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Do Physicians Referred for Competency Evaluations Have Underlying Cognitive Problems?
Abstract
Research suggests that there are concerns about the neuropsychological functioning of physicians who undergo physician competency evaluation. Academic health center faculty often participate in the evaluation and remediation of these physicians. The purpose of this study was to compare the cognitive abilities between a group of physicians referred for competency evaluations and a control group.
Using the MicroCog, a computerized neuropsychological screen originally designed for physicians, the authors compared the cognitive performance of 267 physicians referred for competency evaluations with a control group of 68 recruited physicians. Physicians referred for competency evaluations took the MicroCog as a part of their evaluation at CPEP, the national Center for Personalized Education for Physicians, from January 1997 to January 2004. The control group comprised practicing physicians whose competency was not in question.
Compared with the control group, the competency evaluation group had a greater proportion of physicians with scores suggesting possible cognitive impairment and performed significantly lower on scores of processing speed, processing accuracy, and cognitive proficiency. The control group of physicians performed significantly better than the age- and education-corrected normative sample.
Because there were significant neuropsychological differences between physicians referred for competency evaluations and physicians whose competency was not in question, it is important that neuropsychological screening be included as part of physicians' competency evaluations.
... The AMA has defined physician "impairment" as "the inability to practice medicine with reasonable skill and safety due to 1) mental illness 2) physical illnesses, including but not limited to deterioration through the aging process, or loss of motor skill, or 3) excessive use or abuse of drugs, including alcohol." Studies suggest that physicians referred to programs that assess and remediate medical/clinical competence issues perform significantly worse on neuropsychological testing than their peers [12,[18][19][20][21][22] and that cognitive impairments likely contribute to competency issues and failure to improve with remedial CME [12,20]. ...
... More specifically, the five samples included: Sample 1) Age and education corrected norms for the MicroCog as reported in the manual (MicroCog Norm sample) [29]; Sample 2) a physician sample reported in the MicroCog manual (Powell sample) [30]; Sample 3) published findings from the previously mentioned study of a physician control sample (Korinek Control sample) [31]; Sample 4) published findings from a study of underperforming physicians with medical/technical concerns referred for clinical competency evaluation to a non-for-profit center (Korinek Medical/Technical sample) [31]; and Sample 5) new data from physicians referred to a Midwestern center for assessment and remediation of workplace behavioral issues (Williams Behavioral Comportment sample). The Korinek Medical/Technical sample, beyond identifying the physicians as having been referred for assessment of their competence secondary to performance reviews, does not provide information on the types of competency concerns [19]. Clinical competence evaluations typically have more of a focus on issues related to medical knowledge, medical judgment, clinical decision-making, procedural skills and poor charting among other skill sets. ...
... As its original use was to identify impaired physicians, it can detect cognitive deficits in well-educated higher functioning individuals [32]. The MicroCog was selected for use as it has been a widely used clinical tool with outcome measures in a variety of populations, including physicians referred for competency evaluations, National Football League players, and United States Air Force pilots [19,33,34]. ...
Introduction
The literature suggests that 6–12% of practicing physicians are dyscompetent. Dyscompetence can manifest as failures in direct provision of care, but also issues with interpersonal and communications skills and professionalism. There is a growing literature suggesting the value of neurocognitive screening in physicians with clinical competency issues. The contribution of such screening in physicians with workplace behavioral issues is not as established. The aim of this exploratory study was to examine patterns of performance on a commonly used neuropsychological screening instrument. Performances differences, if present, could have implications for remediation and/or monitoring.
Methods
Published data on a computerized neurocognitive screening instrument (MicroCog) for normative physician samples, published data on physicians referred for clinical competency issues, and newly collected data on physicians with workplace behavioral issues were analyzed. A two-way analysis of variance (Sample X Index) and post-hoc paired comparisons were conducted. A second analysis was performed employing an aggregated estimate of normative physician performance.
Results
Results revealed a significant main effect for Sample and Index and a significant interaction effect. The second analysis of variance employing the pooled samples (Sample X Index) was conducted. The workplace behavior issues sample differed significantly from each of the samples. The Sample by Index interaction was significant.
Discussion
Significant differences in performance on a neurocognitive screening instrument were found between non-referred physicians and physicians with behavioral or medical/technical competency concerns. Those with workplace behavioral issues performed significantly better than those with medical/technical issues, but significantly worse than non-referred physicians. Using these findings, 2.0% of the normal sample versus 35.1% of the medical/technical sample, and 10.9% of the behavioral sample would fail the screen using typical, conservative cutoffs. Further study of the potential role of neurocognitive factors in physicians referred for behavioral comportment issues is warranted.
... Actively licensed physicians who are 60 years of age or older represent the single largest age category of physicians (31%, up from 26% in 2012) [2]. Although age, in itself, does not imply incompetence, the cognitive function does begin to decline from age 55 and cognitive decline is quite prevalent among older physicians who are referred for competency evaluations [3,4]. In current healthcare environment, there is growing emphasis on "physician burn out", "patient safety", "value-based care", "health information technology" and "integration of care", therefore at the same time we must remain cognizant of the disproportional workforce of aging physicians asked to carry out these challenging tasks for the populace. ...
... In current healthcare environment, there is growing emphasis on "physician burn out", "patient safety", "value-based care", "health information technology" and "integration of care", therefore at the same time we must remain cognizant of the disproportional workforce of aging physicians asked to carry out these challenging tasks for the populace. Patient safety advocates, consumer groups, and policy makers have questioned whether older physicians maintain the necessary cognitive and motor skills to provide safe and competent care [4]. A systematic review published in 2005 found an inverse relationship between years of practice and several measures of quality, suggesting that older physicians might be at risk of providing lower-quality care [5]. ...
... All individuals age, however the rate of change in executive function, wisdom, memory, and other components of cognition are not linear, they often fluctuate over time, and can be influenced by a variety of factors independent of age. The dearth of research studies looking at the association between aging physicians and quality of care along with anecdotal evidence of cognitive decline in older physicians behooves policymakers, researchers and healthcare leaders to prioritize and invest resources in mitigating this challenge [3,4]. There may not be a perfectly desirable solution to the problem; however, taking logical steps in safeguarding patient's optimum care, collecting data, performing meaningful analysis followed by development of robust strategy will be an excellent start. ...
... There is a developing literature that indicates that lower than anticipated neuropsychological performance is associated with physician performance difficulties [26][27][28][29]. A recent study found that cognitive impairment in physicians is responsible for 57% of adverse medical events, most of which were determined to be preventable [30]. ...
... Data utilized were general norms found in the MicroCog™ Manual as well as a Physician Sample, as reported in Chapter 5 of the MicroCog™ Manual [33]. A second physician sample [29] and data from Air Force pilots [32] were also compared. The original data, as reported, are provided in Table 1, to facilitate comparison. ...
... Sample 3 korinek physician sample (KPS). This sample consisted of 68 practicing physicians whose competence was not in question; 60.3% were male, 39.7% were female [29]. Their mean age was 41.9 (SD = 12.5) with a range of 31-76. ...
