Diagnosing the aging physician

The cardboard boxes piled floor to ceiling in the basement of Dr. Ah-Yin Eng's office hold more than just medical records — they hold stories. Some of these stories, the remnants of 37 years of family practice, didn't end well. Standing amid the stacks that line the wood-panelled walls, Eng grimaces as he recalls the 8 patients he lost to lung cancer. For the 79-year-old doctor, an antismoking advocate of some renown, the memory stings. But this stockpile of manila folders, some an inch thick, also contains positive stories — accounts of conquered illnesses and trouble-free pregnancies and thriving babies.

“Some of the babies I delivered are now practising medicine,” says Eng, who lives and works in Pembroke, a city of 15 000 in eastern Ontario.

Lately, Eng has been sharing a story about doctors. It's a tale he wishes didn't need telling. The Pembroke Regional Hospital, where he once treated as many as 100 emergency room patients a day, amended its professional staff bylaw last year to create a senior staff category for physicians aged 70 and above. The bylaw states that “from time to time a senior staff member's privileges may be reduced or not renewed in favour of granting privileges to a new or existing active staff member.”

Many hospitals around the world harbour concerns about their dependence on aging medical professionals. About 24% of Australia's medical workforce is at least 55 years old. In Canada, the percentage of doctors aged 65 or above is expected to reach 20% by 2026. Australian and Canadian researchers have, in fact, taken the lead in exploring how the greying of the medical profession is affecting health care.

Researchers have learned that determining exactly how aging affects a physician's performance isn't straightforward. Nor is it easy to decide at what point older doctors should be encouraged to hang up their stethoscopes rather than be encouraged to improve their skills. Refusing to employ capable doctors because they have a lot of candles on their birthday cakes reeks of ageism. On the other hand, allowing physicians to keep working long after their skills have slipped below par endangers the public. But most experts agree that older physicians make valuable contributions to health care and, considering the doctor shortage in Canada, it's important not to alienate strong performers when weeding out those unfit to practise.

To address concerns about aging doctors, Canadian hospitals began creating senior staffs about a decade ago, says Joshua Liswood, a Toronto lawyer who helped draft the Pembroke bylaw. (The Pembroke Regional Hospital's president, Noel White, suggested the CMAJ contact Liswood for comment on the new bylaw.) He estimates that between 30% and 50% of Ontario hospitals follow some incarnation of an age-based staffing policy. Because many hospitals, particularly those in rural areas, have trouble attracting doctors, they are loath to let go of older physicians. However, administrators don't want the resources required to employ older staff to preclude them from recruiting younger doctors, who could serve their communities for years to come.

“It was out of the interest to fully utilize the available and capable physician without an age restriction but still meet the ongoing obligations to the community that resulted in the genesis of the senior staff category,” says Liswood, chair of the national health practice for Miller Thomson LLP.

Eng, a slim, energetic man who, in the words of one Pembroke native, is “as sharp as a cricket,” claims the new designation is an insult to older competent doctors. He believes it amounts to nothing more than age discrimination. Although he voluntarily withdrew from active staff 5 years ago, the new policy still affects him personally; his wife, a 74-year-old anesthesiologist, still puts in 14-hour days at the hospital. He worries that she could be dismissed without cause at the administration's whim.

Though he is winding down his solo practice, Eng has no intentions of retiring from medicine altogether. He acknowledges that some physicians become physically or mentally incompetent with age, but believes each case should be considered individually. Having come up empty in his search for studies that suggest reclassifying older physicians en mass benefits the public, Eng has formed a blunt opinion: The Pembroke Regional Hospital has, in effect and for no good reason, labelled all older doctors as second-rate. “We're supposed to practise evidence-based medicine, but they don't have to practise evidence-based administration.”

There is, however, ample evidence that patients often have better outcomes when cared for by younger physicians. One study found that someone undergoing a complex operation, such as pancreas removal or heart bypass, is more likely to die within 30 days of surgery if the surgeon is 60 or older (Ann Surg 2006;244[3]:353-362). When Harvard Medical School researchers explored the topic, they discovered that 45 of 59 studies relating physicians' ages to quality of care indicated that older doctors perform worse than younger doctors in many areas, including screening for cancer and diagnosing depression (Ann Inter Med 2005;142[4]:260-73).

But experts on aging warn against jumping to conclusions. Doctors nearing traditional retirement age, as well as those who have long since surpassed it, vary widely in their abilities. Studies may consistently find a negative relationship between age and performance because those who continue to practice despite being impaired are dragging down the group as a whole.

“To make sweeping statements about people falling into a different class or category based on their age alone is probably inappropriate,” says Kevin Eva, associate chair of McMaster University's Department of Clinical Epidemiology and Biostatistics. “There will be some exceptional doctors practising into their 90s.”

Eva's interest in the performance of aging doctors stems from contra-dictions he discovered in the scientific literature. Although many studies show overall ability declines with age, some data suggests that older doctors are superior at particular tasks, such as making initial diagnoses.

