In April of last year, a task force appointed by Dean Philip Pizzo began working to develop a policy for late career practitioners at Stanford. After first seriously considering whether Stanford should have such a policy and why, the task force developed a Late Career Practitioner Policy that has been approved by the Medical Executive Committee and will be implemented in September. The complete policy and some frequently asked questions are posted on the Medical Staff website. It is important to note that this is a Medical Staff policy, and therefore addresses only clinical privileges at SHC. Decisions about teaching, research and faculty appointments are made independently by the School of Medicine.
Let me tell you a little bit about why the policy was developed, and what it entails.
As we age, the natural aging process and specific medical conditions and medications have the potential to adversely affect our capacity to carry out our clinical responsibilities. Most of us have known at least one physician who practiced beyond the time when he/she was most effective, and many of us have struggled with how to best handle that knowledge to protect patients and the reputation and self-esteem of the physician. For these reasons, the task force decided that it was important from the point of view of both patient safety and physician well-being to establish a process by which late career physicians’ performance and capacities can be fairly and accurately evaluated.
The policy provides for a three-component screening process for physicians age 75 and older who have clinical privileges at SHC. The first component is a peer assessment by three colleagues on the medical staff who are in a position to evaluate the practitioner’s clinical performance. These colleagues will be chosen from among six recommended by the practitioner himself/herself. They will be asked to complete a clinical evaluation form that has been adapted from the form currently used by the School of Medicine in the faculty appointments and promotions process.
The second component of the screen is a comprehensive history and physical exam, typically to be performed by the individual’s primary care physician.
The final component of the screen is a cognitive screen, which will be performed by experts in the neuropsychology division of the Stanford Department of Neurology, and paid for (at least in the first year) by a grant from the Stanford University Medical Indemnity and Trust Insurance Co.
It is important to recognize that this is a screening evaluation, not a pass/fail test, and if there are any potential patient-care concerns identified during the screening evaluation, further evaluation will be recommended if indicated.
Age 75 was chosen somewhat arbitrarily, but the choice was guided by data that show that the rate of decline of cognitive functions, including inductive reasoning, spatial orientation, perceptual speed, numeric ability, verbal ability and verbal memory, is relatively slow from age 60 until age 75, when it begins to increase at a faster pace. In addition, according to the Alzheimer’s Association, rates of Alzheimer’s disease increase significantly with age. Of those with Alzheimer’s, only 10 percent are younger than 75; 45 percent are 75 to 84; and 45 percent are 85 or older.
Thus, it seems reasonable to evaluate practitioners as we age, but only 5 to 10 percent of U.S. hospitals do any kind of screening of late career physicians. Stanford is now one of a very few major academic medical centers with such a policy, and admittedly there are no data thus far confirming that this policy will alter patient outcomes. However, there are many data to support the value of evaluating practitioners as we age. In some complex procedures, the patients of surgeons older than 60 have higher mortality rates than those of younger surgeons (Waljee,Annals of Surgery 2006). Most concerning is the fact that the preponderance of evidence from a systematic review of physician self-assessment suggests that physicians have a limited ability to accurately assess their own competency (Davis, JAMA 2006).
Although this kind of evaluation is uncommon for physicians, a number of professions actually have mandatory retirement ages even in the absence of demonstrated concerns or prior screening. The Federal Aviation Administration mandates retirement of commercial pilots at age 65 and of air traffic controllers at age 56 (with some exceptions up to age 61). FBI special agents and national park rangers are required to retire at age 57, and some states even require volunteer firefighters to retire when they reach a certain age.
Of note, the medical staff of Lucile Packard Children's Hospital has had a similar policy in place since early last year (screening practitioners beginning at age 70), but has adopted this newer policy to supersede its earlier policy.
To quote the policy, "Key elements … are to assure high quality care for the patient, to be supportive of the practitioner and to address issues that the individual may not recognize." It is clearly a first step, and may need to be altered as we gain experience with this process.
We sincerely appreciate and truly value the expert clinical service and other valuable contributions to this institution now and throughout the distinguished careers of the late career members of our medical staff, many of whom plan to continue to contribute as long as possible. I have spoken individually with almost all of the SHC physicians who will be newly affected by this policy, to personally make them aware of it and to answer questions they may have had. I will be happy to answer any questions others may have as well.
As always, feel free to tell me what you think.
Ann Weinacker, MD