Objective
To determine whether population-specific normative data should be employed when screening neurocognitive functioning as part of physician fitness for duty evaluations. If so, to provide such norms based on the evidence currently available.
Methods
A comparison of published data from four sources was analyzed. Data from the two physician samples were then entered into a meta-analysis to obtain full information estimates and generate provisional norms for physicians.
Results
Two-way analysis of variance (Study x Index) revealed a significant main effect and an interaction. Results indicate differences in mean levels of performance and standard deviation for physicians.
Conclusions
Reliance on general population normative data results in under-identification of potential neuropsychological difficulties. Population specific normative data are needed to effectively evaluate practicing physicians.
... Thirty-one physicians performed poorly on competency assessment, 12 were found to have moderate or severe cognitive impairment, which was likely to have led to their poor performance. 14 Studies by Korinek et al., 15 Peisah and Wilhelm 16 also report similar findings. Korinek et al. completed a study with 335 physicians in Colorado. ...
... The referred physicians showed slower processing, less accuracy and less proficiency. 15 A descriptive study by Peisah and Wilhelm looked at 41 case records of notifications to the Impaired Registrants Program of the New South Wales Medical Board, Australia, of those aged over 60 years. Cognitive impairment or dementia was found in 22 cases. ...
... The study by Turnbull et al. 14 found that English as a first language was found to be a positive predictor of performance on PREP. In the studies by Korinek et al. 15 and Perry and Crean 17 those who trained outside the United States or who did not have English as their first language were excluded. ...
Objective:
To examine the performance assessments and cognitive function of practitioners referred to the National Clinical Assessment Service (NCAS).
Design:
Retrospective observational study.
Setting:
Practitioners referred to NCAS for performance assessment due to suspected performance problems.
Participants:
One hundred and nine practitioners over the age of 45 years referred to NCAS between 1 September 2008 and 30 June 2012.
Main outcome measures:
Reasons for referral of practitioners and their characteristics; details of their assessments including screening for cognition using Addenbrooke's Cognitive Examination Revised (ACE-R); outcome of the process.
Results:
Reasons for referral included 'clinical difficulties' and 'governance or safety issues'. Eighty-seven practitioners scored above 88 on ACE-R. Twenty-two were found to have an ACE-R score of ≤88. On further assessment, 14 of these 22 practitioners were found to have cognitive impairment. The majority of all practitioners were found to be performing below the expected level of practice for someone at their grade and specialty. Of those scoring ≤88 on the screening, only seven continued in clinical practice.
Conclusions:
A high proportion of practitioners scoring poorly on ACE-R were found to have cognitive impairment following detailed neuropsychological testing, the youngest aged 46 years. Many were working in isolation. Nearly all practitioners scoring poorly on ACE-R were international medical graduates; reasons for this are unclear. Performance assessment results showed persisting failings in the practitioners' record keeping and in their assessment of patients. Our findings highlight the need for increased vigilance and training of responsible officers to recognise performance problems and emphasise the importance of comprehensive assessment.
... Although it may be fair to infer the presence of cognitive deficits based on the observed rates of low scores (i.e., low average, below average, and exceptionally low scores), research suggests physicians may be reasonably expected to obtain scores approximately 1 standard deviation above the mean on age-normed tests. 33,34 Moreover, caution is warranted regarding the criterion for cognitive deficits. The validity of summing the number of low scores is limited by the absence of base rates of expected low scores for the specific combination of tests used. ...
... The results offered compelling evidence for performance differences between referred and physicians without professional concerns on a computerized cognitive screen. 33 Another recent study evaluated the adequacy of existing normative data in the appraisal of physicians' cognitive function. 37 MicroCog's five Level 1 index scores were compared. ...
Late-career physicians (LCPs) are at risk for cognitive changes that may affect their ability to practice medicine. This review aggregates and discusses research that has examined cognitive functioning among physicians, typically when clinically referred for various medical and psychological reasons that may interfere with their ability to practice medicine. Special consideration is devoted to the role of approaches for examining cognitive functioning (e.g., cognitive screening, cognitive testing, & neuropsychological assessment), normative challenges, and cultural factors that should be considered when evaluating a physician. Based on published studies, there is evidence supportive of the use of cognitive testing and neuropsychological assessment among physicians in a fitness for duty setting. However, prospective studies designed to identify physicians at-risk (i.e., to prevent medical error) are lacking. Additional research is warranted to establish physician-based normative reference groups and aid in test interpretation and prognostication. Moreover, given limitations associated with cognitive testing in isolation, there is a potential role for comprehensive neuropsychological assessment to identify cognitive changes in physicians and provide a supportive pathway to preserve physicians' ability to practice medicine.
... 45 The strongest evidence for criterion validity of cognitive screening was reported by Korinek and colleagues. 46 Performance on the MicroCog was compared between 2 groups: 267 physicians referred for competency evaluations based on poor professional performance and 68 practicing physicians without reported concerns. The competency evaluation group performed poorer on cognitive proficiency: a composite index combining accuracy and response speed across many cognitive domains. ...
... Perhaps most compelling is Korinek and colleagues' evidence that the cognitive performance of a group of physicians whose competency/safety has been questioned is lower than a group of physicians whose practices are without noteworthy concerns. 46 Using more extensive assessment, Del Bene and Brandt similarly reported further evidence that physicians referred for assessment were frequently neurocognitively impaired. 69 One barrier to establishing more robust criterion validity data for LCPs has been accessing quality measures and linking those to physician cognitive performance. ...
Screening measures are widely used in medicine to assess the increased probability that members of a defined population have a particular condition and therefore require more extensive assessment. The rationale for prospective screening of late career physicians (LCPs) is drawn from the following circumstances: Senior physicians—prone to the vicissitudes of aging—comprise nearly a third of the US physician workforce, physicians are poor at self-evaluation, data suggest many have clinically relevant cognitive decline, and screening is an evidence-based, method to detect individuals at risk and determine whether a comprehensive evaluation is necessary. A handful of professional organizations (eg, surgeons, obstetricians, and a growing number of medical staff credentialing committees) have developed policies in this arena. This focused review compares cognitive screening methods used or recommended for LCPs, with particular attention to the psychometric properties, ease of operational implementation, and appropriate application to physicians—a population selected for high cognitive reserve and skills. Further, we identify gaps in knowledge and practice, including the need for more career-span normative data on physicians’ cognitive and work performance. Stakeholders can improve rehabilitation and other supports to LCPs in transition, calling upon the unique expertise of those neuropsychologists who are trained on conducting fitness for duty evaluations, as well as rehabilitation professionals who can assist in developing modifications to practice when indicated or facilitate graceful transitions to retirement when necessary.
... Previous publications have described the development of the CPEP program 5 and various characteristics of its participant physicians. [6][7][8] Although other published data about physicians who present for competence assessment in the United States and Canada are limited, this body of work is growing. 3,6,[9][10][11][12] In this study, we examine CPEP program data to identify the predictors of performance on CPEP competency assessment. ...
