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
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.