Health,performance and conduct concerns among older doctors: A retrospective cohort study of notifications received by medical regulators in Australia

Abstract

Objectives

To determine whether ‘older doctors’ (aged over 65) are at higher risk of notifications to the medical regulator than ‘younger doctors’ (aged 36–60 years) regarding their health, performance and/or conduct.

Design

Retrospective cohort study.

Setting

National dataset of 12,878 notifications lodged with medical regulators in Australia between 1 January 2011 and 31 December 2014.

Participants

All registered doctors in Australia aged 36–60 and >65 years during the study period.

Main outcome measures

Incidence rates of notifications and incidence rate ratios of notifications (older versus younger doctors).

Results

Older doctors had higher notification rates (90.9 compared with 66.6 per 1000 practitioner years, p < 0.001). Sex-adjusted incidence rate ratios showed that older doctors had a higher risk of notifications relating to physical illness or cognitive decline (incidence rate ratio = 15.54), inadequate record keeping (incidence rate ratio = 1.98), unlawful use or supply of medications (incidence rate ratio = 2.26), substandard certificates/reports (incidence rate ratio = 2.02), inappropriate prescribing (incidence rate ratio = 1.99), disruptive behaviours (incidence rate ratio = 1.37) and substandard treatment (incidence rate ratio = 1.24). Older doctors had lower notification rates relating to mental illness and substance misuse (incidence rate ratio = 0.58) and for performance issues relating to problems with procedures (incidence rate ratio = 0.61).

Conclusions

Older doctors were at higher risk for notifications relating to physical or cognitive impairment, records and reports, prescribing or supply of medicines, disruptive behaviour and treatment. They were at lower risk for notifications about mental illness or substance misuse. Incorporating knowledge of these patterns into regulatory practices, workplace adjustments and continuing education/assessment could enhance patient care.

Keywords

Doctors at risk medical negligence law medical regulation medico-legal issues professional regulation risk management

Introduction

Workforce participation, including health workforce participation, among persons aged over 65 years has risen dramatically with the trend expected to continue.^1,2 Older practitioners often possess a depth of experience that may benefit patients³; however, declining practitioner health and out-of-date practices can potentially harm patients. The emerging body of evidence about the risks associated with practitioner ageing has prompted vigorous debate about workforce planning, education, retention, revalidation and patient safety.^4–7 Several countries are now implementing measures to assess and support older doctors in practice.^8–15

Medical regulators are charged with protecting the public by ensuring doctors are fit to practise. Regulators hold extensive data on notifications of concern, lodged by the public, practitioners and employers about the care delivered by practitioners. These data offer a valuable window into understanding quality of care.¹⁶ To date, no published studies have used Australian regulatory data to analyse notification patterns between older and younger doctors. Using comprehensive national registration and regulatory data this study sought to determine whether older doctors were in fact at increased risk of notification and, if so, to identify whether such increased risks related to specific areas of clinical practice.

Methods

Data

We obtained and linked two de-identified datasets relating to medical practitioners from the Australian Health Practitioner Regulation Agency (AHPRA):

A register dataset – all doctors registered to practice in Australia between 1 January 2011 and 31 December 2014; and

A notifications dataset – all notifications of concern lodged with medical regulators during the same period.

The de-identified register dataset held information on all doctors registered for any period of time during the study period across Australia’s six states and two territories. It included age, sex, specialty, and state or territory of practice; practice location (geographic remoteness); and dates during which registration was held. Doctors registered to an address outside Australia and practitioners who held non-practising registration were excluded.

The de-identified notifications dataset included information on notifications of concern (issue, source and outcome) lodged with the Medical Board of Australia during the study period across all states and territories, except New South Wales which functions under a co-regulatory model with that state’s Medical Council, Health Professionals Council Authority (HPCA) and the Health Care Complaints Commissioner as co-regulators. We obtained notification data from HPCA pertaining to the same period, which aligned with the variables present in the APHRA notifications dataset.

We linked the register data with the notifications data using anonymised, unique identification variables provided by AHPRA and HPCA.

