Assessing Older Anesthesiologists

Some medical staff leaders think neuropsychologic testing and specialty-specific vision and motor testing constitute best practices for assessing older physicians before renewing their practice privileges.¹ They reason that the cognitive decline of some older anesthesiologists could impair their abilities to diagnose accurately or plan safe anesthetics and that age-related vision and hearing deficiencies could impair their abilities to read or communicate effectively. They worry that frailty could affect physical stamina and manual dexterity. Anesthesiology practice requires mental vigilance, decision-making, and physical actions, but assessing just older anesthesiologists for these capabilities can be divisive, unproven, and discriminatory. Creating barriers for older anesthesiologists could impede improvements in workforce diversity and numbers, reduce practice experience, and increase burnout. In this article, we look at why proposals for age-based assessments of older anesthesiologists arose, and why some institutions are rejecting them. “Older” is generally defined as age 65 and greater, although some institutions and researchers use different ages for age-triggered assessments and studies.

THE ARGUMENT FOR COGNITIVE TESTING

Proposals for cognitive testing of older anesthesiologists and other physicians before renewal of their medical staff privileges gained attention during the past 2 decades.^2,3 Supporters of cognitive testing cite a predictable and progressive deterioration in mental, physical, and behavioral functions with aging,⁴ high rates of dementia among older physicians,⁵ more malpractice suits involving anesthesiologists over age 65,⁶ and a responsibility for physicians to maintain competency and protect patients from harm.

The intersection of public safety and testing is quite significant, especially where the cognitive abilities of an individual may impact public health and safety. Even though federal law prohibits age-related restrictions on employment, it allows exceptions in areas of public safety such as police officers, firefighters, air traffic controllers, and commercial pilots. It can then be argued that physicians should also be tested because their performance may impact patient safety.

Proponents of cognitive testing of older physicians generally view it as just a screening test that can become a comprehensive evaluation only when necessary.

THE ARGUMENT AGAINST COGNITIVE TESTING

Job performance itself reflects cognitive abilities, especially in occupations with high cognitive demands.⁷ Many jobs, like the practice of anesthesiology, require effective communication, teamwork, and people skills. Performance decreases may manifest in difficulties with comprehension, expression, or maintaining professional relationships, and reduce job performance and productivity. Measuring competence is the desired evaluation. Thus, monitoring and assessing job performance for these attributes can provide insights into cognitive functions without specific tests. Just adjusting work schedules for older anesthesiologists has the potential to keep some individuals active and competent.⁸

Cognitive testing of physicians older than a threshold age has proven controversial because people age biologically at different rates (eg, chronological age is not always the same as biological age), cognitive disorders vary greatly,⁹ and no reliable studies have shown that testing of physicians improves patient care. In fact, some physician skills and cognitive functions improve with age and experience.¹⁰ A study using national data of Medicare beneficiaries in the United States found that patients treated by older surgeons had lower mortality than patients treated by younger surgeons.¹⁰ No difference was observed in mortality between female and male surgeons regardless of age. These findings indicate that there is a significant learning curve in surgical practice, which can have a considerable impact on patients’ outcomes over time regardless of the surgeon’s gender. Given that this was an observational study, these findings can also be attributed to surgeons selectively choosing to perform simpler procedures, working on lower complexity patients, or deciding whether to continue to operate at all, based on their perceived skills. Similar to surgeons, the clinical performance of anesthesiologists may improve as they gain skills and experience throughout their careers, yet it could also diminish due to decreases in manual dexterity or outdated knowledge.

Assessing just older physicians without evidence of impairment can constitute ageism, an unfair and discriminatory practice. Federal law prohibits discrimination based on age in programs and activities that receive federal funding.¹¹ Some older physicians whose practice privileges have been restricted or denied due to age-based policies and testing have filed discrimination lawsuits against their institutions and won monetary awards. The Equal Employment Opportunity Commission (EEOC) recently settled an age and disability discrimination charge with Scripps Clinical Medical Group after it subjected some physicians to a mandatory retirement age without consideration of the individual’s abilities to do the job. Scripps agreed to provide $6.875 million to the impacted individuals.¹² When Yale New Haven Hospital (Yale) implemented a requirement for cognitive testing of physicians at age 70, the EEOC sued Yale for violating federal antidiscrimination law.¹³ This suit filed in February 2020 remains unresolved.

