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Is There a Case for Cognitive Testing for Senior Neurologists?

Article In Brief

The article revisits the controversy around policies at some academic medical centers that require older neurologists to undergo cognitive testing for recredentialing.

Aging is known to be associated with cognitive decline. Is that reason enough to test more senior neurologists and other physicians for potential cognitive deficits that might cause a patient-care problem?

A growing number of health systems say “yes” and are implementing policies that require cognitive and other screenings when physicians reach a certain age. But the policies are controversial: One state passed legislation prohibiting the practice, although the ban was reversed the next year; most recently, the Equal Employment Opportunity Commission (EEOC) filed a lawsuit that argues one health system's mandatory-examination policy is illegal.

Physician demographics suggest the controversy will not go away soon. There are currently about 150,000 practicing physicians age 65 and older in the US, up from about 95,000 in 2013, according to the American Medical Association.

Proponents of age-based screenings say evidence shows they are needed. At Yale New Haven Hospital, the teaching hospital for Yale School of Medicine, physicians age 70 or older must complete a neuropsychological assessment; of the first 141 to undergo the assessment, nearly 13 percent demonstrated cognitive deficits that were likely to impair their ability to practice independently, according to a January 14 report in JAMA.

Meanwhile, about 70 older physicians from across the country have undergone a late-career health screening through the University of California-San Diego (UCSD) Physician Assessment and Clinical Education program and roughly 20 percent have been referred for further evaluation, said David Bazzo, MD, director of the UCSD Fitness for Duty program.

Opponents disagree with the idea of age-based screening. Scott E. Hirsch, MD, a neuropsychiatrist—board-certified in neurology and psychiatry—at NYU Langone Health, who evaluates physicians on behalf of the New York State Office of Professional Medical Conduct, is one of them. Dr. Hirsch pointed out that maintenance of certification exams require physicians to demonstrate mastery of the knowledge needed to practice.

“The tests are fairly challenging and I don't think you can do well on them if you have an underlying cognitive problem,” he said. “We are already doing so much to stay credentialed. I don't see how cognitive screening adds anything.”

A number of neurology leaders contacted for this story declined to be interviewed, but those who did agree to be interviewed had mixed opinions about mandated cognitive screening.

Where We Are Now

Policies mandating routine age-based screening started emerging about a decade ago, Dr. Bazzo said. In 2011, his UCSD program and the Coalition for Physician Enhancement convened a range of professionals—physician-evaluators conducting assessments on behalf of state medical boards investigating complaints; geriatricians; administrative law judges who preside over physicians' disciplinary hearings; and prosecutors and defense attorneys involved in physician disciplinary cases—to discuss the aging physician workforce.

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“The [maintenance of certification] tests are fairly challenging and I dont think you can do well on them if you have an underlying cognitive problems. We are already doing so much to stay credentialed. I dont see how cognitive screening adds anything.”—DR. SCOTT E. HIRSCH

In addition to educational sessions and a review of age-based physician screening commonly conducted in Canada, conference participants were surveyed on the issue. The majority favored age-based screening for physicians, starting at age 70, that includes assessments of physical and mental health and a cognitive screen, according to a report in the Journal of Medical Regulation.

“That sort of started the ball rolling,” Dr. Bazzo said.

Since then, many organizations—ranging from huge systems like Scripps Health to community hospitals like Sinai Hospital in Baltimore—have implemented age-based screening policies. In 2014, the University of Pittsburgh Medical Center (UPMC) became one of the first to implement a policy to assess physical and cognitive abilities, said Donald M. Yealy, MD, senior medical director of the system's health services division.

Dr. Yealy and colleagues drafted the policy for two reasons. First, they recognized that some other fields—commercial aviation, for example—have age-related thresholds that trigger a professional re-evaluation or practice change to optimize safety.

