A commentary published in in the New England Journal of Medicine argues most hospital programs screening older physicians for cognitive and physical decline skip the safeguards that would make them fair — and lays out how to fix that.
Here are 8 takeaways from the report:
1. Nearly a quarter of U.S. physicians are over 65 — right when the workforce needs them most. Nearly a quarter of practicing physicians in the U.S. are older than 65, according to the commentary, published Jan. 21 in NEJM by Daniel Kramer, MD, MPH; Thomas Gallagher, MD; Paulina Osinska, MPH; Andrew White, MD; Kelly Davis Garrett, PhD; and Michelle Mello, JD, PhD. The commentary was referenced in a recent editorial published in Medscape July 22.Those physicians are practicing at a moment of overall physician scarcity, making their continued contributions especially valuable to patient care.
“Older physicians bring valuable wisdom and expertise to patient care, but many will experience cognitive and physical decline that may affect their clinical skills,” the authors wrote.
2. Age-related decline is real and hard to catch through informal channels. Population-level data consistently show an age-related decline in physician performance across clinical specialties, the authors wrote, which raises the risk of poorer outcomes for patients treated by late-career physicians. Historically, hospitals have relied on voluntary self-referral or peer reporting to catch decline, but neither approach reliably works. Cognitive and technical slippage can be subtle enough that physicians themselves don’t notice it, and colleagues or staff who might notice often face hierarchical barriers to flagging concerns — and tend to report only after an adverse event or near miss has already happened.
3. Screening programs are catching on, but they’ve drawn real pushback. More hospitals have moved to mandatory screening for late-career physicians, typically triggered by an age threshold — commonly 70 — tied to renewal of clinical privileges. But the concept remains controversial among physicians. In 2020, the federal Equal Employment Opportunity Commission sued Yale New Haven Hospital, alleging its late-career physician program constituted age and disability discrimination.
“Whatever the merits of the claim or its fate in the Trump administration, the suit reflects many physicians’ view that [late-career physician] policies are unfair, burdensome, unnecessary, and even offensive,” the authors wrote.
4. Most existing policies skip the basic protections that would make screening fair. The authors reviewed late-career physician policies at 29 organizations and interviewed 21 medical leaders responsible for implementing them. Fewer than a quarter of those policies described a substantive standard for restricting a physician’s privileges, an evidentiary standard, an appeals process, or a right to legal representation. Leaders tended to describe fairness in terms of evenhandedness — that every physician is subject to the same policy — rather than in terms of formal procedural protections.
5. Fix No. 1: Bring physicians into the design process, and screen everyone equally. The authors’ first recommendation is to engage physicians early in building a screening program, explaining clearly why mandatory testing is needed and building in real opportunities for input on details like test frequency, type, and location. They also argue screening should be universal — applied to physicians across all specialties, not just those in high-risk or procedural fields — and should generally begin around age 70, the most common threshold already in use.
6. Fix No. 2: Keep the tests simple, accurate, and hard to game. Screening tools should have strong predictive accuracy, be validated against physicians in good health rather than the general population, and resist manipulation, the authors wrote. Physicians should get clear notice of what’s being tested and why, and results should be delivered confidentially, ideally alongside an expert who can walk through the findings and suggest areas for improvement. Independent, third-party testing can help preserve that privacy and consistency.
7. Fix No. 3: Build in a menu of accommodations and a real appeals process. Rather than jumping straight to restricting privileges, the authors recommend hospitals consider a range of accommodations first: cutting night shifts, shifting duties toward teaching, reducing patient volume, scheduling longer appointments, or limiting a physician’s caseload to lower-risk patients. Physicians flagged for concerning results should also have access to a confidential appeals process, with the ability to argue for retesting, and awareness of their right to legal representation.
“Providing procedural fairness actually builds trust and promotes harmony by increasing acceptance of adverse determinations,” the authors wrote.
8. Fix No. 4: Track outcomes over time, and consider outside oversight. Screening programs should be evaluated on an ongoing basis, the authors wrote, tracking metrics like the share of eligible physicians actually screened, the number of positive and confirmed-positive results, appeals outcomes, and adverse events among patients treated by physicians 70 and older. State medical boards, they suggest, could play an independent oversight role, offering physicians another avenue for assurance and complaints outside the walls of their own hospital.
“When [late-career physician] program designs include procedural protections and reflect evidence about when age-related decline occurs and how it can be detected and addressed, [late-career physicians] can be treated differently from younger physicians, to promote patient safety, without being treated unfairly,” the authors concluded.
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