The Australian Medical Board’s Proposals for Medical Examinations of Late Career Doctors

Mandatory Medical Examinations for Doctors Aged 70: A Debate on Discrimination versus Safety

By Dr Philip Morris

In recent discussions about professional regulations, a contentious proposal has emerged from the Medical Board of Australia. This proposal suggests mandating repeated medical examinations and cognitive testing for doctors aged 70 and older. This initiative has sparked a debate about whether such measures are a necessary safeguard for public safety or an unjust form of age discrimination.

Understanding the Proposal

The Medical Board of Australia has expressed concerns that existing regulatory frameworks might not be sufficient to identify doctors with health issues that could impact patient care. They argue that by instituting mandatory examinations and cognitive assessments for older doctors, they aim to mitigate risks associated with aging practitioners.

However, this proposal raises critical ethical questions. Profiling a specific age group based on the assumption that they inherently pose a higher risk is a form of age discrimination. This is particularly concerning given the lack of robust evidence supporting the claim that all doctors over 70 are a significant threat to patient safety.

Examining the Data

The Board’s own data from 2015 to 2023 reveals some intriguing patterns. The rate of notifications of medical complaints increased similarly for doctors both below and above 70 years old, indicating no disproportionate rise in issues among older doctors. Specifically, from 2015 to 2019, notifications increased by 70% for those under 70 and 73% for those 70 and older. From 2019 to 2023, the rates plateaued, with a slight decline for younger doctors and a modest increase for older doctors.

Furthermore, the nature of regulatory actions in 2022-23 showed that younger doctors faced more severe sanctions than their older counterparts, suggesting that the perceived risk might be higher among younger practitioners.

A Fair Approach to Regulation

If the goal is to enhance patient safety, a more targeted approach would be more effective and fairer. The Medical Board already possesses substantial authority to evaluate doctors of any age who exhibit signs of impaired performance, such as through multiple complaints or significant lapses in care. This strategy would allow for a nuanced assessment without age profiling.

The current proposal does not address the variability in individual health and performance among doctors of all ages. Without clear evidence linking age directly to increased risk, enforcing blanket medical examinations and cognitive tests on older doctors appears to lack justification.

Challenges with Cognitive Testing

The cognitive tests proposed by the Board, such as the Montreal Cognitive Assessment (MoCA) and the Addenbrooke’s Cognitive Examination, have not been validated specifically for assessing the capacity of physicians. The lack of norms and the potential for test familiarity among doctors undermine the reliability and relevance of these tests in determining a doctor’s professional competency.

Moreover, cognitive tests often fail to capture the full range of skills required in medical practice, such as interpersonal communication, practical problem-solving, and emotional intelligence. They also tend to overlook the context in which a doctor works, which is crucial for a comprehensive evaluation of their capabilities.

The Value of Experience

Older doctors bring invaluable experience, mentorship, and continuity of care to the medical profession. Their contributions are critical, especially in an era of physician shortages. Discriminatory practices that target this group could drive experienced professionals away from the field, potentially harming the quality of patient care and the overall healthcare system.

Alternative Solutions

Rather than imposing mandatory repeated testing on all older doctors, a more balanced approach would involve regular health check-ups for all practitioners, regardless of age. This could ensure that all doctors, young or old, maintain their health and capability without singling out a specific age group.

Additionally, focusing on targeted assessments based on frequent notifications and performance concerns, rather than age, aligns better with principles of fairness and evidence-based regulation. This approach would help maintain high standards of care without resorting to age profiling.

Conclusion

Mandatory medical examinations and cognitive testing for doctors aged 70 and over raise significant concerns about fairness and discrimination. The evidence does not support the need for such blanket measures, and a more nuanced approach would better serve both practitioners and patients. Ensuring regular health check-ups for all doctors and targeting assessments based on specific performance issues would provide a more equitable and effective strategy for safeguarding patient care. This would be consistent with the Medical Board of Australia’s Code of Conduct that requires

“all doctors to have their own general practitioner (GP) to help them take care of their health and wellbeing throughout their working lives.  Healthy doctors are the cornerstone of Australia’s healthcare system.”