“At the same time, we also realized that we had some reported safety concerns in which we wondered, but were never certain, if a more scheduled and proactive approach might have helped us avert a patient care issue,” Dr. Yealy said.

The UPMC policy applies to advanced practice providers as well as physicians. The UPMC medical staff accepted the policy, which follows steps similar to those used with other physicians when a concern arises, without much controversy.

“We learned that having a set policy creates a natural and non-threatening opportunity for any physician to personally re-evaluate,” he said. “We have had many who, at their 70th birthday, have altered what privileges they request or shifted into a different type of practice.”

By contrast, Intermountain Healthcare, a large system based in Utah, had a very different experience. That system had a mandatory retirement age of 72 for medical staff in 2013, when neuropsychologist Kelly Garrett, PhD, was asked to help plan a late-career physician program.

“Our credentialing committees were giving exemptions, allowing physicians to practice beyond age 72, but they felt that they did not have enough data in order to be able to grant these extensions with much degree of confidence,” Dr. Garrett said.

In 2014, Intermountain's medical staff approved a policy that required late-career physicians to complete a history and physical, including sensory and cognitive screenings. Four years later, the Utah State Legislature prohibited mandatory age-based screenings for physicians. In 2019, the ban was reversed but the new law dictates some principles that must be followed.

“Intermountain has been reticent to return to business as usual and is now exploring reorganizing the program such that at least the cognitive screening part would be a voluntary program available to physicians regardless of age,” Dr. Garrett said.

In February, the EEOC filed suit against Yale New Haven Hospital saying its policy requiring neuropsychological and eye examinations before physicians can obtain or renew staff privileges violates the Age Discrimination in Employment Act.

What Neurologists Think

For some neurology leaders, age-based screening smacks of ageism. The idea of screening to make sure a physician's cognitive skills are adequate for the job does not alarm S. Andrew Josephson, MD, FAAN, professor and chair of neurology at the UCSF Weill Institute for Neurosciences. But age-based screening bothers him.

“I would worry that, if we set some arbitrary age cutoff, we are not really focusing on the problem we should be concerned about, which is identifying physicians who have cognitive impairment from a variety of issues, whether it be a neurodegenerative process, substance abuse issues, or some other problem,” he said.

Richard P. Mayeux, MD, MSc, FAAN, professor of neurology, psychiatry and epidemiology and chair of neurology at Columbia University College of Physicians and Surgeons, also gives age-based screening a thumbs-down.

“It's illegal to do it as part of job credentialing based on age,” said Dr. Mayeux, co-director of the Taub Institute for Research on Alzheimer's Disease and the Aging Brain at Columbia University Medical Center. “Our strategy is to single out and test only people who have demonstrated some impairment of some sort. Impaired physicians, I have no problem evaluating—but evaluating people simply because they're old, I think is inappropriate.”

Neil A. Busis, MD, FAAN, associate chair for technology and innovation in the neurology department at New York University Grossman School of Medicine, said it's important to balance the twin goals of maintaining a robust neurology workforce and protecting patients. Screening for potential impairment might be a way of striking that balance, he said. Commercial airline pilots older than 40 years must have a “first-class medical certificate” renewed every six months.

“I think well thought-out processes from other industries can be applicable to medicine,” he said. “Certain kinds of health screening seem like a reasonable thing to do.”

That said, if protecting patient safety is the reason for screening, singling out physicians might not be justified. “If you're going to mandate screening for physicians, how about nurses and everybody else who works at the hospital?” Dr. Busis said.

Wide Range of Approaches

There is no standard approach to age-based screening or assessment programs, which vary considerably on at least three variables.

