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L’éthique du leadership et le problème du médecin vieillissant
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Peer monitoring and reporting are the primary mechanisms for identifying physicians who are impaired or otherwise incompetent to practice, but data suggest that the rate of such reporting is lower than it should be.
To understand physicians' beliefs, preparedness, and actual experiences related to colleagues who are impaired or incompetent to practice medicine.
Nationally representative survey of 2938 eligible physicians practicing in the United States in 2009 in anesthesiology, cardiology, family practice, general surgery, internal medicine, pediatrics, and psychiatry. Overall, 1891 physicians (64.4%) responded.
Beliefs about and preparedness for reporting and experiences with colleagues who practice medicine while impaired or who are incompetent in their medical practice.
Sixty-four percent (n = 1120) of surveyed physicians agreed with the professional commitment to report physicians who are significantly impaired or otherwise incompetent to practice. Nonetheless, only 69% (n = 1208) of physicians reported being prepared to effectively deal with impaired colleagues in their medical practice, and 64% (n = 1126) reported being so prepared to deal with incompetent colleagues. Seventeen percent (n = 309) of physicians had direct personal knowledge of a physician colleague who was incompetent to practice medicine in their hospital, group, or practice. Of those with this knowledge, 67% (n = 204) reported this colleague to the relevant authority. Underrepresented minorities and graduates of non-US medical schools were less likely than their counterparts to report, and physicians working in hospitals or medical schools were most likely to report. The most frequently cited reason for taking no action was the belief that someone else was taking care of the problem (19% [n = 58]), followed by the belief that nothing would happen as a result of the report (15% [n = 46]) and fear of retribution (12% [n = 36]).
Overall, physicians support the professional commitment to report all instances of impaired or incompetent colleagues in their medical practice to a relevant authority; however, when faced with these situations, many do not report.
We searched MEDLINE (Ovid Technologies, 1966 to June 2004; English language) for terms describing physician experience (keywords: physician age, clinician age, physician experience, clinician experience), physician demographic characteristics (keywords: physician characteristics, clinician characteristics), practice variation (subject heading: physician's practice patterns), and performance in various domains (subject headings: clinical competence, health knowledge, attitudes and practice, outcomes assessment[health care]; keywords: knowledge, guideline adherence, appropriateness, outcomes). We retrieved potentially relevant articles and reviewed their reference lists to identify studies that our search strategy may have missed (Figure 1). We also searched our personal archives to identify additional studies. We included studies if they 1) were original reports providing empirical results; 2) measured knowledge, guideline adherence, mortality, or some other quality-of-care process or outcome; and 3) included years since graduation from medical school, years since certification, or physician age as a potential explanatory variable. We excluded studies if they described practice variation that is not known to affect quality of care (for example, assessed test-ordering behavior in clinical situations where optimal practice is unknown) or evaluated the performance of fewer than 20 physicians. For studies that examined several different end points, we included only those outcomes that are linked to knowledge or quality of care.
We used a standardized data extraction form to obtain data on study design and relevant results. We categorized studies into 4 groups on the basis of whether they evaluated knowledge (for example, knowledge of indications for blood transfusion), adherence to standards of care for diagnosis, screening, or prevention (for example, adherence to preventive care guidelines), adherence to standards of care for therapy (for example, appropriate prescribing), or health outcomes (for example, mortality). We classified the results of each study into 6 groups on the basis of the nature of the association between length of time in practice or age and performance: consistently negative, partially negative, no effect, mixed effect, partially positive, and consistently positive. “Consistently negative” studies were those for which all reported outcomes demonstrated a statistically significant decrease in performance with increasing years in practice or age. “Partially negative” studies showed decreasing performance with increasing experience for some outcomes and no association for others. We used similar definitions for “consistently positive” and “partially positive” studies. “Concave” studies found performance to initially improve with years in practice or age, then peak, and subsequently decrease.
The question of when a surgeon should retire has been the subject of debate for decades. Both anecdotal evidence and objective testing of surgeons suggest age causes deterioration in physical and cognitive performance. Medical education, residency and fellowship training, and technology evolve at a rapid pace, and the older a surgeon is, the more likely it is he or she is remote from his or her initial education in his or her specialty. Research also shows surgeons are reluctant to plan for retirement. Although there is no federally mandated retirement age for surgeons in the United States, surgeons must realize their skills will decline, a properly planned retirement can be satisfying, and the retired surgeon has much to offer the medical and teaching community.
