Webinar: Too Old to Practice: Should There Be a Cut-Off Age for Physicians?

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Too Old to Practice: Should There Be a Cut-Off Age for

Physicians?

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SPONSORED BYToo Old to Practice: Should There Be a Cut-Off Age for Physicians?

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Jaclyn Schiff

ModeratorEditorial Programs Manager

Modern Healthcare

Too Old to Practice: Should There Be a Cut-Off Age for Physicians?

Welcome!

During today’s discussion, feel free to submitquestions at any time by using the questions box

A follow-up e-mail will be sent to all attendees with

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SPONSORED BY

Dr. Mark KatlicChairman, Department of

Surgery and Surgeon-in-ChiefSinai Hospital of Baltimore and

Northwest Hospital

Dr. Janis M. OrlowskiChief Health Care OfficerAssociation of American

Medical Colleges

Lisa McGiffertDirector

Safe Patient Project

Dr. Ann WeinackerVice Chair of Medicine, Quality ImplementationStanford Health Care




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Dr. Janis M. Orlowski

Chief Health Care OfficerAssociation of American Medical Colleges


780000

790000

800000

810000

820000

830000

840000

850000

860000

2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025

Projected FTE Physician Supply: All Physicians

Retire Later +2

GME Growth

Status Quo

Millennial Hours

Retire Earlier -2

Retirement scenarios create the two most extreme

physician supply projections:

Source: 2016 Update: The Complexities of Physician Supply and Demand: Projections from 2014 to 2025

A growing number of active physicians are approaching

retirement age.

16,356

(2013)

22,946

(2020)

22,492

(2025)

0

5,000

10,000

15,000

20,000

25,000

2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025

Number of physicians reaching age 65

Source: AMA Physician Masterfile (December 31, 2012)

Mean Age of Retiring Physicians (age 50+)

63.364.5 65.6 66.0

68.4 67.6 68.1 68.2 67.1 67.7

0

10

20

30

40

50

60

70

80

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Me

an

Age

Year

Source: AAMC analysis of the American Community Survey. Vertical lines represent standard errors for individual-year estimates.

A large share of physicians retire between ages 71-73

Sex NAverage Age

Female 8,451 69

Male 47,561 73

Average age of physicians who retired between 2007 & 2014

Source: AMA Physician Masterfile

Physicians at the oldest ages comprise a greater share of the workforce now than in years past.

0

5

10

15

20

25

30

35

45-54 55-64 65-74

Perc

ent

Age distribution of active physicians over time

2007 2008 2009 2010 2011 2012 2013 2014

Source: AMA Masterfiles, 2007-2014

39% of physicians planned to accelerate their retirement plans in response to how health care is changing.

Source: Physician’s Foundation 2014 Survey of America’s Physicians



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Lisa McGiffert

DirectorSafe Patient Project


What patients need from doctorsWhat patients need from doctorsWhat patients need from doctorsWhat patients need from doctors

• Competence and skill (especially for surgeons)

• Knowledge about procedures being recommended/done; drugs being given; medical devices being used

• Honesty about the risks and options

• To be listened to and for preferences to be taken seriously

• Communication in language they can understand

Goal: give patients what they need and do no Goal: give patients what they need and do no Goal: give patients what they need and do no Goal: give patients what they need and do no

harmharmharmharm

• Public mis-assumptions of physician oversight

• Physicians don’t hold colleagues accountable

• Peer assessment and disclosure is needed to identify doctors who are putting patients at risk

• No ongoing reliable system for testing for incompetence or impairments of all physicians

• Timing of such testing should not rely on chronological age

• Should be triggers for such testing regardless of age

• medical errors, intervention during surgery

• Certain malpractice cases and patterns

Options beyond practice

• The wise elders – resources in education, training and expertise

• Should not assume that “aging” doctors should keep practicing for “vulnerable” and “rural” populations



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Dr. Ann Weinacker

Vice Chair of Medicine, Quality ImplementationStanford Health Care


Late Career Practitioner Policy:

Appropriate and Defensible

June 30, 2016

Late Career Practitioner Policy

at Stanford Health Care

• Requires peer clinical skills assessment and

health screening every two years for all

medical staff age ≥75 to address competence

to perform the clinical privileges requested

• May be applied to practitioners of any age

when concerns are raised about their ability to

practice competently

• Requires screening only

• Does NOT impose mandatory retirement (although some other

institutions do require mandatory retirement from clinical

practice after reaching a specified age)


at Stanford Health Care


• Age-related declines in cognitive and physical functioning can

affect professional performance -- Physicians are not immune

• Several studies of older physicians referred to medical boards

or regulatory bodies for poor practice show that about 50%

have cognitive difficulties

Mandatory retirement?

• Other professions have mandatory retirement

ages.