... CPEP receives an average of approximately 100 referrals annually. Detailed descriptions of the CPEP competence assessment have been previously published [6][7][8] and can also be found on the CPEP Web site. 20 We note here only that the assessment is an indepth evaluation that is tailored to the physician's practice area and specialty. ...
Purpose:
To identify factors associated with physician performance in a comprehensive competence assessment.
Method:
The authors conducted a retrospective analysis of 683 physicians referred for assessment at the Center for Personalized Education for Physicians from 2000 to 2010, who were evaluated as either safe or unsafe to return to practice. Multivariate logistic regression was used to determine factors predictive of unsafe assessment outcome. Covariates included personal characteristics (e.g., age), practice context (e.g., solo practice), and referral information (e.g., previous board license action).
Results:
Older physicians were more likely to have unsafe assessment outcomes (odds ratio [OR] = 1.07; P < .001). Board-certified individuals were less likely to have poor assessment outcomes (OR = 0.40; P = .003) than uncertified individuals. Physicians in solo practice were more likely (OR = 2.15; P = .037) to be deemed unsafe than physicians in other settings. Physicians with a practice scope that matched their training were less likely (OR = 0.29; P = .023) to have unsafe assessment outcomes than those whose did not. Physicians with current or previous board action (suspension, revocation, limitation, or stipulation) were more likely to be deemed unsafe (OR = 2.47; P = .003) than those without.
Conclusions:
Findings suggest that important predictors of physician performance on competence assessment include personal characteristics, practice context, and reasons for assessment referral. These findings have implications for development of policies and programs designed to assess risk of poor physician performance and quality of care improvement efforts through organizational/practice design or remedial education.
... Indeed, it has been postulated that increasing age leads to physiological and cognitive changes that impair performance. 15,31,32 Also, it has been proposed that physicians with increased years in practice are less likely to keep current with evolving clinical practice standards and guidelines. 31 The negative impact of age on performance is particularly concerning in the context of an ageing physician workforce. ...
... 29 cognitive impairment. 10,11,12,13 A Peer Assessment Program in Ontario, Canada found that 22% percent of physicians over 75 years old "had gross deficiencies in their practice," compared to 16% in the 50-to-74 year-old group and 9% of doctors age 49 or younger. 14 An Australian study found that compared to doctors in the 30-60 years old age group, doctors who were over 65 years old had higher rates of notification to medical regulators regarding physical illness, cognitive decline, improper record keeping, illegal use or supply of medications, inadequate certificates and reports, incorrect prescribing, disruptive behavior, and provision of substandard treatment to patients. ...
Older physicians benefit from their many years of experience and the skills they have developed over decades of practice. At the same time, they may be at risk of cognitive decline, which raises concerns about job performance deficits. The question that this article addresses is whether state medical boards have a role to play in identifying clinicians with cognitive decline. It discusses what state medical boards currently do in this regard and analyzes whether they should do more. It also discusses relevant legal constraints and ethical obligations. The article ultimately concludes that state medical boards would be wise to adopt late career screening programs that are carefully designed to balance the interest of clinicians and patient safety. Such programs could be implemented only after experts determine which preliminary tests and more comprehensive follow-up tests can best identify job-related cognitive impairment and at what age the testing program should commence. Any testing program would have to include due process protections, efforts to provide reasonable accommodations to facilitate job performance, and a public relations campaign to build support among clinicians and professional organizations. Although the article focuses on state medical boards, its analysis and recommendation are relevant to all state licensing boards that oversee health care providers.
... Multiple studies have demonstrated that 25-50% of physicians with practice performance complaints have neurocognitive deficits sufficient to explain their performance problems and that age is a relatively weak correlate to neurocognitive performance among reactive referrals. [34][35][36][37][38][39] Cognitive impairment results in performance problems across the physician career span and age is confounded by a host of other variables when studied in the context of physician performance. 22 A recent comprehensive review of risk and support factors related to physician performance identified age, gender, exam scores and specialty as risk factors, given the strength of the evidence. ...
Senior physicians are an invaluable community asset that comprise an increasing proportion of the physician workforce. An increase in demand for health care services, with demand exceeding the supply of physicians, has contributed to discussions of the potential benefit of delaying physician retirement to help preserve physician supply. The probable increase in the number of senior physicians has been associated with concerns about their competent practice. Central to this issue are the changes that occur as part of normal aging, how such changes might impact medical practice and what steps need to be taken to ensure the competency of senior physicians. We propose that while age may be an important risk factor for performance issues, it is not the only factor and may not even be the most important. Data on cognitive performance among physicians referred for behavioral and performance concerns reveal that cognitive impairment afflicts physicians across the career span. If the overarching goal is to prevent patient harm through early detection, older physicians may be too narrow a target. Approaches focusing on health screening and promotion across the career span will ultimately be more effective in promoting workforce sustainability and patient safety than age-based solutions.
... Domains identified in the research as important include various forms of attention, auditory and visual memory, fluid reasoning, quantitative reasoning, verbal reasoning, verbal fluency, visual-spatial reasoning, and processing speed. [53][54][55][56][57] Within the auditory and visual memory domains in particular, we have selected tests that assess working memory, short-term memory and long-term memory. Tests assessing each of these functional cognitive domains are identified below. ...
Background:
As the population of aging physicians increases, methods of assessing physicians' cognitive function and predicting clinically significant changes in clinical performance become increasingly important. Although several approaches have been suggested, no evaluation system is accepted or utilized widely.
Study design:
Literature was reviewed using Medline, PubMed and other sources. Articles discussing the problems of geriatric physicians were summarized, stressing publications that proposed methods of evaluation. Selected literature on evaluating aging pilots also was reviewed, and potential applications for physician evaluation were proposed. Neuropsychological cognitive test protocols were reviewed, and a reduced evaluation protocol was proposed for interdisciplinary longitudinal research.
Results:
Although there are several articles evaluating cognitive function in aging physicians and aging pilots, and although a few institutions have instituted cognitive evaluation, there are no longitudinal data assessing cognitive function in physicians over time, and correlating them with performance.
Conclusion:
Valid, reliable testing of cognitive function of physicians is needed. In order to understand its predictive value, physicians should be tested over time starting when they are young, and results should be correlated with physician performance. Early testing is needed to determine whether cognitive deficits are age-related or longstanding. A multi-institutional study over many years is proposed. Additional assessments of other factors, such as manual dexterity (perhaps using simulators) and physician frailty are recommended, but detailed discussion of these issues is beyond the scope of this article.
... [9] Findings like these underlie the difficulty in applying age-based recommendations to the issue of how to assess cognitive decline in late-career physicians. Further complicating the matter is the fact that age alone does not cause cognitive impairment, [10] and standard cognitive tests have limited predictive value in assessing intelligent individuals when compared to age-matched controls. [11] Other research suggests physicians have increasing difficulty practicing medicine as they age without offering any causal explanations. ...