The Medical Board of Australia should reconsider its approach and adopt practices that uphold the principles of fairness and evidence-based regulation, rather than implementing age-specific mandates that may inadvertently lead to discrimination and loss of valuable experience in the medical field.

Prof Philip Morris AM
MBBS BSc (med) PhD FRANZCP FAChAM (RACP) ABPN
President NAPP

The following podcast covers this topic as well: 

https://open.spotify.com/episode/6tppDvncUvakvneb7f82Vn 

Mandatory Medical Examinations of Doctors Aged 70: Unjust Discrimination or Necessary Safeguard?

Introduction

In the realm of medical ethics and professional practice, the proposal to subject doctors aged 70 and older to medical examinations and cognitive testing raises crucial questions regarding discrimination, public safety, and the preservation of invaluable experience.

Profiling of a community group based on stereotypical assumptions dependent on a particular characteristic of a group such as race, age, ethnicity, religion, disability, marital status, or sex and using this to justify a regulatory or administrative action is a form of discrimination that is outlawed in most countries. 

Yet, the Medical Board of Australia proposes to mandate repeated medical examinations and cognitive testing on doctors based on a single characteristic of being aged 70 and on an unproven negative stereotypical assumption that these doctors are a risk to patient welfare just because of their age [1]. 

This proposal raises the question of whether the Medical Board of Australia (the Board) is age profiling older doctors.  While not wanting the public to be at risk from impaired doctors, either younger or older, a reasonable person could ask whether the Board is discriminating against these doctors based on age. 

Notifications

The Board justifies this proposal on the rate of notifications (unsubstantiated complaints) to the Australian Health Regulation Authority (Ahpra) of registered Australian doctors.  The Board claims that the higher rate per 1000 doctors of notifications for doctors aged 70 (older doctors) and over compared with doctors below age 70 (younger doctors) indicates that these older doctors pose a risk to public safety. 

The Board notes [1] that the rate of notifications (per 1000 doctors) for older doctors is about 1.5 to 1.8 times the rate for younger doctors, and that the rate for older doctors increased from 2015 to 2023.  While the rate of notifications increased from 2015 to 2019, this increase was the same for both younger and older doctors: 70% and 73% respectively.  From 2019 to 2023 the rate of increase in notifications plateaued; there was a small decline of 3% for younger doctors and only a modest increase of 9% for older doctors (Table 1). 

The Board notes there has been an increased number of notifications from 2015 to 2023 for doctors aged 70 and older [1].  Using the Board’s own data the number of notifications for older doctors (age 70 and above) was 189 in 2015, 380 in 2019, and 485 in 2023 (see Table 1).  In 2023 the number of notifications for older doctors as a proportion of all registered older doctors was 6.9%.  Regulatory action was taken against just 23% of the doctors who received notifications.  These data indicate that just 1.5% of all older doctors experienced a regulatory intervention in 2023.  However, in 2023 the number of notifications for younger doctors (under age 70) was substantially higher at 4,765.  On an absolute level, the number of notifications for younger doctors was ten times higher than for older doctors (Table 1). 

The pattern of increased rate of notifications from 2015 to 2019 and then a reversal of this pattern from 2019 to 2023 was seen in the category of Clinical Care notifications.  The rate of notifications increased 190% from 2015 to 2019 among younger doctors and increased 222% for older doctors.  But, from 2019 to 2023 the rate of notifications in this category declined by similar amounts for both younger and older doctors: 28% and 22% respectively (Table 1). 

Other than providing broad categories of notifications, the Board does not provide (deidentified) details of the nature of the notifications made against older doctors, or how these notifications put patient care at risk, and nor does the Board provide details of how many notifications were substantiated and how many doctors received multiple notifications.  This information is vital to determine whether older doctors as a group pose an unacceptable threat to the public or are more of a risk than younger doctors. 

The nature of regulatory action taken by the Board in 2022-23 was much more severe (requiring suspension, fines and reprimands) for younger doctors than older doctors.  34 younger doctors required sever regulatory action whereas no older doctor need this intervention (Table1), suggesting that the younger doctors presented a greater risk to the community.

