Study finds late-career physician screening programs often lack fairness

Nearly 1 in 4 U.S. physicians with an active license is over age 65. This has spurred a small minority of hospitals to enact policies to assess these caregivers' cognitive and physical health, with the aim of reducing lapses that harm patients.  Doctors whose assessments show deficits could be asked to change their clinical schedule or to shift to administrative or teaching duties. 

An analysis of late-career practitioner programs, published today in the New England Journal of Medicine, found that most lack basic fairness protections for doctors. This shortcoming might tend to limit their engagement with these programs.

The authors identified several considerations they think are crucial to creating policies that protect patients while fairly treating physicians, who long have been able to make career choices autonomously. 

This is about finding the right balance: Patient safety must come first, but we also need to treat physicians fairly," said

Dr. Thomas Gallagher, the paper's author

He is a professor of medicine and a bioethicist at the University of Washington School of Medicine.

Policymakers must be pragmatic, too, he said: Only regulations that doctors interpret as clear, transparent and equitable will win their support and thereby make possible the physician screenings that ultimately benefit patients.

Research has shown that, across medical specialties, physician performance can decline with age. Most hospitals rely on doctors to altruistically report their mistakes and to acknowledge declines in their skills. They also rely on clinical colleagues to voice concerns and thereby potentially jeopardize peer relationships. Both presumptions often fail to keep patients from harm.

Existing policies' conspicuous omissions 

A tiny subset of U.S. hospitals have developed mandatory late-career screening programs, typically starting at age 70. Obstacles, however, have emerged. In 2020, federal regulators sued Yale New Haven Hospital over alleged age and disability discrimination. That action reflects widespread concerns that such policies are unfair and burdensome. 

In a prior study, these researchers analyzed 29 hospital screening policies and interviewed 21 medical leaders. Fewer than one-fourth of the policies described clear standards for restricting physicians' privileges, appeal processes, or rights to legal representation. 

The medical leaders focused on applying programs equally to all physicians but neglected to specify how fairness considerations were built into screening procedures, among other details. Leaders made efforts to consult with physicians about policy design, and to minimize logistical hassles, but often overlooked other fundamental considerations important to physicians. 

Key recommendations proposed 

In the new paper, the authors made content recommendations to improve these policies' fairness and make them more acceptable to late-career doctors:

• Early engagement: Hospital leaders should clearly explain why mandatory screening is necessary, solicit physicians' comments about policy design early on, and genuinely consider their suggestions. 
• Universal application: All medical specialists should be subject to screening starting at 70, an age that reasonably reflects current evidence. 
• Better testing: Screening should use validated tests that reliably predict clinical performance. An individual's results should be compared with healthy, high-performing physicians rather than the general 70-plus population. Doctors should receive results confidentially with explanations and clarity about opportunities to improve. 
• Clear processes: Programs should transparently explain how concerning results lead to additional evaluation, and what scores lead to restricted privileges. Physicians should have clear appeal rights, including the ability to be retested and to seek legal representation. 
• Meaningful accommodations: Before restricting a physician's work, hospitals should explore less drastic options like adjusting schedules, shifting to lower-risk patients, or moving to teaching roles. 

Conventions at odds with expectations 

Lead study author Dr. Daniel Kramer, a cardiologist at Beth Israel Deaconess Medical Center in Boston, offered context to why physician-screening policies have taken so long to emerge. 

"Historically, most physicians were independent practitioners, essentially small-business owners. They had their own offices with hospital privileges, but they weren't employees of the hospital. Today, I think these physicians are having trouble accepting that loss of autonomy. 

"And states recognize that medical practitioners are worthwhile in communities, so relatively high thresholds have existed to take steps that would curtail doctors' ability to provide care. I think that has slowed the uptake of screening programs," he said.

Gallagher noted that in his conversations with patients and patient advocates, however, "They're aware that other safety-sensitive occupations have age-related policies, and they are astounded that programs like this are not the norm in medicine.

"It's one of the reasons I hope that the profession will step up and embrace these programs as a way of demonstrating to patients and to the public that our commitment to self-regulation is real and something we take seriously."

The study's authors were from the Harvard Medical School Center for Bioethics; Intermountain Health; the Law School and the Department of Health Policy at Stanford University; and the schools of medicine and public health at the University of Washington.

Funding for the study was provided by the Greenwall Foundation.