Air traffic controllers face mandatory retirement at age 56, with exceptions up to 61. Commercial airline pilots must bow out at 65, same for foreign service employees. Physicians, however, have no age limit, regardless of specialty.
That doesn't mean the topic of "how old is too old," hasn't been one of the profession's most heated debates for many years now.
As the profession rapidly ages — some 30% of the physician workforce is currently a senior, according to the AMA — the topic of whether or not there should be a standard measure or age for retirement is front and center. The AMA's Council on Medical Education formed a workgroup to look into the issue in 2015 and 2018, and in 2021, delegates adopted a set of guidelines for screening and assessing physicians, but stopped short of a mandate.
Mark Katlic, MD, chair of surgery at Lifebridge Health System, Baltimore, Maryland, has devoted a decade of time studying this topic. "I'm a bit of an outlier looking into this," he says. "The public is unaware and seemingly unconcerned about the issue. Even among the medical profession, there's been a series of fits and starts to develop a cohesive approach."
One of the reasons guidelines — mandatory or otherwise — have been tough to come by is that aging brings with it a huge degree of variability. "If you look at a group of 80-year-olds, there will be much more variability than within a group of 40-year-olds," Katlic points out.
Indeed, some 80-year-olds can easily continue to teach college courses, keep up in 10k running races, or perform delicate surgeries. Yet others in their peer group might struggle to properly button a shirt, walk a flight of stairs, or remember yesterday's meals. Functional age is not the same as chronological age.
Frank Stockdale, MD, PhD, an 86-year-old practicing oncologist at Stanford University Health, counts himself in the camp opposed to age-based assessments. "It's age discrimination," he says. "Physicians receive assessments throughout their careers as part of the accreditation process — there's no need to change that as doctors reach a certain age."
Stockdale even suggests that in many cases, malpractice suits are filed against mid-career doctors, not those of advanced age. "If you're using the argument that there is an accumulation of deficits with age, the fact is that those deficits begin well before your 70s," he says. "It's better to have a uniform screening policy and begin at a much younger age."
At Stanford, in fact, there was a former assessment policy that included cognitive testing, but physicians were successful in seeing that portion of testing eliminated. "It is a physical examination, by a physician of choice, certifying that for the privileges requested there is no physical or mental reason the candidate cannot safely perform them," Stockdale explained.
In some cases, medical staffs have filed lawsuits to fight age-related testing. In New Haven, Connecticut, for instance, the US Equal Employment Opportunity Commission (EEOC) filed a suit in 2020 on behalf of the Yale New Haven Hospital staff, alleging a discriminatory "late career practitioner policy."
A similar case in Minnesota reached a settlement in 2021, providing monetary relief to staff impacted by out-of-pocket costs for the assessment, in addition to requiring that the hospital in question report to the EEOC any complaints related to age discrimination.
James Ellison, MD, MPH, chair in Memory Care and Geriatrics with ChristianaCare in Wilmington, Delaware, points out that aging can also bring benefits for practicing physicians. "Age is very individualized and there are good and bad consequences," he said. "Experience can build knowledge and confidence and expertise, and it does improve diagnostic accuracy."
On the flip side, however, age-related brain changes include loss of volume and lower levels of some neurotransmitters, resulting in cognitive changes. "Functional changes occur too," Ellison said.
"Just as some aging athletes may lose a degree of speed, strength, and flexibility, and some aging scientists may lose a part of their former cognitive speed, flexibility, and mental strength, aging healthcare providers can lose some of the physical coordination, strength, and visual acuity necessary to perform demanding surgical operations. They can also lose some of the processing speed, working memory, and executive function that allows them to excel in cognitive professional tasks."
An estimated 5.8 million Americans age 65 and older have Alzheimer's dementia today, according to the Alzheimer's Association.
Picking an arbitrary age for mandatory retirement isn't the right approach for physicians, said Katlic. Rather, he said, the answer is to establish late-practitioner screening programs. "Very few hospitals have them, however," he points out. "We do [at Lifebridge Health], and so do a few dozen others, but that's out of hundreds."
Instead, what typically plays out is that hospital staff might begin to notice a decline in a colleague. Things like a disheveled appearance or lack of hygiene, or trouble with memory, such as getting lost en route back to his or her office. Even dangerous behaviors like nodding off during a procedure are not unheard of.
