Assessment of fitness for duty of underperforming physicians: The importance of using appropriate norms

A rationale and framework for addressing physician cognitive impairment

Medical error is costly, in terms of the health and wellbeing of the patient, their family, and the financial burden placed on the medical system. Reducing medical error is paramount to minimizing harm and improving outcomes. One potential source of medical error is physician cognitive impairment. Determining how to effectively assess and mange physician cognitive impairment is an important, albeit difficult problem to address. There have been calls and attempts to implement age-based cognitive screening, but this approach is not optimal. Instead, we propose that neuropsychological assessment is the gold standard for fitness-for-duty evaluations and that there is a need for the development of physician-based, normative data to improve these evaluations. Here, we outline the framework of our research protocol in a large, academic medical center, in partnership with hospital leadership and legal counsel, which can be modeled by other medical centers. With high rates of physician burnout and an aging physician population, the United States is facing a looming public health crisis that requires proactive management.

Physician norms for the Automated Neuropsychological Assessment Metrics (ANAM)

INTRODUCTION

The development of population specific norms for the Automated Neuropsychological Assessment Metrics (ANAM) is to help expand the utility for use with other population groups. Currently, normative data are available for general military, special operations, athletic, and community populations. The current study provides normative reference values for use in assessing physicians.

MATERIALS AND METHODS

Retrospective data from a sample of 2,288 physicians who completed the ANAM were examined. The data were gathered from practicing civilian physicians serving in the National Guard or Reserves who completed the assessment as part of the mandated Department of Defense clinical testing policy. The effects of age and sex on performance were examined for all subtests. Normative tables were stratified by age (23-29, 30-34, 35-39, 40-44, 45-49, 50-54, 55-59, 60-64, 65-79) and sex. Base rates of low scores among the physician population were also examined.

RESULTS

Older age was associated with lower performance on all subtests with small-to-medium effect sizes. A mixed pattern of performance was observed as a factor of sex with females scoring better on one subtest and males scoring better on three subtests. However, effects sizes associated with sex were small and likely of minimal clinical significance. A total of 11.3% of the physician sample scored below average on two or more tests in the battery.

CONCLUSIONS

This study provides normative data for practicing physicians that can be used to help inform clinical decision-making.

Neuropsychological Assessment of the Aging Physician: A Review & Commentary

Late-career physicians (LCPs) are at risk for cognitive changes that may affect their ability to practice medicine. This review aggregates and discusses research that has examined cognitive functioning among physicians, typically when clinically referred for various medical and psychological reasons that may interfere with their ability to practice medicine. Special consideration is devoted to the role of approaches for examining cognitive functioning (e.g., cognitive screening, cognitive testing, & neuropsychological assessment), normative challenges, and cultural factors that should be considered when evaluating a physician. Based on published studies, there is evidence supportive of the use of cognitive testing and neuropsychological assessment among physicians in a fitness for duty setting. However, prospective studies designed to identify physicians at-risk (i.e., to prevent medical error) are lacking. Additional research is warranted to establish physician-based normative reference groups and aid in test interpretation and prognostication. Moreover, given limitations associated with cognitive testing in isolation, there is a potential role for comprehensive neuropsychological assessment to identify cognitive changes in physicians and provide a supportive pathway to preserve physicians' ability to practice medicine.

Cognitive Screening Tools for Late Career Physicians: A Critical Review

Screening measures are widely used in medicine to assess the increased probability that members of a defined population have a particular condition and therefore require more extensive assessment. The rationale for prospective screening of late career physicians (LCPs) is drawn from the following circumstances: Senior physicians-prone to the vicissitudes of aging-comprise nearly a third of the US physician workforce, physicians are poor at self-evaluation, data suggest many have clinically relevant cognitive decline, and screening is an evidence-based, method to detect individuals at risk and determine whether a comprehensive evaluation is necessary. A handful of professional organizations (eg, surgeons, obstetricians, and a growing number of medical staff credentialing committees) have developed policies in this arena. This focused review compares cognitive screening methods used or recommended for LCPs, with particular attention to the psychometric properties, ease of operational implementation, and appropriate application to physicians-a population selected for high cognitive reserve and skills. Further, we identify gaps in knowledge and practice, including the need for more career-span normative data on physicians' cognitive and work performance. Stakeholders can improve rehabilitation and other supports to LCPs in transition, calling upon the unique expertise of those neuropsychologists who are trained on conducting fitness for duty evaluations, as well as rehabilitation professionals who can assist in developing modifications to practice when indicated or facilitate graceful transitions to retirement when necessary.

