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OLDER doctors could face a mandatory performance assessment when they reach a certain age, says the head of the Medical Board of Australia.
Dr Joanna Flynn, the board’s chair, said that in the future the board may look at targeting performance assessments at high risk groups including older doctors.
“Not in the next 3 years, but beyond that we may want to take a more active approach, in partnership with colleges and the AMA.”
She said a mandatory assessment was somewhat analogous to the mandatory driving test that older drivers are required to sit in some Australian states.
Some jurisdictions, particularly in Canada, had introduced mandatory peer assessments once doctors reached a certain age, Dr Flynn said.
For example, in Quebec regulators recently issued data about the performance of older doctors in general, which showed some decline with age, Dr Flynn said. The regulators sent the data to older doctors, asking them to reflect on their own performance and advising that assessments would be conducted, prompting some doctors to restrict their practice or retire.
Dr Flynn emphasised that all doctors, regardless of age, needed to recognise and work within the limits of their competence, as specified in the Medical Board’s code of conduct. (1)
She also encouraged doctors to seek advice from colleagues about their skill and health, especially when performing challenging or unfamiliar tasks.
“We rely on doctors to exercise good judgement and it can sometimes be helpful to have the stimulus of knowing that there is data to suggest that doctors’ performance in certain areas declines as they age”, she said.
Dr Flynn’s comments come in response to two MJA articles looking at work transitions in older doctors.
Professor George Skowronski, professor of critical care at the University of NSW, and Dr Carmelle Peisah, associate professor of psychiatry at the same university, wrote that older doctors were affected by several age-related sensory and cognitive changes, such as a decline in processing speed and memory. (2)
There was a need for strategies that capitalised on older doctors’ strengths while supporting areas of decline, “trading off the benefits of experience against declining stamina and performance”, they wrote.
They also noted that older doctors were more likely to face disciplinary action.
However, Dr Flynn said that out of 90 000 doctors in Australia, only about 2500 faced complaints each year. This was such a small proportion that “it doesn’t tell you what the vast majority of people are doing”.
She said it was important to retain experienced doctors, particularly given workforce shortages, provided they were practising safely.
Dr Flynn ruled out a mandatory retirement age, emphasising that the cognitive and physical ageing process was highly variable. She said any initiative needed to be respectful and not age-discriminatory.
In another article in the MJA, Dr Bruce Waxman, director of general surgery at Southern Health, Melbourne, wrote that retention strategies for older doctors could include a phased withdrawal from operating, with enhanced roles in teaching, administration or medicolegal work. (3)
Professor Simon Willcock, professor of general practice at the University of Sydney, told MJA InSight that more support was needed for career transitions that played to the strengths of older doctors.
“The challenge to the profession is to come up with career development paths and get away from the rigid disciplinary silos”, he said. Enhancing flexibility in this way could also improve performance.
“If you look at the people before the boards, they’re often suffering burnout, substance abuse, depression — which are more likely to happen if people feel they’re locked on a treadmill”, he said.
In his article, Dr Waxman said the Royal Australasian College of Surgeons senior surgeons group had developed a draft position statement to provide guidance to ageing surgeons.
The position statement recommended an annual health check from a GP, a performance review including a practice visit, and CPD modifications for surgeons not practising clinically.
Professor Willcock said a mandatory medical check when doctors reach a certain age, such as 75 years, could be useful, but he did not support a re-registration performance assessment.
– Sophie McNamara
1. Medical Board of Australia: Good Medical Practice: A Code of Conduct for Doctors in Australia
2. MJA 2012; 196: 505-507
3. MJA 2012; 196: 498
Posted 7 May 2012
Perhaps Dr Sue Ieraci and Dr Joanna Flynn should be measuring cognitive function of doctors at graduation, so that those those with a low level compared with average let alone high should be under review much sooner than those with a high level, presuming the “age associated cognitive decline” described by Sue Ieraci is the same for all doctors. Can one assume then that doctors with initial higher function decline at the same rate as those with lower function? I doubt that there is any evidence base to any of this, including any evidence of what Dr Ieraci refers to as “sparkling”. If one wishes to make a comparison with driver’s licences, or pilots, perhaps Dr Flynn and Dr Ieraci could compose a “Fitness for medical licences” and require doctors on insulin or with a heart condition or with visual loss to have annual specialist review.
I graduated in 1947 and retired in 2011 due to the landlord wanting my rooms. I practised in an area, sports medicine, where the most mechanical activity I did was an injection or a manipulative procedure. My practice did not significantly diminish in the last 20 years nor am I aware of any complaints about my regimens. A CPD course run by the RACP was a waste as there is not enough material for this specialty to be fostered. My following the program did nothing to improve my practice.
