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Miscellaneous See other Miscellaneous Articles Title: Mental decline in older physicians concern for patients? If so, what should be done about it?" Turning the Tables of Time "Do you feel that doctors over the age of 65 should be screened for cognitive decline?" began a general practitioner. Many, particularly those who identified as older doctors, chafed at any suggestion of testing for aging physicians. "I am appalled at the notion of cognitive testing. I do not plan to retire until I sense I am losing my touch," said one 70-year-old internist. More than a few physicians flipped the script, pointing out the shortcomings of younger colleagues. "I'll take a thoughtful history, skilled physical exam, and decades of experience over some young pup who stares at the computer screen and asks questions from a list of checkboxes... If my clinical skills fell to [that level] I'd retire voluntarily. It's not the older physicians who are threatening patient safety," said a pediatrician. "I am 67 and chair a multispecialty peer-review committee. The vast majority of complaints are not against the elderly physicians but against the young (naively intelligent) docs," said an ob/gyn. A general practitioner continued in this vein, writing, "There are a lot of younger physicians out there who have substance abuse problems, mental illness, etc., who probably represent a far greater danger to patients than your average 70-year-old physician." "The young ones here will change their minds as they get older," an experienced radiologist predicted. Some older practitioners supported the idea of testing. Several remarkably candid physicians took stock of themselves. A 79-year-old general practitioner said, "I find myself going to Epocrates more to look up treatment meds on problems that I have treated before because I couldn't quite remember exactly, and that worries me. Am I losing it? I wouldn't mind being tested if the test would say, 'yes you are all right,' or 'no you are not.'" A 68-year-old psychiatrist added, "I know that my mental processing speed has declined. My memory, which used to be amazingly good, is now only average. Vocabulary that used to be under my control...now seems just beyond reach. My patients love me and say I am a caring doctor. That is a good thing, but it does not necessarily mean that I know what I am doing!" An older ER doc noted, "Perhaps anyone who fears being retested may really need to be." More than a few physicians shifted the focus off of medicine, suggesting that other professions require tests for competency. "I think if we consider competency testing for the medical profession, we should require it also for members of the legal profession -- Congress and the Supreme Court as a minimum competence for holding those positions," said one cardiologist. Some cited personal experience with evaluating older physicians' competency. "I see many docs in my community practicing long past the time when they should have retired because no one wants to say anything until they do something that risks killing someone. Early dementia is subtle...I've seen at least one doc continue to practice after an Alzheimer's diagnosis," said one general practitioner. Checking the Checks and Balances A psychiatrist wrote, "As the Medical Director of several geropsychiatric units and after multiple conversations with physicians who were on my unit and still believed they could practice (those with Alzheimer's as well as other forms of dementia don't always have insight into their debility), I am convinced that testing would be helpful ...I can tell you that...extremely impaired physicians can still practice for a very long time if left to their own devices." Many physicians, like one general practitioner, felt that current screening is sufficient: "Isn't the Medical Board supposed to be monitoring when a physician drops below reasonable criteria? Failure to pass boards or maintain certification activities, repeated malpractice suits, etc. are all pretty strong indicators. Otherwise, why should we engage in age discrimination? The mere fact of aging doesn't automatically render someone dangerous." A surgeon also saw no need for change: "If reasonable maintenance of certification is in place and hospitals have a good peer-review process (two things that are almost universal nowadays), then I see no great need to single out older docs as people at risk." And a few physicians questioned the accuracy of the cognitive tests themselves. "I have had neurocognitive testing (following an automobile accident) years ago...I have concerns that the testing ...is a poor reflection of the skills actually needed to practice medicine. I am not at all sure that available tests are particularly useful," wrote one psychiatrist. A neurologist agreed and said, "Neuropsychological testing is extremely variable, unreliable, and generally useless. Likewise I have had many demented patients pass a [Mini-mental State Exam-type] test with flying colors. My biggest clue for dementia comes from the history of their behavior and observing the patient during the exam." To Err Is Human, to Laugh, Divine Though the discussion frequently grew heated, quite a few doctors were ready to inject some comedy into the debate, like an internist who simply asked, "What was the question again?" The full discussion of this topic is available at: boards.medscape.com/forums/.2a33e0e6 Post Comment Private Reply Ignore Thread
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