Study takes a hard look at where older doctors are falling short

Just like the rest of the population, doctors are vulnerable to the vagaries of ageing and now a new Australian study has provided strong evidence for their professional competence to be routinely tested from the age of 70.

This study, thought to be the largest of its kind in the world, has taken a hard look at where older doctors are falling short.

It looked at complaints made against all doctors across the country over a four-year period.

Many senior doctors provide high-quality care well beyond the traditional age of retirement and the study showed almost 87 per cent of doctors over the age of 65 were not subject to any complaints.

But there is something hidden in these numbers. It's like looking at older drivers. They have fewer accidents but then they drive less often and travel far fewer kilometres.

Many older doctors work part-time and when the study took their total hours into consideration, they had 37 per cent more complaints levelled against them than were levelled against younger doctors.

This is the first time this exercise has been done definitively in Australia and it raises important issues, says senior author of the study Associate Professor Marie Bismark who is a medical doctor and a lawyer.

"Our results suggest that patient care may be affected by changes in doctors' cognitive and physical health resulting in notifications [complaints] to the medical regulator."

Out of step

While many elderly doctors, well beyond the traditional age of retirement, use their wisdom and experience to provide excellent care, some don't realise they are losing it and should hang up their stethoscope.

The highest rate of complaints was levelled against older general practitioners and psychiatrists. The hottest spots of risk, across all specialties, were physical and cognitive impairment.

"Some of these doctors have little awareness they are out of step with their peers," says Bismark, of Melbourne University's Faculty of Medicine, Dentistry and Health Sciences.

"And some are also falling out of date, particularly with prescribing practices, supply of medication, management processes, record keeping and report writing – they are not on par with their younger colleagues."

But, she says, complaints about mental illness, substance abuse and problems with procedures were higher among younger doctors.

Drugs are a hotspot of risk with some older doctors known to maintain registration in order to prescribe for themselves and family and friends.

Older doctors had 40 per cent more conduct complaints that include disruptive behaviour such as bullying, harassment and discrimination.

Most of these complaints involved older male doctors.

Drugs are a hotspot too, with some older doctors maintaining registration to prescribe for themselves, family and friends.

While this is against good medical practice, these doctors have been slow to adapt to evolving professional standards

Older doctors work fewer hours than younger ones and when the study took this into consideration, they had 37 per cent more complaints levelled against them. Peter Braig

Ongoing support

Some have also been slow to keep abreast of new drugs or changes in protocols and tend to revert to familiar patterns of prescribing.

Previous research has suggested some older doctors lack the ability to self-assess and may not be aware of a decline in their cognitive ability, skill or technical competence.

Despite the predictable risks this presents to patients, Bismark says there are no internationally recognised thresholds of cognitive impairment at which a doctor is considered a risk to the public.

The right to practise medicine well into advanced age is very important to doctors, says AMA Federal President Michael Gannon. Alex Ellinghausen

Unlike commercial pilots, there is no "compulsory" age of retirement for doctors

The study, led by Melbourne University lawyer and epidemiologist, Laura Thomas, suggests they need ongoing professional assessment, education and support.

"Medical regulators must balance their primary role of protection of the public with the need to respectfully partner with the medical profession and avoid unlawful and unjustified aged-based discrimination."

"The medical profession does not have good processes for utilising the full depth of the experience of older doctors."

For patients the choice between consulting an elderly doctor with decades of experience or a much younger one, more in touch with new developments, is not simple.

And the tension between these options is increasing because, at one end doctors are retiring later and at the other, technology is driving medicine very hard.

It has been suggested that mixed-age practices would capture the experience of the old and the knowledge of the young, but this can have its own challenges.

While all Australian doctors are obliged to remain current by completing continuing education courses, the quality and quantity of these have been variable.

The vast majority of those practicing in “their autumn years” still do so at a high level. Engin Cevik

The study, published in the Journal of Patient Safety and Risk Management, analysed almost 13,000 notifications lodged with regulators from all registered doctors in clinical practice in Australia, aged 36-60 and over 65, between 2011 and 2014.

Those aged 60-65 in 2010 were excluded as they crossed over from the one group to the other during the study period.

Managing risk

The Medical Board recently announced a new Professional Performance Framework that involves identifying practitioners at risk of poor performance and managing that risk.

It will require doctors who provide clinical care to have peer review and health checks at the age of 70 and three yearly thereafter.

This new study provides evidence the board can use to say it got it right, says AMA Federal President, Dr Michael Gannon.

While the AMA cautiously supported the changes, Gannon said doctors close to or in that age group were not particularly happy about it.

He says the AMA was against a process of "revalidation" or mandatory retirement and is happy where the current policy sits, although the devil will be in the detail when it is implemented.

Refusing to employ capable doctors because they have a lot of candles on their birthday cakes reeks of ageism.iStock

While the vast majority of doctors retire between 65 and 70, he says the vast majority of those practicing in "their autumn years" still do so at a high level. And have the insight to make appropriate changes to their work load and procedures they perform.

When this was announced late last year, he told ABC Radio the right to practise medicine well into advanced age was very important to doctors.

"You get very used to the title, you get very used to the respect that other members of the community afford you and, in many cases, you can appropriately practise medicine well into your advanced years."

Ageism claim

Writing in the British Medical Journal a couple of years ago, one doctor described the complexity of ageing in the profession. "If we can change job roles and requirements to support older doctors, retain the skills they bring, and phase-in retirement rather than have them fall off a sharp work-retirement cliff, surely we should?" he said.

When the effect of the greying of the medical profession was examined in the journal of the Canadian Medical Association in 2008, it was noted how difficult it was "to decide at what point older doctors should be encouraged to hang up their stethoscopes rather than be encouraged to improve their health skills."

"Refusing to employ capable doctors because they have a lot of candles on their birthday cakes reeks of ageism. On the other hand, allowing physicians to keep working long after their skills have slipped below par endangers the public."

While there was ample evidence that patients often have better outcomes when cared for by younger physicians, it could be that those who continue to practice despite being impaired, drag down the group as a whole.

Some data suggests older doctors are better at tasks, such as making initial diagnoses, because they rely on intuition rather than analytic reasoning. But when wrong, some are reluctant to explore alternatives.

Rather than forcing incompetent doctors to retire, it said medical regulators preferred to allow them to exit gracefully.

But older doctors – who, define themselves by their profession – can be notoriously averse to retirement.

* Jill Margo is an adjunct associate professor at the University of NSW

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This article was published and provided by the Australian Financial Review.

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