OUR EXPERIENCE

In 2019 and 2020 one of our authors, Robert Johnstone, participated in an ad hoc medical staff committee that considered cognitive testing of older physicians for their biennial reprivileging. After extensive review, the committee determined that dozens to hundreds of physicians would be required to undergo cognitive testing depending on the age threshold selected for testing, and that communication and personality deficiencies, not cognition, underlay most past incidences of poor physician performances. Our review of these findings found that they correlate with national statistics. The United States has 1,044,734 licensed physicians, of whom 32% are age 60 and older, and 13% are age 70 and older.¹⁴ Depending on the age threshold selected, tens to hundreds of thousands of physicians nationally would be required to undergo cognitive testing, a potentially large time and expense burden for institutions and individuals. The age statistics for anesthesiologists are similar, with 57% of active anesthesiologists in 2021 aged 55 or older.¹⁵ Studies of physician performance indicate that organizational and systemic factors are as important as individual factors in determining competent care.¹⁶ Although individual clinician performance may lead to adverse events, they occur primarily due to poorly designed systems, which allow predictable human errors to result^.17

If testing physician cognition is nonetheless desired, how to do it is unclear. Cognition, the process of acquiring and using knowledge, has multiple domains, including attention, memory, and executive function, each with specific tests. Many tests of cognition exist, each better at testing some cognitive domains than others. The MicroCog test is a popular, automated, and quick screening test used in many health care settings to detect cognitive dysfunction. To understand cognitive testing better Dr Johnstone took the MicroCog Assessment of Cognitive Function, Windows Version 3.0, and found it had little to do with anesthesiology or medical practice. The test seemed like a parlor game, for example, to identify which word does not belong in the sequence of cow, pig, car, and horse, and repeat the flashed numbers, 6, 3, 4, 9, 2, and 8 when they are no longer visible. The cost for this test is $350, with lower-cost versions available. Ultimately, the institutional committee recessed without recommending cognitive testing of older physicians, awaiting the outcome of the EEOC lawsuit against Yale and recommendations from national medical societies.

ANESTHESIA WORKFORCE NEEDS: RETENTION AND BURNOUT PREVENTION

A survey of American Society of Anesthesiologists (ASA) members in 2023 found unprecedentedly high levels of workplace stress.¹⁸ Related to this stress, 38% of practicing anesthesiologists planned to retire early, and 25% had reduced or planned to reduce their work hours.¹⁹ A 2022 Anesthesia Workforce Summit organized by the ASA identified a shortage of several thousand anesthesiologists after an accelerated loss of anesthesiologists, primarily older ones, from clinical practice during the coronavirus disease-2019 (COVID-19) pandemic. Practice groups want to retain older anesthesiologists who have learned through experience how to calm anxious patients, troubleshoot difficulties, lead teams, and communicate with surgeons. Summit recommendations to enhance the retention of practicing anesthesiologists included improving clinical workloads and offering more flexible work schedules. Creating barriers for older anesthesiologists to continue practicing, such as passing cognition and other tests, might exacerbate the anesthesia workforce shortage and feelings of burnout and reduce patient safety. Physician burnout is associated with reduced productivity and quality of clinical care.²⁰

ACCOMMODATIONS FOR SAFETY

The field of medicine plays a crucial role in safeguarding public health. Physicians are entrusted with the responsibility of ensuring patient safety and well-being, which includes recognizing when their cognitive decline could affect their ability to practice medicine safely. Various factors, however, may contribute to a reluctance of physicians to report themselves or colleagues for marginal competence or unsafe practices. A dilemma for leaders of practice groups and medical staff is how to retain older, experienced anesthesiologists while assuring the public of their competence. Testing, or more broadly, assessing, them is an occasionally proposed solution. However, to reassure the public competency assessments should apply to all anesthesiologists and to avoid conflicts with federal and state age discrimination laws.

Some occupations in safety-critical fields do have mandatory retirement ages. The Federal Aviation Administration, for instance, requires air traffic controllers to retire at age 56 and commercial pilots at age 65. The American Board of Anesthesiology (ABA) only allows examiners to volunteer until age 65. Many anesthesiologists, though, desire to continue practicing clinically after age 65. Their reasons include beliefs that by continuing to practice they contribute to safe patient care, advance the specialty, and maintain their health. Older physicians who want to continue practicing often cite career satisfaction, a feeling of purpose, a strong work identity, and few interests outside of medicine. Other reasons include continuing to earn income and enjoyment of their physician status. With 98 million adults age 65 and older expected in the United States by 2045, the number of older physicians desiring to continue working seems likely to increase.

