CMDA's The Point

Mandatory Re-Testing?

April 11, 2019
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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.

3 Comments

  1. Avatar F Ray Nickel, MD, MPH on April 30, 2019 at 12:01 am

    This is a great article in concept but touches on the difficulty inherent in determining what the physicians skill set is relative to the skills that their practice requires. It also touches on the failure of the maintenance of certification process to effectively monitor the profession. My observation has been that physicians and especially surgeons begin to self select within a few years of starting practice. They will choose not to treat certain pathologies or certain age groups, etc. They are than required during a 10 year cycle to review a lot of information that has little to do with the type of practice which they have selected to perform. The testing process measures the ability to follow the instructions of the testing board and to study for and pass a test which measures their recently acquired knowledge base but not necessarily that knowledge base which is required to treat the patients that they treat. This is why a community can have a board certified physician that few physicians in the community would allow to treat their family. Conversely the physician who is realizing that their age may be affecting their ability to treat patients may choose to further self-limited their practice and still be an excellent physician, even though they could not pass a knowledge based test because of its emphasis on the breath of knowledge within their specialty. Evaluating whether a specific physician is competent to perform a specific practice is going to be much more subjective than objective and therefore much more difficult to legislate standards.
    For the record, I am 70 and have informed my physician’s assistant that one of their job requirements is to fire me when the time comes and they can collect 3 months severance pay for doing so! We share the humor but they understand that there is a solid intent behind the statement.

    • Avatar Robert Cranston, MD on May 1, 2019 at 11:40 am

      Thanks for your feedback. We all want to practice high quality, compassionate medicine. God Bless.

  2. Avatar sushil m sethi md on April 30, 2019 at 1:09 pm

    Your prejudice on age is very disheartening.
    God has given different strengths to different people.
    I spent 15 years of residencies and fellowship and I am
    blessed with excellent health.I am passionate being a doctor
    and believe I provide the best care than many younger less experienced
    doctors.Usually fellow physicians can observe and inform when one is less than
    perfect.Blanket statements like yours are not uplifting but very depressing.I will
    not renew my mebership in CMD next year
    sushil m sethi md,mph,facs

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