A growing dilemma for hospitals: How to assess older doctors

For as long as anyone could remember, leaders at Sinai Hospital of Baltimore would get alerted to concerns about the performance of an aging physician in the way that most hospitals do: episodically, when someone reported a decline in someone's performance or behavior. Other times, older doctors would ask for help in assessing their own mental and physical abilities.

Doctors and their colleagues recognize that "cognition deteriorates with age," notes Mark R. Katlic, MD, director of the Aging Surgeon Program at LifeBridge Health System, which includes Sinai (a teaching hospital) and two other acute care hospitals in Maryland.

There was a growing sense that the sort of happenstance process wasn't good enough, he says. In 2015, LifeBridge instituted an approach that has slowly taken hold at about three dozen other hospitals: a late-career-practitioner policy, whereby it conducts cognitive and physical assessments of doctors when they enter their 70s and are up for renewal of their hospital privileges. Most doctors pass the assessments with no changes to their work, but some have had their privileges restricted and others have chosen to retire.

"There's such enormous variability among individuals," Katlic says. "That's why you need some type of screening evaluation" for each person.

The push for screening late-career physicians has grown as the physician workforce has gotten older. Almost one-quarter (23.9%) of practicing physicians are 65 or older, according to 2024 survey data from the AAMC. That's up from 16.8% in 2014.

That poses challenges for medical administrators. As the workforce has aged, "[we've] had a growing awareness of cognitive issues" among some older doctors, says P.J. Brennan, MD, chief medical officer of the University of Pennsylvania (UPenn) Health System, explaining why that system instituted a late-career assessment policy. "From time to time, someone [an older physician] would start to get a lot of complaints. We'd look into it. Occasionally, we would realize that there's something cognitive going on here" that needs to be addressed.

A review in JAMA Surgery noted that "between ages 40 and 75 years, mean cognitive ability [for people overall] declines by more than 20%, but there is significant variability from one person to another. … While some older physicians are profoundly impaired, others retain their ability and skills."

In several professions where the declining abilities of an employee pose a danger to people whose lives depend on their performance - airline pilots, truck drivers, police officers, Secret Service agents, firefighters, and soldiers - there are requirements for testing or retirement. Commercial-airline pilots are required to retire at age 65; FBI and Secret Service agents, at 57.

Yet late-career screening policies for physicians often meet resistance from doctors, and an ongoing lawsuit by the U.S. Equal Employment Opportunity Commission (EEOC) against such a policy at Yale Medicine might have chilled some screening efforts.

"It's something that has been uncomfortable for the profession to talk about," says Andrew White, MD, professor of general internal medicine at the University of Washington School of Medicine, in Seattle, who has published several papers on this issue. One study, published in Annals of Internal Medicine and based on interviews with leaders at 29 health care organizations with late-career-practitioner policies, noted that "the increasing age of the U.S. medical workforce has raised questions about how to ensure the safety of care provided by late career physicians."

Below are samples of some of the policies, along with their results and challenges.

What hospitals assess

Late-career-physician assessment policies have been implemented at some hospitals over the past 15 years or so because the traditional methods of getting reports from colleagues and the doctors themselves proved insufficient.

"Peers feel uncomfortable ratting out a colleague," says Thomas Gallagher, MD, an internist and bioethicist at the University of Washington in Seattle, who has studied late-career trajectories. (He was a co-author of the JAMA Surgery study, among others.)

And although some doctors report to leadership that they sense a decline in their abilities, Gallagher notes that "the physicians who are struggling the most with the effects of aging are the least likely to be aware of their own limitations."

In ongoing professional-practice evaluations, older doctors are often in a "gray zone," Katlic says. Their skills have faded but not egregiously enough to warrant restrictions. By the time signs appear that an older doctor's decline is more troubling, Gallagher adds, "bad things have already happened" for patients.

That has left it to administrators, such as department chairs and peer review bodies, to grapple with these sensitive matters on a case-by-case basis. "Medical directors are in the difficult position of trying to figure out how to manage these situations," White says. The policies vary in such details as the types of assessments, which clinicians are evaluated, when the age for assessment kicks in, and how the results are handled. The tests typically include some mix of memory, motor skills, vision, and strength, White notes. The timing of the assessments tends to align with when a clinician applies for privileges or is up for recredentialing of privileges (which typically occurs every two years) after a certain age.

