A guest column by the American College of Physicians, exclusive to KevinMD.
I recall with crystal clarity the day I finished my residency training and thinking to myself that at that point in time, I probably knew the most medicine I ever would.
Fast forward to today after many, many years of clinical practice, and I realize that I know so much more about the science and art of medicine now than I ever did. This is even though the world of medicine has changed so dramatically in terms of basic science information, clinical knowledge, therapeutics, and the systems in which we provide care that it is almost unrecognizable from the time in which I trained.
This rapidly progressive nature of medicine and the ongoing challenge of incorporating new learning and skills in the service of patients and society is something that actually attracted many of us to the profession in the first place. The process of gaining new knowledge, mastering new skills, and applying them to the care of individual patients, each with their own unique set of circumstances, goals, and values, has always made being a physician an incredibly rewarding pursuit. And in this regard, I realize that even if my medical factual knowledge may not be as broad or as extensive as it was when I started, I certainly know more “real” medicine than I did when I completed my training, having accumulated the patient care and life experience which is fundamental in effectively caring for others.
Yet, I am keenly aware that I am rapidly approaching “advanced career” status and the implications that doing so holds for the future.
Not only is the U.S. population aging, so is the physician workforce. It’s estimated that upwards of 30% of practicing doctors are now 65 years of age or older. As such a high percentage, this demographic group makes up an essential part of the physician workforce. And the fact that those in this category are facing eventual retirement certainly has implications when we are already facing a shortage of physicians.
However, the more “personal” aspect of achieving this milestone is that it confronts each of us in this age range with the real question of being able to maintain the currency needed with a rapidly changing medical landscape as we get older, and even more importantly, of being able to recognize when our level of knowledge, clinical skills, and cognitive function decline to a point where we are no longer able to provide safe and effective patient care.
We know that physical reserve, manual dexterity, and visuospatial ability decrease with age, which is one of the primary reasons why there are mandatory retirement ages for certain professions such as airline pilots and law enforcement. It is also one reason that in some of the more procedurally-focused segments of medicine, professional societies recommend a review of these abilities with advancing age. For example, the American College of Surgeons recommends that starting at age 65 to 70 years that surgeons voluntarily begin periodic health assessments, including a physical examination and visual testing, and to consider voluntary assessment of their neurocognitive function.
Yet, the heterogeneity of medicine and the highly variable effects of age on clinical performance make it both difficult to establish clear guidelines for either screening or more formal evaluation for clinical competency as physicians get older.
For example, we know that cognitive decline is not caused or predicted by age alone, and even though both performance on knowledge exams and some measures of practice performance may decline with age, how this affects each individual physician is highly variable. Plus, many of the attributes essential in delivering high-quality health care – judgment, resilience, compassion, and tolerance for stress – actually increase with age and clinical experience.
Additionally, the ability to practice safely and effectively with age appears in many ways to be situationally related. Physician performance is complex and has multiple dimensions that vary considerably for different types of patient-physician encounters. And the factors that influence performance do not necessarily do so independently from one another. As a result, the performance of physicians who have practiced in a specific focus area for many years does not necessarily correlate with specific assessments of individual capabilities, such as standardized methods of measuring cognitive function. All of these factors make the development and implementation of more widespread age-based screening programs using measures of different aspects of function both difficult and extremely controversial.
Unfortunately, as physicians, we seem to have considerable difficulty in recognizing a decline in our own knowledge or skills, and by inference, our ability to safely and effectively practice. I suspect that this is related to the personality traits of many of those who pursue medicine, the cultural aspects of being a physician that relate to being in control and comfortable with our clinical abilities, some aspect of denial, and may also be related to the aging process itself.
So how do we, as the medical profession and individual physicians entering the latter portion of our careers manage this transition?
Despite being an imperfect process, it is incumbent on us as individual physicians to continually assess our own physical and mental health as part of our duty to the profession, and just as we strive to evaluate our patients objectively based on available evidence, we need to be honest with ourselves in terms of recognizing our own limitations that occur with age that may affect our ability to practice.
And as a profession, peer-to-peer assessment should be a primary mechanism by which we ensure that our colleagues’ knowledge, skills, attitudes, behaviors, and ability to care for patients remain at the highest level as we all grow older. This should be a part of a broader professional initiative in which all physicians, regardless of age, are continuously or periodically evaluated in terms of practice competency in an objective, routine, non-judgmental way that would be able to identify competency and performance issues, and in the case of older physicians, would help ensure that physician function remains adequate despite the changes of aging.
This would allow those of us approaching older age and our patients and society to be comfortable that we can practice safely and effectively while taking advantage of the wisdom and experience we have accumulated during the course of our careers.
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