CMDA's The Point

Mandatory Re-Testing?

April 11, 2019
04112019POINTBLOG

by Robert E. Cranston, MD, MA (Ethics)

Driver’s license renewal age standards vary from state to state. In Arizona, drivers over the age of 65 have a shorter license renewal cycle. In Hawaii, the renewal cycle drops from every eight years to every two years for persons over 72. In Illinois, the renewal cycle drops from four years to two after the age of 81, and then it drops to a yearly renewal cycle after 87 years.

Vision testing also varies by state. In Kansas, vision is assessed with every renewal. In Massachusetts, vision testing is required for every renewal over the age of 75. In Maine, it is assessed at every renewal after age 62, while in Maryland it is required with every renewal for persons over age 40. In some states, the “licensing agencies have the authority to go beyond the standard procedures if they have doubts about any person’s fitness to drive.”

One can easily see how this might lead to inequities in testing. While this stipulation may be well intended, it is fraught with potential examiner bias. After all, no state has a mandatory cutoff age for driving.

Sometimes family members end up deciding their elder relatives should no longer drive, while at other times the Department of Motor Vehicles or doctor/caretaker is tasked with the difficult discussion of “taking away the keys.” Some believe family members are the best judges of this, but as a practicing neurologist I have seen instances where the family members did not want to play the enforcer, fearing hard feelings between them and their loved ones, not wanting to be inconvenienced to drive their aging family members around, or perhaps fearing they would be excluded from the will. At times, they knowingly allow an unsafe senior to continue to drive, because they dislike crucial conversations.

In my practice, I often persuade questionable drivers to have formal occupational therapy driver assessments. In Illinois, our therapists do not legally have the right to rescind driving privileges, but they can make recommendations to physicians as to possible limitations. Sometimes the advice is to halt driving. Sometimes variable non-binding limitations are recommended, such as no night driving, no driving in bad weather, no driving on the interstate or driving only within a limited radius of the patient’s home. Sometimes no restrictions are suggested.

Some seniors sense their growing limitations and willingly surrender their driving privileges. They say, “I’ve never had a car accident and I don’t want to start now.” Others say, “I’ve never had a car accident, so that proves I should be allowed to keep driving.”

A similar paradigm exists in professions requiring sharp thinking, quick reflexes, good vision and good manual dexterity. Federal firefighters have a mandatory retirement age of 57. Air traffic controllers have a mandatory retirement age of 55. The International Civil Aviation Authority (ICAO) sets the maximum retirement age for commercial pilots at 65. Japan recently raised the mandatory pilot retirement age to 67, while China restricts flying to those 60 or younger. Some airlines have different rules, but all “have strict health and skills testing requirements to ensure individual pilots—regardless of age—are qualified to fly.”

Commercial airline pilot Captain Chris Manno states, “I do feel like a mandatory retirement age is a good idea because motor skills and overall physical vitality diminish with age.” Manno doesn’t state his age in this interview, but he has been flying for more than 32 years. With his seniority he now has “an ideal flying schedule: 13 days a month, home every night.”

The limitation of his scope of practice is similar to the way some physicians voluntarily restrict their practices: fewer days per week, more frequent vacations, no night call, no long procedures or no new patients.

Airline pilots and physicians both:

  1. Have long and arduous training programs
  2. Often have high educational debt by the time they become commercial pilots or practicing doctors
  3. Typically earn relatively high salaries
  4. Enjoy well-deserved high public regard
  5. Provide a valuable service to society

These factors work to discourage the motivation to retire and certainly mitigate against early retirement. A major difference between pilots and physicians is that pilots are required to have frequent physical exams, cognitive assessments and simulated and in-person check rides. While the specifics vary between airlines, the principal regulations apply to all commercial airlines. The Federal Aviation Administration (FAA) also has the right to perform unannounced jump seat evaluations where a “check airman” shows up to observe the pilot in action and quiz the pilot orally. Manno states, “If you have trouble answering questions or don’t know regulations you may be grounded and sent for remedial training.”

Like pilots, physicians are responsible for the lives of many people. Given this public responsibility, and one’s inevitable, though variable, decline in motor skills, vision, manual dexterity and physical vitality, is it time to mandate re-testing of physicians based on age? (As long as the age criteria is based on population-based biological factors and is applied equally, discrimination is not a valid charge.)

Some argue that board-certification and maintenance of certification (MOC) processes are already in place and fill this need. On the other hand, individual doctors and specialty associations are raising questions about the fairness and utility of these processes, and they are being widely re-examined. Additionally, while MOC evaluates knowledge and cognitive skill, it does not adequately assess the other areas listed above which are necessary to be a competent, safe physician.

Recently, a growing number of large institutions have dealt with this older physician question on a policy level. Stanford Hospital and Clinics, Lucile Packard Children’s Hospital, Driscoll Children’s Hospital and many others have instituted late career policies. No one is suggesting mandatory retirement guidelines, but several have instituted mandatory re-evaluations. The devil, of course, is in the details. Stanford’s policy applies only to doctors over 75 years of age. Driscoll’s policy applies to physicians over the age of 70. The components of the testing vary from center to center, but may include proctored procedures, physical exams and, at times, neurocognitive testing.

Greeley Company is a “full service healthcare consulting practice specializing in, (among other things)… quality, external peer review, credentialing, privileging and education.” In a March 2018 white paper, Greeley strongly encourages hospital systems to create an aging policy for their doctors (and others including APNs, CRNAs, CNMs) and suggests that policies should cover credentialing, privileging, mental and physical assessments, legal and other considerations and age determination. Greeley does not support age-based mandatory retirement.

The rights of healthcare professionals are extremely important, but competent patient care should always come first. Mandatory re-testing is a good idea. A change in the scope of practice, much like Captain Manno, as opposed to loss of licensure and privileges, will often be sufficient to protect patient safety and physician dignity. In this age of predicted doctor shortages, we should not dismiss veteran, skilled doctors based solely on age, but patient safety and welfare are paramount. What conscientious healthcare professional really wants to put his or her patients at risk because of their own diminishing skills?

Related Resources
Am I Too Old to Practice? by Al Weir, MD
Balancing Safety with Dignity When Evaluating Aging Practitioners

Robert E. Cranston, MD, MA (Ethics)

About Robert E. Cranston, MD, MA (Ethics)

Robert E. Cranston, MD, MA (Ethics), MSHA, FAAN, CPE, is a board certified neurologist, with additional training and experience in palliative medicine, executive coaching and medical leadership. He currently serves at Carle Foundation Hospital, in Urbana, Illinois, as an attending neurologist, Medical Director for Talent Development and Learning and (Past Chair—14 years) of the Carle Ethics Committee. He is a clinical associate professor of medicine (neurology) at University of Illinois College of Medicine, Urbana-Champaign and Carle Illinois College of Medicine, and he is a member of the CMDA Ethics Committee.

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