Late-career physicians now represent a significant part of the physician workforce in the United States. The American Medical Association Council on Medical Education tracks physician demographic data and found that in 1975 there were 50,993 practicing physicians 65 years or older, but by 2013, this number had risen to 241,641 physicians, a 374% increase. The AMA Council also concluded that aging was associated with decreased processing speed, increased difficulty inhibiting irrelevant information, reduced hearing and visual acuity, decreased manual dexterity and visuospatial ability. There is mounting concern that the effects of aging can adversely impact the practice of medicine by late-career physicians. Although results are mixed, studies suggest late-career physicians have a higher rate of disciplinary action, fail to acquire new knowledge and have greater variability in test scores and their patients experience higher mortality rates after complex surgical procedures. Hospital administrators in their efforts to assess cognition of their aging medical staff are limited by the absence of validated metrics when it comes to older individuals with above-average years of education. Also, attempts to curtail medical practice based on age are fraught with legal implications arising from the Americans with Disabilities Act of 1990 and the Age Discrimination in Employment Act of 1967. We examined the issues hospital administrators face when formulating policies regulating the medical practice of late-career physicians. Our review summarizes the state of the literature of late-career physicians, reviews the legal implications of policies regarding age and the practice of medicine and offers our experience in creating a late-career physician policy for a multi-disciplinary medical staff.
... These evaluations potentially affect an estimated 7% to 10% of physicians (i.e., those practicing medicine while impaired; cf. Korinek, Thompson, McRae, & Korinek, 2009). Police officers and other public safety employees that exhibit posthire problems are often required to submit to mandatory psychological evaluations of their fitness for duty (Fischler et al., 2011;Piechowski & Drukteinis, 2011), as are military (Budd & Harvey, 2006) and aviation (Kennedy & Kay, 2013) personnel. ...
Psychological evaluations are relied on by employers, professional licensing boards, and civil service commissions to make hiring and employment decisions affecting individuals, organizations, and the public. To promote best practices, these professional practice guidelines were developed for use by psychologists who perform clinical evaluations of individuals for occupational purposes, regardless of whether the evaluation is intended to obtain employment, to achieve licensure/certification, or to maintain either. These guidelines were created by the Committee on Professional Practice and Standards (COPPS) to educate and inform the practice of psychologists who conduct occupationally mandated psychological evaluations (OMPEs), as well as to stimulate debate and research in this important area.
... 32 Physicians referred to CPEP for competence evaluations scored significantly lower than physician controls on three cognitive domains: processing speed, processing accuracy, and cognitive proficiency. 33 Altogether, these studies emphasize the existence of cognitive impairment among older physicians as an important factor in the impaired performance of individuals referred "for cause" on the basis of identified deficiencies. Data on the prevalence of clinically significant cognitive impairment and on the prevalence of diagnosable neurocognitive disorders among aging physicians, currently not available, would be very helpful in assessing the magnitude of this problem and informing policies that address this issue. ...
Our older physicians, an increasing number of those in practice, constitute a valuable human resource in the medical profession. Professional satisfaction, increasing life expectancy, concerns regarding financial security, and reluctance to retire are among the many reasons a physician might choose to extend practice into later adulthood. Despite the benefits of experience and expertise acquired by older physicians, cognitive changes associated with normal or pathological aging have been shown to have a significant negative effect on physician performance. Age-based cognitive assessment of physicians has been adopted in some countries and by some United States health care institutions for patient protection and improvement of physician quality of life, but there is no general guideline for the assessment and assistance of cognitively impaired late career physicians in the United States. Self-reports and reports from peers are an inadequate safeguard, leaving impaired physicians and their patients at risk. In this discussion, we will describe cognitive aging, the effects of cognitive aging on physician performance, some current monitoring systems, and recommendations for identifying and assisting physicians found to be impaired.
... They also recommend peer assessment by colleagues approved by the Well-being Committee and observations by others in the clinical setting such as operating room supervisors, circulating nurses, ward managers, and risk management clinicians. In addition, they recommend an assessment of cognitive function such as MicroCog, 34 St Louis Mental Status Examination, or the Montreal Cognitive Assessment. 35 While to our knowledge, no institution has adopted mandatory retirement ages for physicians, there are at least 3 hospitals in the United States that now mandate physician health assessment and/or examination of competence at a certain age: University of Virginia Health System, Charlottesville; Driscoll Children's Hospital, Corpus Christi, Texas; and Stanford Hospitals and Clinics, Stanford, California. ...
Importance:
The issue of the aging physician and when to cease practice has been controversial for many years. There are reports of prominent physicians who practiced after becoming dangerous in old age, but the profession has not demonstrated the ability to prevent this. A mandatory retirement age could be discriminatory and take many competent physicians out of practice and risk a physician shortage. An increasing body of evidence regarding the relationship between physicians' age and performance has led organizations, such as the American College of Surgeons, to revisit this challenge.
Observations:
Since 1975, the number of practicing physicians older than 65 years in the United States has increased by more than 374%, and in 2015, 23% of practicing physicians were 65 years or older. Research shows that between ages 40 and 75 years, the mean cognitive ability declines by more than 20%, but there is significant variability from one person to another, indicating that while some older physicians are profoundly impaired, others retain their ability and skills. There are age-based requirements for periodic testing and/or retirement for many professions including pilots, judges, air traffic controllers, Federal Bureau of Investigation employees, and firefighters. While there are not similar requirements for physicians, a few hospitals have introduced mandatory age-based evaluations.
Conclusions:
As physicians age, a required cognitive evaluation combined with a confidential, anonymous feedback evaluation by peers and coworkers regarding wellness and competence would be beneficial both to physicians and their patients. While it is unlikely that this will become a national standard soon, individual health care organizations could develop policies similar to those present at a few US institutions. In addition, large professional organizations should identify a range of acceptable policies to address the aging physician while leaving institutions flexibility to customize the approach. Absent robust professional initiatives in this area, regulators and legislators may impose more draconian measures.
... Laboratory assessment or other inquiries about an evaluee physician's medical condition may be helpful in clarifying issues related to substance use disorders or metabolic issues that may impact functional 29 performance. Neuropsychological screening is strongly recommended, as previous research suggests that physicians referred for issues related to impairment have a higher frequency of cognitive dysfunction than those not referred (Korinek, Thompson, McRae, & Korinek, 2009). Structured assessments of personality function, symptomatology, distress, or impairment may also usefully add to the evaluation by providing objective data not reliant on the physician's engagement in the interview. ...
Physicians have a responsibility to treat their patients in a safe manner. When unable to do so based on a health condition, physicians may become “impaired.” As a fluid concept, the term impairment warrants better guidelines that support the medical community in identifying who is impaired and what steps should be taken to identify, report, and address impairment. Uniform regulations should be put in place in the United States to protect and support physicians. In addition, a regulated reporting system has the potential to safeguard both physicians and their patients. An evaluation system independent from—yet recognized by—medical boards, physician health organizations, credentialing agencies, and insurance companies could offer guidance in the process of identifying, evaluating, and treating impaired physicians.
