We tend to revere our older colleagues for their clinical wisdom, but this should not compromise patient care
He will be the physician that should be the patient.
Troilus and Cressida, William Shakespeare
Every few years I receive a note from the New York state education board to renew my license to practise medicine. Almost routinely, I write a check for the renewal fee, answer a few questions, and continue to practise my craft. This year though is different: I realise that soon I will be an octogenarian. What, in the past, had been a routine of filling forms and writing checks turned into an existential question: should I continue to practise medicine?
I recall the words of one of my mentors who told me early in my medical school days: “Medicine is not a profession but a calling. Physicians are what we are, and always will be.” Yet warring with this philosophical view of medicine as a lifelong vocation is the practical question of whether we need to ensure that US doctors working into their later years are still physically and cognitively fit to practise.
For despite my age, I was told that no test or examination was necessary to renew my license to practise medicine. In other words, I could continue to practise medicine well into my dotage without anyone checking my ability to be an effective physician.
In the absence of having a mandatory retirement age, older physicians, some even nonagenarians, work in various specialties all over the world—for the most part successfully and without any problems. Yet while many give up their license to practise willingly as they become aware of their limitations, there are those who continue to work despite impairment, causing alarm among colleagues. Many doctors have likely heard stories of such colleagues. We hear about them in the corridors or in the cafeterias, almost always in sotto voce. But in these kinds of cases there may often be a reluctance among colleagues to report the impaired doctor to a licensing board or credentialing body, sometimes due to loyalty to a senior colleague who might have been, early in his or her career, a mentor or a teacher.
We tend to revere our older colleagues for their clinical wisdom earnt after years of experience treating patients, but this should not become a compromising factor in patient care. And, with the number of practising physicians older than 65 growing in the US (in 2015, 23% of practising physicians were 65 years or older), the question of whether we need to in some way test or assess the competency of older doctors needs to be asked.
Over the past few years, a few studies have started to broach this topic by investigating through different measures whether older physicians are more or less competent than their younger colleagues. As yet, there is no data to support the notion that older physicians are more likely to be sued for malpractice, yet nevertheless these studies have thrown up questions of how doctors can maintain their competence.
Older motor vehicle drivers are required to pay higher insurance premiums because, statistically, they are more likely to have a road accident; and some states require an examination, after a certain specified age, prior to renewing the license to drive. Might it be time to contemplate something similar for physicians?
It will, of course, be argued that recertification requirements and periodic credentialing procedures in hospitals are sufficient to guard against impaired physicians practising. Yet these procedures—although necessary and useful—may not identify those with a mild cognitive impairment or subtle physical disabilities.
While it would be tempting to throw up my hands and protest against yet another bureaucratic infringement on our practice, I would rather not discover a colleague’s impairment only after an adverse outcome in a patient’s treatment. And if physicians have some kind of impairment, it doesn’t necessarily preclude them from practising in his or her specialty: for example, an intentional tremor could be a major hurdle for, say, a surgeon, but may not mean much for a psychiatrist.
Physicians may be what we are and always will be, but surely we owe it to our patients to be at our best when caring for them.
Chaitanya Haldipur is professor emeritus of psychiatry at Upstate Medical University, Syracuse, in the United States.
Competing interests: None declared.