Effects of Aging on Clinical Performance: Known and Yet to Know

1. Effects of Aging on Clinical Performance: Known and Yet to KnowStephen H. Miller MD, MPH Voluntary Clinical Professor, Family Medicine and Surgery UCSD School of Medicine

2. Pilots • Mandatory National Standard All pilots must maintain currency-exam, simulation and medical exam (frequency of latter varies with age (age 40=6 vs. 12 mo.) • Study NTSB (2000-2004) of all pilots (recreational, corporate and commercial, transport) in US; Over age 60=15 % of all pilots and 24% aviation accidents. • Study NTSB/FAA (2007-2009) air line pilots; Early indications, increasing age to 65 did not affect passenger safety. More study needed

3. Physicians • All physicians must maintain (generic) licensure to practice No national standard(s) for licensure • No assessment of competence, currency or quality performance required in area/scope of practice • Physician competence/performance data is scant, incomplete and of little use to the profession and even less to the public

4. Should there be age based retirement for physicians? • Yes- Aging reduces the quality and quantity of contributions. Set mandatory age and all must retire from active practice-in the case of surgeons they must stop operating at a specific age. • No- Age maybe a risk factor but it is not the only one.

5. Scientific Discovery and Age “Age is, of course, a fever chill That every physicist must fear He’s better dead than living still When once he’s past his thirtieth year” Paul Dirac -Nobel Laureate in Physics- research published at age 26

6. The Genius and Creativity of Youth • Many geniuses- Mozart, Shelley, Keats etc. made enormous contributions at early ages. • What might they have contributed if they lived longer??

7. The Creativity and Contributions of the Aged

8. Wisdom of the “Ages/Aged” • Changing balance between imagination (youth) and knowledge (aged) –Aristotle • Developmental intelligence-maturing of cognition, judgment, emotional and social intelligence, life experience and consciousness –Gene Cohen M.D., Ph.D. • How old would you be if you didn’t know how old you was? –S. Paige

9. Aging and Performance • Growing old is better than the alternative, providing that one is GROWING and not existing old. • Averages tend to gloss over levels of performance-bad and good. • When judging decrements in performance, creativity and contributions to society which might occur with aging, one must also consider the baseline from which a person began.

10. Graying of Academia • Past performance is a much better predictor of scientific productivity than is age: Researchers who are highly productive in their 30s are also likely to be much more productive in their 60s and 70s than are researchers who are not very productive at a young age. Loss of resources (grants), compulsory retirement age reduces the number of aged scientists. • Nobel prizes , except for this year not given posthumously and not given to the same person more than once. Stroebe American Psychologist 65:600, 2010

11. Characteristics of aging whichmayaffect clinical competence What we know: • Physical-motor capabilities (dexterity), stamina, energy, strength, reflexes (reaction time), acuity of vision (visio-spatial skills) and hearing, immune capacity, propensity for illness. • Mental-memory (short term), diminution of risk taking, impairment of puzzle and problem solving (information processing), reduced ability to adopt new ideas and or reexamine old ideas.

12. Other risk factors which mayaffect clinical competence • Poor performance in medical school • Solo practice • Lack of hospital privileges • Lack of ABMS Board Certification • Out of scope practice • Clinical volume • New knowledge/procedural skills • Fatigue/Stress/Burnout • Health issues-Mental and Physical-may or may not relate to aging

13. Old vs. Young: Diagnostics • Old make more accurate initial diagnosis-rely on experience and non-analytic thinking • Young take longer to make diagnosis: rely more on analytic reasoning • Problem 40% of initial complex diagnosis may be incorrect. • Can the older physician be taught to abandon first impressions and use more analytic reasoning)? • Objective peer feedback K. Eva Academic Medicine 2002:77: S1-S6

14. Clinical experience and quality health care • 52% negative association;21% negative association for some outcomes, 13% no association and 2% positive association • 1.Knowledge, adherence to standards of care ,2. diagnosis, 3.treatment, or 4. health care outcomes. • Outcome data is less consistent, knowledge data is most consistent. • Retrospective review-selection bias; span of articles span 30+ years with more recent ones suggesting better outcomes Choudhry et al AnnInt.Med 142:260, 2005