... Previous research shows there are differences in cognitive resources between physicians who experience difficulties in training and clinical practice, and those who do not [9][10][11]. For example, Perry [12] found that physicians referred for remedial action scored significantly lower than a comparison group on a wide variety of cognitive ability tests; including picture arrangement, numerical attention and complex figure learning. ...
Background:
Treating patients is complex, and research shows that there are differences in cognitive resources between physicians who experience difficulties, and those who do not. It is possible that differences in some cognitive resources could explain the difficulties faced by some physicians. In this study, we explore differences in cognitive resources between different groups of physicians (that is, between native (UK) physicians and International Medical Graduates (IMG); those who continue with training versus those who were subsequently removed from the training programme); and also between physicians experiencing difficulties compared with the general population.
Methods:
A secondary evaluation was conducted on an anonymised dataset provided by the East Midlands Professional Support Unit (PSU). One hundred and twenty one postgraduate trainee physicians took part in an Educational Psychology assessment through PSU. Referrals to the PSU were mainly on the basis of problems with exam progression and difficulties in communication skills, organisation and confidence. Cognitive resources were assessed using the Wechsler Adult Intelligence Scale (WAIS-IV). Physicians were categorised into three PSU outcomes: 'Continued in training', 'Removed from training' and 'Active' (currently accessing the PSU).
Results:
Using a one-sample Z test, we compared the referred physician sample to a UK general population sample on the WAIS-IV and found the referred sample significantly higher in Verbal Comprehension (VCI; z = 8.78) and significantly lower in Working Memory (WMI; z = -4.59). In addition, the native sample were significantly higher in Verbal Comprehension than the UK general population sample (VCI; native physicians: z = 9.95, p < .001, d = 1.25), whilst there was a lesser effect for the difference between the IMG sample and the UK general population (z = 2.13, p = .03, d = 0.29). Findings also showed a significant difference in VCI scores between those physicians who were 'Removed from training' and those who 'Continued in training'.
Conclusions:
Our results suggest it is important to understand the cognitive resources of physicians to provide a more focussed explanation of those who experience difficulties in training. This will help to implement more targeted interventions to help physicians develop compensatory strategies.
... What is true is that cognitive impairment may be harder to detect in physicians, at least initially, because early-onset dementia is less apparent among people with advanced education and greater intellectual resources [2]. Impaired physicians can pose a risk to patient safety if they continue to practice [3]. Accordingly, some have proposed creating objective measures of evaluation and screening guidelines to assess dysfunction in this population [4,5]. ...
Background
Physicians are not immune to cognitive impairment. Because of the risks created by practising doctors with these issues, some have suggested developing objective, population-specific measures of evaluation and screening guidelines to assess dysfunction. However, there is very little published information from which to construct such resources.
Aims
To highlight the presentation characteristics and provide evaluation recommendations specific to the needs of physicians with actual or presumed cognitive impairment.
Methods
A retrospective database and chart review of cognitively impaired doctors who presented to a physician health programme (PHP). Complex cases were highlighted using simple descriptives and clinical vignettes.
Results
A total of 124 cases were included. Clients presented with a variety of issues other than cognitive concerns. We identified four principal domains of impairment: (i) diseases of (or in) the brain (48%); (ii) mood/ anxiety disorders or treatment side effects (28%); (iii) substance use (9%) and (iv) traumatic brain injury (7%). Age was not a good predictor of impairment and brief screening using the Montreal Cognitive Assessment demonstrated a ceiling effect with this cohort. Although many clients underwent some type of professional or personal transition, impairment did not necessarily indicate worse functioning after care.
Conclusions
Physician cognitive evaluations should consider a variety of secondary sources of information, particularly vocational performance reports. It may take time before cognitive impairment can be diagnosed or ruled-out in this population. Prior assumptions, especially for non-cognitive referrals, can lead to inaccurate diagnosis and referrals. PHPs must manage cognitive cases carefully, not only in their clinical complexity but also in their psychosocial aspects.
... Previous papers about CPEP have described the program and its development 1 or have discussed limited characteristics of participants. 11 Cerda et al described the University of Florida Comprehensive Assessment and Remedial Education Services (CARES) program and provided the specialties of 30 physicians who completed that program in its first two years. 12 The most comprehensive information published about any U.S. program has been from the University of California, San Diego, Physician Assessment and Clinical Education (PACE) program. ...
This study compares key characteristics and performance of physicians referred to a clinical competence assessment and education program by state medical boards (boards) and hospitals. Physicians referred by boards (400) and by hospitals (102) completed a CPEP clinical competence assessment between July 2002 and June 2010. Key characteristics, self-reported specialty, and average performance rating for each group are reported and compared. Results show that, compared with hospital-referred physicians, board-referred physicians were more likely to be male (75.5% versus 88.3%), older (average age 54.1 versus 50.3 years), and less likely to be currently specialty board certified (80.4% versus 61.8%). On a scale of 1 (best) to 4 (worst), average performance was 2.62 for board referrals and 2.36 for hospital referrals. There were no significant differences between board and hospital referrals in the percentage of physicians who graduated from U.S. and Canadian medical schools. The most common specialties referred differed for boards and hospitals. Conclusion: Characteristics of physicians referred to a clinical competence program by boards and hospitals differ in important respects. The authors consider the potential reasons for these differences and whether boards and hospitals are dealing with different subsets of physicians with different types of performance problems. Further study is warranted.
Background : Dementia increases as individuals age. Aging physicians represent a growing population. Studies have demonstrated there are physicians with cognitive impairments practicing medicine. The medico‐legal consequences of physicians with cognitive impairments have not been investigated.
Methods : The Canadian Medical Protective Association (CMPA) is a national medical association with 108,000 members who advise and assist doctors with medico‐legal matters. They maintain a national repository of legal actions and complaints to regulatory bodies and hospitals. We looked at civil‐legal and regulatory college cases closed over a 10‐year period associated with physicians aged ≥55. A word search of the cases was conducted using “Dementia, Alzheimer, Cognitive impairment, Cognitive decline, Memory loss, Memory issues, Fit for/to practice.”
Results : The CMPA closed 67,566 cases between 2012 and 2021 and 16% (10,599) involved members ≥55. A mixed methodology approach identified 65 cases associated with physician's cognitive ability to practice medicine. Of these 65 cases, the average age of physician was 71.3 (56.1–88.5). The proportion of cases where concern was associated with a physician's cognitive ability to practice medicine increased, from 0.2% of cases in 55–60‐year‐olds, to 7.7% in physicians over 80.
Interpretation : As physicians age, concerns about cognitive impairment are more likely to contribute to medico‐legal matters.
Objectives:
To synthesize evidence relevant for informed decisions concerning cognitive testing of older physicians.
Methods:
Relevant literature was systematically searched in Medline, EMBASE, PsycInfo, and ERIC, with key findings abstracted and synthesized.
