The aging physician: Maintaining competence and practising safely

With an aging physician population, doctors at all stages of their careers will want to be cognizant of the impact that aging may have on abilities like visual acuity, working memory, and speed of mental operations—and how these and other related factors may impact the safety of medical care for patients. There will likely come a time in every physician’s career when it would be prudent—or even necessary—to modify or sunset a clinical practice.

Self-awareness, practice assessments, or advice from treating physicians and colleagues may reveal cognitive or health issues. This article provides guidance on the obligations of physicians and steps they can take when their own or a colleague’s cognitive abilities or health show signs of decline.

Cognitive concerns

Studies have confirmed that many older physicians perform at the same level or close to the same level as their younger peers,⁴ though each physician’s journey and abilities are different. The literature generally highlights the importance of functional age rather than chronological age, owing to the large individual variations in aging.⁵ Indeed, many physicians are able to maintain their full practice or continue in some form even at an advanced age, by modifying their work if necessary—for example, changing the type of activities they perform or the number of patients they see. Research has identified concerns in this area, leading to calls for more research or mandatory neurocognitive screening for older physicians and surgeons.⁶⁷⁸

While implementing work modifications may be a viable option for some, this has been linked to a decrease in successful aging, possibly because of its impact on a physician’s sense of identity.⁹ Nevertheless, identifying cognitive and related health issues in physicians remains an important contributor to patient safety and in reducing medico-legal risk, as well as to enable potential options for continued work in the future.

Medico-legal risks

The CMPA’s analysis of closed CMPA medico-legal cases between 2012 and 2021 reveals that the proportion of cases where a physician’s cognitive ability was a concern increased from 0.2% among doctors 55-60 years of age to 8.3% for physicians 80 years of age and older.¹⁰ Among the cognitive-related issues that led to complaints:

• concern by a patient that their doctor was disorganized and forgetful
• a treating physician noted their physician patient was having difficulty managing their own medication regime
• an employee observed that the doctor was consistently having difficulty remembering patient names and computer passwords
• a regulatory authority (College) became concerned when a physician wrote several lengthy, repetitive letters to the College

College and hospital policies

There are no national guidelines in Canada around continued competency for older physicians to practise safely and effectively, nor is there a mandatory retirement age for doctors. Some Colleges monitor and assess physicians beyond a specified age through formal assessments and quality assurance programs. For example, in Ontario physicians are required to undergo a peer and practice assessment when they reach age 70 and then every five years thereafter.¹¹ The Collège des médecins du Québec evaluates physicians 60 years of age and over through a questionnaire designed to assess certain risk factors.¹²

Physicians should be familiar with the applicable requirements in their jurisdiction. As well, 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.

How to practise safely and maintain competence

Support yourself and colleagues

• Monitor your own cognitive and physical health, and consider the concerns of treating physicians, colleagues, patients, family members and friends regarding your health and medical practice. Consider the possibility of cognitive decline.
• Seek timely assistance and support when any concerns or questions arise about your health or practice abilities.
• If you encounter a colleague who appears to be experiencing challenges possibly due to advancing age, speak with them 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.

Evolve the clinical practice

• Where appropriate, consider modifying the scope of your practice or work, such as shifting to other clinical work (e.g. surgical assist), shortening your work hours or week, and decreasing workload.
• Factor in any additional time that may be required to address cases involving rapid cognitive processing, when necessary. Plan for longer appointments for patients with complex medical problems.
• Avoid, where possible, practising in isolation and work in collaboration with other providers who are supportive of an evolving role.
• Be particularly conscious of documenting patient care and your thought process through good documentation.
• Proactively consider your approach to winding down your practice well in advance so you can continue to plan and meet the needs of your patients and your own personal goals. (See the CMPA article “Closing or leaving a practice: Tips for primary care physicians.”)
• If you are in an administrative or leadership position, collaborate with all members of your department to support aging physicians. This support may include finding alternative contributions for the department member who must reduce or cease clinical work.

