Cognitive Testing of Senior Doctors
by Prof Philip Morris AM
Today I wish to discuss the proposal by the medical registration authorities to test the mental capacity of doctors at age seventy in an attempt to improve the safety of health services and to protect the public. I will demonstrate that this proposal is nothing more than the equivalent of racial profiling. I will show that there is no evidence that healthy aging among older doctors is associated with any significant cognitive impairment that would affect patient care. The proposal to cognitively test older doctors at age seventy is nothing more than ageism. Medical boards already have extensive and legitimate powers to assess younger and older doctors who have medical conditions that might affect their cognitive performance and clinical practice. Medical boards do not need to cognitively profile older doctors in order to keep the public safe.
As an empathic exercise, I would like you to think that you are an African-American (black) young man who has gone with his black male friends of the same age to a Southern Baptist Church service on Sunday in the deep south of the United States. After the service is finished, he and his buddies walk back through the city laughing and joking and talking loudly and listening to rap songs on their boom boxes. Everything seems to be going fine until two police cars with sirens screaming turn up. The police officers jump out of their cars and at gunpoint ask the young black males to stand against the wall of a nearby building. The young men ask the police officers why they are doing this. The police officers say that they are going to strip-search them and check them for weapons and drugs because black young males have higher rates of violent crime and drug use than other Americans. The young men protest that they have just been to Church and are minding their own business and are on their way home. The police are not deterred and proceed to strip search and humiliate them in front of all the other people in the street.
What are the police doing? This is racial profiling. The definition of racial profiling is “any action undertaken for the reasons of safety, security or public protection that relies on a stereotype about race, colour, ethnicity, ancestry, religion or place of origin, or a combination of these, rather than on reasonable suspicion, a singling out of an individual or group for greater scrutiny or different treatment” .
This practice has led to civil unrest in the United States with black Americans feeling that they have been persecuted and discriminated against on the basis of their race. Those who justify this behaviour draw on the argument that although only 13% of Americans are African Americans, yet black offenders (mainly males) commit 52% of the homicides recorded in the United States and the offending rate for black individuals is seven times higher than for whites. FBI records show that 38% of murders were carried out by black offenders to 31% by whites despite the smaller number of black individuals in the United States population .
While some might try to justify the practice of racial profiling with this information, it is generally accepted that racial profiling is just another form of discrimination and racism.
Racial profiling is not fair. Even if the statistics show that young black males in the United States have higher rates of violent crime and drug offending this is no reason to single out a group of young black males walking home from Church on Sunday morning. The only reason that the police could justify the behaviour of strip-searching a group of young black males would be on a ‘reasonable suspicion’ that they might have committed a crime. For example, there may have been a robbery close by and eyewitnesses saw a group of young black males running away from the scene. That would be reasonable suspicion and would justify the police singling out a group of young males. But just being a member of a certain class of individuals is no justification for racial profiling.
You may have now picked up what relevance this might have to medical registration authorities wanting to force seventy-year-old doctors to undergo cognitive testing. The medical authorities are claiming that they are doing this for reasons of safety or public protection. The authorities want to cognitively test all older doctors with a justification built on a stereotype of doctors based on their age rather than on ‘reasonable suspicion’. In this case, we are dealing with ‘age profiling’ rather than racial profiling but the behaviour is just as offensive. Medical authorities in Australia are considering enforcing ‘strip-searching’ the brains of older doctors with cognitive tests based on an age stereotype.
This proposal is nothing more than ageism. Ageism is any attempt to group doctors together as a class based on age and apply ‘special’ rules to the whole class while denying individuals in that class to be assessed on their individual merits or characteristics. This ageism is a reflection of prejudice and discrimination.
While ageism and age profiling of older doctors is totally unacceptable, is there anything that might provide a justification for doing this with older doctors? For example, is there evidence that older healthy doctors as a group have high rates of cognitive impairment that would affect their clinical practice compared with other doctors? In order words, does healthy aging pose cognitive concerns for older doctors practising medicine?
We need to distinguish healthy aging from medical conditions that become more common as doctors age. We know that as individuals get older, they may come into age categories that put them at higher risk of different diseases (Alzheimer’s disease, vascular dementia, ischemia heart disease and cancer, for example). However, we must distinguish these disease states from healthy aging. If a doctor develops a condition of Alzheimer’s disease when they are older, they should be treated in a way no different than if a doctor at the age of thirty-five develops alcohol or methamphetamine dependence and has difficulties in medical practice because of cognitive alterations caused by drug intoxication. The medical registration authorities have the power to intervene in both situations in order to protect the public.
Is there any evidence to suggest that healthy aging in doctors poses a problem for clinical practice?