In summary, there is no evidence in these data that there is an explosion of notifications among older doctors.  The change in the rate of notifications is similar between younger and older doctors.  The rate of notifications increased about 70% in both groups between 2015 to 2019 and then flattened out to 2023. 

The explanation for this pattern is not clear, but given it was observed in both groups and is of the same magnitude, it is likely that for the period 2015 to 2019 it related to changes in reporting such as the start of health ombudsmen offices in states, encouraging the public to consider making complaints to health regulators, as well as making notifications easier via electronic means.  The data do not support the notion that the rate of notifications for older doctors are continuing to increase or rise disproportionally.

Table 1

Further Evidence Needed

If the Board wanted to provide more convincing evidence to justify its proposal to mandate medical examinations and cognitive testing for older doctors, the Board should commission a properly designed study or survey of doctors across different age cohorts examining their physical health, mental health, substance use, and cognitive status, and their capacity to examine and treat patients competently.  In addition, the Board should conduct a properly designed trial comparing the Board’s preferred model of repeated medical and cognitive examinations for older doctors with current arrangements. 

Only after a survey identified problematic performance of older doctors, and a trial demonstrated the superiority of the Board’s preferred examination of older doctors on reducing risks to patients and improving the health of older doctors, could the Board legitimately argue for mandatory medical examinations and cognitive testing of these doctors.

Medical indemnity insurers in Australia do not increase their premiums based on the older age of doctors.  Their policies are based on two primary characteristics.  The first is the nature and risk profile of the practice and, second, the number of cases (patients) that practitioners look after during periods in their career (for example, as reflected in practice income).  The actuaries that advise the medical indemnity insurers do not counsel that older age is an additional risk factor that would justify additional premiums.

Health committees of medical boards across Australia are generally aware of those doctors who have impairments based on underlying medical conditions. A report from an Australian medical board noted that there is no significant difference in the proportion of doctors over age 60 among doctors known to these committees [2]

In view of all this evidence, there is no substantial indication that older doctors as a group pose a significant risk to the public.  The Board’s age profiling of older doctors is not sufficient grounds to mandate physical examinations and cognitive testing for these doctors. 

Cognitive Testing

The Board also proposes to force older doctors to undergo regular cognitive tests.  This is despite any robust evidence that healthy aging among older doctors is associated with any significant cognitive impairment that would affect patient care.  We need to distinguish healthy aging from the development of medical conditions that become more common as individuals age.  Medical boards already have the capacity to intervene to protect the public in situations where older doctors develop illnesses (for example Alzheimer’s disease) that affect cognitive capacity. 

Healthy aging is associated with subtle changes in cognition.  There are gradual changes that occur in fluid intelligence and crystallised intelligence [3].  Fluid intelligence peaks in early adulthood and then declines slowly.  These changes are small and gradual.  The changes in fluid intelligence are counter-balanced by age-related improvements in crystallised intelligence.  In healthy aging, these changes complement each other.

These changes of healthy aging have not been linked to problems in clinical practice that would lead to concerns for public safety.  Studies of physician age and in-hospital patient mortality have generally shown no association with age when controlled for procedural volumes [4] and no association between physician age and patient readmission [4].  The reasons behind associations between age and specific clinical outcomes are complex and are not likely to just relate to age of physician [5]. 

It is important to note that individual variation is substantial in all doctors who age.  There is no consensus or agreed guidelines that help medical authorities decide what level of age-related cognitive changes may put the public at risk.  The Board acknowledges this significant limitation [1, page 20]:

It is difficult to relate the precise degree of neurocognitive loss to doctors’ competence because the actual levels of cognitive impairment that preclude safe practice have not been determined.  There are no agreed guidelines to help medical boards decide what level of cognitive impairment in a doctor may put the public at risk.

Prospective studies have not been done addressing this issue [2].  The American Medical Association in 2015 [6] noted:

the effect of age on any individual physician’s competence can be highly variable,

and in 2018 it withdrew its support for testing physicians cognitively at 70 years of age [7].

The Board recommends that screening cognitive tests be used for regular testing of older doctors [1].  The tests mentioned include the Montreal Cognitive Assessment (MoCA), the Addenbrooke’s Cognitive Examination (ACE-III), the Mini Mental State Examination (MMSE), and the Clock Drawing Test (CDT). 

