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Age-related impairments: denial is not the answer

BY MARY M. BEARDEN and ALLISON SHELTON, BROWN & FORTUNATO, P.C.

December 2011

Twenty percent of the population is age 65 and older, and the percentage is expected to increase. This portion of our population is likely not only to increase in number but also to remain in the workforce through the coming years. Due to the current dismal state of the economy, people are reluctant to retire at a traditional age. This is especially true for physicians, as they face significant decreases in reimbursement rates for medical services, making retirement more difficult.

The increasing number of aging practitioners serving on the medical staff may present a unique set of issues for medical staff leaders and hospitals. Many studies suggest an inverse relationship between the age of a treating physician and the quality of care provided to the patient. In a meta-analysis conducted in 2005, Harvard Medical School reviewed studies measuring the relationship between the age of the physician and the quality of care. Fortyfive out of 59 of the studies found that older p h y s i c i a n s p e r f o r m e d less well than younger physicians at various tasks, i n c l u d i n g d i a g n o s i n g d e p r e s s i o n and screening for cancer.

Generalized studies cannot be applied to individual practitioners, however. Many practitioners remain sharp and competent well past the age of traditional retirement. Moreover, a practitioner’s years of experience can be a real asset to both the medical staff and the patients under the practitioner’s care. Still, age-related impairments are a harsh reality for every person, including health-conscious practitioners.

Various neurological diseases, psychiatric illnesses, and other medical problems are more debilitating and more frequent later in life. For example, dementias such as Alzheimer’s and Parkinson’s disease tend to be associated with age. Also, tremors may become more pronounced as people age. Medical problems that affect all ages, such as diabetes, vision impairments, and hearing problems, are often less tolerable as a person ages. Other issues arise due to the side effects of the medications prescribed to treat a person’s illnesses. According to one recent study, the average 65-year-old takes at least eight medications during a 24-hour period. These medications may result in a variety of side effects, some of which may be caused by the interaction between or among the medications. Medical problems and side effects from medications may impair a person’s senses, motor skills, or ability to think. When practitioners are impaired, the risk of error increases. Unfortunately, many age-related impairments appear gradually. As a result, neither the affected practitioner nor his or her peers may be aware of any risk to patient safety.

B e c a u s e patient safety is a real concern for practitioners and hospitals, m e d i c a l staff leaders should work diligently with the hospitals where they serve to empower a committee of the medical staff to (1) r e s e a r c h m e d i c a l l i t e r a t u r e regarding the effects of age-related impairments on patient safety, (2) identify risks that may affect the quality of care provided at the hospital, and (3) discuss how the medical staff and the hospital should work together to address any identified risks. The committee should review existing policies and procedures to determine which committees (e.g., the medical executive committee, the credentials committee, or the practitioner health committee) are equipped to address issues caused by agerelated impairments. Also, the committee should research approaches taken by the medical staffs at other hospitals.

Some hospitals have found that their existing procedures for complaints, confidential reports, and corrective action are insufficient for identifying the risks that need to be addressed. Due to the gradual onset of diseases and impairments, individuals may not be aware of issues that need to be reported. Moreover, according to a survey published in 2010 and reported by the Texas Medical Association, one in every three physicians did not report a fellow physician who had a known impairment. Therefore, in addition to reporting procedures, medical staffs and hospitals may want to consider other methods for addressing age-related impairments that place patient safety at risk.

Some hospitals utilize approaches designed for early detection of and intervention in age-related impairments. For example, hospitals may require aging practitioners to undergo more frequent re-credentialing (e.g., annually rather than every other year). Another approach requires aging practitioners to undergo a period of focused professional practice evaluation (FPPE). Hospitals may require FPPEs periodically or as part of the re-credentialing process.

A similar approach requires aging practitioners to complete an examination that measures the practitioner’s fitness to work. Such examinations evaluate whether practitioners have the necessary knowledge and skills to perform their delineated clinical privileges. Accordingly, an examination will have physical, cognitive, and neuropsychological components tailored to the practitioner’s privileges. If the medical staff elects to periodically require a comprehensive examination, a peer review committee should be charged with overseeing the examination. This committee may either select the examining physician or generate a list of approved physicians who may conduct the examination. The examining physician should not have any personal or economic interests that could influence the results of the examination. For example, the examining physician should not be a close, personal friend of the practitioner. Also, the examining physician should be familiar with not only the knowledge and skills necessary to perform the selected privileges, but also the signs and symptoms of agerelated impairments.

Policies and procedures involving comprehensive examinations, periodic FPPEs, and/or more frequent recredentialing for aging practitioners can be implemented in a manner that is fair and respectful to practitioners. First, practitioners should receive advance notice of the necessary standards through the written documents governing the medical staff. Next, the standards should apply to all practitioners who reach a certain age. As a result, individuals are not singled out, and the likelihood of questionable confrontations is reduced. Finally, hospitals should implement procedures that not only identify potential risks, but also accommodate a practitioner with an agerelated impairment when possible. If agerelated impairments are identified early, the responsible medical staff committee may be able to implement certain safeguards to accommodate the continued practice of the affected practitioner. Examples of accommodations include fewer hours, a modified scope of practice, regular monitoring, and staff assistance.

With our aging professionals in the health care industry, hospitals and medical staffs must address risks related to age-related impairments. Thorough research and careful drafting is required for any procedure based on the age of a practitioner. The committee responsible for researching and formulating methods to address risks caused by age-related impairments should carefully review the adopted approach. Issues the committee should consider include the following: (1) Do the procedures violate age discrimination laws? (2) Does empirical evidence support the adopted procedures? (3) Do the procedures adequately address risks affecting the quality of care? (4) Are the procedures applied equally and consistently? Any procedure that is ultimately adopted must treat practitioners fairly and promote patient safety.