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Q&A with Dr. William Norcross, Part 2: Aging Physicians May Not Know They Are Impaired

Q&A with Dr. William Norcross, Part 2: Aging Physicians May Not Know They Are Impaired

Picture of William Heisel

The first part of my interview with Dr. William Norcross, head of the UC San Diego School of Medicine's Physician Assessment and Clinical Education (PACE) Program, ran Monday. The second part is below. 

Q: If you're worried about having a solution to age-based problems with older physicians forced on the profession, what do you recommend instead?

dr. william norcross, william heisel, patient safety, aging doctors, doctor oversight

A: Why don't you appoint an expert committee to review the evidence and make some recommendations. There should be a safe, confidential way to screen doctors at a certain age. I don't know what that age would be, and there might be a scientific answer to that question. I think people toss out 65 or 70 because we live in a decimal system. The answer would be related to where our tolerance for risk is. There's some chance that even much younger physicians could be impaired or have cognitive disease. People can look at prevalence curves for Parkinson's, hearing impairment, vision impairment, anything that could have an impact on how the physician treats patients. It is in some ways like the issue with commercial airline pilots getting older. There was a big battle there, too, and it used to be that they stopped flying at age 60. Recently they increased it to 65 with careful monitoring.

Secondarily to screening, all of us in the profession need to understand that we have a deep professional responsibility to our patients, and when we observe impaired behavior in a colleague or ourselves we must do something about it. That means we must have relatively safe mechanisms for reporting. One of the most disconcerting things for me and my colleagues as we have begun to examine this issue is how the physicians themselves are often the last ones to know there is a problem. I'm pretty sure when this day comes for me, I won't know it. That's the most terrifying message. When doctors get old and sick and lose a step, they often don't recognize it until something really dramatic happens. I can't tell you how many times we have physicians who come here and get worked up fairly extensively and find out they have major deficits. I would say 95 out of 100 truly do not believe there is a problem, even if they might be paralyzed on one side of their body.

Q: If some of these problems are so hard to detect, why would they matter in terms of clinical competency?

A: We have physicians who are referred to us who come here and get lost in the building. Our building is not a big building. It's a small office with only eight people working here, and yet some physicians get lost. These are physicians who have been protected by their colleagues. They do better in the familiar environment of their hospital, but once they are somewhere unfamiliar or confronted by something unexpected, things can go wrong.

The second answer is that we just did a program on the aging physician here, and you can view it online. We looked at how, as we get older, our distant memory and our crystallized knowledge remain untouched. Sometimes even with advanced dementia. But the ability to learn new knowledge and especially to handle and adapt and respond to novel situations gets worse. Our ability to do night calls and deal with sleep deprivation gets worse. Our ability to multi-task gets worse. With older physicians, their hospital or medical group slowly takes them out of situations where these things happen. But medicine is unpredictable. You never know what you will see in a clinic, hospital or emergency room. Strange occurrences and new occurrences are just part and parcel of our work in medicine. Even people with their full physical and mental faculties working as hard as they can have a challenge practicing at an excellent level all the time.

If you found out precisely what is going on, maybe a hearing aid would help the doctor. Maybe a stethoscope with electronic amplification would help. Maybe treatment for glaucoma would help. Maybe the person could be put in a situation where they wouldn't be running behind or be overscheduled. The occupational medicine field is way ahead of us. It gives people with problems accommodations in the workplace. If we did full bore screening, we would probably find that most doctors have some early, mild deficits and we would probably do something about it.

Q: As far as I can tell, MicroCog is the only test PACE uses routinely for assessment. Is that right?

A: The MicroCog is simply a one-hour computerized screening test, and it's been normed for the general population by age. So if a doctor performs sufficiently well on the MicroCog, that's it. In a decade, we have never had a doctor pass the MicroCog and turn out to have a cognitive disorder. But if the test is abnormal, we will send a doctor for full psychological testing, which takes nearly a day. And sometimes a doctor will perform poorly on the MicroCog and then do well on the neuro-psychological exam.

Q: Can you tell me how many doctors have undergone the MicroCog test and how many have succeeded and failed?

A: I have a pretty good guess. There's a paper in Academic Medicine that was published along with our paper in 2009 from the Colorado Personalized Education for Physicians program and they reported on hundreds of MicroCogs and all of their outcomes. My guess is that we have done probably around 800 to 900 MicroCogs, and I would say 20% are abnormal. There tends to be an association with age, but it's not perfect. For example, the MicroCog is supposed to be relatively impervious to language and culture, so that foreign medical school graduates can score the same as American graduates, but we think that there is a slight disadvantage.

Q: I wrote about a Dr. Bernard G. Sarnat, who went to his grave with a valid California medical license, He was a pioneering plastic surgeon who died at age 99 and still had a license. Does that make sense?

A: I'm a geriatrician myself and understand perfectly what you're getting at. In a perfect world, I think we would live in a system where there was confidential screening way before that age. And then there would be a way by which we would confidentially encourage physicians of a certain age to retire, and I would not make it something humiliating. I would maybe even surround the occasion with honor in some way, so it was a positive thing. If you did say that all physicians over 90 would have to surrender their licenses, lawyers would attack that and say it was ageism. In fact, there is a physician in Italy, a Dr. Rita Levi-Montalcini who will turn 103 next month. She has won the Nobel Prize in medicine, and she seems to feel that she's sharp as a tack. Aging is heterogeneous.

Q: How can a physician be expected to keep up with all the recent advances in medical science if not fully engaged in the practice of medicine?

A: That's why I would favor having confidential screening that would help everybody in medicine understand that they have a professional obligation to their patients, and nobody is able to hold back the hands of the clock. If I want to fulfill my obligations as a physician, I must submit to an inexpensive confidential battery of studies that would probably include a physical exam from my doctor and maybe some neurocognitive testing. I would trust that the people who looked at that would make a fair and unbiased decision about me. And I would participate in that every few years and turn my fate over to them. Maybe a 99 year old in that situation would be a great teacher, but not be covering the trauma service overnight.

Q: What happened when you wrote your piece for the Medical Board of California in 2006 advocating the type of age-based testing you just described? What are the main barriers keeping that from happening?

A: I think the situation is pretty much the same. We do have two hospitals in the country, at least, that have embraced screening. But I don't see a lot in the literature to indicate that people are concerned about this. I think that somebody is going to pop up and make a big mistake that will have serious consequences. This will become a banner that somebody carries into war. Something is going to happen. Rather than conscientious people reflecting on the evidence and trying to come up with a solution, we are going to have a solution forced on us that may or may not be what's best for patients.

Comments

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Not only will age-based screening likely be implemented in the medical profession ONLY after a catastrophic publicized event forces the issue, but doctors themselves are reluctant to come forward even when they are acutely aware of serious concerns about their colleagues competence to practice medicine.

A study reported in JAMA (July 2010) suggested that, although most physicians believe that their medical colleagues who are “significantly impaired or incompetent to practice medicine” SHOULD be reported, the reality was that a disturbing number actually chose instead to sit by and do nothing - even when they admitted they had “direct personal knowledge” of such incompetence. http://ethicalnag.org/2010/07/15/reporting-impaired-incompetent-doctors/

This is terrifying for the average patient to contemplate.

Picture of William Heisel

Carolyn,

Thanks for your note. I'm not sure medicine is much different from journalism, law enforcement, or many other professions in this regard, but, of course, the consequences of the code of silence you describe can be much higher in medicine. Terrifying, indeed. This is why I appreciate Dr. Norcross' candor and willingness to  continue to raise the issue.

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