Adverse Childhood Experiences in Trainees and Physicians With Professionalism Lapses: Implications for Medical Education and Remediation

PURPOSE

Unprofessional behavior, which can include failure to engage, dishonest and/or disrespectful behavior, and poor self-awareness, can be demonstrated by medical trainees and practicing physicians. In the authors' experience, these types of behaviors are associated with exposure to adverse childhood experiences (ACEs). Given this overlap, the authors studied the percentage of ACEs among trainees and physicians referred for fitness-for-duty evaluations and patterns between the types of ACEs experienced and the reason for referral.

METHOD

A final sample of 123 cases of U.S. trainees and physicians who had been referred to a Midwestern center for assessment and/or remediation of professionalism issues from 2013 to 2018 was created. Included professionalism lapses fell within 3 categories: boundary violation, disruptive behavior, or potential substance use disorder concerns. All participants completed a psychosocial developmental interview, which includes questions about ACE exposure. Overall rate of reported ACEs and types of ACEs reported were explored.

RESULTS

Eighty-six (70%) participants reported at least 1 ACE, while 27 (22%) reported 4 or more. Compared with national data, these results show significantly higher occurrence rates of 1 or more ACEs and a lower occurrence rate of 0 ACEs. ACEs that predicted reasons for referral were physical or sexual abuse, feeling unwanted or unloved, witnessing abuse of their mother or stepmother, or caretaker substance use.

CONCLUSIONS

In this sample, ACE exposure was associated with professionalism issues. Remediating individuals with professionalism issues and exposure to ACEs can be complicated by heightened responses to stressful stimuli, difficulties with collaboration and trust, and decreased self-efficacy. Adoption of a trauma-informed medical education approach may help those that have been impacted by trauma rebuild a sense of control and empowerment. The findings of this study may be useful predictors in identifying those at risk of problematic behavior and recidivism before a sentinel event.

Cognitive Impairment in Aging Physicians: Current Challenges and Possible Solutions

Aging physicians are at a higher risk of cognitive impairment, undermining patient safety and unraveling physicians' careers. Neurologists, occupational health physicians, and psychiatrists will participate in both health system policy decisions and individual patient evaluations. We address cognitive impairment in aging physicians and attendant risks and benefits. If significant cognitive impairment is found after an appropriate evaluation, precautions to confidentially support physicians' practicing safely for as long as possible should be instituted. Understanding that there is heterogeneity and variability in the course of cognitive disorders is crucial to supporting cognitively impaired, practicing physicians. Physicians who are no longer able to practice clinically have other meaningful options.

Importance of neuropsychological screening in physicians referred for performance concerns

Introduction

The literature suggests that 6–12% of practicing physicians are dyscompetent. Dyscompetence can manifest as failures in direct provision of care, but also issues with interpersonal and communications skills and professionalism. There is a growing literature suggesting the value of neurocognitive screening in physicians with clinical competency issues. The contribution of such screening in physicians with workplace behavioral issues is not as established. The aim of this exploratory study was to examine patterns of performance on a commonly used neuropsychological screening instrument. Performances differences, if present, could have implications for remediation and/or monitoring.

Methods

Published data on a computerized neurocognitive screening instrument (MicroCog) for normative physician samples, published data on physicians referred for clinical competency issues, and newly collected data on physicians with workplace behavioral issues were analyzed. A two-way analysis of variance (Sample X Index) and post-hoc paired comparisons were conducted. A second analysis was performed employing an aggregated estimate of normative physician performance.

Results

Results revealed a significant main effect for Sample and Index and a significant interaction effect. The second analysis of variance employing the pooled samples (Sample X Index) was conducted. The workplace behavior issues sample differed significantly from each of the samples. The Sample by Index interaction was significant.

Discussion

Significant differences in performance on a neurocognitive screening instrument were found between non-referred physicians and physicians with behavioral or medical/technical competency concerns. Those with workplace behavioral issues performed significantly better than those with medical/technical issues, but significantly worse than non-referred physicians. Using these findings, 2.0% of the normal sample versus 35.1% of the medical/technical sample, and 10.9% of the behavioral sample would fail the screen using typical, conservative cutoffs. Further study of the potential role of neurocognitive factors in physicians referred for behavioral comportment issues is warranted.