Addressing Physician Cognitive Decline

Thursday, February 4, 2016 | Larry Sobal

A physician leader of a cardiovascular surgery program recently asked me an age-old (no pun intended) question: “What are my options regarding a colleague’s potential cognitive decline?”  I thought my response might make good fodder for this week’s blog.

Obviously, this is a delicate question and one that gets asked in almost every health organization. I recall leading a physician retreat awhile back and asking the participants if they had ever worked with a colleague whom they had concerns about regarding their cognitive status. Every physician in the room raised his or her hand.

The reality is that the medical profession has never really had well organized ways to measure physician competency, whether it be cognitive, technical, integrative, etc… To be fair, very few other professions have developed methods either. One exception is commercial airline pilots, who are, like physicians, also responsible for the safety and well-being of others; pilots must retire at age 65 and must undergo physical and mental exams every six months starting at 40.

In my conversation with the physician leader, we discussed that cognitive decline is most often thought of in terms of aging, but there are many factors that contribute apart from age. These include, among others, head trauma, diabetes, depression, sleep apnea, medications, medical treatment (such as chemotherapy), hearing loss, and substance abuse.

However, age is considered the leading factor, as all aging humans will develop some degree of decline in cognitive capacity over time, usually including the following symptoms:

• forgetfulness
• decreased ability to maintain focus
• decreased problem solving capacity

The fact is that older individuals are at higher risk. This is such a reality that in January 2011, the Patient Protection and Affordable Care Act added a new Medicare benefit, the Annual Wellness Visit, which requires an assessment to detect cognitive impairment. It’s interesting that this is considered critical for assessing patients, but not for providers.

Age contributes to a wide range of neurological, psychological and other medical problems, including dementia, Parkinson’s disease, major depression, cardiovascular disease, diabetes and cancer. These conditions — and the medications prescribed to treat them — can degrade a physician’s cognitive, sensory and motor skills and put patients at risk.

Many doctors, of course, retain their skills and sharpness of mind into their 70s and beyond. But physicians are hardly immune to dementia, Parkinson’s disease, stroke and other ills of aging. Therefore, it would only make sense that we should be systematically and comprehensively evaluating physicians on some sort of periodic basis.

What I shared is that an estimated 5-10% of health organizations have begun to introduce a process to invoke cognitive assessment, usually through the hospital medical staff privilege and credentialing process or as an aspect of all employment contracts. The challenge is determining what the evaluation should entail and how it should be triggered.

I also pointed out that there are several well-validated tests that are used to assess mild cognitive impairment. For example, the MicroCog was developed at Harvard University specifically to screen physicians age 65 and older. The 30- to 90-minute computer-based assessment employs 18 kinds of cognitive tasks such as object-matching, analogies and story recall to generate scores in nine related areas.

However, because there is no single conclusive test that would apply in all potential instances, it is important to have some flexibility and customization in an assessment process.

We closed out our discussion agreeing that this topic should be addressed thoughtfully and deliberately, although a lengthy process to develop the right (and legally valid) assessment program does not help in this particular situation. As a result, he agreed that he would try another age-old method, that being a candid conversation with the individual about the concerns. Of course, I urged him to do that only after some coaching from Human Resources and the right attorney…

What would you have advised?

 

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Larry Sobal is Executive Vice President of Business Development at MedAxiom. He has a 35-year background as a senior executive in medical group leadership, hospital leadership and insurance. As part of his current role, Larry consults, writes and presents on topics relevant to transforming physician practices and health systems.

 

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