Measures

Practitioner birth dates were provided by AHPRA in five-year bands (e.g. 1970–1974). Using these bands, we created two age groups reflecting doctors’ ages in 2010, i.e. 36–60 years (‘younger doctors’) and >65 years (‘older doctors’). We chose doctors aged 36–60 years as the comparison group as this cohort has usually completed specialist training and left junior doctor roles. Doctors aged between 60 and 65 years in 2010 were excluded from the analysis as they crossed over from the younger age group to the older age group during the study period.

Aligning with the definitions in the Health Practitioner National Regulation Law Act,¹⁷ we classified notifications into three broad categories of health, performance or conduct, and 17 subcategories (listed in Table 3) to define the nature of the primary concern raised. This coding process is described in more detail elsewhere.¹⁸

Exposure time

Doctors are ‘exposed’ to risk of notification only when they are engaged in clinical practice. If clinical practice time differed substantially across doctors in our two age groups, it may confound any measures of risk. To account for this, we created a measure of exposure time (‘practitioner years’) and adjusted our analyses to accommodate exposure.

Practitioner years were estimated at the doctor level, as a multiplicative function of two variables: (1) the amount of time in the study period each doctor was registered (denoted in fractions of years); and (2) the average number of clinical hours worked per week (denoted in fractions of 40 h, including values >1). The amount of time each doctor was registered was calculated directly from the AHPRA register data. The clinical hours per week was estimated from Health Workforce Australia’s 2015 Health Workforce Survey,¹⁹ using subgroup averages based on a matrix of values accounting for work hour differences by sex, specialty and age. Details of the method used to derive the clinical hours values are provided in Appendix 1.

Data analyses

We used counts and percentages to describe the characteristics of doctors and notifications, stratified by the younger and older doctor age groups.

To understand how notification rates varied across the two age groups, we began by fitting a negative binomial model to the data. The outcome variable in this model was the number of notifications per doctor and the covariates were specialty, sex and remoteness, as well as interaction terms between these three variables and each age group.

We conducted analyses to estimate the incidence of notification by age group within each of the three domains (health, performance, conduct) and the 17 issue types (e.g. inadequate record keeping, physical illness/cognitive decline), adjusting for ‘practitioner years’. The association of interest in these analyses was the sex-adjusted incidence rate ratio (IRR) of doctor age on the number of notifications (i.e. the ratio of the notification rate amongst older doctors to the notification rate amongst younger doctors after adjustment for any sex differences between these groups). We calculated this measure by using the standard Mantel–Haenszel method, first estimating the IRR for male and female doctors separately and then combining these into a weighted IRR. This method gives similar results to negative binomial regression with indicator variables for age group and sex.

All analyses were conducted using Stata 14.2.

Patient involvement and ethics approval

An expert advisory group contributed to the research development and results interpretation. A patient advisor, the heads of two independent agencies charged with resolving patient complaints (the Aged Care Complaints Commissioner and Health Services Commissioner for Victoria), and a representative of the Health Issues Centre, one of Australia’s peak consumer organisations were members of the group.

The University of Melbourne’s Human Ethics Sub-Committee approved the study (Approval Ethics ID: 1543670.2). AHPRA provided data in de-identified form under a strict data protection plan and deed of confidentiality.

Results

Characteristics of practitioners and notifications by age group

During the study period, 49,313 registered doctors aged 36–60 years (younger doctors) and 7627 registered doctors aged >65 years (older doctors) (Table 1). Within the study cohort, 84.2% of younger doctors and 86.8% of older doctors did not receive a notification. A total of 12,878 notifications were lodged. Differences in the distribution of notifications were noted in speciality, sex and practice location (p < 0.001). Notifications about older doctors were more likely to involve male doctors (younger: 78.4% versus older: 91.6%), general practitioners (younger: 39.9% versus older: 42.4%), surgeons (younger: 17.0% versus older: 20.9%) and psychiatrists (younger: 7.9% versus older: 10.8%).

Table 1.

Characteristics of younger and older doctors, and notifications about them.

