When is a Doctor Too Old to Practice?

I thought of this question recently while reading the case of Dr. Richard Jefferson, a Los Angeles obstetrician: when is a doctor too old to practice medicine safely?

In January 2009, the Medical Board of California filed charges of gross negligence and repeated negligent acts against Jefferson. In practice in California since 1968, Jefferson should have had plenty of experience, but he was apparently failing to do some basic things. The board says he failed to give simple pelvic exams to at least eight patients. He also failed to keep good records of his patient visits.

Seven months after the filings – lightning speed for any medical board – the board and Jefferson cut a deal. Jefferson agreed to a stipulated decision under which he had to enroll in the Physician Assessment and Clinical Education Program (PACE) offered by the University of California – San Diego School of Medicine. This is a standard part of the California medical board's disciplinary package.

As part of PACE, Jefferson had to take a test known as "MicroCog." Isn't that a beautiful little piece of bureaucratese – promising much and revealing little? MicroCog – the name is trademarked – is described by the board as a "computer-based assessment of cognitive skills that helps determine whether a PACE participant should be referred for full neuropsychological evaluation."

Jefferson was 75 in 2009, and the medical board said he performed "in the low average range on indices measuring general cognitive functioning, general cognitive proficiency, and reasoning/calculation; and he performed in the below average range on indices measuring information processing speed and spatial processing."

So Jefferson was given more neurological exams and clinical exams. He performed poorly there, too. For example, he had trouble "distinguishing between normal and abnormal intrauterine pregnancies, knowing how to treat pelvic inflammatory disease, and knowing options for treating a prolapsed uterus or vaginal walls," the board wrote.

 A judge granted an interim suspension order in February 2011. In September 2011, Jefferson surrendered his license entirely.

Two things jumped out at me.

First, Jefferson was working as a prison doctor. He told the board that he took the job at the Los Angeles County Women's Jail because it was easy "and does not require that he pay for malpractice insurance." This appears to be yet another example of a doctor with lesser skills treating underserved populations, such as low-income communities, immigrants, and prisoners. The assumption is that certain patients deserve less. As I have said before, prisoners may have little sympathy among the general readership, but we have to ask at what point does poor treatment by a physician for very real ailments translate into "cruel and unusual punishment"?

Second, why are PACE and Microcog limited only to doctors who are caught straying outside the lines? Should there be an age at which physicians are required to take psychological exams? Many of the physicians that Antidote has written about over the years, including Dr. Andrew Rutland and Dr. Lawrence Hansen, are in their 70s and 80s. Motor vehicle departments require older drivers to take exams more regularly. Should a medical board license come with some age requirements?

I tried to find out how often the MicoCog test is administered but was stymied by the medical board's own poor record-keeping. All the board was able to tell me was that 27 physicians failed the PACE competency assessment since 2002, which means that some subset of that group failed MicroCog.

I am anticipating some strong arguments against any age-related tests from the doctors who read Antidote.

Share your thoughts in the comments below, send them to me personally at askantidote@gmail.com or contact me via Twitter @wheisel.