Here are some examples:

LifeBridge: The assessment policy starts at age 75, requiring a physical exam, eye exam, and neurocognitive evaluation in order for the privileges application to be processed. The policy has been adopted across the LifeBridge system, Katlic says.

UVA (University of Virginia) Health: Starting at age 70, a mandatory history and physical examination is performed by an internist, says Karen Warburton, MD, professor of medicine and director of UVA Health's Clinician Wellness Program (CWP), which implements the policy. It includes neuropsychological testing for cognitive impairment that covers attention, language, and memory. The initial exam process takes 30 to 60 minutes, Warburton says.

UPenn Health System: Administered starting at age 70, the test consists of six sections of a few minutes each. The sections include object identification, manual dexterity (such as tapping a keyboard space bar on cue), and matching symbols and letters. "It's less than half an hour," Brennan says.

The doctors being tested "have to take the screening before their application [for renewal of privileges] can go forward," Brennan adds. "You can refuse to take the screen, but the department in question will do an FPPE [Focused Professional Peer Evaluation] to assess your practice."

Yale New Haven: Mandatory as of age 70, neuropsychological and eye exams assess memory, executive function, processing speed, and related abilities.

Impact of results

When assessments return results that raise concerns, the case might be handed over to leadership - such as a department chair or credentialing committee - to decide on next steps. (Some systems, such as UVA, retain that process with the assessment team and don't share results with hospital leadership.) The policies tend to give wide latitude.

"Policies prioritized institutional discretion in interpreting and responding to test results," according to the study published in Annals of Internal Medicine, for which White and Gallagher were lead authors.

The actions might require more frequent assessments, restrictions on the procedures that a doctor is allowed to perform, the conditions under which the doctors perform them (such as with an assistant), workload reductions, or measures to mitigate impairments (such as physical therapy or magnification of radiological images).

Much depends on how a condition affects the core of what the doctor does. Says White: "An internist might be able to continue practicing with limited eyesight and an excellent cognitive screen result, but a radiologist who's cognitively intact but has limited eyesight probably couldn't do their job at some point."

There are few aggregate results on the assessments at specific institutions. Across systems, the best evidence is that 12% to 14% of assessments reveal concerns requiring follow-up, White says.

At UVA, approximately 200 people have been screened since the program began in 2011, Warburton says.

"It is very rare that individuals score below the defined cutoffs on the neuropsychological testing, and even rarer that the medical evaluation uncovers an issue that leads to a change in clinical privileges," she says. She recalls the latter happening with four clinicians, one of whom could not continue clinical care.

Some physicians have pushed back against the policies, arguing that they have demonstrated their commitment to patient well-being through decades of practice and would best know when they should pull back. Sometimes, Katlic says, a doctor retires before the assessment is initiated or on the basis of the results.

Another major objection has come from the federal government, through the EEOC lawsuit against Yale. Progress in the case over the past few years deals largely with procedural matters, such as document discovery. Gallagher says the lawsuit "has had a chilling effect on some organizations," which paused plans to develop similar policies.

In Utah a law took effect in 2023 that prohibits age discrimination in employment, including restricting health care facilities from mandating cognitive tests for physicians based solely on reaching a specific age.

Leaders say several elements of these policies can somewhat mitigate the concerns expressed by clinicians and government. These include bringing clinicians into the development process, ensuring that the results of assessments do not lead to the loss of a job (for example, by impacting state licensing or a faculty appointment), and ensuring that the results are kept private from colleagues and even, in some cases, supervisors.

The last item is not always fully possible, because supervisors (such as department chairs) often must make decisions based on the assessment results. At UVA, Warburton points out that the evaluations and discussions with physicians are done by the CWP - the wellness program that she directs - without involvement of a department chair or credentials committee.

That "provides an additional layer of confidentiality for practitioners," she says. The CWP works with physicians on retesting, accommodations, and changing privileges or patient-care responsibilities when concerns arise.

Katlic himself commenced a sort of semiretirement when he reached age 73 last year. He'd made that decision long ago, unrelated to the assessments that would eventually kick in at LifeBridge through the program he directs.

"For my own pride," he says, "and feeling that I've always done the right thing for my patients throughout my 40-year career, I decided that on this date I was going to retire as chair of surgery and I would stop doing elective surgery."

He smiles and recites a famous show business maxim that has spread to wider use: "You want to leave the stage while they're still clapping."