	Doctors			Notifications
	36–60(n = 49,313)	>65(n = 7627)	P value	36–60(n = 11,271)	>65(n = 1607)	P value
	%	%	P value	%	%	P value
Specialty			<0.001			<0.001
General practice	35.9	30.8		39.9	42.4
Internal medicine	13.5	12.3		10.4	10.3
Surgery	7.9	14.7		17.0	20.9
Psychiatry	4.6	5.5		7.9	10.8
Other specialties	18.6	16.6		12.7	9.7
Non-specialists	19.5	20.2		12.1	5.8
Sex			<0.001			<0.001
Female	37.2	13.3		21.6	8.4
Male	62.8	86.7		78.4	91.6
Practice location			<0.001			<0.001
Metropolitan	79.3	83.5		77.6	83.8
Regional and remote	20.7	16.5		22.4	16.2

Source of notification and issues raised in notifications about older doctors

The proportion of notifications lodged by patients, employers and other practitioners was similar across the two groups (Table 2). However, there were differences in the types of issues raised. A larger proportion of notifications about older doctors involved conduct concerns (younger: 34.4% versus older: 39.4%) and health concerns (younger: 4.0% versus older: 6.2%), whereas a smaller proportion of the older doctor’s notifications concerned performance overall (younger: 61.6% versus older: 54.4%) (Table 3).

Table 2.

Source of notifications about younger and older doctors.

	36–60(n = 6885)	>65(n = 870)	P value
	%	%	P value
Source^a			0.004
Patient or patient’s relative	74.6	71.3
Employer	3.6	2.3
Fellow practitioner	9.6	11.4
Other (e.g. commissioners)	12.1	15.1

^aData on the source of notification was not included for NSW (n = 5123).

Table 3.

Issues for notifications about younger and older doctors.

	36–60(n = 11,271)	>65(n = 1607)	P value
	%	%	P value
Issue
All health concerns	4.0	6.2	<0.001
1. Physical illness/cognitive decline	0.4	4.5
2. Mental health and substance misuse	3.4	1.5
3. Other health concerns	0.2	0.2
All performance concerns	61.6	54.4	<0.001
4. Inappropriate prescribing	4.0	6.5
5. Substandard treatment	21.1	21.3
6. Inadequate investigation/tests	3.4	2.9
7. Poor assessment/diagnosis	9.5	7.8
8. Poor communication	4.1	2.9
9. Problems with procedures	6.0	3.2
10. Other performance concerns	13.5	9.8
All conduct concerns	34.4	39.4	<0.001
11. Inadequate record keeping	3.5	5.6
12. Substandard reports and certificates	3.1	5.0
13. Unlawful use or supply of medications	2.2	3.9
14. Disruptive behaviour	9.9	11.2
15. Breach of boundaries	3.9	4.6
16. Fraud/overcharging	3.9	2.4
17. Other conduct concerns	8.0	6.8

Incidence rate of notifications

The notification rate for doctors aged >65 years was 1.4 times higher than for doctors aged 36–60 years (90.9 per 1000 practitioner years versus 66.6 per 1000 practitioner years; IRR = 1.37; 95% CI 1.29–1.44; p < 0.001).

Rates of notifications were higher among older general practitioners (IRR = 1.63), psychiatrists (IRR = 1.61), internal medicine specialists (IRR = 1.50) and other specialists (IRR = 1.22) than among their younger specialty colleagues (Table 4). Older non-specialists were at lower risk of notifications than younger non-specialists (IRR = 0.69), as were older surgeons (IRR = 0.90). Older female (IRR = 1.72) and male (IRR = 1.20) doctors, respectively, had higher rates of notifications than their younger counterparts.

Table 4.

Number, incidence rates and incidence rate ratio of notifications by age group, specialty, sex and practice location.