Any program must be adapted to the doctor’s experience and conducted by people who have had no significant contact with the doctor in the recent past.
Rural statistics indicate that rural GPs are leaving practice in their fifties – does Dr Joanna Flynn think that rural doctors are aging faster than their city counterparts? Is no GP in a country town better than an aging GP?
Sue must not have done any CPD like APLS, CPR, emergency medicine, plaster workshops, which assesses clinical competence – interestingly those who failed at those I attended initially were very young doctors. I find Dr Joanna Flynn’s bias against age discriminatory. I have worked for and with older GP doctors, and found them a useful, wise resource. Perhaps a more pragmatic approach would be to introduce compulsory practical CPD in addition to annual CPR, every 3 years, such as APLS, EMST for all practitioners, including Dr Flynn, funded by Medicare, to assist older GP doctors to remain in the workforce, which, in case Dr Flynn has not noticed, is in very short supply in rural areas. Currently, some of this CPD is funded for VMOs, discriminating against private GP doctors who are not VMOs.
Most GPs older than me are male, and do something positive for the rural GP shortage. Should all board members be examined for bias?
The phenomenon of age-related cognitive decline is a real one – well documented. Of course its onset is variable between individuals, as are the domains affected. As described in this paper: “Age-Associated Cognitive Decline” (at http://bmb.oxfordjournals.org/content/92/1/135.short), “Some mental capabilities are well maintained into old age. From early adulthood, there are declines in mental domains such as processing speed, reasoning, memory and executive functions, some of which is underpinned by a decline in a general cognitive factor.” Many congitive features are preserved – particularly language-related ones. Since most doctors start with a congitive level well above the population average, they can maintain many aspects of this ability into old age. Is being a sparkling elderly person, however, enough to ensure safe medical practice? Although most clinical principles do not change over time, many aspects of medical pratice – especially diagnostics and therapeutics – are changing rapidly. Cognitive flexibility is required to keep one’s abilities sharp and up-to-date. Much of this ability may be preserved in one’s sixties, but can we honestly be confident about them into our late seventies and eighties? Perhaps it is kinder to allow ourselves to think about life after career than to assume we will be fit for practice into the grave.
Doctors with physical and psychologic ailments need support and direction to disciplines in which they are least likely to hurt their patients. Older and young doctors like the rest of society suffer from these disabilities.Older doctors can also retain all of their faculties and add value by experience. Flynn should focus on the real problems ie. health and not age.
Another example of age discrimination, pure and simple. Doctors are individuals and any determination about fitness to practice should be made on the merits of the individual case, not based on an arbitrary age criteria. All doctors of any age can face illness that can impair performance of medical duties, but again any determination of fitness should be made on the individual circumstances. And we have ways of doing this at the moment. So no need to bring in something ‘special’ for older doctors unless the motivation is age discrimination.
Any ethically-driven doctor regardless of age, limits their practice in sympathy with that doctor’s interests, experience and capacity. Collegiate support is critical in this regard. My close colleagues were told that I expected a tap on the shoulder if they ever felt my performance was lacking.
Sue Ieraci says that CPD cannot assess competence. This surely indicates that mandatory CPD is just another expensive and ineffective public relations exercise by the Board. Now add mandatory assessment of ageing doctors to this list. Clearly the Board is driven by politics and public perceptions rather than developing policy based on evidence.
I have visions of people being failed for diverging from official “practice guidelines” based on their experience which may be more valid than the guidelines. That could have happened to me in my 40s, let alone later in life. That said I’m only working part time now in my 60s and don’t expect to bother to in my 70s. I may do the new 3 year MD programme my old University is introducing though, as I’d like to get into something new, and therefore more stimulating.
Let everyone do the RACGP multiple choice questions exam every 5 years. Suggest over 30% would fail and they would not all be over 60. (Dr at 70)
I have a few observations on this article. It certainly, to me, is an age discrimination attack
In the second sentence, Dr Flynn implies that older doctors are a high risk group.
The papers from Uni of NSW stated that older doctors were prone to more health problems than younger doctors. I would remark that the older non-medical senior citizens are prone to more health problems than the younger non-medical senior citizens.
The ADF Proposal included an annual check. Nothing original about that suggestion in this article.
They state that “older doctors were more likely to face disciplinary action” without giving the basis for that statement. Perhaps it was in the original articles in MJA? I have not seen the articles and no reference is given. Certainly the MBQ and MBA have not been able to give any instances of “danger to public safety’ arising from the decade or so of waiver of registration fees in Qld.