What the Board fails to mention is that these tests have not been validated specifically for assessing the capacity of physicians.  There are no norms for the cognitive screening tests they propose (MoCA, ACE-III, MMME, or Clock Drawing Test) for medical practitioners.  None of these screening instruments have been evaluated to discover what scores would determine the doctor’s capacity to practice.  The lack of norms and the potential for test familiarity among doctors undermine the reliability and relevance of these tests in determining a doctor’s professional competency.

Discouraging Older Doctors

The targeting of older doctors for forced medical examinations and cognitive testing by the Board will discourage older doctors from contributing to the profession.  Older doctors have a lot to offer the medical profession.  Their experience, mentoring skills, continuity of care, patient advocacy, and research contributions are invaluable.  By continuing to practice, older doctors can help to improve patient care and contribute to the advancement of medical knowledge.  The loss of senior doctors will be a major disadvantage the community at this time of physician shortage. 

The Way Forward – Improving Current Arrangements

Mandatory cognitive testing of all older doctors is inappropriate and raises the question that it is a form of age discrimination.  There is insufficient evidence to support the notion that healthy aging doctors pose a significant risk to patient care.  Age profiling undermines the principles of fairness, equality, and individual assessment.  

The Board claims that current regulatory measures are failing to detect some practitioners with health issues, and this therefore increases the risk to patients.  But the Board provides no robust evidence that supports this claim apart from age profiling older doctors. 

The Board already has extensive and legitimate powers to assess younger and older doctors who have medical conditions that might affect their cognitive performance and clinical practice without the need to specifically target older doctors.  One way the Board can identify doctors of concern is to ask doctors with two or more complaints in a defined period, or who have been reported for a significant lapse in standard of care, to undergo a health check.  The Board has this capacity, and this should be the norm regardless of age.  By implementing a strategy of proactively identifying doctors of concern, no matter what age, the Board would be able to achieve its aim of reducing risk to the public without discriminating against older doctors. 

Alternatively, if the Board believes it is a good idea for older doctors to have regular health checks from their general practitioners to benefit the doctor’s health and to reduce the risk to the public, then this should be mandatory for all doctors regardless of age, given that younger doctors have 10 times the number of notifications than older doctors, are just as valuable individuals as older doctors, and the risk of unwell (or drug affected) doctors of any age on the public is just as important.  The Board would be well advised to ask all doctors to have a regular medical check-up with their general practitioner and apply its Code of Conduct [1, page 5]:

The Board’s code of conduct (Code) requires all doctors to have their own general practitioner (GP) to help them take care of their health and wellbeing throughout their working lives.  Healthy doctors are the cornerstone of Australia’s healthcare system.

This approach would reassure the medical community that the Board was not trying to unfairly target older doctors. 

Dr Philip Morris AM

MBBS, BSc(med), PhD, FRANZCP, FAChAM (RACP)

President National Association of Practising Psychiatrists

References

1. Medical Board Ahpra. Health Checks for Late Career Doctors, Consultation Regulation Impact Staement, 7 August 2024.
2. Adler R, Constantinou C. Knowing – or not knowing – when to stop: cognitive decline in ageing doctors. Med J Aust 2008;189(11):622-624.
3. Harada C, Love M, Triebel K. Normal Cognitive Aging.  Clin Geriatr Med 2013 Nov;29(4):737-752.
4. Tsugawa Y et al. Physician age and outcomes in elderly patients in hospital in the US: observational study. BMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j1797
5. Aiken LH, Dahlerbruch JH. Editorial: Physician age and patient outcomes. BMJ2017; 357 doi: https://doi.org/10.1136/bmj.j2286
6. AMA Council on Medical Education (A-15), Competency and the Aging Physician: Appropriateness of Guidelines for Testing for and Judgment of a Physician’s Competence to Care for Patients. Chicago, IL: American Medical Association; 2015.
7. Devi G et al. Cognitive Impairment in Aging Physicians: Current Challenges and Possible Solutions. Neurol Clin Pract 2021 Apr; 11(2): 167–174.