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Age is just a number
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The population of older Americans is increasing. The population of Americans who are 65 years and older was 41.4 million in 2011, which was an increase of 6.3 million, or 18%, since 2000. Life expectancy is even longer in many European countries, as well as in Japan, Australia and New Zealand. The physician workforce in the United States reflects the growing impact of an aging population, with 25% of practicing physicians being 65 years of age or older — a number that is also steadily growing.
With advancing age, people experience a decline in physical capacity. For a while, the decline may be offset by steady cognitive abilities combined with experience and maturity. But eventually, mental abilities also decline. Unfortunately, there is no clear indication of the reduction in cognitive abilities, and the pace and extent of the reduction widely varies.
The Federal Government Age Discrimination in Employment Act (ADEA) protects individuals 40 years of age and older from employment discrimination based solely on age. To arbitrarily select a certain age as the point when physicians are no longer allowed to practice medicine is clearly age discrimination.
Anthony A. Romeo
Aging physician
The AMA recently passed Resolution 308, A-14 to assess the competency of the aging physician. It states the “AMA will study the issue of competency in aging physicians and develop guidelines, if the study supports such a need, for appropriate mechanisms of assessment to assure that America’s physicians remain able to provide optimal care for their patients and report back to the House of Delegates.”
Although not addressed in the resolution, the focus of the competency evaluation will be related to cognitive abilities and may not provide insight on competency related to the physical ability to successfully accomplish surgical procedures.
Unlike specific rules that exist for other occupations, like commercial pilots, military personnel and firefighters, where lack of physical and mental competency can have serious consequences, there are no objective national standards other than age to ensure safe and effective care by older physicians. Some people have suggested specific rules should be applied to physicians because of a similar concern. However, many physicians believe they should be allowed to remain in practice as long as patient safety is not endangered.
Orthopedic surgeons face these same issues. The management of orthopedic problems after 65 years of age has been the subject of many scholarly articles. Currently, there are more than 28,000 practicing orthopedic surgeons on record with the American Academy of Orthopaedic Surgery (AAOS). The average age of the practicing orthopedic surgeon is 55 years. However, more than 10% of practicing orthopedic surgeons are older than 70 years. Professional satisfaction remains the most common reason orthopedic surgeons keep practicing beyond age 65 years.
Surgical competency
Even today, the methods we use as a profession to determine competency, especially surgical competency, remain rudimentary and inadequate, at all stages of an orthopedic career. We are tested for cognitive abilities with board exams and continuing medical education examinations. However, we have no standardized process to determine when young surgeons have achieved competency to perform an operation, when practicing surgeons have maintained the ability to competently perform an operation or when older surgeons have lost their abilities to competently perform an operation. It is likely there are 70-year-old surgeons who can perform procedures with a skill and effectiveness unsurpassed by younger surgeons.
Individuals age both physically and cognitively at different rates. There is no objectively defined age when a surgeon is no longer able to provide the standard of care to patients. However, at some point in our careers, reaction time and cognitive measures will decline, although surgeons typically test better than age-appropriate norms. Therefore, there is a strong need for objective measures of a physician’s cognitive and surgical skills competencies — not just an arbitrary designation of incompetence at a certain age.
When validated tests and tasks about cognitive functioning were analyzed in a group of general surgeons, 78% of surgeons between 60 years and 64 years were able to perform within the range of surgeons younger than 60 years. However, only 38% of practicing senior surgeons 70 years and older were able to perform at the same level of younger surgeons. Although increasing age cannot be the sole criteria for triggering the evaluation of competency, an age of 70 years and older should lead to cognitive and physical performance assessments to ensure appropriate and competent patient care.
For now, there are no widely accepted and validated tests specific for physicians, but a number of programs have developed in response to the concerns of the competency of aging physicians. The University of Virginia started a program in which physicians are required to undergo physical, cognitive and psychological assessments at age 70 years, 75 years, then every 2 years until retirement. Stanford University also started a program that monitors physicians at 70 years old.
Value to physicians, health care system
Allowing physicians and surgeons to practice until 70 years old and older is not only valuable to physicians, but also the entire health care system. They are often in senior positions of mentorship, assume leadership roles with practice management and help to lessen the burden of physician shortage.
Aging surgeons need to help themselves maintain their abilities as long as possible. Poor health and health habits have been associated with mental illness, decreasing job satisfaction, cognitive abilities and physical competency. Health should be a high priority and include the basic health principles as part of daily routine. Once we have made it to age 65 years, then 85 years old is likely, and good health can help ensure professional satisfaction.
Age is just a number. The age of 70 years may signify a point in many orthopedic surgeons’ careers where comprehensive cognitive, physical and technical assessments are warranted. However, it is completely inappropriate and a violation of ADEA to use age as the sole criteria to alter a surgeon’s practice, reduce partnership benefits or force retirement from orthopedic surgery. The AAOS and some subspecialty societies are working toward better objective measures of surgical competence through the use of surgical simulators, but much work needs to be done. A computer-based examination every 10 years will not help with late-career decisions. If you need an orthopedic procedure, it is likely an orthopedic surgeon in his or her 70s can accomplish the task with incredible skill and competence.
References:
www.aaos.org/research/stats/Surgeonstats.asp.
www.aoa.gov/Aging_Statistics/Profile/2012/docs/2012profile.pdf.
www.mag.org/sites/default/files/downloads/ama14-refcommC-report.pdf.
For more information:
Anthony A. Romeo, MD, is the Chief Medical Editor of Orthopedics Today. He can be reached at Orthopedics Today, 6900 Grove Rd., Thorofare, NJ 08086; email: orthopedics@healio.com.
Disclosures: Romeo reports he receives royalties, is on the speakers bureau and a consultant for Arthrex; does contracted research for Arthrex and DJO Surgical; receives institutional grants from AANA and MLB; and receives institutional research support from Arthrex, Ossur, Smith & Nephew, ConMed Linvatec, Athletico and Miomed.