There are many examples of physician decline that fly under the radar. "Unfortunately, it's unusual for cognitively impaired healthcare providers to recognize and report their own difficulties," said Ellison. "Although peers are expected to report cognitively impaired colleagues, they often fail to do so. In some other countries, age-based assessment is an accepted policy. In the US, this is not a uniform policy."
Sometimes physicians can remain on the job in spite of decline thanks to certain "props," according to Ellison. "Good procedures, efficient supports, and various work-arounds compensate," he says, "but often are not sufficient to maintain high-quality practice."
Most often, these situations play out slowly, until the problem becomes glaringly obvious and potentially dangerous, and someone in a position of power must step in. "Often, it's hearsay from a nurse or another staff member, and then a hospital president or chief of staff must make a career-affecting decision for the doctor in question," said Katlic.
Because there is little self- or colleague policing — and barring official or binding guidelines on the aging physician issue — both Katlic and Ellison are proponents of late-career screening.
How Screening Can Help
As it stands now, Katlic maintains that the profession isn't doing enough to ensure public safety. "We have peer review and recertification processes, but when you get down to it, we don't police ourselves well," he said. "All physicians are assessed throughout their careers as part of the hospital accreditation process, which is fair and adequate."
Katlic said that there are three main benchmarks that physicians should be able to meet at an agreed upon age: a physical exam, a neurocognitive screening, and an eye exam. "At some reasonable age, I personally believe these exams should take place," he explains. "We can allow doctors to pick their own practitioners for the eye and physical exams, but the neurocognitive exam should be completed by a PhD neuro-psychologist."
At Lifebridge, for instance, these screenings begin at age 75 and take place every 2 years, during the recredentialing process. It applies to all specialties, not just surgeons. "Surgery is a little different in that it requires fine motor skills in addition to the others we test, but you want any physician to be cognitively intact," Katlic points out. "All doctors need the ability to make decisions quickly, often under noisy, distracting conditions."
Ellison supports applying the screenings to all specialties. "Let's not forget that all physicians must be alert to the many ways in which their patients reveal what needs attention, evaluation, and treatment," he reminds. "Some healthcare tasks could be performed without visual input, for example, perhaps psychotherapy could be provided competently by a clinician who lacks visual acuity. Auditory input might not be necessary for reading X-rays — but the information a healthcare provider gets from their eyes and ears is important, not just for surgeons."
University of California San Diego has established what it calls its Physician Assessment and Clinical Education (PACE) program. One of the nation's oldest and largest such programs, the hospital founded PACE in 1996. Most physicians taking part arrive as a requirement of disciplinary action from the state medical board, but a small percentage self-refers.
PACE involves two phases. The first is a 2-day set of tests and measures core competency knowledge. Phase 2 is more comprehensive and lasts 5 days. Here, within their specialty, physicians participate in the activities of the corresponding residency program. Faculty evaluates the physician, and a multidisciplinary team meets to review all the findings of the combined phases.
Depending on the results, doctors may face remediation steps that range from programs to address performance deficiencies to residency-level clinical experiences. According to a paper on the program published by the institution, "most physicians referred to the PACE program are found to have mild-to-moderate performance dyscompetence."
In the case of the 2021 guidelines adopted by AMA delegates, there are nine principles for assessment. They should be evidence-based; ethical; relevant; accountable; fair and equitable; transparent; supportive; non-burdensome; and afford physicians due process protections.
Even Katlic worries about the possibility of Congress intervening to establish federal-level, mandatory retirement age. "This just doesn't make sense for our profession given the great variability we see," he said. "My biggest hope is that more individual hospitals will institute these screenings."
As the physician population ages — and the influx of new doctors shrinks — the slope becomes even more slippery. The AMA is predicting a physician shortage of nearly 40,000 by the year 2034. This strengthens arguments to keep existing physicians practicing for as long as possible and might make institutions less likely to screen.
It's all a delicate balancing act and a continuing work in progress, said Ellison. "Ultimately, I believe we need to find a way to understand and address the possible implications for public safety, while at the same time protecting the privacy and dignity of our valued older physicians and other healthcare providers."
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Image 1: Betsy Stockdale
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Cite this: How Old Is Too Old to Work as a Doctor? - Medscape - Apr 27, 2022.