Results:
Cognitive abilities of physicians may decline in an age range where they are still practicing. Physician competence and clinical performance may also decline with age. Cognitive scores are lower in physicians referred for assessment because of competency or performance concerns. Many physicians do not accurately self-assess and continue to practice despite declining quality of care; however, perceived cognitive decline, although not an accurate indicator of ability, may accelerate physicians' decision to retire. Physicians are reluctant to report colleagues' cognitive problems. Several issues should be considered in implementing cognitive screening. Most cognitive assessment tools lack normative data for physicians. Scientific evidence linking cognitive test results with physician performance is limited. There is no known level of cognitive decline at which a doctor is no longer fit to practice. Finally, relevant domains of cognitive ability vary across medical specialties.
Conclusion:
Physician cognitive decline may impact clinical performance. If cognitive assessment of older physicians is to be implemented, it should consider challenges of cognitive test result interpretation.
Medical licensing boards use competence assessment and educational intervention programs as tools in disciplinary actions. Few studies measure the impact of these remedial interventions on the quality of care provided by participants after such interventions. CPEP, the Center for Personalized Education for Professionals, provides clinical competence assessment/educational intervention services and practice monitoring, primarily for physicians complying with board orders due to substandard care. Depending on the board requirements, some physicians complete an assessment/educational intervention and, after completion, subsequently undergo practice monitoring (Intervention Group). Others participate in the practice monitoring without first completing an assessment/educational intervention (Non-Intervention Group). CPEP conducted a retrospective study of chart reviews (n=2073) performed as part of each group’s participation in the Practice Monitoring Program. When compared to the charts from the Intervention Group, charts from the Non-Intervention Group were more than five times more likely to demonstrate care below standard (P < 0.0001) and almost four times more likely to have documentation issues that prohibited the monitor’s ability to determine the quality of care (P < 0.0001). This study suggests that completion of a competence assessment/education intervention program is an effective means of achieving acceptable quality of care that is sustained over time (average 18 months) after completion of the intervention.
Aging physicians are at a higher risk of cognitive impairment, undermining patient safety and unraveling physicians' careers. Neurologists, occupational health physicians, and psychiatrists will participate in both health system policy decisions and individual patient evaluations. We address cognitive impairment in aging physicians and attendant risks and benefits. If significant cognitive impairment is found after an appropriate evaluation, precautions to confidentially support physicians' practicing safely for as long as possible should be instituted. Understanding that there is heterogeneity and variability in the course of cognitive disorders is crucial to supporting cognitively impaired, practicing physicians. Physicians who are no longer able to practice clinically have other meaningful options.
The unprecedented number and proportion of aging physicians in the workforce in both the United States and the world is a unique challenge of the current medical era. Fully 43% of all US physicians are aged 55 years or older, including 61% of psychiatrists, 52% of radiologists, 46% of general surgeons, and 44% of internists.¹ Moreover, approximately 15% of practicing US physicians are older than 65 years, tripling from 23 000 in 1980 to 73 000 in 2012-2016.² Every year, 20 000 more US physicians turn 65 years of age, and, even though half retire by age 65, many continue practicing for years and decades more. Indeed, US policy makers are counting on these older physicians to do so to help mitigate the nation’s growing physician shortage. Currently, an estimated 50 million to 70 million US office visits and 11 million to 20 million hospitalizations each year are overseen by physicians older than 65 years.³,4
Importance
Aging is well documented to be associated with declines in cognitive function and psychomotor performance, but only limited guidance is currently available from medical professional societies or regulatory agencies on how to translate these observations into the appropriate monitoring of physician performance.
Observations
The Society of Surgical Chairs conducted a panel discussion at its 2017 annual meeting and a subsequent survey of its membership in 2018 to develop recommendations for the transitioning of the senior surgeon.
Conclusions and Relevance
Recommendations include mandatory cognitive and psychomotor testing of surgeons by at least age 65 years, potentially as a component of ongoing professional practice evaluation; career transition discussions with surgeons beginning early in their careers; respectful consideration of the potential financial needs, long-standing work commitments, and work-life concerns of retiring surgeons; and creation of teaching, mentoring or coaching, and/or administrative opportunities for senior surgeons in modified clinical or nonclinical roles. Ideally, these initiatives will catalyze a thoughtful and comprehensive new vista in supporting an aging workforce while ensuring the safety of patients, the efficient management of health care organizations, and the avoidance of unnecessary depletions to a sufficiently sized cadre of physicians with case-specific competencies.
Objective: To discuss specific issues regarding consent for neuropsychological evaluation and the patient–psychologist relationship within the context of the Ethics Code of the American Psychological Association and relevant literature.
Method: The author makes recommendations based on the Ethics Code and published sources. This article is advisory and does not prescribe ethical practice.
Conclusions: The presence or absence of a patient–psychologist relationship is an essential consideration. The consent process varies, depending on the absence or existence of a patient–psychologist relationship and the type of evaluation. Circumstances when the examiner has the option of establishing a patient–psychologist relationship and guidelines regarding multiple relationships affecting legal testimony by treating providers are considered. Differences in the consent process between clinical and forensic evaluations, and the need for tailoring the consent process for the specific type of clinical or forensic evaluation, are emphasized. Specific provisions that can be included in consent forms in clinical and forensic evaluations, the rationale for their inclusion, and the benefits of consent to both the examiner and the examinee are considered. Circumstances are defined that dictate the need for assent rather than consent. The consent process is discussed in relation to evaluations of fitness for duty and civil capacity. Mandatory reporting of impaired drivers in some jurisdictions, fee agreements, and other issues are considered. Guidance is provided on role limitations in legal testimony by a clinical evaluator that addresses conflicting recommendations now in the literature.
Importance
Understanding the distribution of patient complaints by physician age may provide insight into common patient concerns characteristic of early, middle, and late stages of careers in ophthalmology. Most previous studies of patient dissatisfaction have not addressed the association with physician age or controlled for other characteristics (eg, practice setting, subspecialty) that may contribute to the likelihood of patient complaints, unsafe care, and lawsuits.
Objective
To assess the association between ophthalmologist age and the likelihood of generating unsolicited patient complaints (UPCs) among a cohort of ophthalmologists.
Design, Setting, and Participants
Retrospective cohort study with variable duration of follow-up. The study assessed time to first complaint between 2002 and 2015 in 1342 attending ophthalmologists or neuro-ophthalmologists who had graduated from medical school before 2010 and were affiliated with an organization that participates in Vanderbilt University Medical Center’s Patient Advocacy Reporting System. Participants were stratified into 5 age bands and were followed up from the time of their employment to receipt of their first complaint. Trained coders categorized UPCs into 34 specific types under 6 major categories.
Main Outcomes and Measures
Time to first recorded complaint. Multivariable Cox proportional hazards model was used to measure the association between time to first complaint and ophthalmologist age after adjustment for predetermined covariates.
