The aging physician: Maintaining competence and practising safely
Originally published March 2016
As physicians age, there is increasing attention on their ongoing clinical competency by medical regulatory authorities (Colleges) and others. Aging physicians and their colleagues should be familiar with the main issues associated with working later in life, including the key medical-legal risks, and how to support the ongoing delivery of safe medical care.
Research and anecdotal reports suggest a range of clinical performance among older physicians. These doctors can bring significant knowledge and experience to their practice and the profession, and many perform at the same level or close to the same level as their younger peers.1 Some are able to maintain their full practice or continue in some form by modifying their work, for example changing the type of activities they perform or the number of patients they see. Others may experience challenges as they age and may need to stop their medical practice earlier than they expected. And some may have limited ability to assess their own competence2 and may be unaware of a decline in their performance.
Health problems and cognitive decline
Physicians generally retain their deep medical knowledge as they age, but several factors related to aging may impact their health and cognitive abilities. A 2011 study shows the prevalence of mild cognitive impairment is estimated to be 10% to 20% in individuals who are 65 years old and older.3 Sensory and motor impairment, decreasing working memory, and slowing speed of mental operations can affect physicians’ analytical processes as they grow older.4 While the effects of aging vary from doctor to doctor, other factors impacting an older physician’s level of competence include personal issues, practice setting, clinical volume, specialty, and overall level of stress.5
Doctors also face the same health issues as the general aging population, making them susceptible to infections, stroke, diabetes, dementia, and other acute and chronic illnesses and conditions. These health issues, and others, may be detrimental to older physicians’ performance and may increase risks in their practice.
Risks to healthcare safety
Several studies indicate deficient performance due to age-related issues of some physicians may place patients at risk. An American 2005 study concluded some “…older physicians possess less factual knowledge, are less likely to adhere to appropriate standards of care, and may also have poorer patient outcomes.”6 As well, some older physicians may be less likely to acquire knowledge over time and others may hesitate to renew their training or to stay abreast of the latest clinical practices.5 A 2006 study that looked at surgeon age and operative mortality in the United States found that “for most procedures “…surgeon age is not an important predictor of operative risk,” however, "for some complex procedures, surgeons older than 60 years, particularly those with low procedure volumes, have higher operative mortality rates than their younger counterparts."7
This does not discount the fact many senior physicians bring advanced experience that can positively affect patient outcomes. And as some areas of the country are experiencing doctor shortages, it can be to everyone’s advantage to support older physicians who are performing well in practice.8
Monitoring aging physicians: College and hospital policies
There are no national guidelines in Canada to help ensure older doctors are still competent to practise safely and effectively, nor is there a mandatory retirement age for doctors. Some Colleges monitor and test older physicians through audits, competency reviews, and other programs. For instance, the College of Physicians and Surgeons of Manitoba initiates chart audits at age 75 and repeats them every five years,9 while the College of Physicians and Surgeons of Ontario conducts peer assessments at the age of 70 and then every five years.10 The Collège des médecins du Québec evaluates physicians 60 years of age and over through a questionnaire designed to assess certain risk factors.11
Some hospitals have specific guidelines requiring older physicians undergo screening to evaluate their clinical competency, as a condition to renew their privileges, and as a way to retain particular expertise that may not otherwise be available. It also has been reported many Canadian hospitals began creating senior staff categories nearly a decade ago to address these and other concerns about doctors who are aging.8
The numbers — Statistics collected by the Canadian Medical Association indicate 15% of physicians (12,128 out of 78,657 medical doctors) are 65 years of age and older. This cohort is followed by 19,555 doctors in the 55-64 age group.12 Moreover, it is estimated 20% of Canadian physicians will be 65 years or older by 2026.8
How to practise safely and maintain competence
The following tips may be helpful for physicians as they age:
- Consider your own health issues and the possibility of cognitive decline. Strive to maintain a healthy lifestyle through good diet and exercise.5
- Carefully consider the concerns of family members, treating physicians, colleagues, friends, and patients regarding your own health and practice. Seek timely assistance and support for issues and problems.
- Where appropriate, consider narrowing or limiting the scope of your practice or work, shortening your work hours or week, and decreasing the workload based on the time demands, your stamina, and fatigue levels.4
- Take appropriate time with cases requiring rapid cognitive processing, when necessary. Plan for longer appointments for patients with complex medical problems.5
- Avoid, where possible, practising in isolation and work in collaboration with other providers.
- Be familiar with any relevant College competency review programs, and hospital guidelines and policies regarding screening to maintain competency and proficient performance in practice.
