Assessing Age-Related Cognitive Decline in Physicians

Executive Summary 

Physicians who are impaired due to an age-related cognitive decline are less likely to adhere to the appropriate standards of care and are more likely to have an increase in poor patient outcomes. Allowing an impaired physician to continue their medical practice compromises patient safety and the integrity of the medical profession.       

To assess whether a suspected physician has a cognitive impairment, one option is referring the individual to an external party who is trained and credentialed to evaluate and confirm the impairment. However, sometimes the warning signs of an impairment are obvious. Frequent patient complaints, poor standard of care and increased forgetfulness may indicate that a physician is impaired. 

      
Physicians have a general duty to report behavior that puts patients at risk. When an impairment is identified by a colleague, an intervention must be conducted in a timely manner so that the impaired physician does not compromise patient safety. 

An intervention can be conducted one-on-one or in a group setting and is intended to help the physician recognize their impairment and the risks it poses. It is not uncommon for impaired physicians to be in denial. Therefore, interveners should be prepared to communicate the consequences of refusal to comply, such as suspension of privileges or being reported to the licensing board. 

In general, to reduce risk with impaired physicians, healthcare organizations should establish mechanisms to promote health and wellness among physicians. In addition, organizations should assure that, after being identified, impaired physicians are confronted in a timely manner to ensure that quality patient care continues to be provided safely.  

What Is an Impaired Physician? 

According to the American Medical Association, an impaired physician is a physician with a physical or mental health condition that interferes with their ability to engage safely in professional activities. As a result of the impairment, the physician compromises his or her professional relationship, puts patients at risk and undermines trust in medicine.  

How to Assess Impairment 

Impairment is commonly understood as a physician who is suffering from substance abuse. A less spoken of, but still important, impairment is a decline in cognitive function or motor skills due to old age. Physicians suffering from age-related cognitive decline are less likely to adhere to appropriate standards of care, are less likely to consider and adopt newly proven therapies, and may have poorer patient outcomes. Therefore, an impaired physician can risk compromising the safety of their patients. If a physician is suspected of being impaired, a credentialed third party should collect information to evaluate and confirm the impairment before intervening. However, sometimes the warning signs of an impairment are obvious.  

Warning signs

 
There is little guidance on how to identify impaired physicians prior to an adverse event. The Federation of State Medical Boards Policy on Physician Illness and Impairment is an excellent resource for identifying a potentially impaired physician and guiding their rehabilitation. In addition, these warning signs may help determine whether an intervention is necessary: 

• Increased patient complaints  

• Poor patient outcomes 

• Decreased quality of care and careless medical decisions 

• Increased irritability or forgetfulness  

• Decreased productivity or efficiency 

• Depression, anxiety and mood instability. 


If a physician colleague cannot clearly identify an impairment through these warning signs, a credentialed third party must conduct an evaluation to confirm the impairment.  

When Should You Intervene? 

An intervention is designed for the impaired physician to recognize their impairment and the risks it poses. In general, there is a duty to respect the autonomy of physicians. But if there is a suspicion about a physician’s mental or physical health, this duty can be waived. Physicians have an ethical and legal duty to report behavior that puts patients at risk. Failure to monitor themselves and their colleagues can compromise the physician’s reputation, including their physician colleagues, and the integrity of the medical profession.

The AMA Principles of Medical Ethics state that patient well-being must always be the primary consideration. Healthcare organizations should establish mechanisms to promote health and wellness among physicians and assure that impaired physicians promptly cease practice. Keeping the ethics guidance and applicable law in mind, physicians should confront and report impaired colleagues in a timely manner.  But ascertaining when and how to intervene with a colleague can be tricky.  

To decide whether to confront a colleague, you must: 

• Know what behaviors constitute impairment 

• Understand the duty to report impaired colleagues 

• Realize reporting colleagues often creates emotional conflict 

• Understand recovery options and resources available for impaired practitioners. 


How Should You Intervene? 

Physicians may not feel comfortable confronting an impaired colleague. An intervention can be awkward; however, it is necessary to reduce risk. The first step in an intervention can be as simple as expressing collegial concern. For example, a genuine “How are you?” can open the door to a more meaningful conversation.  

Some impaired physicians may be reluctant to seek help or admit their impairment because they fear the potential consequences. If a physician is in denial of their impairment or unwilling to discuss their mental or physical health, a more formal intervention with other medical professionals may be required. During the intervention, the interveners should present the impaired physician with options that will reduce the risk of compromising patient safety. For example, an impaired physician can reduce their hours, take a break from work or cease their practice altogether.  

Interveners should also be prepared if physician they think is impaired refuses to comply. For example, it may be necessary to communicate consequences such as suspension of privileges or reporting the impaired physician to the licensing board if the physician stays in denial.  

Consequences of Avoiding Intervention 

Physicians who fail to file reports concerning impaired colleagues generally aren’t placing themselves at risk unless reporting is required by a state board. But failing to address an impaired physician can jeopardize the integrity of the medical profession itself. 

Because an impaired physician cannot practice medicine safely, their patients will continue to be at risk. An increase in poor patient outcomes may lead to frequent complaints by patients and their families and even litigation. Individuals involved in the intervention would not be named parties in the lawsuit. Instead, the impaired physician and the healthcare organization would be the named parties. To reduce the risk of poor patient outcomes and litigation, a timely intervention should be conducted when an impaired physician is identified and the impaired physician should promptly modify their practice to ensure that quality patient care continues to be provided safely. 

Action Plan 

Here are some steps you can take to conduct a timely intervention for an impaired physician: 

1. Express concern to the physician. 

2. Arrange a meeting with the physician that is either one-on-one or with other healthcare professionals. 

3. If patient safety isn’t at risk, present options such as reducing hours or taking a break from work. If patient safety is of concern under reduced or restricted practice, recommend ceasing their practice. 

4.  If the physician stays in denial, communicate consequences such as the suspension of privileges or being reported. 

5.  If the physician still refuses to comply, it may be necessary to contact the licensing board. 


In Summary

 
Physician impairment due to an age-related cognitive decline can put patient safety at risk and increase poor patient outcomes. When a physician is identified as being impaired, physician colleagues have an ethical and legal obligation to confront and report the impaired physician to avoid compromising patient safety. A timely intervention must be conducted during which the colleague(s) express concern and present options that the impaired physician can take to reduce risk. If an impaired physician stays in denial, interveners should be prepared to communicate the consequences of refusing to comply such as being reported to the licensing board. 

To reduce the risk of impaired physicians and compromised patient safety, healthcare organizations should establish mechanisms to promote health and wellness among physicians. Finally, after an impaired physician has been identified and confronted, healthcare organizations should make sure the impaired physician modifies their practice to ensure that quality patient care continues to be provided safely.