Perspectives of Indonesian Dermatologists on the Competence Evaluation of Geriatric Doctors

In Indonesia, under Law No. 17 of 2023 regarding medical practice licenses, it is mandatory for a doctor to hold a medical registration certificate. To obtain this certificate, a doctor must undergo an assessment of both mental and physical health.¹ 

Additionally, the Ministry of Health Regulation No. 79 of 2014, regarding geriatric care in the hospital, states that an elderly is a person whose age is >60 years old and a geriatric patient is one whose age is >60 years old with one physical and psychological disease or one disease and a decreased function of body organ, psychological, social, and economic aspects who needs medical care.²  The debate surrounding age restrictions in clinical practice has gained traction in recent years, particularly as the practitioners’ age and the demand for healthcare services increases. Age restrictions may be proposed to ensure that practitioners maintain a certain level of competency and adaptability in a rapidly changing medical landscape. Therefore, geriatric doctors may face limitations in managing patients related to their aging.

We conducted an online survey among Indonesian dermatologists in order to identify their opinions regarding the requirements for geriatric doctors to perform professional activities, non-intervention professional activities, knife surgical intervention activities, and non-knife surgical intervention activities.

The survey was a nationwide cross-sectional study to gather opinions from Indonesian dermatologists regarding geriatric doctors performing professional activities. The survey included both multiple-choice and open-ended questions. The survey questions were structured to cover the demographic information of the respondents, opinions on age limits, and competency requirements for geriatric doctors (Figure 1). The survey was distributed online in 2023 through the Indonesian Society of Dermatology and Venereology (INSDV) branches. Of the 600 members who received the survey, 529 completed responses were collected, resulting in a return rate of 88.2%. The initial e-mail invitation was sent on January 10, 2023. To encourage participation from those who had not yet responded, a reminder e-mail was sent on January 24, 2023. The survey was closed on February 14, 2023. Respondents considered old or geriatric were those aged over 60 years. The collected data were then tabulated with Microsoft Excel and categorical variables were analyzed by Chi-square using Graphpad Prism 8.0.2.

A total of 529 respondents from the available Indonesian dermatologists were enlisted in the study. An online questionnaire was used to collect the data. Respondents were asked questions regarding geriatric dermatology. The first question was: should there be any age limit for a dermatologist that would not allow them to perform professional activities as a doctor, with 87.5% of the respondents answering that there should not be any age limit for a doctor, and only 12.5 % answering that an age limit was needed to perform professional activities for a doctor (Table 1). Interestingly, of the 12.5% who agreed regarding age limitations, the largest proportion was from the age group 31-45 years old (60.61%), and they felt that the age limitation should be 70 years old (87.9%) (Table 2). Further classification of the respondents based on whether they were considered geriatric or not showed that the majority of respondents in both groups did not favor age restrictions, with the younger group showing a slightly greater tendency to agree with them compared to the older group (Table 3). However, there was no significant difference between younger and older respondents in their views on the necessity of self-assessment.

All respondents were then asked whether physical and mental well-being for performing their profession should be assessed through self-evaluation or verified with medical certificates (Table 1). Most of them (68.6%) agreed with self-assessment. Respondents were also asked that, in order to perform as a doctor, whether a medical certificate was required for physical and mental function, eye function, ear function, motoric function, and memory function. According to the results of this question, only 25.9% agreed regarding the medical certificates for physical and mental checkup, 20% for an eye checkup, 16.3% for an ear checkup, 17.7% for a motoric function checkup, and 18.8% for a memory checkup. They were also asked for each of the following activities: non-intervention, surgical intervention, and non-surgical intervention (Table 4). Most respondents gave similar responses, indicating that medical certificates for the physical and mental checkups (94%-98%) should be required for all types of intervention. However, only 36%-37% of the respondents agreed for an ear checkup, and 43%-50 % for a memory checkup. Nonetheless, 60%-64% of the responses mentioned that medical certificates for motoric and eye function were required for all dermatologists who performed surgical interventions.