In the journal Academic Medicine, Eva argued that this disparity might exist because of changes in the way people think as they age (Acad Med 2002;77[10]:S1-S6). Older doctors make more accurate initial diagnoses because they tend to rely on non-analytic diagnostic strategies — that is, they often go with their guts. With years of experience to draw upon, it's little surprise they often hit the mark. This tendency most likely increases as sensory acuity degrades. “Declining visual or auditory capacities could facilitate a reliance on gist,” writes Eva.

Doctors with less experience rely more on analytic reasoning to make diagnoses. Since about 40% of initial diagnoses prove incorrect, the reluctance of some older doctors to explore alternatives can lead to problems. That's not to say analytic reasoning is superior to nonanalytic reasoning, stresses Eva. “If one takes too long analyzing a problem, it can hurt performance. If you go with the gut too much, it also hurts performance.”

The challenge lies in determining why older doctors often struggle to abandon incorrect first impressions and if this tendency can be tempered. If some form of neuropsychological impairment is the cause, efforts to remediate the problem might be futile. If it instead stems from the natural effects of aging, Eva argues, perhaps older doctors could be trained to be more critical of their initial diagnoses. “I'm more optimistic that we may be able to find strategies to help people keep practising.”

Dr. Galt Wilson, former president of the College of Physicians & Surgeons of British Columbia, shares Eva's optimism. There are means to optimize the performance of older doctors who aren't impaired, he says. And Canada is too dependent on older doctors to not explore ways to prolong the careers of those who wish to keep working. “Some of the most productive doctors are the oldest doctors.”

The skills of older doctors complement those of younger colleagues and the creation of mixed-aged practices would benefit not only the medical profession but the public, says Wilson. Because older doctors are less capable of tolerating sleep deprivation or maintaining a frenetic pace, hospital administrators should schedule them accordingly. Wilson also encourages older physicians not to ignore physical problems, such as vision or hearing impairment.

Though optimistic that capable older doctors can compensate for their weaknesses, Wilson believes that, at some point, skills lost are gone forever. “I see no reason for optimism as to the prospects of incompetent older doctors regaining their competence.”

Rather than forcing incompetent doctors to retire, medical regulators prefer to allow them to exit gracefully. But older doctors — who, more so than younger physicians, define themselves by their profession — can be notoriously averse to retirement. Those who practise too long run the risk of sullying their reputations.

“It is tragic when doctors' distinguished careers are tarnished by declining clinical judgment, knowledge or skill and it is thus advisable that doctors retire before age adversely influences their performance,” write Australian physicians Dr. Kay Wilhelm and Dr. Carmelle Peisah (Intern Med 2002;32[3]:457-9).

Although many doctors do realize when their white-coat days are over, some are simply unaware of their own incompetence. This became more apparent to Australian medical boards after a study of doctors flagged by the Impaired Registrants Program in New South Wales was released last year (Int Psychogeriatr 2007;19[5]:974-84). More than half of the 41 doctors examined were cognitively impaired and, more worrisome, 5 had frank dementia. Though the study was small, coauthor Peisah says the findings are still cause for concern.

“We just want doctors to realize that they, like their patients, are vulnerable to the vicissitudes of aging. You can't go on forever and you can't be a doctor forever.”

Peisah and Wilhelm claim proactive measures are needed to address the issue. Older doctors should be encouraged to find interests outside medicine. Those worried about loss of income should receive financial counselling. To alleviate retired physicians' concerns about losing status in the community, some medical boards allow them to keep the title of “doctor” and even permit them to retain limited prescription privileges.

“The aim is to guide them towards a dignified retirement,” says Wilhelm.

Dignified or not, retirement is not something Dr. Joseph Foohey of Pembroke sees in his future. Though Eng is more vocal in his opposition to the hospital's bylaw, Foohey, who has been on staff since leaving the army in 1949, also feels that he's been “downgraded.” Like Eng, he's skeptical of the grounds for creating a senior staff, believing a good doctor is a good doctor regardless of age.

“I think a doctor is like a clergyman. This is my calling. As long as I can keep going, I'll keep going,” says Foohey, a New Brunswick native who admits to being over 80 but keeps his age to himself. “Maritimers don't discuss their age or how much money they have.”

Two mornings a week, Foohey sees patients at a clinic. On Wednesdays he visits residents at the Marianhill long-term care facility, where his wife lives. If any of his patients are in hospital, he visits them — everyday, even holidays. He also attends weekly post-graduate medical lectures. “When you stop wanting to learn, that's the time you should quit.”

On this day, a Friday, Foohey has the morning off. But at noon his kitchen clock, on which each hour is represented by a different bird, starts to chirp — a reminder of the afternoon patient visit he has planned. Things are normally slow for him this late in the week, but he has been busier than usual of late. “I'm covering for another doctor for 2 weeks.”