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Notebook Medicine

Physicians in white

(Buero Monaco/Getty)


Physicians in white

What happens when old doctors’ skills fade, fade away?

A new law will allow Japan’s Emperor Akihito, who would otherwise have had to serve for life, to abdicate; he plans to step down in 2019 at the age of 85. This extreme approach to tenure contrasts with America’s federal judges: Firing one would take a (literal) act of Congress, but they’re free to leave whenever they choose.

Some lines of work take the opposite approach, setting a mandatory retirement age. Commercial pilots have to retire at 65—it had been 60, until a 2007 law added five years—and air traffic controllers normally retire at 56. In the Old Testament, the Levites had to step down from Tabernacle service at 50.

Where do doctors fit in? Pioneering heart surgeon Michael DeBakey practiced until his death at 99, and one of my own mentors practiced into his late 70s and stopped only because his mobility was failing him: He could no longer respond quickly to emergencies, but his memory and intelligence remained intact.

This isn’t always the case, and a 2012 Washington Post article on the subject quoted geriatrician William Norcross as estimating that 8,000 practicing doctors suffered from dementia. Concerns of that sort have given rise to a controversial idea called MOC, or Maintenance of Certification. Under MOC, medical board certification has moved from a once-for-life pair of exams to an increasingly complicated series of steps that repeats every 10 years. MOC proponents say the program ensures doctors keep their knowledge current. Detractors call it an expensive distraction from clinical practice.

Some hospitals and practices now require doctors to have MOCs, but critics ask: Who sets the topics that should be examined? Who chooses the right answers where there is disagreement? How often should doctors face these checks? What allowance should they receive for focusing on specific areas of practice—areas that may be only a small portion of a modern MOC exam? Will MOCs allow politicized credentialing bodies to insist on conformity with their agendas?

Many state departments of motor vehicles have started to require eye exams as drivers age, and some have introduced a system where people can report potentially impaired older drivers for a closer check. It’s not every day that I think DMVs do a better job than my own credentialing body, but their system works better than MOC. Like drivers, physicians often respond to their advancing years by setting limits for themselves: Where an elderly driver might avoid the roads at night or in inclement weather, older doctors often stop taking night calls, limit their practices, and gradually restrict how many patients they see in a day. MOC doesn’t account for those adaptations.

Some medical authorities now follow DMV practice. The University of California, San Diego, offers an Aging Physician Assessment, and Baltimore’s Sinai Hospital has a similar program focusing on surgeons. Both are voluntary, but Stanford went even further in 2013, requiring all doctors over 75 to undergo biennial evaluations. In each case, the programs focused on mental and physical health—as opposed to test scores and quizzes about guidelines.

The Stanford policy met with considerable debate about whether it constituted age discrimination, but even a rebuke from the faculty senate failed to stop it. It makes sense, and I agree with its emphasis on health instead of attitudes: I don’t want my doctor’s decisions to be micromanaged, but evaluating whether his skills are still equal to his job description seems fair. Dr. DeBakey commented—at 91—that he would not mind being operated on by a 91-year-old surgeon. If the surgeon were as skilled and robust as he was at 91, I’d agree.