For hospital and medical group leaders who are considering screening older doctors for competency, letting an objective third party take over the task may eliminate perceived conflicts or bias, and avoid accusations of restraint of trade.
That's one reason , the University of California San Diego's Physician Assessment and Clinical Education program, has launched a service it hopes will help identify doctors who may no longer be quite up to snuff because of their advancing years, and validate those who are. The half-day program is called PACE Aging Physician Assessment, or PAPA.
"The issue of bias is much less of an issue, or it doesn't become one at all, if you have an independent third party who is performing the screening," said , PAPA director. "Of course, it's not as convenient as having your screening done in-house. But that's if you have trusted people who will give you objective findings; you don't want someone who is super friendly to all the doctors, and just passes everybody even though there might be some indicators of problems."
On the other hand, he said, "You also don't want someone saying 'Oh, this person is a competitor, and my buddy wants me to make sure I make it hard for him to get recredentialed because he's cutting in to my caseload.' These are shenanigans that are real in life. They happen," Bazzo said.
Some medical groups and medical executive committees "have very good relationships with their doctors, but some have more trying relationships," he said.
Screen First, Privileges Later
The idea of screening doctors as a condition for granting hospital staff privileges or for medical group employment or partnership, especially as doctors practice into their 60s and beyond, is gaining traction across the country as the physician workforce ages and one in four doctors is now at least 65.
The American Medical Association in June approved its Council on Education saying more attention needs to be paid to the topic because of numerous studies linking age of physicians to a higher risk of developing physical and mental issues that could affect patient safety.
PAPA was launched in late 2013 after Bazzo and PACE colleagues started hearing concerns about older doctors' failing competencies from hospitals and medical groups around the country.
Those concerns surfaced at PACE because it operates the nationally recognized Fitness for Duty and competency assessment programs, as well as others, that have evaluated more than 1,600 doctors who have had health or substance abuse problems, or made serious medical or judgment errors that threatened or curtailed their practices. Doctors from almost every state have been referred to undergo PACE review because of incidents or concerns.
But Fitness for Duty is triggered after something bad has happened, Bazzo said. There's a need to look proactively to screen older doctors with age-related issues.
There is enough evidence to give some pause about what age might do to some older doctors. Bazzo said that when PACE researchers looked at a small subset of their doctors who were referred for Fitness for Duty evaluation, doctors who had exhibited problems and were recommended for review, "what we found was that if they were over age 70, a higher percentage of those physicians did display cognitive deficit that would safely affect their ability to practice" compared with younger physicians in that group. More study is underway.
Come to PAPA
Currently PAPA has two arms.
In the first arm, large medical groups or hospital medical executive committees are invited to send all of their doctors who have reached a certain age for screening at PACE/PAPA. The groups pay PACE a fee that varies depending on the extent of requested tests and the number of physicians.
These are doctors who have not had specific questions raised about their competency, but they desire to continue practicing into their senior years and want to maintain staff privileges.
One large hospital is under contract now, and has sent doctors who have reached age 70 to undergo this half-day battery of tests. And the PAPA team is in discussion with several other hospitals and medical groups to send their senior doctors to San Diego for the service, or have PAPA experts help them develop their own programs at those organizations' locations.
"It's less about 'weeding out' problem doctors than it is finding doctors with health problems and guiding them to treatment, sometimes with a cure and at other times with resuming their practice with accommodations," said PACE executive director .
The half-day program includes a review of the doctor's background, training, practice, continuing medical education, health issues. The doctors take depression and anxiety screening tests, fill out a substance abuse questionnaire, undergo a physical exam with a review of their medical history, and take vision and hearing tests. They also undergo two cognitive tests utilizing both the Montreal Cognitive Assessment and MicroCog tools.
Bazzo said the organizations seeking PAPA's service wanted to screen an entire group of doctors that had reached a certain age and "wanted to be a little more proactive, while others want to prevent incidents instead of waiting for something to occur."
But he is careful to emphasize that PAPA is only a preliminary screening program for age-related changes. Even if you find areas of concern, he said, "you have to avoid the trap of making a diagnosis based on that. You have to go to the next step, which is a diagnostic test, which provides greater detail" on whether something is seriously wrong. That's something PACE's other programs, such as the Fitness for Duty exam or the competency review, can undertake but is not included with PAPA's services.
Research Function
The second arm of PAPA is in research mode: recruiting 30 older physician volunteers who undergo a 4-hour battery of tests to determine how physicians of various ages perform. The PAPA researchers also gather feedback from the physicians about the testing process. Each volunteer is paid $350.
Bazzo said the study is designed to eventually establish testing norms for performance of physicians at certain ages, those who are retired and still working, as opposed to norms for non-physicians.
Ira Levine, MD, a San Diego general surgeon who retired in 2011, just after he turned 70, was asked to take the PAPA screening as a volunteer last year.
The exams, some of which he did on a computer, asked him to perform certain tasks, such as read paragraphs of a story. "One was about a professor, who lived at such and such an address. An hour or so later they would ask you what was his name and what street did he live on. They also give you some words at the beginning and later ask you to recall, and remember the sequence."
It required a lot of concentration, he said, "but it was really fun."