When Leo M. Cooney Jr., MD, was charged with chairing an advisory committee to recommend a way to assess the cognitive abilities of older physicians at Yale New Haven Hospital in New Haven, Conn., that group included himself.
The hospital's Medical Executive Committee had voted to require neurological assessments of physicians ages 70 years and older reapplying for medical staff credentials. Dr. Cooney worked with two other senior physicians on the advisory committee and a professor in the department of psychiatry to come up with a neuropsychological screening test. He was then asked to join the committee that reviews the test results and makes recommendations to the hospital's chief medical officer.
And he had to take the test himself. “I passed. It's about 45 minutes, and it's sort of like an IQ test,” said Dr. Cooney. “We asked the neuropsychologist to focus as much as he could on decision-making process, problem solving, identifying normal versus abnormal—more than just memory and calculation.”
From October 2016 through January 2019, 141 older clinicians (mean age, 74 years; 86% men; 89% physicians) underwent the assessment, according to results published in January by JAMA.
Eighty-one clinicians (57%) met the requirements, proceeded with recredentialing, and were scheduled to be retested in two years. Thirty-four (24%) proceeded with recredentialing but were scheduled for a retest in a year due to minor abnormalities in their test results. The remainder showed greater cognitive limitations. Once screening and/or full neuropsychological testing was completed, the committee determined that 18 clinicians (13%) showed cognitive deficits that were likely to impair their ability to practice medicine independently. All chose to discontinue their practice or to practice in a closely proctored setting.
Dr. Cooney, who is the Humana Foundation Professor of Geriatric Medicine at Yale Medical School in New Haven, Conn., recently spoke with ACP Hospitalist about the testing.
Q: What led the hospital to decide to evaluate cognitive function of older clinicians?
A: It's been an issue for the last 15 years now. There is very good data in the literature. . . . One of the major articles was in Annals of Internal Medicine back in 2005 by Choudhry, where they looked at over 60 studies and the vast majority found that older physicians did less well than younger physicians in caring for patients. The [American Medical Association] had a Council on Medical Education report in 2015 that called for the development of guidelines and standards for monitoring and assessing the competency of aging physicians.
Q: Did the results of the assessments surprise you?
A: I was surprised. . . . I did not think that we had 18 physicians who had significant cognitive problems. Now, half of them are over [age] 80, so I also didn't realize we had that many people on our medical staff of that age. Eighty-seven percent did fine, but still . . . you want to have your patients protected against any less than excellent care, and we worried about these 18 individuals [after seeing their test results].
Q: How did the physicians who were found to have deficits react?
A: In 18 different ways. We went over each case individually, we sat down with their supervisor, and then usually, the supervisor, the chief medical officer, and one of us would meet with each of the applicants and review things with them. We were able to work things out, I think, in a judicious and amicable manner. If the clinician did not want to resign and wanted to continue with the application process [through a credentials committee], he or she was certainly able to do so . . . but none of the 18 individuals wanted to go to the credentials committee. They all agreed to take voluntary steps [toward retirement or proctored practice].
Q: What were the benefits and challenges of implementing this process?
A: The benefits are that you are protecting your patients from caregivers who do not have the cognitive abilities to practice outstanding medicine. The challenges are multifold. One of them is that we really don't have hard data on which we can make these determinations. There's not a lot of information in the literature that would identify at what level cognitive impairment is an impediment to the practice of medicine. So we spent a lot of time going over each one of these cases. I think a very important part of our process was that the neuropsychologist met with the three clinicians [on the committee] and went over each one of the individuals in great detail. He was able to point out to us what it meant to have problems with executive function, or processing, or a whole variety of other cognitive domains. So it's challenging to do it, and it is not the most popular thing in the world to do. But as we went further along, I've reported to our medical board probably five times and I've reported to our board of trustees a couple of times, and they have felt unanimously that we should continue and go ahead with this.
Q: What are the next steps?
A: This is an ongoing process. Since 2016, every member of the medical staff [over age 70] who comes up for recredentialing will undergo these tests. . . . As we were talking to members of our medical staff, the leading complaint they had was that this should only be given to people on whom we had concerns. Having said that, of the 18 individuals who we didn't think should be practicing, none of them had been brought to the attention of the authorities of the hospital or medical school. Waiting for a problem to occur is not a good idea. When we started this, I thought it was a good idea; as of now, I think it is an essential process—and I'm an older physician. Older physicians bring a lot to the table. I think they add tremendously to the experience, to the background knowledge, to the training of our younger clinicians. [The hospital wants] to make sure they're capable of doing it, that's all.
Q: What is your advice for other hospitals?
A: I think they should all be doing [testing]. I think that having a skilled neuropsychologist who can do all or almost all of the assessment is very helpful, because he starts to get knowledgeable and we start to get knowledgeable about the process—what's important, what's not important. So I think we're building a database as we go along. I think the other thing that's very important is that you need a committee of clinicians who have some credibility in the institution who have had some supervisory experience who can work very closely with the neuropsychologist.