How Yale's Flagship Hospital Determines Aging Clinicians' Fitness to Practice

The hospital's approach to reappointing aging clinicians to the medical staff is nuanced rather than pass/fail.

This article appears in the March/April 2020 edition of HealthLeaders magazine.

Yale New Haven Hospital has developed a two-step assessment process for all clinicians who are at least 70 years old and seeking reappointment to the medical staff.

Like the general population, the proportion of the country's physician workforce entering retirement age is growing. In 2019, the American Association of Medical Colleges reported that nearly half of physicians were either at retirement age or approaching retirement age in the next decade: 15% of physicians were more than 65 years old and 27% of physicians were between the age of 55 and 64.

In an article published recently by the Journal of the American Medical Association, doctors from Yale New Haven Hospital and Yale Medical School describe how the New Haven, Connecticut-based hospital is rising to the aging clinician challenge. "The two most important steps in this assessment process are the selection of a neuropsychologist and the selection of the members of the review committee," the article co-authors wrote.

1. Evaluation of cognitive function

For clinicians at least 70 years old, the first step in determining reappointment status is a screening with multiple tests to assess cognitive ability, the JAMA article says. A neuropsychologist administers 16 tests:

• Rudimentary information processing (two tests)
   
• Visual scanning and psychomotor efficiency (two tests)
   
• Processing speed and accuracy under decision pressure (one test)
   
• Concentration and working memory (one test)
   
• Visual analysis and reasoning (two tests)
   
• Verbal fluency (two tests)
   
• Memory (one visual test and one verbal test)
   
• Prefrontal self-regulation (one test)
   
• Executive functioning (three tests) such as the ability modify behavior when circumstances change

The time to complete the tests ranges from 50 minutes to 90 minutes.

"A cognitive screening battery of tests was developed and designed to balance brevity with broad coverage of abilities relevant to clinical practice. The instrument was constructed to account for the cognitive decline and neurodegeneration commonly associated with aging," the journal article co-authors wrote.

2. Review committee process

The next step in determining reappointment status is an assessment performed by the hospital's Medical Staff Review Committee (MSRC), the journal article says. The MSRC has four members: the previous and current chief medical officers of the hospital, a faculty geriatrician, and the neuropsychologist who performed testing on the reappointment candidates.

The MSRC reviews the test results and makes recommendations to the hospital's medical staff credentialing panel. Rather than making pass/fail determinations, the MSRC makes a range of decisions based mainly on the cognitive functioning level of reappointment candidates, the journal article says.

• Clinicians who post test scores within normal limits are recommended for the hospital's regular credentialing process. These clinicians are subjected to rescreening and recredentialing in two-year intervals.
   
• Clinicians with test scores marginally below normal limits or with weakness but no deficits in one or two abilities are recommended for credentialing. These clinicians are subjected to rescreening and recredentialing in one-year intervals.
   
• Clinicians with some weaknesses that could compromise the safe practice of medicine are requested to have a comprehensive neuropsychological exam.
   
• Clinicians who demonstrate significant deficits in the screening tests are either asked to have the comprehensive exam or undergo evaluation for their ability to practice medicine. If these further reviews show inadequate cognitive abilities to practice medicine, the clinician meets with the CMO and possibly another MSRC member to weigh options including a restricted form of proctored practice and retirement.

Reappointment data

The neuropsychological assessment was conducted for 141 Yale New Haven Hospital clinicians from October 2016 to January 2019, the journal article says. The mean age was 74.3 and the oldest clinician tested was 92.

Most of the reappointment candidates were physicians (125). The other candidates were five advanced practice registered nurses, four dentists, three psychologists, two podiatrists, one physician associate, and one midwife.

The disposition of the MSRC reviews included the following:

• Eighty-one reappointment candidates (57.4%) posted screening test scores within normal limits, were recommended for the regular recredentialing process, and were set for rescreening at two-year intervals.
   
• Thirty-four candidates (24.1%) posted test scores marginally below normal limits or with weakness but no deficits in one or two abilities. These clinicians were recommended for credentialing and set for rescreening at one-year intervals.
   
• The testing of 18 clinicians (12.7%) showed inadequate cognitive abilities to practice medicine independently. These clinicians decided to either practice in a proctored environment or stopped practicing medicine.

An editorial accompanying the JAMA article calls for a balanced approach in the assessment of aging clinicians' fitness to practice medicine. "It is imperative that medicine forge a thoughtful path forward—patients deserve nothing less. Nuanced, supportive, evidence-based programs can help ensure that patients are protected from late-career physicians who become affected by cognitive decline, and also that they may continue to benefit from physicians with successful cognitive aging and their unique breadth of experience and wisdom."