In September 2011, a patient went to Dr. Seymour Leven, 88, at the Lewis County Mental Health Center in Lowville, New York asking for a prescription of Oxycontin. The painkiller is prone to abuse, and Leven knew the patient had tendencies in that direction, but eventually filled the prescription on an emergency basis, on the condition that he immediately admit himself to the nearest detox facility.
The patient walked out — prescription in hand—and instead of seeking the help he needed, shopped around, filling prescriptions for the same drug after conning other area doctors. The federal Drug Enforcement Administration picked up on it, fingered Leven for improper prescribing and urged the state’s Office of Professional Medical Conduct to take action. The office threatened Leven with discipline and possible legal action for improper prescription practices, so instead of fighting the state, he opted to surrender his license and retire.
“I think if I was a bit younger I would have been a bit more surly about the matter and say, ‘Go get your drugs some place else.’ But I was, in a sense, overly charitable and that was poor judgment,” said Leven.
This oversight, he recalled, was preceded about a week earlier when he forgot to evaluate a new patient before bringing him into group therapy, breaking standard protocol where he worked. It simply “dropped out of my mind,” he said.
Leven remains irked at being considered a “crook” in the eyes of the New York State Department of Health. The issue was instead, he contends, was one he planned for, and inevitable.
“I think it does indicate that at a certain age, it was time to quit.”
Leven isn’t alone. While only a little over one-quarter of New York State’s doctors are 60 or older, more than 40 percent of all the enforcement actions taken by the state since 2008 targeted senior doctors, according to an analysis of recently published actions by the state Office of Professional Medical Conduct. Out of 1,547 actions listed in the state database, 677 were attributed to physicians 60 and older at the time of the action. (The dates of the incidents leading to the actions are not included in the state data, may have taken place weeks, months or years prior.)
In the past five years, the state disciplined aged doctors for oversights ranging from botched surgeries and improper diagnoses to failing to maintain proper medical records. One subjected a patient to cervical cryotherapy — a treatment in which part of the cervix is frozen to kill abnormal cells — without providing a compelling medical need.
“Most physicians I think, feel the effects of age and take the appropriate steps to deal with it, but some do not,” said Dr. William Norcross, clinical professor of family medicine and director of the University of California San Diego’s Physician Assessment and Clinical Education program.
Norcross, a 64-year-old physician himself, is a leading advocate nationally of age-mandatory screenings for doctors. He said that the majority of older doctors are competent and certainly can still contribute to medicine. But he added that requiring aging doctors to have basic physicals and medical history exams would not prohibit competent doctors from continuing to practice well into old age, and could help struggling physicians either seek the assistance they need or consider retirement.
“Sooner or later, people are going to start realizing this is a reasonable thing when you’re dealing with a profession where people are making life-and-death decisions and performing life-and-death procedures.”
Dr. Henry Pohl, Vice Dean of Academic Administration at Albany Medical College and director of the Upstate New York Clinical Competency Center echoed those concerns.
“A significant number of people we evaluate are over 65,” he said. “There definitely are older physicians who we’ve tried, and in many instances convinced, not to practice anymore because it’s a little harder to remediate people when it’s harder for them to learn.”
The New York State Department of Health, whose Office of Professional Medical Conduct investigates doctors and carries out disciplinary actions, said that it would not provide comment for the story because the department does not track doctor ages at the time of misconduct, and thus could not systematically assess any connection between doctors’ ages and their performance.
But a growing body of research on the topic of the aging doctor has shown that with graying hair often comes a worsening of abilities. One study found that patients who underwent knee replacement surgery had fewer complications when performed on by a younger surgeon. Another found that patients undergoing complex surgeries experienced higher mortality rates when seen by older surgeons.
Similarly two studies, one in California and another in Oklahoma, found that aging was a risk factor for higher rates of discipline. (Other factors included being male, having completed medical education outside of the United States and lacking board certification.) It’s unclear what is responsible for the connection, but other professions avoid the problems through mandatory retirement.
In the United States, airline pilots and FBI agents have mandatory retirement ages of 65 and 57, respectively. No such stringent rules are being discussed for doctors, but a handful of hospitals like Driscoll Children’s Hospital in Corpus Christi, Texas, have been putting the issue of age in the office under the microscope.
At their 70th birthday, all physicians there complete an exam that checks for physical and cognitive decline. In two years of testing, fewer than half a dozen doctors have gone through the process. All have passed, according to Vice President of Operations and Quality Donna Quinn.
“The purpose is to ensure that patient safety and quality are supported by carefully assessing the capabilities and competencies of each practitioner,” she said.
Above all, she added, the review strives “to be supportive and respectful to the practitioner.”
Bodily decline isn’t the only threat. Senility is, too.
UCSD’s Norcross estimates that as many as 8,000 doctors nationally are affected by some sort of cognitive impairment, based on the rates of mental decline in the general population. He also noted that studies have shown that somewhere around 30 percent of doctors don’t have a personal physician themselves — a relationship that could spot cognitive decline before it becomes a problem.
“We see several doctors every year that have been disciplined or identified by their medical group that have some age-related cognitive deficits, that’s what alerted me to the fact that there was a problem,” he said.
“The problem is that people with cognitive deficits are always the last ones to know.”
New York is only one of five states in the country that doesn’t mandate continuing medical education for physicians who seek to maintain their license to practice through the decades. If a physician isn’t diligent about keeping up with the ever-evolving world of technology and medical procedures, older doctors could be practicing what was state of the art when they graduated from medical school a half-century earlier.
“There is no question that the state needs to recognize that physicians are certified in perpetuity, and only aside from the few that are disciplined, we don’t know how many are practicing competently,” said Arthur Levin, director of the New York patient advocacy group Center for Medical Consumers. He calls the need to assess doctors’ readiness to practice throughout their careers a “big issue.”
Specialty boards—like orthopedic surgery and internal medicine—do require physicians to recertify, usually about every 10 years. And hospitals by and large won’t grant privileges to a doctor that doesn’t have certification.
But board certification is not a requirement for state licensure to practice — meaning those that work outside of a hospital setting have no duty to remain certified. In 2010, about 1 in 5 doctors in New York State were not board certified.
Further, some boards originally granted older doctors lifetime certifications, which in many cases have grandfathered older physicians out of new recertification requirements. By one estimate more than 230,000 doctors nationally are either not certified or exempt from recertification.
Dr. Pohl from Albany Medical College sees promising strides in recertification, as the Federation of State Medical Boards and independent specialty boards develop new, more rigorous testing programs. But Pohl maintains that the problem is still here.
“If you don’t have hospital privileges, no one is checking,” he said. “Recertification for licenses, at this point, doesn’t work.”