Regular objective screenings for cognitive function of all physicians can help identify any who may be at risk and provide opportunities for early intervention and support. These objective assessments can include a standardized evaluation of cognitive abilities. By addressing physician cognitive decline through a combination of testing and proactive measures, health care organizations can promote the well-being of physicians and ensure high-quality patient care.

Several factors beyond age contribute to cognitive dysfunction and physician frailty, including chronic health conditions, work-related stress, and lifestyle choices. Long hours, sleep deprivation, and the emotional toll of caring for patients can contribute to fatigue and burnout among physicians. Recognizing and addressing these workplace challenges are essential for maintaining high standards of patient care and ensuring the well-being of health care providers of all ages. Opportunities for life-long learning are also important.

RECENT SOCIETY REVIEWS AND RECOMMENDATIONS

The US Preventive Services Task Force concluded in 2020 that current evidence is insufficient to assess the benefits versus harms of cognitively screening older adults.²¹ The ASA Statement on the Aging Anesthesiologist, reaffirmed in October 2023 and available on its website (https://www.asahq.org/standards-and-practice-parameters/statement-on-the-aging-anesthesiologist), states, “Most groups of physician anesthesiologists include at least 1 member (who is older than 65). These experienced older and late-career physicians can bring powerful benefits to their departments, peers, and patients…Currently, there is no universally accepted agreement on the role of cognitive testing to assess professional competency among late-career physicians.” Similarly, the American College of Surgeons (ACS) Statement on the Aging Surgeon (https://www.facs.org/about-acs/statements/aging-surgeon/#:~:text=The%20ACS%20maintains%20that%20it,personal%20and%20professional%20well%2Dbeing) states, “the ACS does not favor a mandatory retirement age because the onset and rate of age-related decline in clinical performance vary among individuals.” The American Medical Association (AMA) recommends a case-by-case assessment of physician competence due to the variability of cognitive findings among older physicians (https://www.ama-assn.org/system/files/n21-cme01-annotated.pdf). The AMA states, “While research shows cognitive dysfunction is more prevalent among older adults, aging doesn’t necessarily result in cognitive impairment.” Functional age rather than chronological age is a better predictor for the ability to continue clinical practice safely (https://councilreports.ama-assn.org/councilreports/downloadreport?uri=/councilreports/n21_cme_01_annotated.pdf). The AMA Council on Medical Education states that physicians can continue practicing as long as they do not affect patient safety and deliver evidence-based care (https://www.ama-assn.org/system/files/n21-cme01.pdf).

The Joint Commission, in its standard MS.11.01.01, emphasizes educating physicians to recognize health issues in themselves and others (https://www.ama-assn.org/system/files/n21-cme01.pdf). It also encourages referral for confidential diagnosis, treatment, and rehabilitation to support practitioners to retain or regain optimal professional functioning while ensuring patient protection. This standard addresses the importance of managing physicians’ health issues within health care entities through education, self-referral mechanisms, and appropriate corrective actions. Rigorous evaluation should be the standard protocol after any lapse in the standard of care, and applied consistently across all cases, regardless of individual factors such as age.

OUR PERSPECTIVE ON COGNITIVE TESTING

With legal challenges to age-based cognitive testing, professional society statements opposing it, and an uncertain link between cognitive tests and physician competence, it seems unlikely cognitive testing triggered by age alone will soon be adopted. Physicians deserve clinically valid, confidential, and respectful processes for determining competence.²² Existing advice to base privileges for all anesthesiologists, including older ones, on peer review, outcomes measurement, and comparative norms makes more sense.²³ This reflects a balanced approach that prioritizes patient safety and quality of care while recognizing the valuable experience and expertise that older physicians can bring to health care systems.

Cognitive testing for specific causes, such as a physician who has had a stroke, traumatic brain injury, or “brain fog” after COVID-19, also presents challenges. What test should be used? What is the cutoff? How does a traditional cognitive test assess all the complex elements required for clinical competency? No tool that is easy to use and valid fulfills all necessary criteria. There is no easy answer to when a recovering physician can return to clinical work and would be a difficult decision to make based on mandatory testing where little evidence exists of how test scores relate to clinical practice. Cognitive testing of all older anesthesiologists or anesthesiologists recovering from an illness seems unlikely to improve the evaluative and therapeutic process. These decisions require assessments of many complex issues, including prior performance and supervision of the physicians on return to work.