Results
The median physician age was 47 years, with 9% who were 71 years or older. The cohort was 74% male, 90% held MD degrees, and 73% practiced in academic medical centers. The mean follow-up period was 9.8 years. Ophthalmologists older than 70 years had the lowest complaint rate (0.71 per 1000 follow-up days vs 1.41, 1.84, 2.02, and 1.88 in descending order of age band). By 2000 days of follow-up (or within 5.5 years), the youngest group had an estimated UPC risk of 0.523. By 4000 days (>10 years), participants in the older than 70 years age band had an estimated risk of UPC of only 0.364. The 2 youngest age bands were associated with a statistically significant shorter time to first complaint. Compared with those aged 71 years or older, the risk of incurring a UPC for those aged 41 to 50 years was 1.73-fold higher (hazard ratio [HR], 1.73; 95% CI, 1.21-2.46; P = .002). Similarly, participants aged 31 to 40 years had a 2.36 times higher risk of incurring a UPC (HR, 2.36; 95% CI, 1.64-3.40; P < .001).
Conclusions and Relevance
This study suggests that older ophthalmologists are less likely to receive UPCs than younger ones. Although limitations in the study design could affect the interpretation of these conclusions, the findings may have practical implications for patient safety, clinical education, and clinical practice management.
The increasing number of senior physicians and calls for increased accountability of the medical profession by the public have led regulators and policymakers to consider implementing age-based competency screening. Some hospitals and health systems have initiated age-based screening, but there is no agreed upon assessment process. Licensing and certifying organizations generally do not require that senior physicians pass additional assessments of health, competency, or quality performance. Studies suggest that physician performance, on average, declines with increasing years in medical practice, but the effect of age on an individual physician's competence is highly variable. Many senior physicians practice effectively and should be allowed to remain in practice as long as quality and safety are not endangered. Stakeholders in the medical profession should consider the need to develop guidelines and methods for monitoring and/or screening to ensure that senior physicians provide safe and effective care for patients. Any screening process needs to achieve a balance between protecting patients from harm due to substandard practice, while at the same time ensuring fairness to physicians and avoiding unnecessary reductions in workforce.
As the population of aging physicians increases, methods of assessing physicians' cognitive function and predicting clinically significant changes in clinical performance become increasingly important. Although several approaches have been suggested, no evaluation system is accepted or utilized widely. This article reviews literature using MEDLINE, PubMed, and other sources. Articles discussing the problems of geriatric physicians are summarized, stressing publications that proposed methods of evaluation. Selected literature on evaluating aging pilots also was reviewed, and potential applications for physician evaluation are proposed. Neuropsychological cognitive test protocols were summarized, and a reduced evaluation protocol is proposed for interdisciplinary longitudinal research. Although there are several articles evaluating cognitive function in aging physicians and aging pilots, and although a few institutions have instituted cognitive evaluation, there are no longitudinal data assessing cognitive function in physicians over time or correlating them with performance. Valid, reliable testing of cognitive function of physicians is needed. In order to understand its predictive value, physicians should be tested over time starting when they are young, and results should be correlated with physician performance. Early testing is needed to determine whether cognitive deficits are age-related or long-standing. A multi-institutional study over many years is proposed. Additional assessments of other factors such as manual dexterity (perhaps using simulators) and physician frailty are recommended.
Objective:
Age correlated changes in mental and physical capacity have contributed to increasing concerns about older physicians' clinical competence. This paper explores the relationship between age and health in a clinical population referred for fitness for duty evaluations.
Methods:
Fifty cases from an evaluation center performing fitness for duty evaluations were randomly selected. Cases were reviewed for referral reason, demographic information, diagnosis, and recommendations.
Results:
Age ranged from 28-70 (median age of 51, mode of 45).Eighty-eight percent of cases had a diagnosed medical condition with potential cognitive sequellae.
Conclusion:
While the literature supports performance concerns in aging practitioners, health independent of age, appears to be an important contributing factor. A screening process considering biopsychosocial reserve and professional load while applicable to older clinicians would optimally be implemented for physicians across their careerspan.
Healthcare practitioners' fitness to practise has often been linked to their personal and demographic characteristics. It is possible that situational factors, such as the work environment and physical or psychological well-being, also have an influence on an individual's fitness to practise. However, it is unclear how these factors might be linked to behaviours that risk compromising fitness to practise. The aim of this study was to examine the association between job characteristics, well-being and behaviour reflecting risky practice amongst a sample of registered pharmacists in a region of the United Kingdom. Data were obtained from a cross-sectional self-report survey of 517 pharmacists. These data were subjected to principal component analysis and path analysis, with job characteristics (demand, autonomy and feedback) and well-being (distress and perceived competence) as the predictors and behaviour as the outcome variable. Two aspects of behaviour were found: Overloading (taking on more work than one can comfortably manage) and risk taking (working at or beyond boundaries of safe practice). Separate path models including either job characteristics or well-being as independent variables provided a good fit to the data-set. Of the job characteristics, demand had the strongest association with behaviour, while the association between well-being and risky behaviour differed according to the aspect of behaviour being assessed. The findings suggest that, in general terms, situational factors should be considered alongside personal factors when assessing, judging or remediating fitness to practise. They also suggest the presence of different facets to the relationship between job characteristics, well-being and risky behaviour amongst pharmacists.
Although there are considerable published data on how physician characteristics are related to knowledge and actual clinical practice, the findings are variable and influenced by how quality is measured. In a 2005 study by Choudhry et al,⁴ the relationship between age and academic knowledge was consistently inverse but significantly more variable when quality was measured by adherence to guidelines, treatment standards, or mortality. Furthermore, any correlation between physician characteristics such as age and clinical performance is complex and influenced by patient factors and comorbidities. More than 90% of the variance in physician adherence to guideline recommendations may be explained by differences in patient characteristics and the need to individualize care.⁶ In addition, a review of Massachusetts claims data showed no clinically meaningful correlation between physician characteristics and adherence to process-based measures of quality.⁷ The relationship between surgeon age and surgical outcomes such as mortality are variable and dependent on the type of surgery, surgical volumes, and surgical subspecialty and whether risk adjustment for patient characteristics was included in the analysis.⁸ Overall, the research in this area is inconclusive, and physician age may have less influence on clinical performance than previously thought. Taking physician age as the sole criterion for assessment could well limit how significantly competency assessment programs can improve patient safety and quality.
This title provides a unique perspective on what it is like to be brain damaged, seen through the eyes of doctors or neurosurgeons who have themselves suffered a brain injury or brain illness. Each of the personal accounts, written over the past 120 years, is accompanied by a commentary written by the author which critically examines the experiences of the sufferer, relating them to current issues in clinical neurology and cognitive neuroscience. The author also provides an introduction to each contribution, and in a final overview chapter he combines the lessons learned from all the articles. Accounts from over 40 individuals cover a wide range of conditions including: memory disorders, language disorders, visual disorders, Parkinson's disease, stroke, brain tumour, head injury, and epilepsy.