Senior or geriatric doctors’ knowledge and experience are indispensable assets to the patient, the community, and medical societies. Their experiences in clinical care improve their expertise and wisdom, which improves diagnostic accuracy. However, in general, a geriatric doctor can possibly experience cognitive impairment, behavioral disorders, and a high risk of dementia, which is included in the group of neurobehavior disorders.³  Neurobehavior disorders comprise a large group of behavioral disorders seen in association with transient brain disorders such as stroke, multiple sclerosis, dementia and neuro-oncological conditions, permanent brain disorders such as metabolic and toxic encephalopathy, and/or injury such as trauma, hypoxia, and/or ischemia.⁴  For a geriatric doctor who is active in their professional capacity, these disorders must be detected in order to provide optimal care to patients and prevent any risk of medical errors.⁵ 

In this study, we distributed an online questionnaire to Indonesian dermatologists regarding their opinions regarding working geriatric doctors. Of the total of 529 respondents, 463 of them (87.52%) responded that age is not a justification for restrictions on professional activity during patient care. This result is supported by the previously mentioned statement that, in the medical community, expertise and wisdom were gained through experience.⁶  However, previous studies reported that deteriorating clinical performance was observed in senior physicians.⁵  In this study, only 12.48% of the respondents agreed that there should be an age limitation, and that the cut-off age should be 70 years old. It was mentioned that fluid cognitive skills have the tendency to reach their peak in the third decade of life and start to diminish more steeply starting at the age of 70s.⁵  This perception aligns with our result that view the age limitation should be 70 years old. Additionally, the focus on this age limit might be due to the assumption, observed in professional environments, that relatively few physicians remain active in practice beyond the age of 75. Therefore, the focus on the 71-75 age range likely captured the majority opinion on the practical age limit for managing patients, while fewer responses were directed at the older age ranges due to fewer physicians continuing to practice at those ages. Senior doctors tend to rely on past experience and pattern recognition in managing complex clinical conditions which can cause incorrect diagnosis.^{5, 7}  We also observed that despite the majority of respondents in both groups did not favor age restrictions, the younger group showed a slightly greater tendency to agree with them compared to the older group. This finding of agreeing on age restrictions might be due to younger respondents being more aware of formal regulations to assure competency.⁸  This could indicate a generational shift in attitudes regarding accountability and the significance of regulations in upholding professional standards. Therefore, the decrease in the percentage for higher age ranges did not necessarily indicate an expectation for older physicians to manage patients but rather reflects a practical recognition of retirement trends and a shift in attitudes regarding accountability.

This study also reported that 68.6% of the respondents chose that physical and mental well-being should be determined by self-assessment, and only 31.4% said that it needed to be proven with a medical certificate. Also, only 25.9% agreed regarding the need for medical certificates for physical and mental function, 20% for eye function, 16.3% for ear function, 17.7% for motoric function, and 18.8% for memory function. This study differs from the results from the questionnaire used in a previous study which reported that 62% of the respondents agreed that age-based doctor screening should be used.⁹  However, in the previous study, the participants were from respondents with both doctor and non-doctor backgrounds. The authors of that study recommended that there should be screening for doctors’ well-being starting at age 70, and that the screening should consist of mental and cognitive health, as well as hearing, vision, and dexterity for the doctors who perform medical procedures.⁹  Previous reports mentioned that the speed and precision of medical procedures also decreased with aging; thus, further study was required to establish rules for doctors practicing procedural and non-procedural medicine.⁶  In this study, 60%-64% of the responses mentioned that screenings for motoric and eye function for physicians who perform medical procedures were required. A previous study showed that as physicians age, their performance also changed; thus, it is important for aging doctors to perform self-evaluation as well.⁹  It is recommended to limit working hours or the number of patients treated per day to maintain high performance among geriatric doctors.

Here we reported dermatologists’ opinions regarding geriatric doctors that showed self-assessed physical and mental health evaluations were necessary for geriatric doctors. Different assessments should be considered for aging physicians who perform intervention and non-interventional procedures.

The authors would like to acknowledge the participation of the Indonesian Society of Dermatology and Venereology (INSDV)/Perhimpunan Dokter Spesialis Kulit dan Kelamin Indonesia (Perdoski) and their willingness to share their thoughts and opinions on this important topic.