially if the individual still enjoys practice or needs to continue for financial reasons.
Off topic, but just to clarify, ‘primum non nocere’ is a noble principle, and it’s embedded in the ethics of medicine, but it’s too simplistic, and it’s not realistic. Every time we prescribe a medication we are potentially ‘causing harm’ due to the risk of adverse effects and interactions. Every time we refer for X-ray or CT we are causing harm by radiation exposure. Every time we make a referral there is the risk of ‘second degree harm’, if the referred doctor ‘hams’ the patient. Every time we provide advice, there is the potential for harm from the advice (I had a patient who threatened to sue me for a broken ankle, sustained when he was following my advice to do exercise. He didn’t go ahead with legal action). And so it goes on. So although our intentions – the ‘primum’ of whatever we do – may not cause harm, there is intrinsic harm with those actions.
Revalidation for all medical practitioners (all ages) has been up and running in the UK since 2012.
Does anyone know how revalidation works in the UK?
I had a look at a report on revalidation in the UK for 2012-2018. The non-revalidation rate was about 0.4% for under 70s, and 2.2% for doctors aged 70 and over. This seems to suggest that age may be a factor in competence for safe practice.
I’m under 70. FWIW, if, at any age, I lost the capacity for safe and effective clinical practice, and I simultaneously lost the insight that I had lost the capacity, I would want someone to tell me that I am not competent, and I would want to be stopped from practising. I don’t want to hurt anyone, primum non nocere.
Geoff Chapman says “Surely when an aged person (OR any age) becomes incompetent–(not speaking surgically here)-they run out of patients—the bush telegraph is very acute when it comes to these things.” Unfortunately, this is not the case. Patients may not perceive that the quality of their doctor’s decision-making has gradually deteriorated, or they may feel such a strong allegiance that they are unwilling to change doctors DESPITE perceived deterioration. For the protection of vulnerable patients, we can’t rely on popularity as a performance test.
“No doubt we will see progressive developments, additional research, and regulatory guidance in this area as well as in the broader medical practitioner revalidation approach in the coming years. While these changes will be greatly welcomed and adopted into our daily administrative practices, this article has attempted to outline an experience of a practical and standardised approach that perhaps may prove helpful to medical administrators in the interim.”
It must be nice to see the value of another admin burden on your busy clinical day! (Lucky you, author.) Even better, one that puts your professional standing on the line. I guess Geoff Chapman has the only answer to this juggernaut. Examine everyone, including the examiners who may never have engaged in clinical medicine. Also, make sure the examiners and the entire web of parasites surrounding them are NOT paid out of the health budget, because we want more money available for actual health care.
I understand there are significant risks where cognitively impaired doctors hold a scalpel in the OT or ICU protocols in their hand. Maybe GPs don’t hold that immediate chance of disaster with each consultation, but we can definitely do bad things. The trouble is we already do bad things and get praised for it.
We have been brain-beaten and acquiesce to grossly unhealthy national dietary guidelines. We prescribe lipid, antibiotics and other medications without any evidence an individual patient actually needs or will benefit from them. We sit in meetings that promote vested interests in health, like corporate health care providers or pharma and go home with CPD credits and a full belly. I think I am screwed when my time comes, not for lack of competence, but lack of compliance!
We don’t have the guts to stand up for a profession being systematically dismantled by outsiders and politically motivated non-clinical doctors. Revalidation is not the only example. Don’t get me wrong, I don’t want incompetent doctors in my profession. However, I believe a blanket, wooden spoon addition to our professional surveillance is unlikely to help.
Here’s a suggestion. At age 70 all of us should be paid (really well) to provide experience-based education to the profession at a university, practice and hospital level for 2 years. If the evidence from audiences suggests reduced competence, then at 12 to 18 months we should be advised of it. Let the profession do accurate and anonymous assessments. Those found lacking will then have some more paid time to plan their future AND the system would not pay for a pack of pseudo-expert parasites contributing nothing, just the ones collating comments.
Or better still, who will examine the Regulators (Examiners) FIRST, to see if they are competent in ALL General Practice fields.
Perchance ONLY then, could we be sure they are competent to examine their Fellow practitioners, and I’m not talking Academics here, with the Govt. paying for their time.
I know of quite a few older (>70) GP’s who could teach a few younger practitioners a practice trick or two. Surely when an aged person (OR any age) becomes incompetent–(not speaking surgically here)-they run out of patients—the bush telegraph is very acute when it comes to these things.
So if we are going to have yearly exams, let’s have them for EVERY one, and see what age group is the one with the most problems, in those that are still practising.
I agree with the above, who regulates the regulator unless it is an organisation like APHRA. ?
Consider this scenario. Young doctors newly appointed as VMO’s in hospital practice are competing with one another for sessional work. They then target vulnerable older VMO’S to grab their work with alleged misconduct, lack of skills etc. This is well known in professions such as anaesthesia.
I am 74 years old and have been practising as a psychiatrist since I began my training in 1973. I have no immediate intention of retiring, being physically fit, noticing no dramatic decline in my short-term memory and following a healthy lifestyle with good sleep, regular exercise, healthy eating and a physically and emotionally close relationship.
I’m convinced these factors qualify me to keep on practising. The only problem being that this is my view of myself and therefore suspect. Clearly I should be regularly assessed on a regular basis.
There is no doubt that cognitive ability declines over time, including flexibility and the ability to incorporate new learning. This has been tested in high-cognitive-load professions such as air traffic control as well as in medical practice. The review paper “The Aging Physician, Changes in Cognitive Processing and Their Impact on Medical Practice”, in Academic Medicine 2002, found that increasing age was correlated with declines in memory, comprehension and reasoning, and that these changes were not fully compensated by greater experience.
The issue with regulation is that the timing of these changes, and their impact on performance, are highly variable – varying with both the individual clinician and the practice setting.
At age 70, many clinicians remain competent and sufficiently agile, but fewer at age 75, and very few beyond that. In my view, management should include a combination of reporting, testing and practice setting modification. Practice settings appropriate to the aging clinician include group practices with structured supervision and audit and embedded peer review. Ironically, some of our oldest practitioners remain in solo practices that do not provide either support or insight into performance changes.
Deficits in ability, knowledge, skills and wisdom change from the day we start to practice until we retire. The assessments if any that are used to assess ability to practice if introduced should not be restricted to one age group. There are some attributes of ability, knowledge skills and wisdom that are deficient in younger practitioners that are potentially more dangerous. It is a continuum and does not just start at age 70.
For some, but not all, clinicians, maintaining salary towards the end of their carers will be an important consideration that may influence their decision on when to retire.
If a doctor had to reduce their worked hours following a stroke they would be able to access paid sick leave, but do we similarly regard age-related cognitive decline a health issue? If so, and a doctor has to change their mix of clinical and non-clinical duties and cut back on working hours, should this be supported by the ability to use accrued sick leave for the hours not worked?
There would be an obvious cost involved in this approach but the alternative is some doctors continuing to work longer than they should do due to their need to maintain an income.
The author is institution bound. What of General Practice? How do the regulators of quality influence independent practitioners to undertake similar reflections? Only AHPRA regulation would do this. When do we hear from them?
this is rubbish and will only lead to divisions in the profession. who regulates the regulators ?