Daily, doctors must use sophisticated cognitive skills, and – depending on the specialty – fine-tuned manual dexterity, but these sometimes decline with age, leading to the conundrum of whether doctors can safely continue to practice medicine into their late 60s and beyond.
A recent Medscape commentary by bioethicist Arthur Caplan, PhD, tackled this question.
In his commentary, inspired by an opinion piece in The New York Times titled, How Would You Feel About a 100-Year-Old Doctor?, Caplan said that, unlike airline pilots, who are subject to mandatory retirement at 65 because of the possibility of cognitive or health decline, there is no mandatory retirement age for physicians.
Caplan recommends a “basic competency” recertification process, consisting of “a memory test, some sort of dexterity test, or a simple 20- or 30-minute examination annually or every other year” to “make sure that once you are older than 65, your skills have not slipped in a way that would harm patients or cause the risk of malpractice to increase”.
Heated debate among Medscape readers ensued. One called the commentary “ageism at its finest”, while another wrote: “Age and competency aren’t directly correlated. Testing to maintain licensure based upon age is blatant discrimination.”
Incompetence has no age limit
One debate revolved around experience vs new technology. Many readers felt strongly that older physicians are not only competent but are actually superior to younger ones. “I would go to a 100-year-old doc in a heartbeat!” wrote one. “What they have observed and experienced is priceless. My favourite doc right now is 87 and he is my adviser on all things health.”
But “sadly, our society does not always respect the experience and wisdom that come with age”, another said.
Younger physicians don’t yet have the same amount of wisdom and experience, another noted. “They need to put in their time to reach that level.”
One reader said: “The young doctors might have some technical superiority to the older docs, but bedside manners and quality time are overwhelmingly better with older physicians.” Not to mention experience: “If I know I need surgery, I want the old doctor who has done 1 000 of them. If I want options and new treatment options, the young docs are better.”
Several readers argued that ageing and declining competency don’t necessarily go hand in hand. “As Caplan suggested, there needs to be a way to screen for issues which should preclude practice, (but) age per se is not the issue; it’s competence.”
Another agreed, adding, “incompetence can be found in clinicians of any age”.
One respondent described physicians and other healthcare professionals she works with who are in their 70s and 80s. “You would be shocked to learn they are that old.” On the other hand, she knows many in their 50s “who need to retire, due to physical and cognitive decline”.
For this reason, “if this type of testing is to be done, it should be done at all ages and in a prospective manner to see what indicators there are that a physician is not able to practice well”.
More experienced vs more up-to-date
But there were readers who preferred younger physicians. For example, “I wouldn't go (to a 100-year-old doctor). The best doctors are between five and 15 years in practice, maybe 20 years. Medicine is a constantly-changing field, and we have to keep up to do our best for our patients.” This reader has "seen too many senior partners treat patients with behind-the-times techniques and advice, despite advances in the field.
Is it going too far to test competence?
Many readers balked at the idea of recertification testing beginning at 65. For one thing, doctors are already subjected to a formidable number of tests and requirements. One reader wrote: “I don't believe another exam is necessary to demonstrate my competence. My competence is constantly being reviewed and I am nearly to that mandatory retirement age.”
Others questioned what the exam would consist of and who would administer it. “I think in theory, it is good to test medical personnel – doctors, nurses, EMTs, etc., anyone who has hands-on care. But the rub is: who creates the tests, who audits the tests, how is it handled when someone falls into that category of ‘not doing as well as he/she should?’ Do we just accept the person’s or panel’s decision and retire? It’s a slippery slope, but the idea is valid.”
Another reader expressed similar concerns. “Testing? What are the tests and what will they actually tell us? For instance, does failure to remember a series of five words tell us much about clinical skills? And what happens after ‘failure’? Supervision? Retraining? Reassignment? Loss of licence? This idea is poorly thought out.”
Where's the evidence?
The practice of medicine should rest upon a solid evidence base informed by robust research, says one reader.
Another pointed out that, “before putting in new, non-evidence-based regulations”, people should “think about doing a study looking at the signs and symptoms that predict the inability to practice medicine where the MD does not voluntarily give up practice. Bottom line: is it really a problem that there are a lot of physicians who, due to age, are not modifying their practice so that they are practicing within their capabilities? If so, let’s see the studies.”
Not all or nothing
Some readers suggested that continuing to practice medicine into old age isn’t an “all or nothing” proposition. “Why can’t we create a system where professionals, such as surgeons or ICU staff, must pivot after a certain age to work in a consulting/mentor role?”, a reader asked.
“This could allow valuable expertise to be more widely disseminated to the next generation of doctors. Is the current system, to work just full-force until you must then not work at all, really the best possible system?”
And speciality mattered to several readers. “A 100-year-old surgeon is out of the question,” one wrote. ‘As we age, our reaction time to external stimuli slows, but this isn’t the same as cognitive decline. Maybe I’d go for a consult in non-surgical specialties.”
For the surgeon to desist from performing surgery after his or her manual dexterity has declined does not mean he or she should leave the field of medicine entirely. A reader described an older orthopaedic surgeon who – after realizing he could no longer perform complex surgeries safely – remained with his group instead of retiring.
He continued to use his diagnostic skills to the benefit of patients and fellow surgeons. “I believe he was in his late eighties when I last saw him. He noted a fracture that had been missed by radiology and, more importantly, helped me avoid complications from the related crush injury.”
Already having a historical relationship with the doctor might affect the decision as well. “If it was a physician I knew and trusted, then I would still see them. If it were a new physician to me, then probably not,” a reader commented.
Medscape article – Would You Go to a 100-Year-Old Doctor? (Open access)
Medscape article – Physicians React: ‘Incompetence in Medicine Has No Age Limit’ (Open access)
The New York Times article – How would you feel about a 100-year-old doctor? (Restricted access)
See more from MedicalBrief archives:
UK patient dies after procedure by octogenarian doctor who lied about age
The menopause taboo: Female doctors are retiring early
98-year-old French doctor still practising and rues Dr Google
Over 40% of GPs intend to quit within five years: UK survey