Cognitive Screening for Senior Physicians: Are We Minding the Gap?

Senior physicians are an invaluable asset to the medical community and the public. They serve as mentors and leaders in the profession with contributions that benefit clinical care, education and research. Years of accumulated knowledge and experience can hone diagnostic and patient management skills while also imparting wisdom and expertise that promotes sound clinical judgment and effective patient-physician communication.

Older doctors make up an increasing proportion of the physician workforce in the United States. The Federation of State Medical Boards (FSMB) reports that 31.2% of licensed physicians were 60 years of age or older in 2020, up 6% since 2010. During the same period licensed physicians under age 60 fell by 5.7%.¹  The U.S. population is also growing older: By 2030 the number of Americans age 60 and over is projected to expand by 55%.²  A large increase in demand for health care services is just one expected result of this demographic shift.³ 

Physician supply is not expected to keep pace with this demand. The Association of American Medical Colleges Medical Colleges (AAMC) projects a shortfall of between 46,900 and 121,900 physicians by 2032. Critical initiatives aimed at improving population health and reducing health care inequity will create further demand on the health care system, worsen the shortfall and imperil care access, quality and patient safety. In all AAMC models, delaying physician time to retirement by two years was most protective of physician supply, underscoring the importance of supporting and sustaining senior physicians in the workforce for as long as they are willing and able to safely practice.⁴  This is not a mere theoretical consideration; the recent recruitment of retired physicians to aid in responding to the COVID-19 pandemic demonstrated that senior physicians are valued by the medical community and able to meaningfully contribute to workforce sustainability and safe patient care.⁵  The combination of demographic and economic forces, along with changes in health and longevity, suggest a probable increase in the number of physicians practicing well into old age.

Despite the clear need to retain senior physicians in the health care workforce, important concerns have been raised about competent practice among aging physicians. Central to these issues are the changes that occur as part of normal aging. In the context of medical practice, these changes — many positive, some negative — have important implications for a range of controversial issues. These include the appropriate utilization of older physicians in the medical labor force, whether there is need for mandatory age-based screening or retirement, and the potential legal and societal implications of each of these. While much has been written about these issues, solutions have remained elusive. Performance heterogeneity with normal aging, inconsistent data on age and physician performance, lack of cognitive screening instruments normed to physicians and their work demands, concerns about age discrimination, and the high-stakes nature of physician performance evaluation have fueled uncertainty and stymied progress.

In this article, we propose that while age may be an important risk factor related to physician performance, it is not the only factor and may not even be the most important. Data on cognitive performance among physicians referred for behavioral and performance concerns reveal that cognitive impairment afflicts physicians across the career span, not just older physicians. If the overarching goal is to prevent patient harm through early detection of cognitive impairment in physicians, older physicians may, in fact, be too narrow a target. We suggest that approaches focusing on health screening and promotion, starting in early to mid-career, will ultimately be more effective in promoting workforce sustainability and patient safety than age-based solutions.

Concerns about older physicians are understandable because cognitive performance declines with normal aging and advancing age is the greatest risk factor for neurodegenerative disorders.⁶  However, one of the most robust findings in the field of gerontology is the increase in heterogeneity of cognitive performance across the lifespan. Powell and Whitla have demonstrated that the heterogeneity rule holds true among physicians: On average, physician cognition declines with age, while individual variability in cognitive ability increases.⁷  Thus, age-based inferences about a physician’s cognitive performance are prone to ecological fallacy.

While conventional wisdom holds that performance declines with age, several researchers have reported performance improvements with age and experience as well as relative stability across the lifespan.⁸  For example, wisdom and expertise increase with time in many fields, such as music, chess and medicine.^9,10  Additionally, optimism, empathy, resilience, compassion and wisdom remain stable or increase with age.¹¹ 

The evolving literature on super agers provides another illustration. Contrary to the assumption that cognitive decline must be a part of normal aging, super agers are individuals who remain cognitively sharp into their 80s and 90s.^12–14  Interestingly, animal and human research provides evidence that enriching experiences, such as advanced education and mind-challenging occupations, are protective against cognitive decline.¹⁵ 

