Does IKEA sell rocking chairs?
“The older I grow, the more I distrust the familiar doctrine that age brings wisdom.” —H. L. Mencken
Editor-in-Chief
It was a small thing, really. I was in my home study, creating a slideshow to be presented at an upcoming meeting. I was designing a table of the various approved agents for the topical treatment of onychomycosis. I had already listed the generic names and was about to include the brand names. To my chagrin and utter frustration, I simply could not recall the trade name of one of the drugs. I looked it up by entering the generic name into my accessory brain (Google) and finished my task. But it got me to thinking … wasn’t it just the prior week that I could not remember the first name of a patient I have cared for more than 3 decades? I could picture her and knew her illness and treatment regimen, but I couldn’t remember her first name! I started to worry about being in mental decline, or worse, early stage dementia. When would I forget how to dose terbinafine? Or maybe forget what terbinafine even was? Was it my time to research longterm care facilities and to purchase a comfortable rocking chair?
We all age, and as we do so, some (or all) of our capabilities naturally wane and weaken. At what point do our inherent strengths fade sufficiently for us to conclude our time as healthcare providers? It has been written in many
corners that physicians, as a group, are among the least likely to recognize and acknowledge their own declining professional prowess. Yet it is intuitively obvious that as professionals dealing with human life, clinicians of all types
must possess both the proper physical and cognitive capacities to safely practice medicine. This becomes an especially pertinent concern for dermatologists.
The average age of retirement for American physicians is 65.1 years. Gynecologists retire about a year earlier, cardiologists about a year later. But dermatologists routinely retire 5 years or more after the mean physician
retirement age. So, we traditionally tend to practice longer into life’s journey. Which brings me to this point: at a certain age, should we all be subject to voluntary—or even involuntary—periodic cognitive and physical reassessment? This is much different from taking another iteration of a certifying board examination or collecting a specified number of CME credits annually. What I’m talking about is a comprehensive battery of tests which might measure fine-motor skill, motor planning capability, visual acuity and pattern recognition, psychomotor efficiency,
processing speed under pressure, concentration, capacity of both long- and short-term memory, interpersonal communication skills, and executive functioning, among others. By the way, executive functioning relates to self-regulation, including foresight and flexibility in executing an organized strategy in response to situational demands. For example, you plan a cyst excision but the patient arrives to the office complaining of substernal chest pain!
Taken together, the assessments listed above could determine the ability of a physician to reason, interpret, monitor, problem-solve, adapt, and utilize sound medical judgement.
As you might expect, this concept is not so far-fetched. In fact, Yale New Haven Hospital, Intermountain Healthcare, Stanford Hospitals and Clinics, Scripps Health Care, Penn Medicine, and the University of California, San Diego—to name a few—already have mandatory assessment programs for clinicians at and above a certain age. Indeed, it is
entirely realistic to ask: Should such a requirement become universal? Needless to say, such assessment would have to be consistent and fair, judged against validated normative values reflective of age, and interpreted in terms of relevance to actual clinical duties and responsibilities. Before limiting or revoking licensure/credentials, there must also be a reasonable appeal process, perhaps including repeat testing using an alternative methodology. It
also would be advisable to include gradations of consequence, varying all the way from no change in clinical privileges, to a controlled/ proctored practice, to removal of licensure/ credentials. To some degree, many of the current mandatory periodic assessments include these qualifying parameters.
Nonetheless, I am somewhat hesitant to jump on this bandwagon. Of course, we all want to do what’s best for the very people we serve—our patients. We want them to receive the highest quality of care possible from fully
capable physicians. But the assessment of aging physicians is fraught with many potential difficulties. First, who determines exactly which tests comprise the screening battery? Such screening is an inexact and complex science and legitimate differences of opinion exist. Second, because the prevalence of serious cognitive problems is relatively low in the proposed population to be tested, false-positive screenings are bound to occur. Third, targeting
only physicians above a specific age (60? 65? 70? 75?) is legally questionable, considering existing legislation against age discrimination (the Age Discrimination in Employment Act of 1967). Fourth, objective evidence solidly
verifying that advancing age predicts or closely correlates with poorer clinical outcomes is scant and somewhat debatable.
Finally, I wonder if the entire proposition of mandatory cognitive testing for older physicians doesn’t discount the incredible value of wisdom derived largely from experience. I recall a recent case of dyschromia of the back; my trainees were concerned about macular amyloid and confluent and reticulated papillomatosis of Gougerot and Carteaud. In a rather dramatic fashion, I removed a swath of the pathology by merely rubbing the skin with an
alcohol swab. Having been in practice a long time, I had encountered terra firma-forme dermatosis before, whereas all my younger colleagues—whose fine-motor coordination and short-term memory are most likely superior to mine—simply had not.
I don’t question the sincere and well-meaning intention of those advocating for cognitive assessment of older physicians. But I’m not so sure that the time and money spent on such endeavors is entirely worth it, and might not
actually cause some degree of harm to the healthcare system. Before we rush into this black hole, we need to carefully consider all the ramifications. You need to think about this issue, because—if you’re not there yet—someday you, too, will reach Medicare-eligible age. What might you recommend to your state board or clinic or hospital system?
By the way, I decided not to buy that rocking chair quite yet!