Ethics of Capacity, Mandatory Retirement, & Those at Potential Risk

by Women's Brain Health Initiative:Nearly ten years ago, Dr. Michael Gordon received a panicked phone call from the wife of a physician, a man who was a long-time colleague and friend. She pleaded that it was urgent for Dr. Gordon to see her husband immediately, suggesting vaguely that he was not doing well mentally.Dr. Gordon is a leading geriatrician and the former chief of medicine at Toronto’s Baycrest Health Sciences. One of his residents met with his friend first and emerged wide-eyed from an hour-long session.“The resident said ‘I can’t believe he’s still in practice. He can’t remember anything,’” recalled Dr. Gordon in an interview with Mind Over Matter®.In his own examination of his friend, Dr. Gordon determined quickly that his friend was “absolutely impaired” and told him that he had to stop practising medicine immediately.Dr. Gordon then spoke with his friend’s fellow physicians at his group practice, where a colleague said “I couldn’t report him…it would put him out of business.”Dr. Gordon is now 77 years old and although he stepped down as chief of medicine a decade ago, he is by no means retired. Dr. Gordon is still a professor of medicine at the University of Toronto and the co-director of the ethics program. He is also the oldest person on staff at Baycrest and has no illusions about his own mortality, having ensured that all his personal affairs are in order.He sits on a committee that examines physician retirement issues and has many friends of a similar age who occasionally speak about how long they should continue working. He points out that the end of mandatory retirement at 65 has changed everything, for physicians and many other professions.“Most of us like what we’re doing and most of us think we’re doing a good job. They all said 80 is the new 65!”Dr. Gordon also undergoes a yearly review at Baycrest, an examination to ensure that he is still able to properly fulfil his duties. “Most of us among older practitioners have no desire to continue to practise when we’re no longer able to provide the kinds of service we believe is our duty. I don’t have a right to be a doctor. It’s a privilege,” he said.As a doctor who studies and treats dementia, Robin Hsiung’s days are dominated by thoughts of the disease, so it is natural that he considers a fateful question about his own future: what happens if he develops dementia? “Yes, I do ask, and I have faced a colleague with the disease and it’s a difficult question,” said Dr. Hsiung in an interview with Mind Over Matter® from his office at the University of British Columbia, where he is an Associate Professor in the Department of Medicine’s Division of Neurology. He is also a staff neurologist at the UBC Hospital Clinic for Alzheimer and Related Disorders.He pointed out that dementia does not happen overnight. It might begin with mild cognitive impairment and in the early stages most people can function normally, perhaps employing various forms of reminders.“But doctors need to monitor themselves and stop working if necessary,” said Dr. Hsiung. “Their colleagues also have to spot danger signs. A good colleague will bring it up with their friend…and if it’s serious might need to bring it up with their superiors.” He said in all the cases he has dealt with, the physician was cognizant of the decline and stopped practising.We trust our health and our lives to our physicians. We expect them to be in top form. By their nature, doctors are high achievers. But for the good of their patients, they must also be honest with themselves about when the time comes to step back from their work.Professional guidelines published by the Ontario College of Physicians and Surgeons (OCPS) state that “physicians should only care for patients when they are well enough to do so.” OCPS advises doctors to “be aware of their own health, which includes being able to recognize when they are not well enough to provide competent care” and recommends that they avoid self-treatment. It also notes that doctors may not recognize when they are incapacitated, which can be a feature of dementia, and so they should seek advice about their own care from another physician.WITH THE ALARMING GROWTH OF DEMENTIA IN THE GENERAL POPULATION, IT IS CRITICAL THAT INDIVIDUALS WHO WORK IN ALL KINDS OF JOBS WITH PROFOUND RESPONSIBILITIES THINK ABOUT THESE ISSUES.“It’s not just doctors. I’ve seen lawyers, high-powered lawyers, who have had to stop because they’re not serving their clients properly anymore,” noted Dr. Hsiung.In Ontario, the Law Society Act and the Law Society of Ontario’s Rules of Professional Conduct strongly advise lawyers to seek professional assistance if they feel their capacity is compromised – whether as a result of physical illness, addiction problems or any kind of mental health issue. Lawyers are also required to report any concerns about colleagues to the Law Society of Ontario, which has the power to conduct investigations and hearings, as well as restrict or suspend an individual’s license to practise law, where warranted.Commercial airline pilots face perhaps the most rigorous scrutiny of all. In Canada, they are required to undergo a medical examination every six months to a year, depending on their age, which includes an assessment of their “mental status.” Airlines also require that co-workers report any abnormal behaviour by pilots.But these conversations naturally resonate most among health care practitioners who deal with dementia on a regular basis. Dr. Kirk R. Daffner, a professor of neurology at the Harvard Medical School, wrote about his own concerns about cognitive decline in a remarkable column for The Washington Post. He recalled how as a young doctor in training he witnessed older colleagues making embarrassingly incoherent presentations, and how he was determined that he would never attempt to continue working when he could no longer perform the job effectively. Now in his 60s, he is attempting to put personal safeguards in place to ensure that he will cease working if his mental faculties decline – despite his wife’s insistence that he will never willingly retire.It is a discussion rife with cruel paradoxes. Nearly 30% of physicians in the U.S. are over the age of 60. The wisdom earned through their years of experience is invaluable and the continued mental stimulation of work is believed to contribute to their personal brain health. However, at the same time, as many as 10% of individuals over the age of 65 suffer from dementia, and 15% to 20% of this age cohort suffer from mild cognitive impairment.Dr. Daffner has developed a tentative solution, which starts with a detailed document that outlines how he believes he should comport himself if he faces cognitive decline, which he has shared with trusted colleagues. He has identified peers who will assess his work and give him an honest appraisal. In light of the fact that dementia can profoundly change a person’s outlook, Dr. Daffner also proposes to record a video outlining his wishes so that he can watch it in the future as a frank talk to himself.Dr. Gordon believes that his annual reviews at Baycrest will ensure that he does not continue to work if he is unable to do so. He suspects that there are doctors in private practice who are not being reported when their mental health declines, but he also believes that the younger generation of physicians, by nature of their training, have a greater sense of collective responsibility and will be vigilant to ensure that colleagues do not continue to practise if their cognition deteriorates.Should the day ever arrive for him, Dr. Gordon is prepared to accept the judgement of his peers. “It would be tough because for many physicians it’s the source of their identity, but I’d have to do it. There’d be no way that I couldn’t do it.”Source: MIND OVER MATTER V7