the twilight saga… responding to an aging registrant population moderator:jordan glick, weirfoulds...
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The Twilight Saga…Responding to an Aging Registrant PopulationMODERATOR: Jordan Glick, WeirFoulds LLP
SPEAKERS: Dr. Melissa Frumin, Brigham and Women’s HospitalRaj Anand, WeirFoulds LLPVicki White, College of Physicians and Surgeons of Ontario
Roadmap• An Aging Registrant Population - Introduction
• Medical Views on Cognitive Performancein Aging Professionals– by Dr. Melissa Frumin
• The Impact of Human Rights Legislation– by Raj Anand
• CPSO’s Quality Assurance Program– by Vicki White
• Case Specific Discussions
• Practical Tips for Regulators
An Aging Workforce• When are you planning on Retiring?
A. Before 60B. 60-65C. 65-70D. 70-75E. Over 75
Average Retirement AgeDefined as the age at which the labour
force participation rate drops below 50%
United States:– 1965 - 55– 1993 - 57– 2010 – 59– 2014 - 63
An Aging Registrant Population - Introduction
• People are working longer in life for a number of reasons:– Longer and healthier
lives– More educated (less
physically demanding jobs)
– 2008 economic impact on pension funds
– Insufficient retirement savings generally
An Aging Registrant Population – Introduction
(cont’d)• Meanwhile, workplace demands are
growing:– Longer Hours– Rapidly changing technologies – Increasingly complex and specialized practices
• The public relies heavily on regulators to ensure that registrants discharge their professional obligations safely
An Aging Registrant Population – Introduction
(cont’d)• In most studies, older age correlates
with declining abilities:– Age related decline found in doctors
(decreased knowledge, worse patient outcomes, less adherence to standards)
– Trade related injuries more severe for older tradespeople (carpenters, iron workers, machine operators, etc.)
Current Regulatory Approach
• A complaint is made against an 82 year old registrant at your regulatory body for a breach in standards that raises public safety concerns. This matter would currently be handled by:A. Enforcement / Disciplinary
InvestigationB. Competence InquiryC. Fitness to Practice D. Quality Assurance Program
Questions for the Audience• At what age should you be assessed
for competency (i.e. for declining abilities)?
A. 55B. 60C. 65D. 70E. Never
Case Study #1- The Surgeon
• A 75-year-old ophthalmologist performing routine cataracts surgery places the (intraocular lens) implant in front of the pupil instead of behind, causing increased pressure and swelling in the patient.
• The ophthalmologist is subsequently the subject of, among other things, cognitive testing and peer review. There is evidence of cognitive decline, but not necessarily physical decline.
Case Study #2 – The Grade 1 Teacher
• A 75-year-old grade 5 teacher is noted by a classroom assistant to be consistently making mistakes with identifying cities on a map in a geography class.
• The teacher is subsequently the subject of, among other things, cognitive testing and peer review. There is evidence of cognitive decline.
Normal Aging – The Good• What is well-preserved/stable in
normal aging– Procedural memory - memory of how to
perform tasks, e.g. walking, talking, riding a bike
– Semantic memory – knowledge that is acquired about the external world over a life time
– Skills, ability, and knowledge that are overlearned, well-practiced, and familiar
Normal Aging – The Bad• What declines with age, 70 and older
– Episodic memory – ability to recall autobiographical events
– Working memory – manipulation of information that is held in conscious awareness
– Executive function – "administrative" control to organize and regulate multiple types of information and, therefore, effecting behaviors.
– Processing speed
Aging – The Ugly – Dementias
• Loss of abstract thinking
• Disorientation• Lack of initiative• Language problems
• Misplacing items• Mood swings• Personality
changes• Poor judgment
http://www.ucsfhealth.org/conditions/alzheimers_disease/
http://www.cumc.columbia.edu/dept/sergievsky/pdfs/agingandmemoryinhumans.pdf
What to do with theolder worker
• It is a dilemma
Synonyms for Dilemma• Deadlock, impasse, quagmire,
stalemate, standoff• Knot, problem• Bind, difficulty, fix, hole, jam, pickle,
pinch, plight, predicament, spot
How do we evaluateolder workers?
• (Older meaning 10-15 years older than me!) Are they:
• Revered Elders - some with limitations– Potentially more complicated, requires
individual assessment
How do we evaluateolder workers? (cont’d)
• “Dead Wood” - let’s just get rid of them– rules-based decision – age cut off,
standardized exam– like a driving test - pass/fail
Risk• Health and safety – doctors, pilots,
nurses, engineers, architects, police, firefighters
• Compassionate society – how are we to benefit from their wisdom?
My Perspective• Who am I responsible to?• Physician in a large academic
medical center – patients, students, trainees
• Institutional review boards/ethical review board – 5,000 human research protocols under review every year
• Research and investigators
How do we currently dealwith older physicians?
• Poorly. We are reactive.• Costs are lives, limbs, money and I
would add a poorly-trained next generation of health care workers
Dilemmas• One person setting• Very difficult to evaluate a one
person setting – physicians, dentists, podiatrists, independent visiting nurse.