  • Age threshold. At UPMC, the age-based screening policy triggers when a physician or advanced practice provider reaches age 70 or will turn 70 during the upcoming appointment or reappointment interval. At Stanford Hospital & Clinics, practitioners who are 75 years old are asked to have a peer clinical skills assessment and physical and cognitive screenings every two years. At Cooper University Hospital in New Jersey, physicians' cognitive abilities must be assessed at age 72. The Society of Surgical Chairs, meanwhile, recommends mandatory cognitive and psychomotor testing of surgeons by at least age 65.
  • Screening process. Some health systems do in-house screenings, while others outsource to other organizations, such as UCSD's Physician Assessment and Clinical Education program, to conduct late-career health screenings. Institutions that use UCSD send physicians to San Diego for a physical examination; a cognitive screening using two instruments—the Microcog and the Montreal Cognitive Assessment; and, if the practitioner performs procedures, a fine motor-skills test.
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“Certain kinds of health screening seem like a reasonable thing to do. That said, if protecting patient safety is the reason for screening, singling out physicians might not be justified. If youre going to mandate screening for physicians, how about nurses and everybody else who works at the hospital?”—DR. NEIL A. BUSIS

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“I would worry that, if we set some arbitrary age cutoff, we are not really focusing on the problem we should be concerned about, which is identifying physicians who have cognitive impairment from a variety of issues, whether it be a neurodegenerative process, substance abuse issues, or some other problem.”—DR. S. ANDREW JOSEPHSON

There is no cut-off score that determines that a provider is competent to practice independently, Dr. Bazzo said. Rather, neuropsychologist (and AAN member) William Perry, PhD, vice chair of the UCSD department of psychiatry, reviews and interprets each neurocognitive screening report to determine whether more in-depth testing for diagnostic purposes is recommended.

At UPMC, by contrast, physicians and advanced practice practitioners covered by the age-based screening policy must notify the credentialing committee who will be conducting the physical examination and cognitive assessment they obtain on their own. “Obviously, that would give us an opportunity to make sure that the person who is going to do any part of the assessment was qualified and did not have any conflicts,” Dr. Yealy said.

The credentialing committee requires a specific tool for the cognitive assessment. The physical examination must look for “physical impairment that might impact an ability to function in whatever type of physician you are, whether it's a cognitive specialty and/or procedural specialty,” Dr. Yealy said.

  • Screening instrument. Neuropsychologists who conduct cognitive screens of late-career physicians use a variety of instruments. “There is no single measure that is accepted by all,” Dr. Perry said.

Dr. Perry and other neuropsychologists who are most active in late-career physician screening convened last year to discuss the tools available and agreed that the MicroCog is the best option because it has been normed on physicians. Acknowledging that the instrument has some limitations, Dr. Perry said it is not used to diagnose a specific condition, but rather to determine whether a more in-depth evaluation is needed.

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“Its illegal to do it as part of job credentialing based on age. Our strategy is to single out and test only people who have demonstrated some impairment of some sort. Impaired physicians, I have no problem evaluating—but evaluating people simply because theyre old, I think is inappropriate.”—DR. RICHARD P. MAYEUX

“The idea is not to use the MicroCog to remove people from practice,” he said. “The idea is to catch something before it's extreme and problematic because then a physician is able to make changes to their practice.”

Link Up for More Information

• Cooney L, Balcezak T. Cognitive testing of older clinicians prior to recredentialing https://jamanetwork.com/journals/jama/article-abstract/2758602. JAMA 2020;323(2):179–180.
    • EEOC Sues Yale New Haven Hospital for Age and Disability Discrimination https://www.eeoc.gov/eeoc/newsroom/release/2-11-20a.cfm. Accessed February 11, 2020.
      • Katlic MR, Coleman J. Balancing safety with dignity when evaluation aging practitioners. https://www.physicianleaders.org/news/balancing-safety-with-dignity-when-evaluating-aging-practitioners. American Association of Physician Leadership blog post, March 1, 2018. Accessed March 12, 2020.
        • Moutier CY, Bazzo DEJ, Norcross WA. Approaching the issue of the aging physician population https://jmronline.org/doi/10.30770/2572-1852-99.1.10. J Med Regulat 2013;99(1):10–18.