Adhere to professional obligations

• Be familiar with any relevant College competency review programs, and hospital guidelines and policies regarding screening to maintain competency and proficient performance in practice.
• Keep up to date with clinical standards, and continue to fulfill applicable requirements for continuing medical education and professional development.
• Be familiar with the legislation and College policies on reporting in your province or territory regarding physicians’ responsibilities to report a colleague who appears to be experiencing challenges in their practice.¹³ Contact the CMPA for information and advice on possible reporting obligations.

The CMPA and physician wellness

The CMPA works in collaboration with healthcare organizations to support physician wellness and offers resources aimed at helping doctors cope with stress and manage medico-legal issues. When medico-legal matters arise, the CMPA’s physician advisors are there to listen and provide individual advice and assistance.

More resources

• Physician wellness resources and links on the CMPA website
• Human Factors, CMPA Good practices

References

1. 1. 
   Canadian Medical Association. Number of physicians by specialty and age, Canada, 2000. CMA Masterfile, January 2001. Available from: https://www.cma.ca/sites/default/files/2019-03/2000-02-spec-age.pdf
2. 2. 
   Canadian Medical Association. Number of physicians by specialty and age, Canada, 2019. CMA Masterfile, January 2019. Available from: https://www.cma.ca/sites/default/files/2019-11/2019-04-age-sex-prv.pdf
3. 3. 
   Silver PM, Hamilton AD, Biswas A, et al. A systematic review of physician retirement planning. Hum Resour Health. 2016 Nov 15; 14(67). Available from: https://doi.org/10.1186/s12960-016-0166-z
4. 4. 
   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.
5. 5. 
   Gaudet CE, Del Bene VA. Neuropsychological Assessment of the Aging Physician: A Review & Commentary. J Geriatr Psychiatry Neurol. 2022 May;35(3):271-279. doi: 10.1177/08919887211016063. Epub 2021 May 21. PMID: 34018429
6. 6. 
   Devi G, Gitelman DR, Press D, et al.. Cognitive Impairment in Aging Physicians: Current Challenges and Possible Solutions. Neurol Clin Pract. 2021 Apr;11(2):167-174. doi: 10.1212/CPJ.0000000000000829. PMID: 33842070; PMCID: PMC8032410
7. 7. 
   Bhatt NR, Morris M, O'Neil A, et al.. When should surgeons retire? Br J Surg. 2016 Jan;103(1):35-42. doi: 10.1002/bjs.9925. Epub 2015 Nov 18. PMID: 26577951
8. 8. 
   Dellinger EP, Pellegrini CA, Gallagher TH. The Aging Physician and the Medical Profession: A Review. JAMA Surg. 2017;152(10):967–971. doi:10.1001/jamasurg.2017.2342
9. 9. 
   Wijeratne C, Peisah C, Earl J, Luscombe G. Occupational Determinants of Successful Aging in Older Physicians. Am J Geriatr Psychiatry. 2018 Feb;26(2):200-208. doi: 10.1016/j.jagp.2017.07.008. Epub 2017 Nov 24. PMID: 29239799
10. 10. 
    This finding is based on 67 cases in which a doctor’s cognitive ability to practise medicine was identified as a concern among doctors aged 55 and over, out of the 67,566 total cases the CMPA closed between 2012-2021
11. 11. 
    College of Physicians and Surgeons of Ontario. Assessments [cited 2022 May]. Available from: https://www.cpso.on.ca/Physicians/Your-Practice/Quality-Management/Assessments
12. 12. 
    Collège des médecins du Québec. Programme de surveillance générale [2019 Oct 17; cited 2022 May]. Available from: http://www.cmq.org/pdf/inspection/progr-surveillance-generale-def.pdf?t=1653594474005
13. 13. 
    Canadian Medical Protective Association. Reporting another physician. 2010 Dec, revised 2016 Dec [cited 2022 May]. Available from: https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2010/reporting-another-physician

DISCLAIMER: The information contained in this learning material is for general educational purposes only and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. The use of CMPA learning resources is subject to the foregoing as well as the CMPA's Terms of Use.