Since 1938, the ABA has defined practice standards that instill confidence in the knowledge and skills of board-certified anesthesiologists to provide high-quality patient care. The ABA Maintenance of Certification program assures the public that older anesthesiologists can practice safely. The Objective Structured Clinical Examinations (OSCEs) used by the ABA to test first-time examinees before granting them board-certified status can potentially detect clinical lapses that have patient safety implications.²⁴ For some institutions, requiring maintenance of board certification and OSCEs regularly may be an alternative to testing.

AGE-TRIGGERED HEARING, VISION, AND FRAILTY TESTS ALSO UNNECESSARY

Some administrators propose hearing and vision tests for recredentialing because hearing and vision deficiencies among older adults are common and these deficiencies may be correctable. Safe anesthesia care requires adequate hearing and vision to communicate accurately and read printed and digital information. Studies have detected hearing impairments in 66% of anesthesiologists.²⁵ Competent adults who sense decreases in their hearing and vision, or are informed by colleagues of decreases, will generally obtain evaluations because these decreases will impact their life activities. Making these tests mandatory for anesthesia practice seems overregulation. Requiring them just for older anesthesiologists might open Pandora’s box of unanswerable questions due to little evidence of how any of these measurements relate to clinical competency, as well as constituting age discrimination.

Frailty is a multidimensional loss of reserve. It measures functional rather than chronological age. Even though frailty may be associated with cognitive impairment, there is no available data that frailty testing should be recommended for older physicians. Frailty screening may be recommended for physicians who appear to have new physical or mobility limitations, or getting weaker.

BROADER VIEW

Approximately 37,500 nurse anesthetists practice clinically in the United States, with 3% age 65 or older (DATAUSA). The Joint Commission requires the privileging of nurse anesthetists like physician anesthesiologists, so required assessments of older physicians should also apply to older nurse anesthetists. Adding nurse anesthetists to age-triggered privilege assessments would increase institutional burdens. Testing barriers that reduced physician experience, diversity, and numbers would probably also reduce those of nurse anesthetists.

European countries generally grant licenses and privileges to anesthesiologists based on their documented training and performance evaluations. Fewer European anesthesiologists want to continue working beyond retirement. In the United Kingdom, the National Health Service arrangement for pensions makes it financially unattractive for physicians to keep working beyond the age they can draw their pension.²⁶ Finances, more than reprivileging, is driving the exodus of older anesthesiologists from practice in the United Kingdom.²⁶ Therefore, policies for older anesthesiologists are still under development. There is an emphasis in the United Kingdom for employers to create environments that recognize and support age-related issues. The Association of Anaesthetists in the United Kingdom and Ireland recently produced a consensus document to address concerns over the number of consultants retiring at the earliest opportunity and to find ways to extend their safe working careers.²⁷

SUGGESTED ACTIONS

1. Base the privileges of all anesthesiologists on peer review, outcomes measurements, and comparative norms. Reprivileging should be nondiscriminatory and allow anesthesiologists to practice as long as they can safely do so. For most physicians, work performance is a sensitive measure of cognitive ability.
2. Safe anesthesia care requires adequate hearing, vision, and strength, but this does not require mandatory testing because anesthesiologists will seek testing and corrections themselves. Colleagues and other health care providers should encourage physicians to get testing if they note a deficiency. Health care providers should report physicians who perform poorly.
3. The ABA and the Foundation for Anesthesia Education and Research (FAER) should educate anesthesiologists on their duty to support peer review of clinical performance and patient safety and study how to do this effectively without subjective bias. FAER should support studies on the utility of OSCEs and neurocognitive tests to detect age-based declines in performance.

CONCLUSIONS

Age-triggered assessments of anesthesiologists have pros and cons and thus proponents and opponents. Some of the pros and cons are reviewed in the Table. It is unclear, though, whether any specific tests can determine that an older anesthesiologist remains clinically safe and effective, and age-triggered assessments potentially constitute illegal discrimination. The approach that should be taken is peer recognition of significant changes in the level of function of an anesthesiologist from that previously known and approved. Privileging of all anesthesiologists, including older ones, should be based on peer review, outcomes measurements, and comparative norms. Colleagues, sometimes reluctant to evaluate peers, have a shared responsibility for patient safety. Individual departments should have committees where these issues are discussed, and needed evaluations recommended.