• Fall back upon a standardized exam and review of medical records.
• Patient complaints.
Institution• Credentialing and re-credentialing
process-peer reviewed• More people looking at you• A colleague signs off on my fitness to
practice every 2 years
Institution (cont’d)• Personal relationship can interfere
with the greater good.• Institutional allegiance these days is
mixed• Patient complaints
Medical School• Older physicians hang on for a long
time– I am treating depression in a 90-year old
physician who teaches at a local medical school
• Teaching can also include advice/ supervision
• Physician’s identity, especially for men, can sometimes be their entire identity
Potential Solutions• Maintenance of Certification with
Exam, CMEs, review of records, Specialty Boards
• Board of Registration Medicine– In the US, each state has their own
system for regulating the medical profession. Fill out an application, answer questions, 100 CME units that have to be documented
Potential Solutions (cont’d)• Extensive evaluations
– UCSD – cost benefit – time away from work
– actual cost of evaluation
• Who gets chosen?
Potential Solutions (cont’d)• One consequence of new technology,
especially a new medical records system, is that many older physicians, 80s and above who do not want to take it on!
Potential Solutions (cont’d)• Have a process where older
physicians are seen as Revered Elders– can teach– participate in med school/hospital
activities– have an academic appointment– access to library
Melissa Frumin, M.D., [email protected]
• Neuropsychiatrist, Brigham and Women's Hospital
• Ethical Review Board/Institutional Review Board, Mass General and Brigham and Women's Hospitals
• Assistant Professor of Psychiatry, Harvard Medical School
Age-Triggered QAPs – Human Rights Implications
• Many jurisdictions, including Canadian provinces and the federal government, have abolished mandatory retirement
• Perhaps as a result, ageism has become more widespread in Canada and in North American society generally
• Ageism is a socially constructed way of thinking about older persons– Refers primarily to attitudinal barriers– Based on negative stereotypes about aging– Also based on a tendency to structure society as though
everyone is young
Age-Triggered QAPs – Human Rights Implications
(cont’d)• Ageism is a more complex issue in
professional self-regulation
• A regulator must balance an aging individual’s desire to continue practicing with its public protection mandate– latter includes well-founded concerns that the
public’s health and safety may be jeopardized by permitting a professional to practice in an unrestricted fashion
Age-Triggered QAPs – Human Rights Implications
(cont’d)• Canadian human rights laws protect against
discrimination in services, employment, and membership in self-governing professions, among other social areas
• Professional self-regulatory bodies in Ontario are therefore covered
• Human rights protections enjoy quasi-constitutional status– Courts give them a broad and liberal interpretation,
rather than a narrow “black letter of the law” interpretation
• Overall purpose is to foster respect, dignity and inclusion for all members of society
Age-Triggered QAPs – Human Rights Implications
(cont’d)• Unequal treatment because of
age is prohibited where it relates to one’s membership in a professional regulator
• When “age” was capped at 65, the definition had the effect of authorizing regulators to conduct age-triggered peer assessments for professionals 65 years of age or older
Age-Triggered QAPs – Human Rights Implications
(cont’d)• Now, age-triggered peer or practice
assessments are prima facie discriminatory and contrary to the law
• No special exemption exists that authorizes discrimination in professional self-regulation for age-related reasons (contrast with insurance or employment situations, where direct discrimination is permitted for reasons of age in certain justifiable circumstances)
Age-Triggered QAPs – Human Rights Implications
(cont’d)• A self-regulatory body cannot impose direct or
indirect age-based requirements, rules, qualifications or factors with respect to membership in a profession, unless it can provide rational, credible and bona fide reasons (BFRs) for doing so
• In other words, a discriminatory rule must be adopted for a valid reason
• In the professional self-regulatory context, the most important BFR will be public health and safety
• Such reasons should be based on objective
Age-Triggered QAPs – Human Rights Implications
(cont’d)• A regulator’s justification for treating registrants
differently because of age should:– be based on objective, and not impressionistic,
expert evidence • Expert evidence can canvass both the physical and
mental / cognitive demands of practice in aging professions (see, by analogy, similar evidence adduced in the suppression firefighting context in Espey v. London (City), 2008 HRTO 412)
– be implemented following an investigation of alternative approaches that achieve the same result, but do not have a discriminatory effect
Age-Triggered QAPs – Human Rights Implications
(cont’d)• Most important, such requirements
must be :– reasonably necessary to accomplish the
goal of protecting the public, in the sense that not having the requirements in place would create undue hardship to the regulator in terms of public health and safety
College of Physicians and Surgeons of Ontario
• Provincial equivalent to State Medical Board– (Sort of)
• Broader mandate– Complaints/Investigations/Discipline– Quality Management Division
• Registration• Quality Assurance Program
Ontario• Population 13
million
• 30,000 physicians (approximately)