Primary care physicians in private practice were surveyed in depth to enable evaluation of various structural and sociologic variables as predictors of differential prescribing practices. "Appropriateness" or quality of prescribing behavior was determined by expert judges. While it is often suggested that longer professional experience leads to provision of higher quality medical care, this investigation found more appropriate prescribers to be younger, more recent graduates who have taken additional courses and postgraduate training, but who have had fewer years of experience in practice, maintain larger, hurried practices with more ancillary assistants, and spend less time with each patient. Better prescribes are also found to be more cosmopolitan, modern, and concerned with both psychosocial and quality dimensions of medical care. They frequently consult with (and refer more of their patients to) other physicians and rely most heavily upon journal articles for drug information. Good prescribers are more satisfied with their prior training in therapeutics and more concerned about the current general level of prescribing quality; they seek data on contraindications and are more dissatisfied with existing sources of prescribing information. Finally, the better prcscriber is critical of the pharmaceutical industry and supports an expanded role for the Federal Government in regulating drug quality and costs.
(C) Lippincott-Raven Publishers.
This study examined attitudes and practices with respect to retirement in a senior group of surgeons. The authors studied the extent of planning for retirement and factors that should determine withdrawal from performing operations.
Federal law prohibits mandatory retirement or withdrawal of operating privileges based on age. Some surgeons fail to recognize the effects of aging, which may place their patients and themselves at risk. There currently is no established method to deal with these issues until adverse outcomes occur.
A survey was returned from 75% (659/882) of the members of the American Surgical Association. Work load, level of planning for retirement, and methods to determine when one should cease performing operations were collected. Responses were coded and the data were analyzed. Additional subgroup analyses were conducted, stratified by age and level of operative activity.
Less than 50% of respondents reported any retirement plan, and among those who did, 75% planned activities in medicine. The extent of planning varied by age. In the youngest group (40-50 years), only 6.5% had a plan versus 40% of those older than 70 years who were not retired already. With respect to withdrawal of privileges, the majority of those surveyed favored determination by peer review or onset of physical disability rather than age. The level of activity declined significantly between 60 and 70 years; however, 18% of those older than 70 years of age continued to perform operations.
Both personal and institutional problems can arise when surgeons continue to practice despite limitations of aging. More positive attitudes toward retirement are needed as well as methods for evaluation of performance that reflect a surgeon's response to aging.
The optimal extent-of-disease evaluation for patients with clinically suspected melanoma recurrence is not known. The available modalities are numerous and many are expensive. We documented the extent of work-up carried out by plastic surgeons when their patients with melanoma develop clinical recurrence. A custom-designed questionnaire was mailed to a random sample (n=3,032) of the 4,320 members of the American Society of Plastic and Reconstructive Surgeons (ASPRS). Subjects were asked which specific laboratory tests and imaging studies they would order for a patient with initial T2N0M0 disease treated with curative intent who later presented with either regional nodal metastases or pulmonary metastases. We measured the variability in practice patterns among surgeons and estimated the effects of physician age, U.S. census region, health maintenance organization (HMO) penetration rates, and type of recurrence (regional versus systemic) on work-up intensity. Of the 1,142 questionnaires completed (38%), 395 (35%) were evaluable. Non-evaluability was usually due to lack of melanoma patient follow-up in surgeons' practices. Lesion biopsy, chest X-ray, complete blood count, liver function tests, and computed tomography were frequently used, but there was no consensus for most modalities. More tests, particularly computed tomography, were utilized for evaluating systemic recurrence than for regional recurrence (p<0.05). The intensity of work-up differed significantly (p<0.05) by surgeon age for three diagnostic tests but not by U.S. census region or HMO penetration rate. This is the first empirical data on this subject from a large sample of an international society of highly credentialed experts. The lack of consensus for most tests in current practice is presumably due to multiple factors, including the lack of evidence supporting any particular strategy.
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