- Consider self-assessment programs such as those offered by the Royal College of Physicians and Surgeons of Canada13 to assess your knowledge and practice to further enhance your competence.
- Keep up to date with clinical standards, and meet requirements for continuing medical education and professional development.
- Document patient care in medical records. A physician’s thought process is demonstrated through good documentation.
- Consider your approach to retirement so you can continue to meet the needs of your patients and your own personal goals.
- If you are in an administrative position, collaborate with all members of your department to support aging physicians.
- If you encounter a colleague or another doctor who appears to be having difficulties possibly due to advancing age, it is advisable to talk with the doctor directly and privately. An open and honest discussion, carried out with empathy, is usually well-received. If it is not, speak to another colleague or physician leader for guidance and support. Furthermore, be familiar with the legislation and College policies on reporting in your province or territory in case you conclude you have a legal duty or ethical responsibility to report a physician’s health decline possibly due to advanced age.14
- If you feel you are being discriminated against based on your age, consider contacting the CMPA for advice.
In many cases, doctors can successfully modify their medical practice to accommodate changes as they age and continue to meet their patients’ needs.
- Drag LL, Bieliauskas LA, Langenecker SA, Greenfield LJ. Cognitive functioning, retirement status, and age: results from the Cognitive Changes and Retirement among Senior Surgeons study. J Am Coll Surg 2010;211(3):303-7.
- Davis DA, Mazmanian PE, Fordis M. Accuracy of physician self-assessment compared with observed measures of competence. JAMA 2006 Sep 6;296(9):1094-102.
- Peterson RC. Mild Cognitive Impairment. N Engl J Med. 2011;364(23): 2227-234.
- American Medical Association. Competency and Retirement: Evaluating the Senior Physician. AMA Wire [Internet]. 2015 June 23 [cited 2015 Nov 2]. Available from: http://www.ama-assn.org/ama/ama-wire/post/competency-retirement-evaluating-senior-physician.
- Lee L, Weston W. The Aging Physician. Can Fam Physician [Internet]. 2012 [cited 2015 Nov 2];58(1):17-18. Available from. http://www.cfp.ca/content/58/1/17.full.
- Choudhry NK., Fletcher RH, Soumerai SB. Systematic Review: The Relationship between Clinical Experience and Quality of Health Care. Ann Intern Med [Internet]. 2005 [cited 2015 Nov 2];142( 4):260-74. Available from: http://annals.org/article.aspx?articleid=718215.
- Waljee F, Greenfield L, Dimick J, Birkmeyer J. Surgeon age and operative mortality in the United States. Ann Surg [Internet]. 2006 [cited 2016 March 29]; 244(3):353-362. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1856535/.
- Collier R. Diagnosing the Aging Physician. CMAJ [Internet]. 2008 [cited 2015 Nov 2];178( 9):1121-123. Available from: http://www.cmaj.ca/content/178/9/1121.full?ijkey=93ec04862c1862cbf333b253bb42abcf780cb25f&keytype2=tf_ipsecsha.
- Annual Report 2014 [Internet]. Winnipeg (MB); College of Physicians and Surgeons of Manitoba;[cited 2016 Jan 21]. Available from: http://cpsm.mb.ca/cjj39alckF30a/wp-content/uploads/CPSMAnnRep2014.pdf.
- Selection for Assessment [Internet]. Toronto (ON); College of Physicians and Surgeons of Ontario, Peer Assessment section; [cited 2016 Jan 21]. Available from: http://www.cpso.on.ca/CPSO-Members/Peer-Assessment/Selection-for-Assessment.
- Nouveau Programme 60 Ans. Le Collège [Internet]. 2015 [cited 2015 Nov 10];55(1): 21. Available from : http://www.cmq.org/publications-pdf/p-5-2015-01-01-fr-hiver-2015.pdf.
- Canadian Medical Association. Number of Active Physicians by Age, Sex and Province/Territory, Canada, 2015. CMA Masterfile. 2015. Available from: https://www.cma.ca/Assets/assets-library/document/en/advocacy/04AgeSexPrv.pdf.
- Self-Assessment Programs (SAPs) [Internet]. Ottawa (ON): Royal College of Physicians and Surgeons of Canada, About Us section; 2010[cited 2016 Jan 21]. Available from: http://www.royalcollege.ca/portal/page/portal/rc/members/cpd/cpd_accreditation/self_assessment_programs.
- Canadian Medical Protective Association. Reporting another physician. Dec. 2010. [Internet]. [cited 2016 Jan 21] Available from: https://www.cmpa-acpm.ca/en/physician-wellness1/-/asset_publisher/la3xaaAQQE06/content/reporting-another-physician.