- It’s a subject that few physicians want to face during the later stages of their careers. At what point does a clinician become too old to effective deliver high quality care with a minimum risk to patient safety?
As fewer young medical students aim to enter primary care and a shortage of qualified providers starts to push the healthcare industry into greater reliance on team-based approaches to patient management, it may seem like a bad time to ask the question.
After all, highly experienced and resilient professionals are often the glue holding together a system undergoing major changes and constant flux.
However, healthcare providers facing the growing challenges of caring for a graying patient population must also look inward as their physicians add more candles to their birthday cakes, asserts Joel M. Kupfer, MD, from the University of Illinois College of Medicine at Peoria.
In a viewpoint article published in the Journal of the American Medical Association (JAMA), he argues that organizations should keep a close eye on physician performance, care quality, and patient safety as providers creep up in years, and that proactive healthcare organizations should work to develop appropriate assessments of staff competency to prevent potentially serious avoidable errors.
“Concerns about the competency of aging physicians are not new,” Kupfer says. “Numerous reports have suggested a link between poor clinical performance and physician age. Analysis of data from state medical boards suggests an association between years in practice and risk of disciplinary action.”
More than a quarter of actively licensed physicians in the US are over the age of 60, the article says, and that proportion is likely to grow as fewer young physicians graduate into clinical practice.
“A systematic review published in 2005 found an inverse relationship between years in practice and several measures of quality, suggesting that older physicians might be at risk of providing lower-quality care,” Kupfer continues. “Plausible explanations for these findings are the reluctance of physicians to shift from patterns of care established during training or the effect of biological aging on cognitive function.”
Numerous studies of EHR adoption patterns and physician attitudes towards healthcare reform efforts have hinted at a fairly strong generational divide: older physicians are resistant to change, they say, and have a hard time adapting to new technologies and shifts in patient care patterns.
In January of 2015, Booz Allen Hamilton and Ipsos Public Affairs conducted a study that found pervasive anxiety about the future of the healthcare system among providers. Just 24 percent of primary care providers and ten percent of specialists thought that healthcare was “on the right track.”
The majority of participants were concerned with their perceived loss of autonomy, the burdens of reform initiatives like value-based reimbursement, and high pressure from increased patient workloads and reporting requirements.
“Physicians, especially the older ones and the specialists, have to move into a whole new world, and they are concerned that it’s making their life a lot more complicated than it used to be,” said Nicolas Boyon, Senior Vice President at Ipsos Public Affairs.
“It is partly generational. The average age of practicing physicians in the US is actually slightly over 50, and specialists tend to be even older. A lot of physicians started practicing when the world was very different. They view their role, first and foremost, as caring for patients, and technology was not necessarily what they specialized in or learned a lot about in medical school.”
A 2014 survey of 20,000 providers found that thirty-nine percent of providers were considering an accelerate retirement plan. Older physicians working in independent practices were especially likely to report low morale and feelings of being overextended, while hinting at an early exit from the industry.
But dissatisfaction and trepidation about the future of healthcare might not be the only issues to worry about in older physicians, Kupfer says. He is quick to point out that several studies about the relationship between quality and age have been inconclusive, citing variable patient characteristics and outcomes beyond the provider’s control as complicating factors.
But he maintains that the healthcare system needs to develop a national standard for assessing physician competency in the same way that the industry has started to create standardized metrics for care quality and performance on population health management measures.
“Adding new layers of regulations and administrative requirements that apply solely to aging physicians is unlikely to meet with physician acceptance or enhance patient safety,” he says. “Instead, the American Board of Medical Specialties and physician groups could consider developing a single, integrated national standard that builds on existing programs like ongoing and focused professional practice evaluations and addresses the challenges of recertification and maintenance of certification.”
“For example, ongoing and focused professional practice evaluations could be standardized, be incorporated in biannual clinical review, and count toward maintenance of certification and recertification,” Kupfer suggests.
“Assessment programs need to be patient centered and define relevant and achievable outcomes that take into account costs, patients’ desires, and types of practice including demographics and staffing levels. Physicians (regardless of age) who perform poorly in these areas could then be evaluated by other means to determine the likelihood of effective remediation.”
Any assessment program must take into account the stress and negative productivity impacts of many EHRs and their associated workflows, Kupfer points out, especially in larger organizations where standardized processes for performance and documentation may make it difficult for individual providers to practice according to their own preferences.
“The goals of any competency assessment program are to improve patient safety, reduce costs, and enhance the health of the population,” he says. “Meaningful reform in this area will necessitate reevaluating current models of health care delivery, in particular the functionality of the EHR and clinical workloads on physician performance.”
“The growth of health care informatics and requirements for meaningful use have given the EHR a central role in daily practice. At the same time, however, the widespread availability of the EHR coupled with remote access means that physicians are expected to answer patient emails, review laboratory results, and respond to other clinical demands, even when off duty. Without addressing the endless workday and reducing the stress of using poorly designed EHRs, meaningful advances in quality and safety will prove elusive.”
Providers of every age have been extraordinarily vocal about EHR usability problems, and age seems to have little to do with an individual’s inability to overcome built-in workflow obstacles or other organizational roadblocks. Healthcare providers should not automatically assume that the older a physician gets, the less likely he or she will be to adopt new technologies or succeed in innovative care delivery environments.
Rather, physicians should be assessed holistically, based on their overall performance and patient safety records, and all potential quality issues should be considered on their individual merits.
“Older physicians bring valuable skills, clinical expertise, and life experiences that can be gained only by years of practice,” Kupfer concludes. “Younger physicians bring vitality and innovation. Rather than isolating aging physicians, acceptable standards should be developed that can be applied to all physicians, regardless of age, wherever and whenever they work.”