Peer Assessment Program:A Brief History
• 1977 CPSO approved Peer Assessment Pilot
• Pilot in ‘78-79– to identify physicians practising at an
unacceptable level– to designate methods of correcting the
deficiencies– to ensure that these methods are
effectiveMcAuley RG, Paul WM et al, CAN MED ASSOC J 1990; 143 (I 1)
Peer Assessment History• Program began in 1981• Data from first 5 years
– 923 physicians assessed– 663 (72%) GP’s or FP’s
Results Based on Age (1981–86)
VariableNumber assesse
d
No. (%) with grossly deficient records,
unsatisfactory care or both
Age group
< 50 275 24(9)50 – 74 324 51(16)≥ 75 63 22(35)Total 662 97 (15)
Risks to Regulator• Clear evidence that at least some
cognitive abilities decline with age • High risk group• If we wait for a random peer
assessment there can be significant declines in the interim
Peer Assessment: Introduction of Age-Targeted
Assessment• Introduction of peer assessment for
all physicians at age 70– in 1995 expanded to also assess at five-
year increments thereafter
Cognitive assessment vs. Practice assessment
• Power to require cognitive assessment new
• Currently, require practice assessment
Peer Assessment Currently• An educational program• Provides feedback on performance• Occasionally finds problems• Currently:
– 450 trained assessors– approximately 1,700 assessments
annually
• Random and targeted selection
Powers of Assessment• Ask questions re: practice• Inspect records/charts• Require physician to examine
simulated patients• Require cognitive assessment• Observe physician in practice
• Pre-visit questionnaire
• Patient records review using a structured evaluation toolkit
• Physician interview with feedback
Half-day practice
visit
• QA Committee reviews to determine opportunities for practice improvement
Report sent to College
Peer Assessment: Process
Peer Assessment Outcomes• Three Categories of Assessment
– Category 1 = Satisfactory assessment– Category 2 = Need feedback or
clarification from physician (for clarification, often documentation issues only)
– Category 3 = Interview with Quality Assurance Committee (QAC) when significant documentation concerns or care concerns; higher level assessment
2013 QA Assessment Outcomes
Satisfactory Assessment
Reassessment Interview
Randomly Selected Physicians
91% 7% 2%
Age 70 Physicians
81% 12% 6%
Age 70+ Physicians
79% 11% 10%
Powers after Assessment• Reassessment• Impose terms, conditions or
limitations on practice• Require participation in education
and remediation program• Refer for investigation
CPSO Complaints 2009# MDs < 69 #
complaints#
complaints/MD
22902 1453 .06
# MDs > 70
1456 152 .104
Aging Physician• Analytic processing declines• Managing novel, conflicting and
complex patient situations becomes more difficult
• Increased reliance on experience; less tendency to assess critically novel, conflicting information
• Poorer performance on recertification examinations
Systematic Review: The Relationship Between Clinical Experience and Quality
of Health Care
“Of 62 published studies that measured physician knowledge or assessed quality of care and described time since medical school graduation or age, more than half suggested that physician performance declined over time for all outcomes measured.”
(Choudry, Fletcher & Soumeraiann Intern Med. 2005;142:260-273)
Observations for Peer/PREP• Compared to their younger
colleagues, physicians 70 and older:– More frequently have serious record-
keeping deficiencies– More frequently have care concerns
Observations about Complaints and physician age – committee
decisions• Compared to younger peers,
physicians > 70 who have a complaint that requires a committee decision are more likely to…– …be referred to a discipline committee– …sign an undertaking to restrict their
practice
Hallmarks of a Good Age-Targeted Assessment Program• Consistency
– Tools for assessors – assessor selection (recruitment), assessor guidelines, report writing
– Elements of assessment• History and physical exam• Peer assessment (charts plus interview)• Observations of co-workers• Cognitive assessment
– Tools for decision makers – guide decisions that flow from assessment
Hallmarks of a Good Age-Targeted Assessment Program (cont’d)
• Transparency– Publicly available policy – preferably on
web– Set out what will happen in assessment,
when, and what will happen next– Explain important details
• Who pays, how long will it take, who can they talk to
• What happens to the information gathered
Vicki WhiteCo-Director, Legal Office
(416) 967-2600 ext. 433
College of Physicians and Surgeons of OntarioQUALITY PROFESSIONALS | HEALTHY SYSTEM | PUBLIC TRUST
Case Study #1- The Surgeon
• A 75-year-old ophthalmologist performing routine cataracts surgery places the (intraocular lens) implant in front of the pupil instead of behind, causing increased pressure and swelling in the patient.
• The ophthalmologist is subsequently the subject of, among other things, cognitive testing and peer review. There is evidence of cognitive decline, but not necessarily physical decline.
Case Study #1- The Surgeon
• A 75-year-old ophthalmologist performing routine cataracts surgery places the (intraocular lens) implant in front of the pupil instead of behind, causing increased pressure and swelling in the patient.
• The ophthalmologist is subsequently the subject of, among other things, cognitive testing and peer review. There is evidence of cognitive decline, but not necessarily physical decline.
QUESTIONS AND ANSWERS
MODERATOR: Jordan Glick, WeirFoulds LLP
SPEAKERS: Dr. Melissa Frumin, Brigham and Women’s Hospital
Raj Anand, WeirFoulds LLP
Vicki White, College of Physicians and Surgeons of
Ontario