In medicine, Dreyfus and Dreyfus’s model of professional expertise describes progression from novice through expert with competence developing through accumulated experience over time. It is reported that it takes a physician a minimum of 10 years in practice to move from the level of novice to expert.¹⁶  Performance most often cited as either stable or improving with age includes complex procedural problems, complex diagnostic problems, making initial diagnoses, and complex management or departmental integration problems.¹⁷  These findings are consistent with the observation that physician leadership roles are consistently offered with greater frequency to older and more experienced physicians.¹⁸  Elstad and colleagues investigated attributes of clinical practice, including how physicians conceptualize and describe the meaning of their clinical experience. Their results suggest that over time physicians gain complex social, behavioral and intuitive wisdom as well as the ability to compare the present-day patient against similar past patients.¹⁹ 

Despite these positive findings, the literature also raises concerns about an inverse relationship between age and level of performance among physicians. A consistent finding is that age or years post licensure are risk factors for decreased quality of care as well as increased licensure issues.²⁰  In addition, the gerontology literature has demonstrated that there are a number of decrements in cognitive performance and sensory functioning that occur as a function of advancing age. In his comprehensive reviews, Eva discusses the changes in cognition that occur in physicians as a function of age.^21,22  Within the medical and medical education literature, data support a number of specific age-related performance declines, including decreased quality of medical knowledge,²³  speed and accuracy of medical reasoning,²⁴  speed and precision of medical procedures,^25,26  productivity as well as an increased tendency towards premature closure (deciding on a diagnosis before all of the information is in hand).²⁷ 

These complexities and nuances of aging relative to physician performance underscore the challenge in determining when and how to proactively identify performance problems before safe practice is impaired.

Age-based cognitive screening is a preventive approach aimed at early detection of cognitive decline among older physicians without identified performance problems. It is intuitively appealing and holds the promise of a practical and relatively simple solution to a complex issue. However, the prospect of age-based cognitive screening has raised several question and controversies.

A recent critical review of cognitive screening tools for senior physicians examines the rationale for prospective screening, discusses guidelines from workgroups and guilds, identifies gaps in knowledge and practice, and compares cognitive screening methods used or recommended for senior physicians, with particular attention to the psychometric properties, ease of operational implementation and appropriate application to physicians.²⁸  Included in the review is a description of the MicroCog,^TM a computerized instrument commonly used by health care organizations and specialized centers to screen for cognitive impairment among older physicians.²⁹  It is a sophisticated and versatile instrument, widely considered to be the best test available for evaluating cognitive performance in physicians. However, physician performance is not well represented by the published test norms — and population-specific normative data are needed to effectively evaluate practicing physicians.^28,30  Given the high-stakes nature of such screening, more research is needed to establish norms that are specific to physicians and the job-specific demands of those practicing procedural and non-procedural medicine.

Age-based cognitive screening of physicians has received considerable pushback from the medical community and raised ethical and legal issues regarding age discrimination. Stanford implemented rigorous peer review but abandoned the cognitive testing component amidst protest by its senior physicians. Intermountain Health in Utah, which had been conducting age-based cognitive screening since 2012, put the program under review after Utah legislative action raised questions about the practice.²⁹  Recently, the U.S. Equal Employment Opportunity Commission filed suit against Yale New Haven Hospital, charging the institution with unlawfully subjecting physicians over the age of 70 to neuropsychological and eye examinations.³¹ 

From the perspective of workforce sustainability, high-stakes screening of senior physicians may do more harm than good. It is typical that screening processes are impersonal, inflexible, insensitive to individual circumstances and focused on identifying deficits versus strengths. Such a narrow focus on screening older physicians runs the risk of promoting the egress of valuable clinicians from the profession and may, in fact, ignore opportunities for earlier identification and intervention to mitigate health-related impairment. Intermountain Health experienced double the anticipated departures of senior physicians when they began its screening program.³²  Conversely, physicians might choose to remain in practice if they had objective evidence of intact cognitive abilities.³³  This highlights the need to not only develop valid measures of cognitive performance, but to implement them in a manner that thoughtfully, compassionately and proactively supports physician health and well-being. In the absence of norms, establishing screening cutoff ages is ultimately arbitrary. One solution to arbitrary cutoffs would be to begin screening earlier in the career span to establish a baseline for comparison over time.