Objective:
This study examined the validity of a computer-based cognitive test that was recently designed to screen the elderly for cognitive impairment.Design:
Criterion-related validity was examined by comparing test scores of impaired patients and normal control subjects. Construct-related validity was computed through correlations between computer-based subtests and related conventional neuropsychological subtests.Setting:
University center for memory disorders.Participants:
Fifty-two patients with mild cognitive impairment by strict clinical criteria and 50 unimpaired, age- and education-matched control subjects. Control subjects were rigorously screened by neurological, neuropsychological, imaging, and electrophysiological criteria to identify and exclude individuals with occult abnormalities.Results:
Using a cut-off total score of 126, this computer-based instrument had a sensitivity of 0.83 and a specificity of 0.96. Using a prevalence estimate of 10%, predictive values, positive and negative, were 0.70 and 0.96, respectively. Computer-based subtests correlated significantly with conventional neuropsychological tests measuring similar cognitive domains. Thirteen (17.8%) of 73 volunteers with normal medical histories were excluded from the control group, with unsuspected abnormalities on standard neuropsychological tests, electroencephalograms, or magnetic resonance imaging scans.Conclusions:
Computer-based testing is a valid screening methodology for the detection of mild cognitive impairment in the elderly, although this particular test has important limitations. Broader applications of computer-based testing will require extensive population-based validation. Future studies should recognize that normal control subjects without a history of disease who are typically used in validation studies may have a high incidence of unsuspected abnormalities on neurodiagnostic studies.
Accountability to the public, through assurance of competent care to patients by physicians and other health professionals, is a paramount responsibility of organized medicine.Occasionally such accountability is jeopardized by physicians whose functioning has been impaired by psychiatric disorders, including alcoholism and drug dependence. An equally important issue is the effective treatment and rehabilitation of the physician-patient so that he can be restored to a useful life.A sampling of boards of medical examiners and other sources reveals a significant problem in this area. Also indicative of the problem, and the difficulty organized medicine has in coping with it, are the numerous requests for guidance received by the American Medical Association.The Council on Mental Health makes the following observations and recommendations:It is a physician's ethical responsibility to take cognizance of a colleague's inability to practice medicine adequately by reason of physical or mental illness, including alcoholism or
This study examined the validity of a computer-based cognitive test that was recently designed to screen the elderly for cognitive impairment.
Criterion-related validity was examined by comparing test scores of impaired patients and normal control subjects. Construct-related validity was computed through correlations between computer-based subtests and related conventional neuropsychological subtests.
University center for memory disorders.
Fifty-two patients with mild cognitive impairment by strict clinical criteria and 50 unimpaired, age- and education-matched control subjects. Control subjects were rigorously screened by neurological, neuropsychological, imaging, and electrophysiological criteria to identify and exclude individuals with occult abnormalities.
Using a cut-off total score of 126, this computer-based instrument had a sensitivity of 0.83 and a specificity of 0.96. Using a prevalence estimate of 10%, predictive values, positive and negative, were 0.70 and 0.96, respectively. Computer-based subtests correlated significantly with conventional neuropsychological tests measuring similar cognitive domains. Thirteen (17.8%) of 73 volunteers with normal medical histories were excluded from the control group, with unsuspected abnormalities on standard neuropsychological tests, electroencephalograms, or magnetic resonance imaging scans.
Computer-based testing is a valid screening methodology for the detection of mild cognitive impairment in the elderly, although this particular test has important limitations. Broader applications of computer-based testing will require extensive population-based validation. Future studies should recognize that normal control subjects without a history of disease who are typically used in validation studies may have a high incidence of unsuspected abnormalities on neurodiagnostic studies.
Remediation of some incompetent physicians has proven difficult or impossible. The authors sought to determine whether physicians with impaired competency had neuropsychological impairment sufficient to explain their incompetence and their failure to improve with remedial continuing medical education (CME).
During a one-year period, 1996-97, all 27 participants in the Physician Review Program (PREP) conducted at McMaster University, a physician competency assessment program, undertook a detailed neuropsychological screening battery.
Nearly all physicians assessed as competent also performed well on the neuropsychological testing. However, a significant number (about one third) of the physicians who performed poorly on the competency assessment had neuropsychological impairments sufficient to explain their poor performances. The difficulties were more marked in elderly physicians.
A significant minority of incompetent physicians have cognitive impairments sufficient to explain both their incompetence and, probably, their failure to improve with remedial CME. Testing physicians for these impairments is important: to detect and treat reversible conditions, to manage irreversible conditions that preclude successful educational intervention, and to facilitate compensation in this instance. Serious consideration should be given to the incorporation of neuropsychological screening in all intensive physician review programs.
Noticing that moderately to severely incompetent physicians (as measured by a standardized assessment of physician competence) did not improve after traditional remedial continuing medical education (CME), the authors investigated the effects of a polyvalent, intensive, prolonged educational intervention on five physicians' competence.
The five physicians participated in a CME program that lasted three years and consisted of individualized review, ongoing small-group and evidence-based discussions, simulated patients and role playing, formal chart review, and peer review. At the end of the program, the physicians were reassessed.
Only one physician improved; another remained the same, and three deteriorated.
Successful remediation of severely incompetent physicians is uncertain at best, even with prolonged, intensive CME that incorporates modalities thought to be effective in changing physicians' behaviors. Alternative educational techniques may need to be developed for this select population. Conversely, there may be reasons that preclude improvement even with optimal techniques.
MicroCog: Assessment of Cognitive Functioning version 2.1 (Powell, D. H., Kaplan, E. F., Whitla, D., Catlin, R., and Funkenstein, H. H. (1993). The Psychological corporation, San Antonio, TX.) is one of the first computerized assessment batteries commercially developed to detect early signs of cognitive impairment. This paper reviews its psychometric characteristics and relates them to its clinical utility. It concludes that MicroCog provides an accurate, cost-effective screen for early dementia among elderly subjects living in the community and that it can distinguish dementia from depression. Its ability to detect cognitive decline at other ages or to discriminate dementia from other mental disorders has not been established. MicroCog measures different constructs than do traditional neuropsychological tests, making it difficult to relate test performance to current models of cognitive functioning. The review recommends further development of MicroCog and discusses its implications for the future of computer-based neuropsychological assessment.
Physician-related errors are rising, resulting in an increase in disciplinary actions by licensing medical authorities. It has been previously reported that cognitive impairment may be responsible for 63% of all physician-related medical adverse events. In this paper we examine neuropsychological testing results from 148 physicians referred for assessment by the California Medical Board (CMB) for various infractions. The neuropsychological test performance of the physicians was compared to normative reference samples. Overall, they performed in the average range on most measures; however, they demonstrated relative deficits on tests of sequential processing, attention, logical analysis, eye-hand coordination, verbal and non-verbal learning. These findings reveal that this cohort of physicians is performing lower than expected on tests of intellectual and neuropsychological functioning. Applying a neuropsychological framework to the assessment of physicians may uncover potential cognitive factors that contribute to medical practice errors.
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Differences in cognitive performance between disciplined and non-disciplined physicians and foreign versus domestic medical schools. Paper presented at: Meeting of the North American Primary Care Research Group Annual Meeting
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