New policy to require evaluations for late-career practitioners

Stanford University Medical Center is now one of only a few academic medical centers nationwide to have enacted a policy for evaluating late-career practitioners.

Philip Pizzo, MD, dean of the School of Medicine, said he hopes the move will encourage other academic medical institutions to follow suit. The focus is not on retirement but on helping to optimize the effectiveness of physicians to care for their patients.

 "Most physicians have known at least one colleague who practiced beyond the time when he or she was most effective, and many of us have struggled with how to best handle that to protect patients as well as the reputation and self-esteem of the physician," Pizzo said. "For this reason it is important, from the point of view of both patient safety and physician well-being, to establish a process by which late-career physicians' performance and capacities can be fairly and accurately evaluated."

As of Sept. 1, physicians age 75 or older who practice at Stanford Hospital & Clinics or Lucile Packard Children's Hospital will be required to undergo a series of evaluations to confirm that they are able to continue performing their clinical responsibilities effectively.

Practitioners age 74.5 or older who are applying for medical privileges at the hospitals, as well as current medical staff 75 or older, must receive a physical examination, cognitive screening and peer assessment of their clinical performance. These evaluations must be completed every two years to retain hospital privileges. The policy also applies to practitioners with a PhD, such as psychologists. It replaces a similar policy enacted last year that applied only to physicians practicing at Packard Children's.

About 40 physicians at Stanford University Medical Center will be affected by this new policy when it takes effect Sept. 1, according to Debra Green, director of medical staff services. (However, an additional 14 physicians who will be 75 or older when the policy takes effect won't be screened until 2014; they were already evaluated under Packard Children's policy.)

Developed by a 15-member medical center task force, the policy sets out to ensure high-quality care for patients and protect them from harm; identify problems pertinent to the health and clinical practice of medical staff; support the medical staff; and apply evaluation criteria objectively, equitably, respectfully and confidentially.

It's a necessary step because physicians may have a limited ability to determine their own clinical competence, the task force said, citing a 2006 review, "Accuracy of physician self-assessment compared with observed measures of competence," published in the Journal of the American Medical Association.

"We need to be certain that the benefits in patient care conferred by years of experience aren't overwhelmed by the effects of senescence," said Norman Rizk, MD, a task force member who also is senior associate dean for adult clinical affairs at the medical school and the Berthold and Belle N. Guggenhime Professor in Medicine. "For most of our older physicians, their years of experience do offer an advantage in their breadth of knowledge and familiarity with outcomes, but we must assure that the small number of physicians who may have health problems themselves are aware of their limitations."

Ann Weinacker, MD, chief of staff at Stanford Hospital and chair of the task force, noted that medicine is not the only profession in which health issues associated with age could potentially compromise the well-being of others. However, she said it might be particularly difficult for physicians to recognize or acknowledge age-related limitations.

"As physicians, so much of our identity is tied up in our job," Weinacker said. "It's not just a job; it's a vocation that most of us are deeply, personally committed to. So the idea of having to limit how we practice is uncomfortable."

Weinacker added that the policy is not intended to pressure physicians to retire. "This is intended to support clinicians who may need to transition from a more active career to one more limited in scope," she said.

Weinacker also highlighted the contributions of Janesta Noland, MD, president of the medical staff at Packard Children's and member of the task force, in crafting the policy.

The task force decided to require that evaluations begin at 75 mainly because data show a steep increase in the incidence of Alzheimer's disease, the most common age-related cognitive disease, at that age, said Kathryn Gillam, PhD, a senior adviser to the dean and task force member. Of people who suffer from the condition, only 10 percent are 74 or younger, while 45 percent are ages 75-84 and 45 percent are 85 or older, according to the Alzheimer's Association.

If findings from a physician evaluation point to potential concerns for patient safety, the service chief and the credentials committee will, on a confidential basis, consider the results and recommend further evaluation as necessary, Weinacker said. Specific findings that would flag concerns include low scores in the  peer assessment or the cognitive screening, as well as significant health issues that could interfere with the physician's ability to practice medicine.

If the credentials committee concludes that a physician is unable to safely and competently perform the privileges requested, a committee representative or the chief of staff, or both, will talk with the physician about alternative practice patterns or modification of requested privileges, including the possibility of revocation of privileges, Pizzo said.

"The goal of such discussion is to be supportive and respectful of physicians' careers and contributions and to suggest resources to assist them while also being mindful of the safety and care of the adults and children for whom we have the privilege to provide medical care," he said.

For more information about the policy, call the Medical Staff Services Department at (650) 497-8920. 

John Sanford is a writer in the communications office at Stanford Hospital & Clinics.