Dr Flynn implies by association with that statement that the 2500 doctors out of 90,00 who faced complaints were older doctors (I bet they were not) and that there may have been a lot more. She does not say how many of those complaints were upheld and led to disciplinary action. I would suspect that most complaints laid to Medical Boards do not lead to disciplinary action by the Board.
She supports “retaining experienced doctors provided they were practising safely”. Surely that proviso applies to less experienced doctors also. It seems to me to contradict her declaration in the next sentence that “any initiative needed to be respectful and not age-discriminatory”.
Cognitive capacity varies by individual and any changes due to age varies by individual. The article has no acceptance that while some changes in cognition occur with age there are other cognitive changes that improve so that overall the effect on medical performance is likely to be minimal. Also there no acceptance of the distinction between normal ageing and the onset of medical conditions that do affect cognition such as Alzheimer’s disease.
Performance tests ‘requested to’ and ‘requested by’ should be applicable to both parts without ‘job-barrier stigma’.
bruni brewin – of course there are individuals with a variety of different attributes and skills. For all of us, though, there is a time when our technical and cognitive skills start to decline. This doesn’t just mean having a good or bad memory – it relates to the ability to think flexibly and to acquire new knowledge. DO you really think that having a good manner and being reassuring is all that is required for safe practice? And to the person who asked for the evidence about older doctors: http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid…
Some people have really good memories yet lousy bedside manners – full of pomp and better than thou attitudes. Others do not have such good memories, but with an ability to relate to people and make them feel better just by being who they are. That happens in all professions, regardless of age. These abilities are more about who we are, and most come from our past experiences and upbringing. Who am I that I should be telling you that you don’t meet my expectancies? But if I can make it a legislation then it won’t seem like it reflects my beliefs, it is seen as the general consensus, albeit only made by the minority. If you look at the people before the boards, and you say to us that they are often suffering burnout, substance abuse, depression — then the question needs answering – Why? What has caused that? A bit like the debate of whether it is endogenous or reactive depression. If it is the latter, should what caused it not be rectified, or should we demote you or retire you so that you can continue with your self-medication?
“They also noted that older doctors were more likely to face disciplinary action” . Where is the evidence for this?
I am a GP locum, qualified in 1957. Every locum job results in my being assessed by my employer. Every consultation involves assessment by the patient.
Aniello Iannuzzi – CPD cannot assess “competence” – it reflects exposure to information, not assimilation of the information. There is no doubt that both dexterity and cognitive flexibility decline at an advanced age. That’s the reason why the very elderly are regularly driver-tested. Rather than waiting for these deficiencies to manifest by harm to a patient, wouldn;t it make sense to test people up-front. If the person shows that they are still dextrous and/or cognitively fully functional, then they keep going. This becomes unlikely after the ages of about 75, however (and certainly 80). It is sad that some very elderly practitioners are not able to let go until mistakes catch up with them – that’s a very undignified way to retire.
There are two things in the above posts that capture issues around this mandatory performance testing for older doctors -one was invoking comparison with “air crew” and the other was “bureaucratic humiliation”. Are we just talking ‘pilots’ then we should also just be talking ‘surgeons’ both of who need to have critical mental and physical dexterity – but not lump all doctors together. One would have thought between the HCCC, hospital root cause analyses and the legal profession that the fear of God is well and truly entrenched in surgeons to give it away in time.
And can “bureaucratic humiliation” be taken any further? – surely, we are already governed by the bureaucrats telling us how to practice Medicine. What I would really like to see is mandatory performance testing on judges, politicians and bureaucrats whose decisions affect millions of people.
Phased restriction of practice after 60 is practiced by most doctors, and is a sensible response to aging. There is a need for sensitive re-certification for we aging doctors, just as there is a need for regular re-certification for doctors of all ages. We expect nothing less from air crew.
Some good points have been aired…it sounds as though a
“case.by.case” approach needs to be adopted initially !
Why not regularly on all? Ageing and competence don’t have a correlation high enough to make exclusions or to set a reasonable lower age limit for starting.
I could not agree more with Aniello Iannuzzi. The profession should support senior doctors and not allow bureaucrats to humiliate them. Joanna Flynn should pay attention to the poll results; I wonder if she will have the same attitude to mandatory testing when she grows older!
I thought the whole point of CPD is to assess competence. This is ageism at its worse and as a profession we should not allow it.
It would be interesting to know what percentage of those 2500 complaints relate to older doctors. Secondly, what proportion of older doctors generate compaints.Without this information, further discussion is futile.