Strategies for Managing Aging Clinicians

Physicians experience cognitive declines just like anybody else in the workforce. It's time for hospitals to establish policies that will protect patient safety and prepare the next generation of clinicians.

The healthcare industry is filled with people who view what they do for a living not as a job, but as their reason for being.

"Many people feel they are defined by the medical profession," says Karen Speirs, DO, MPH, president of the medical staff at Munson Medical Center in Traverse City, MI.

But the American workforce is aging, and that includes healthcare professionals. Unlike other industries, where retirement and slowing down professionally is often eagerly anticipated, many healthcare professionals are reluctant to retire. And as the years tick on, there will be more older workers than ever before.

According to the Bureau of Labor Statistics, from 1992 to 2002, the share of the labor force for those aged 55 and over increased from 11.8% to 14.3%. In 2012, their share of the labor force rose to 20.9%. That number is projected to grow to 25.6% by 2022.

Along with aging, of course, comes age-related health deterioration and cognitive decline that includes everything from fatigue and eye strain, to loss the loss of fine motor skills, to dementia. This presents hospitals and health systems with special considerations.

"Physicians get dementia just like anybody else. We're not immune to it," says Scott A. Syverud, MD, chair of the University of Virginia Health System's credentials committee.

When healthcare providers face age-related health declines, though, it's not just their own health and wellness that's a factor; the health of their patients is at stake, too. Yet the years of experience that older clinicians bring to their institutions is incalculable; these aren't people who should just be kicked to the curb.

"To write them off would be a waste," says Peter McMenamin, PhD, Senior Policy Advisor and health economist for the American Nurses Association.

Syverud, agrees, saying, "These are the most-respected members of our clinical staff," and often they are department chairs.

Finding a Balance for Scaling Back
Finding a balance between retaining older clinicians' decades of knowledge and experience and making sure that those clinicians can still safely provide the best patient care is central to how hospitals and health systems should respectfully manage a growing number of aging clinicians.

In nursing, McMenamin believes there should be enough new nurses to fill the vacancies as a bulge of older nurses retires over the next 10 to 15 years or so. But what worries him is that older nurses with invaluable experience are "going to be walking out the door."

"You can't replace 30 or 45 years' worth of experience with a new nurse," he says. "That doesn't compute."

Yet it's impossible to ignore that "there's a lot of physical demand to nursing care, in terms of the actual physical care of the patients," says John R. Combes, MD, AHA Senior Vice President and President and COO of the Center for Healthcare Governance.

Therefore, healthcare organizations should look for ways to reduce older nurses' physical workloads while leveraging their knowledge. Both Combes and McMenamin recommends mentorship programs as a way to do this. As an economist, he views them as a tactic for eliminating waste, as well as a way to allow older nurses to extend their careers and transfer some of their knowledge.

"[Hospitals] should also be contemplating creating a human capital reserve," he says. "That would allow hospitals to grow their own experienced workforce over the next 15 years."

The same can be done for physicians, says Combes, who suggests tasking older physicians with teaching services, allowing them to advise younger physicians who might be the ones to actually render the patient care.

Transitioning to mentorship and teaching roles is just one way that hospitals can scale back their valuable older clinicians' workloads.

"I think it would make sense…if [hospitals] experimented with going back to eight-hour shifts for some of their more senior nurses," McMenamin says.

Combes also suggests ending mandatory on-call coverage for physicians at a certain age, such as 65, which many hospitals have done.

Cognitive Screening
A growing, but anecdotally small, number of hospitals are being proactive by requiring older clinicians to undergo physical and cognitive screenings when they reach a certain age.

Since 2011, the University of Virginia Health System has required physicians to undergo neurocognitive and physical exams when they reach the age of 70, adding an extra step to renewing their hospital privileges. They have to repeat the exam at age 75 and every time they renew their privileges thereafter; the director of the physician wellness program has to sign off on it. Syverud says the exam takes about four hours, and costs about $2,000 apiece. The physicians' clinical departments cover the cost. "It only takes one bad outcome with a patient to make the entire program worthwhile."

That's because a bad outcome is sometimes the first indication of a clinicians' impairment.

"If we didn't have this policy, the traditional way that this happens with physicians is that something happens in their practice," Syverud says. "It's career-ending, and it's a public end to the career. It's not good for the physician, and more importantly, it's not good for the patient." Neither is it good for the hospital or health system.

About 50 clinicians have gone through the evaluation since the policy was established. The results are confidential and they determine what action is taken. For some clinicians, a clean bill of a health is a source of pride, and maybe also validation. If a weakness is detected, the "policy offers them a confidential way to discuss that," Syverud says. "I suspect that would be a relief for many people."

It also gives clinicians the power and privacy to decide how to wind down their own careers, on their own terms, depending on the findings. For instance, a physician might be having trouble with fine motor skills, but be neurocognitively fine and might be able to shift his or her responsibilities accordingly.

Munson Medical Center adopted a similar policy in 2014, requiring physicians at age 70 and every two years thereafter to undergo a physical exam, a hearing screen, and the Montreal Cognitive Assessment. The program is voluntary at age 65. If a physician hasn't taken the exam within 30 days of being notified to do so, he or she will be considered as having voluntarily relinquished their privileges.

Speirs says there was some resistance to the policy when it was first adopted.

"Some of the pushback was that they didn't feel that it was right to take a test, that they would know when they weren't able to practice medicine," she says. But, "the argument does not stand up. Even with signs of mild dementia, you cannot tell in yourself, many times. You may be the last to know."

And although accusations of ageism are a real possibility, age-related restrictions and screenings in other industries are standard. The Federal Aviation Admiration for instance, has a mandatory retirement age of 65 for pilots.

The University of Virginia received "a lot of resistance and negative feedback" to the policy when it was first adopted, Syverud says. Physicians wondered if it was just one more bit of red tape and questioned whether it really added value to patient care. But Syverud says he spoke individually with each of the clinicians to whom the policy applied, and now, there's widespread acceptance of it. In addition, most clinicians perform extremely well on the exams.

"To their credit, our senior clinicians who have gone through this process recognize the value," he says. The possible alternative—a bad patient outcome, having their privileges taken away, and being disciplined—"is a terrible way to end a career."

Being Proactive
Syverud says he gets a lot of calls from other organizations looking for advice or information about implementing a similar program, usually after something has happened involving an older clinician.

"A lot of hospitals are struggling with whether to do this at all," he says.

McMenamin says adopting policies that address an aging workforce—whether it's establishing a nurse mentorship program or an assessment program of older clinicians—might not seem like an obvious priority now. "This is not a crisis that's going to show up in 2016," he says. But hospitals need to think about the long-term projections.

"We're going to be using this policy more and more. We feel we needed to have it in place for" the years ahead, says Speirs. "Instead of reacting, we're being proactive."