Multiple studies have demonstrated that 25–50% of physicians with practice performance complaints have neurocognitive deficits sufficient to explain their performance problems and that age is a relatively weak correlate to neurocognitive performance among reactive referrals.^34–39  Cognitive impairment results in performance problems across the physician career span and age is confounded by a host of other variables when studied in the context of physician performance.²² 

A recent comprehensive review of risk and support factors related to physician performance identified age, gender, exam scores and specialty as risk factors, given the strength of the evidence.⁴⁰  Practice experience, workload and solo practice were identified as probable risk factors. Other factors likely associated with performance include medical health, psychiatric health, personality characteristics, attitudes/beliefs, life stressors, burnout, developmental stressors, system issues, poor initial preparation and failure to maintain currency.³⁰  Similar concerns have recently been noted in physicians with behavioral comportment issues³⁹  and analysis of neuropsychological data using both age and health as explanatory variables indicates that the effect of health eclipses the effect of age such that age no longer shows a significant relationship to performance.^41,42  These data are particularly concerning given that only one third of physicians have a primary care physician, physicians do not follow preventive health guidelines⁴³  and “usual care” for physicians is self-treatment and “working while ill.”⁴⁴ 

If our overarching goal is to prevent patient harm through early detection of cognitive impairment in physicians, older physicians may be too narrow a target. It is not our assertion that age is an unimportant variable to consider relative to physician performance – this has been clearly established. However, merely focusing on concerns related to aging may be a convenient and more comfortable proxy for the larger problem of proactive identification of potentially impairing health conditions at any age.

Health, independent of age, is an under-identified threat to physician performance across the career span (Figure 1).⁴¹  This suggests the need to adopt a positive, proactive lifespan developmental approach, stressing the importance of self-care and wellness across a physician’s medical career (Table 1).

As a group, physicians are healthy and have healthy lifestyle habits.⁴⁶  Good physician health and well-being have consistently been shown to result in better care for patients, whereas compromised health has the opposite effect.^47–55  Just as happy, healthy cows produce the highest quality milk,⁴⁵  physicians who are in good mental and physical health will provide the highest quality patient care. The American Medical Association Code of Ethics holds that physicians have a responsibility to “maintain their own health and wellness, broadly construed as preventing or treating acute or chronic diseases, including mental illness, disabilities, and occupational stress. When physician health or wellness is compromised, so may the safety and effectiveness of the medical care provided.” In fulfilling this responsibility, physicians are expected to follow healthy lifestyle habits, have a personal physician whose objectivity is not compromised, and take appropriate action when health or wellness is endangered.⁵⁶ 

Given the obvious importance of health and ethical overtures to physician health and well-being, attending to personal health must become a core value in the identity of the professional physician if we are to sustain the health care workforce. We suggest that the value of “physician as healthiest-self” be woven into the physician identity beginning in medical school and reinforced throughout the career span. The concept of healthiest-self is intuitive and honors what is attainable and within an individual’s control. It recognizes that health exists across a continuum and that physicians may practice competently even under conditions of sub-optimal health. It must be the shared responsibility of physicians and the systems in which they are educated, train and practice to support healthiest-self behavior and address systemic forces that serve as explicit and implicit barriers to physician health and well-being. We believe that such efforts would not only improve the overall health of the physician workforce but would also go far in alleviating drivers of physician burnout, dissatisfaction, and unprofessional behavior.

Other safety-sensitive professions — such as airline pilots, air traffic controllers, police officers, and firefighters — recognize the link between health and performance and undergo routine compulsory health screening. The absence of such screening for physicians is a conspicuous gap in the professional self-regulation of physicians. If we are truly committed to protecting our workforce and promoting patient safety, then we should mind this gap and consider the merits of mandatory routine health screening for all physicians. This is particularly important, as physicians may have difficulty acknowledging that they are unwell and tend to underutilize health services.

Including cognitive screening as part of a comprehensive health assessment would serve multiple purposes. The brain, exquisitely sensitive to insult, may be the “canary in the coal mine” for a variety of health conditions that could negatively impact cognitive and clinical performance. Also, it is our experience that cognitive ability is of utmost importance to physicians and any evidence of cognitive difficulty can powerfully motivate physicians to attend to their personal health and engage with effective medical care. Completing cognitive testing early in a physician’s career would provide useful baseline data for evaluating age- or illness-related cognitive changes over time.