15. Associations between physician characteristics and quality of care Rand Study ArchInt.Med170:1442,2010 • 124 Process measures (guidelines) across broad range of clinical areas-based on Rand QA tool determined by 4 panels –claims data • High overall performance-female, board certification and graduation from a domestic medical school but effect is small between best and worst. • No association with age, but did not look at test scores, or hypothetical scenarios Reid et al. ArchInt.Med170:1442,2010

16. Differences: Relative vs. Absolute; Clinically Important vs. Statistical • 0.5% increase in mortality for every year since graduation. Norcini et al.-Acad Med 75:1193 2005 • Data from above are relative risks and true risk in the above study actually comes to an absolute increase in mortality of after 20 years of 1%. Subsequent study using similar data (NS) Commentary on Choudhry’s paper by Geoff Norman and Kevin Eva • A difference to be a difference must make a difference Gertrude Stein

17. Cognitive functioning and age in surgeons • Cambridge Neuropsychological Test Automated Battery( CANTAB)-stress tolerance, psychomotor function and visual-spatial functioning related to surgical skill. • Majority(60%) of senior active surgeons performed at or near the level of their younger peers on all cognitive tasks as did 50% of retired surgeons. • Drag et al J ACS 213:303,2010

18. Age and Operative Mortality • Medicare files-460,000 patients undergoing procedures between 1998-1999 • Pancreatectomy, CABG, carotid endarterectomy, esophagectomy, cystectomy, lung resection, aortic valve replacement and AAA repair • Age related( >60) mortality increased only in pancreatectomy, CABG and carotid surgery, but restricted to older surgeons with lowest volume Waljee et al AnnSurg 244:353, 2006

19. Responsibility: Societal/ProfessionalContract -19th C As a self-regulated profession, medicine is granted substantial societal privilege and, in return, is expected to set standards for entering practice, for sustaining privilege to practice, and for sanctioning and removing from practice physicians(5-10%)who neglect or abuse of that privilege.

20. Responsibility 96% of physician responders agreed that impaired or incompetent physicians should be reported to the appropriate authorities and 45% reported that they had encountered such colleagues and failed to report incompetent colleagues Campbell et. al. Ann. Int. Med-2007

21. Characteristics of aging whichmayaffect clinical competence What we assess today: ABMS/ACGME Competencies • Medical knowledge- Multiple choice tests, oral exams, OCE, chart reviews simulations-Do they reflect practice profile? Are they reliable? • Patient care- performance real or simulated, mock patients, orals, chart review (randomized- standards for assessment to assure reliability of assessment • Practice-based learning- CME, is it reflective, practice based, outcomes?

22. Characteristics of aging whichmayaffect clinical competence What we assess today: ABMS/ACGME Competencies • Interpersonal communication skills- 360, observation at test site, chart review • Professionalism- chart audit, 360,mock patients, ethics exams • Systems- based practice-oral exams, chart audits Necessary, but not sufficient

23. Incompetency: A Red Flag • 45 Physicians with competency issues referred by College of P&S of Ontario • 38% found deficient in a standardized test of competency subsequently had moderate to severe impairment in age adjustedneuropsychological testing. Turnbull et al Acad Med 81:915, 2006

24. What we need to know?Where and from whom will it come from- Local/Regional, State and National organizations • Evaluation of mental and physical health regularly and increasing in frequency after age 55 or when illness develops. Neuropsychological testing as necessary • Reliable assessments of actual performance or reliable and relevant proxies for performance which measure outcomes or processes that produce important and desirable outcomes and provide feedback and follow up to document change. • Re-credentialing ( annual), re-licensure based on scope of practice(2 yrs.) and recertification (3 yrs) • Technical/procedural skill- Proctoring/ Simulators for new operations to document proficiency and after age 60, or if illness has developed. These would be specialty specific and based on practice profile.

25. Should there be age based retirement for physicians? • Yes-Aging reduces the quality and quantity of contributions. Set mandatory age and all must retire from active practice-in the case of surgeons they must stop operating at a specific age. • No-Age maybe a risk factor but it is not the only one.

26. Unintended consequences of age based competence decisions/ mandatory retirement • Contribute to predicted physician shortfall as population ages and their needs for medical care increase. • Loss of contributions of medical wisdom and experience. • Economic losses-society paid for medical education; delaying retirement. • Beware the “Law of Averages”-Old does not necessarily mean incompetent • Age maybe a risk factor but it is not the only one. • Age Discrimination in Employment Act (ADEA)

27. Advice to those who say it is too hard to evaluate competency / performance

28. paceprogram.ucsd.edu