Decades ago, during a staff shortage, I was promoted to a more senior role where I was responsible for a ward full of sick patients requiring many consequential decisions.
With my bare experience, I knew I had to stay within my limits.
One day, I met a young non-English-speaking patient with profound weakness and weight loss. She underwent a battery of tests to finally uncover an aggressive cancer. But the diagnosis was just the start. Every day, her anxious children begged me for guidance, not knowing that I was out of my depth and myself needed guidance.
But my boss didn’t seem to be interested in the patients. He attended rounds erratically and, when he did, it was as if he was bestowing a favour. At the bedside, he mumbled pleasantries but seemed incapable of making decisions. Simple questions stumped him and then, before I could talk to him in private, he would beat a hasty retreat. I was flummoxed.
When his stint ended, the new attending’s first task was to call a family meeting. On a whiteboard, he drew simple pictures to depict the devastating diagnosis, gently steering the family towards palliation. I remember the tragedy as if it were yesterday and still regret failing the patient and family for excruciating weeks.
All this time, I had considered the first physician a strange outlier until a recent conversation with a medical executive prompted a rethink. She reflected that the hardest thing she ever had to do was to tell cognitively impaired doctors that they were not fit to practise. Sometimes the trigger had been mounting patient complaints; other times, the concerns of colleagues, whispered, then more insistent.
Inevitably, the doctor demurred: a turning towards perceived as a turning against. On the one hand, a forgetful colleague struggling to manage complex surgery and document decisions; on the other hand, an old friend’s dawn of realisation that something was not right interrupted by moments of terror. Finding the right mix of empathy and firmness, she said, was the hardest part.
As a young doctor, it never crossed my mind that doctors could share the afflictions of our patients. I had no vocabulary to express that my elderly boss might be cognitively impaired, but now that an ageing population, a changing economy and shifting attitudes to retirement have seen a concomitant rise in the number of doctors practising with cognitive impairment, I suspect we will have to find the right words.
A report in 2021 found that 13% of American physicians over age 70 were cognitively impaired to the extent that they could not practise independently. Meanwhile 22% of Canadian physicians over the age of 75 were said to have “gross deficiencies” in their practice.
Of 41 doctors aged over 60 referred to the New South Wales Medical Board Impaired Registrants Program, 54% were found to be cognitively impaired and 12% to have dementia.
Australian doctors over age 65 have a higher rate of notifications regarding incorrect prescribing, cognitive decline, improper documentation and disruptive behaviour.
There is a clear relationship between normal ageing and cognitive decline. But age-related decrements are highly variable and greater cognitive reserve can be protective. Furthermore, what ageing doctors may lose in fluid abilities (finding new ways to solve problems) they often make up for through crystallised intelligence (acquired cumulative knowledge). Some of the most judicious and cherished doctors I know are in the twilight of their career – they may not adopt the newest tricks but they are a safe and reliable pair of hands.
India, Ireland and Japan impose a mandatory retirement age range for doctors due to concerns about performance. Like the US and the UK, Australia does not enforce age-based retirement, which raises the thorny question of how to identify impaired doctors before patients come to harm.
Doctors are typically sympathetic towards their peers and loth to flag their concerns. In a large survey, 17% of American doctors personally knew an impaired doctor who was not fit to practise but one-third of surveyed doctors did not think it their business to interfere and another third felt unprepared to deal with such colleagues.
Voluntarily stepping back from medicine, in many cases one’s primary identity, requires courage and insight that may be absent in the most serious cases.
Patients who daily put their lives in the hands of doctors deserve to know that they are safe and, as new challenges arise, there is a laser focus on their welfare. This leaves regulatory bodies to walk the line between being seen to be discriminating against older doctors and protecting the public interest. The ceiling for retirement may depend on the nature of an individual’s work hence the difficulty in defining a universal policy.
A reactive response to cognitive impairment that involves showing a doctor the door lacks nuance and is unfair. Alternatives could include placing limits on the most onerous jobs that promote error, such as consecutive night shifts and on-call duty, crisis calls and complex procedures. A thoughtful approach could capitalise on the wisdom of ageing doctors by enabling a transition to teaching, mentoring and selected research and administrative roles. At a time of workforce shortage, this could be a win-win proposition.
Competency assessments have long been discussed as a way of maintaining standards.
When undertaken by friendly (or reluctant) peers or an indebted institution, the process can lack rigour. Therefore, experts propose as a starting point an independent age-based cognitive screening of key domains including executive function, language, memory, motor and visuospatial skill. Careful parameters could limit false results and longitudinal testing could be used rather than an arbitrary cutoff.
Failing a screening test would not be the end but the beginning of a more comprehensive assessment to identify the most impaired doctors while reducing the risk of flagging others. Some fear that this process would be not supportive but punitive. But we also cannot let the perfect be the enemy of the good.
While we must respect the seniority and wisdom of doctors, our highest responsibility must be to our patients.
Doctors often counsel patients that in many situations, there is no best approach, only a fair, considered and informed one with the right to obtain a second opinion. Even the most impaired doctor once understood the sanctity of primum non nocere – first, do no harm. When that doctor is no longer able, it is up to the rest of us to honour the sentiment through our actions.
• Ranjana Srivastava is an Australian oncologist, award-winning author and Fulbright scholar. Her latest book is called A Better Death