Proactive health and cognitive screening have the potential to detect health problems before patients are put at risk, while improving the health of the physician and their likelihood of recovery from medical issues. Routine health screening would create accountability and reinforce healthier lifestyle choices and better health care engagement by physicians who might otherwise neglect self-care or seek medical treatment reluctantly. Additionally, several studies have now shown that physicians with healthy personal habits are more likely to encourage their patients to adopt such habits.^47–50  In minding this gap, the medical community would demonstrate a commitment to supporting the pursuit of health and well-being as critical core competencies within the domain of professionalism. Viewed from this perspective, mandatory routine health screening should not only mitigate risk but also promote health protective behaviors that support practice longevity rather than expulsion. It operationalizes and underscores the importance of health and well-being for physicians as well as the systems in which they work. Such an approach is consistent with Trockel and colleagues’ population health framework for advancing physician well-being.⁵⁷ 

We recognize that the prospect of mandatory health screening over the career span is likely to be met with resistance. However, we have argued that health conditions that could negatively impact physician performance and patient safety are not limited to older physicians; thus, the rationale for screening is valid for all physicians. We have also suggested that age is but one factor, probably less important than health, in the complex interplay between cognition and practice performance. In one of the most cited articles on the negative relationship between physician age and care quality, Choudhry and colleagues assert that “older physicians may need quality improvement interventions that are generally applicable to all physicians.”²⁵  We believe that this principle is bi-directional and supports our assertion that routine screening should be applied to all physicians.

Except for scale, the practical challenges that complicate screening are similar whether we are considering senior physicians or the general population of physicians. These include when to begin screening, what screening tests should be implemented, who should conduct the screening, what happens when a screen is positive, and how confidential health information obtained during screening or follow-up evaluation will be protected from employers, credentialing entities or regulatory agencies. Acknowledging health and well-being as central to practice and core elements of professionalism broadens the framework for understanding how screening might be operationalized. We envision a model of shared responsibility, much like the current model of continuing medical education, that includes physician, evaluator and licensing or credentialing entity. The physician’s role would be to initiate activities that promote personal health competency. Such steps might include participating in continuing medical education/continuous professional development opportunities (CME/CPD) aimed at promoting personal health, engaging in routine health and well-being practices and completing routine periodic health screening that includes a cognitive screen. Compliance with compulsory health screening would be reported through attestation, with a subset audited for documentation of compliance (Table 1).

Physicians who have positive screens that result in the need for further health evaluation could be directed to their state physician health program. State Physician Health Programs (PHPs) have a highly effective model to address and rehabilitate impairing health conditions in physicians and other health professionals.^58,59  PHPs also have unique access to a rich reservoir of evaluators and treatment providers with special experience and expertise working with physicians across a continuum of health conditions and severity. This would allow for positive screens to be addressed, and false positives resolved, confidentially, without negative professional or reputational impact. This is of paramount importance to foster a sense of trust and comfort in the process. Should health screening and follow-up reveal an impairment, substantial risk for impairment, or risk of dyscompetence/incompetence, the PHP and physician would work together along the traditional PHP pathway with the goal of rehabilitating the physician’s safe continuation of, or return to, practice. This latter process would need to be consistent with state regulatory requirements regarding a duty to report concerns of competency and impairment. The issue of duty to report is complex and includes ethical, moral and regulatory factors. While a discussion of these factors is beyond the scope of this paper, we note the importance of being aware of state reporting requirements that may be triggered along the evaluative pathway.

Multiple forces, including age demographics, systemic drivers of physician burnout, and the negative impact of Covid-19, have created a perfect storm that threatens the short- and long-term sustainability of the health care workforce. Concerns about performance in older doctors ultimately betrays a gap in the current self-regulation model of physician impairment, namely, the absence of routine, mandatory health screening of all physicians. Although this is the norm in other safety-sensitive workers, medicine has not embraced this approach, perhaps due to lack of perceived need or benefit. However, physicians are ethically bound to practice professional self-regulation.⁶⁰  Proactive, mandatory health screening for all physicians would be more effective than age-based screening in mitigating patient safety risks due to performance deficits, while also creating individual and systemic accountability aimed at health protection and workforce sustainability. However daunting, minding the gap may be a necessary investment toward a future health care system that is structured to intentionally support the health and well-being of its workforce. Our health care professionals are a precious community resource that invest deeply of themselves so that we may thrive.

We ought to recognize this sacrifice with efforts that find a compassionate balance in the tension that can sometimes exist between supporting the professional and protecting the public. Thoughtfully conceived and implemented, periodic health screening of all physicians is the right thing to do for our peers, profession, and the patients we serve.