– Pilots: 65 (and must have regular health screening

beginning at age 40)

– FBI agents: 57

– Air traffic controllers: 56

In Support of a LCP Policy

• Many physicians recognize limitations and restrict their own practices, but others do not– Anosognosia is common as limitations develop, as is

anger in having those limitations pointed out

– Self-monitoring alone typically is inadequate

• Two studies have shown that physicians are reluctant to report concerns about the competency of one of their peers (only ~50% would do so)– One study found that 90% of physicians who would

not report assumed that the competency limitations were already known to others

Is it legal?

• This type of policy does not automatically limit the practice or

mandate retirement

• The medical profession has an obligation to ensure that its

members can provide safe and effective care

• There is strong legal support for hospitals establishing

standards for granting privileges if the standard is rationally

related to the delivery of quality health care

Is it legal?

• The policy is triggered by the age of the practitioner (age is a

screening criterion) but the testing itself is focused on competency

• Any adverse action would result from an adverse assessment of the

practitioner’s competency to practice safely

• It is not clear that ADA applies to age as a disability

• FEHA does not “prohibit compulsory retirement of any employee

who has attained 70 years of age and is a physician employed by a

professional medical corporation…[that requires] compulsory

retirement”

Is it legal?

• Under California law hospitals cannot employ

physicians so CA (e.g. FEHA) and federal employment

laws (e.g. ADEA) can be argued not to apply

– Analysis of other states’ laws necessary to see what applies

• Generally, there are defenses even under

employment laws that are helpful

• There are also defenses to federal (Age Discrimination

Act) and state (e.g. Unruh in California) laws that do

not rely on an employment connection

Growing support for age-based screening

• American Medical Association

• California Public Protection and Physician Health

– http://www.cppph.org/cppph/wp-

content/uploads/2015/07/assessing-late-career-practitioners-

adopted-by-cppph-changes-6-10-151.pdf

• American College of Surgeons

– http://bulletin.facs.org/2016/01/statement-on-the-aging-surgeon/

AMA Statement 2015*

…physicians should be allowed to remain in practice as long as patient safety is not

endangered and… if needed, remediation should be a supportive, ongoing and

proactive process. Self-regulation is an important aspect of medical professionalism,

and helping colleagues recognize their declining skills is an important part of self

regulation. Therefore, physicians must develop guidelines/standards for monitoring

and assessing both their own and their colleagues’ competency. Formal guidelines on

the timing and content of testing of competence may be appropriate and may head off

a call for mandatory retirement ages or imposition of guidelines by others.

*Council on Medical Education Report 5-A-15

Is it legal?

• The adoption of an age-based screening policy is not without

risk, but such policies are defensible and the defensibility has

increased over the past two years



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SPONSORED BY

Dr. Mark Katlic

Chairman, Department of Surgery and Surgeon-in-ChiefSinai Hospital of Baltimore and Northwest Hospital in Randallstown, Maryland


The public believes that we police ourselves

---but this is illusory---

• Initial certification difficult ---but recertification relatively easy---

• Ongoing Professional Practice Evaluations (OPPE) ---but hospital-specific and highly variable---

• Malpractice system ---neither constructed nor capable of helping with this---

• Scrutiny of peers, staff, and administrators ---many barriers to this exist---

But chronologic age alone is an inadequate marker of

impairment

Age 80 Age 80

Human faculties deteriorate with age

Powell DH. Profiles in Cognitive Aging. Harvard University Press, London, 1994;p 14.

Resource to Society

Patient SafetyDignity of

Committed

Practitioner

Liability Risk

ProtocolPre-Visit Screen Client completes history form

Client sends medical records (last H&P; last 5 years of discharge summaries, actual images---esp MRI, CT of brain and spine---and imaging reports)

Day 0 Check in to Radisson Cross Keys Hotel

Day 1 Drive or shuttle to Sinai Hospital8:00am Welcome, Breakfast/Introduction to Program 8:30am General physical examination; hearing screen9:30am Neurology examination10:30am Physical/Occupational Evaluation A12:00pm Lunch/Rest1:00pm Neuropsychology Evaluation A4:30pm Drive or shuttle to Radisson Cross Keys Hotel

Dinner and Evening on own

Day 2 Drive or shuttle to Sinai Hospital8:00am Breakfast8:30am Neuropsychology Evaluation B12:00pm Lunch/Rest1:00pm Physical/Occupational Medicine Evaluation B2:30pm Ophthalmology Examination4:00pm Exit Interview4:30pm Drive or shuttle to Radisson Cross Keys Hotel or Airport or Train

Physical and Occupational Therapy

Evaluation

www.AgingSurgeonProgram.com

Katlic MR. Ann Surg 2014; 260:199-201..

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SPONSORED BYToo Old to Practice: Should There Be a Cut-Off Age for Physicians?

Dr. Mark Katlic

Chairman, Department of Surgery and

Surgeon-in-Chief, Sinai Hospital of

Baltimore and Northwest Hospital

Dr. Janis M. Orlowski

Chief Health Care Officer, Association of

American Medical Colleges

Dr. Ann Weinacker

Vice Chair of Medicine, Quality

Implementation, Stanford Health Care

Lisa McGiffert

Director, Safe Patient Project