One way of testing this proposition is to ask the medical indemnity insurers if they have increased or special premiums on their policies based on the older age of doctors. I have investigated this with a number of indemnity insurers in Australia and they assure me that there is no age-related increase in premiums in any of their policies. Their policies are based on two primary influences. The first is the nature of the practice and the risk profile of that practice and, second, the number of cases that practitioners look after at times in their career (for example, the higher the number of cases as reflected in practice income, the higher the premium). The actuaries that advise the medical indemnity insurers do not advise that older age is an additional risk factor that would justify additional premiums.
Another way of testing this proposition is to identify the age profiles of doctors known to the Health Committees of Medical Boards across Australia. Doctors known to the Health Committees of Medical Boards are generally those doctors who have impairments based on underlying medical conditions. A report from an Australian medical board notes that there is no significant difference in the proportion of doctors over the age of sixty compared to other doctors in the category of doctors known to Health Committees of Medical Boards .
The indication so far is that there is no evidence that healthy older doctors pose a risk to the public that could justify age profiling.
So, what does happen in healthy aging to cognitive capacity over time? There are gradual changes that occur in fluid intelligence and crystallised intelligence . Fluid intelligence involves cognitive characteristics like processing speed, problem-solving, reasoning, learning new information, short-term memory, executive functions and psychomotor ability. Fluid intelligence peaks in early adulthood and then decline very slowly. These changes are small and gradual. The changes in fluid intelligence are counter-balanced by age-related improvements in crystallised intelligence. Crystallised intelligence involves cognitive characteristics like vocabulary, general knowledge, medical knowledge, experience and pattern recognition (the end product of information acquired), and ‘wisdom’. In healthy aging, the influence of balancing changes in these cognitive qualities usually results in the person not significantly changing in cognitive capacity over time.
As far as I can tell, there is little evidence to suggest that these changes in fluid and crystallised intelligence led to any significant deterioration in the capacity of older doctors to function effectively in clinical practice.
It is important to note that individual variation is substantial in all doctors who age. There is no consensus or agreed on guidelines that help medical authorities decide what level of cognitive changes in doctors due to healthy aging may put the public at risk . There is little information about how to identify those physicians who are at risk because prospective studies have not been done addressing this issue .
The American Medical Association had earlier agreed that physicians should be tested at the age of seventy years. However, in 2015 they repudiated this decision and now say that “the effect of age on any individual physician’s competence can be highly variable”. The American Medical Association has now withdrawn its support of testing physicians cognitively at seventy years of age .
What approaches might be available to medical boards to address the risk to the community of cognitive impairment in older doctors? A recent article on this topic canvassed a number of approaches . The alternatives are listed below.
- Reporting by peers
- Physician self-assessment and self-report
- Employer or institutional programs: speciality board recertification/maintenance of certification programs
- Peer recommendations: credentialing process for staff (re)appointments using peer review
- Mandatory age retirement
- Age-mandated cognitive assessments: cognitive testing, direct observation of physician’s practice and work
- An age-based cognitive screening tool
- More research
None of these methods is satisfactory and avoids despicable ageism, age discrimination and age profiling. Perhaps the only one I could endorse is ‘More Research’ is needed!
What then is the way forward? Cognitive profiling of the whole profession based on age is not justified on the evidence available. Medical registration authorities have wide powers to evaluate any doctor who is the subject of a complaint or has been notified to them by colleagues or institutions. This capacity applies to doctors of all ages. These authorities do not need to enter into age profiling or age discrimination in order to identify doctors who are having difficulties.
One way of identifying doctors who may be considered to be under ‘reasonable suspicion’ and therefore subject to justified cognitive and health testing would be doctors with two or more complaints made against them in a defined period of time. It is known that the majority of doctors who have health or cognitive problems are ones that have been identified as having multiple complaints made against them – that is many prior notifications or ‘frequent flyers’. This would qualify as a reasonable justification for testing this group of doctors.
In addition, older doctors could also be evaluated for their cognitive and health status after significant lapses in standard of care, but this should be the norm regardless of age and would apply to younger doctors as well as to older doctors.
Finally, it is absolutely vital that all doctors recognise and take seriously their responsibility to identify concerns with their medical colleagues, discuss these concerns with them, and make sure that they get into appropriate care as required.
I hope I have demonstrated in this paper that cognitive profiling of seventy-year-old or older doctors is not justified. A more targeted approach that avoids ageism and age discrimination needs to be developed. I have made a number of suggestions as to how this might be carried out. Further research is required into the best way forward. Discussion between the profession and medical registration authorities needs to examine more respectful ways of identifying older doctors that might be a safety risk to the public.
- Ontario Human Rights Commission
- Adler R, Constantinou C. Knowing – or not knowing – when to stop: cognitive decline in ageing doctors. Med J Aust 2008;189(11):622-624.
- Harada C, Love M, Triebel K. Normal Cognitive Aging. Clin Geriatr Med 2013 Nov;29(4):737-752.
- Devi G, Gitelman D, Press D et al. Cognitive Impairment in Aging Physicians. Neurol Clin Pract 2021 Apr;11(2):167-174.