	Notifications	IR per 1000 practitioner years	IRR (95% CI)	P value
Speciality
General practice				<0.001
36–60 years	4494	71.8	1.00
>65 years	681	117.2	1.63 (1.50–1.77)
Internal medicine				<0.001
36–60 years	1170	52.2	1.00
>65 years	166	78.4	1.50 (1.27–1.77)
Surgery				0.039
36–60 years	1916	119.5	1.00
>65 years	336	107.8	0.90 (0.80–1.01)
Psychiatry				<0.001
36–60 years	894	121.8	1.00
>65 years	174	196.2	1.61 (1.36–1.90)
Other specialities				0.010
36–60 years	1432	44.8	1.00
>65 years	156	54.8	1.22 (1.03–1.44)
Non-specialists				<0.001
36–60 years	1365	47.0	1.00
>65 years	94	32.3	0.69 (0.55–0.85)
Sex
Female				<0.001
36–60 years	2436	44.4	1.00
>65 years	135	76.1	1.72 (1.43–2.04)
Male				<0.001
36–60 years	8835	77.2	1.00
>65 years	1.472	92.5	1.20 (1.13–1.27)

CI: confidence interval; IR: incidence rate; IRR: incidence rate ratio.

Outcome of notifications

Of all notifications received, 8.5% resulted in regulatory action, i.e. a reprimand, fine or imposition of conditions. The rate of notifications resulting in regulatory action was 1.5 times higher among doctors aged >65 years than among doctors aged 36–60 years (IRR = 1.48; 95% CI 1.23–1.76; p < 0.001).

Relative risks for health, performance and conduct concerns among younger and older doctors

The rate of health-related notifications was higher among older doctors than younger doctors, after adjusting for sex (IRR = 2.07) (Figure 1); however, this overall measure masked considerable heterogeneity among issue types in this domain. Older doctors had a much higher risk of notification relating to physical illness or cognitive decline (IRR = 15.54), but a lower rate of notifications relating to mental illness and substance misuse issues (IRR = 0.58).

Figure 1.

Sex-adjusted IRRs for health, performance and conduct concern notifications for older doctors. CI: confidence interval; IRR: incidence rate ratio.

While the overall rate of performance-related notifications was slightly higher among older doctors (IRR = 1.09), there were again substantial differences by issue type. Older doctors had higher rates of notifications for inappropriate prescribing (IRR = 1.99) and substandard treatment (IRR = 1.24), but a lower rate for notifications relating to problems with procedures (IRR = 0.61). There were no statistically significant differences in notification rates for several other performance-related issues.

For conduct-related issues, older doctors were at higher overall risk of notifications (IRR = 1.39) including higher rates of notifications about inadequate record keeping (IRR = 1.98), substandard certificates/reports (IRR = 2.02), unlawful use or supply of medications (IRR = 2.26) and disruptive behaviours (IRR = 1.37). There was no significant difference in rates of notifications relating to breach of boundaries, fraud or overcharging, and a range of other conduct-related concerns.

Discussion

Results in context

Many senior doctors provide high-quality care well beyond the traditional age of retirement.²⁰ The vast majority (86.8%) were not subject to any notifications during the study period. Nonetheless, as a group, the older doctors had a higher overall notification rate than their younger colleagues highlighting several areas of clinical practice in which increased risk was evident.

The well-documented age-related declines in cognitive and physical abilities in the general population are likely to be reflected in the health practitioner community^6,21 with possible implications for safe clinical decision-making.²² Our results suggest that patient care may be affected by changes in doctors’ cognitive and physical health resulting in notifications to the medical regulator. Previous research suggests that some health practitioners lack the ability or insight to self-assess competence and may not be aware of a decline in their cognitive ability or skills.^23–27 In addition, chronic illness and physical limitations among older practitioners may have an impact on technical competence which can in turn affect treatment provided which may relate to our findings of the higher notifications rates for substandard treatment amongst older doctors. Despite the predictable and known risks to patients associated with impairment, there are no internationally recognised thresholds of cognitive impairment at which a doctor is considered to be a risk to the public.¹⁰

The prescribing, use and supply of medicines was identified as a hot spot of risk for older doctors. Some older doctors are known to maintain registration in order to prescribe for themselves or for families and friends. Whilst this practice is in breach of ‘Good medical practice: a code of conduct for doctors in Australia’,²⁸ some older doctors have been slow to adapt to evolving professional standards. In addition, failures to keep abreast of new drugs or changes in regimens, reversion to familiar patterns of practice or a reluctance or inability to follow new protocols have been identified as risks for older doctors.²⁹

Record keeping and report writing was a further hot spot. Previous research confirms that older doctors are slower to adopt technologies, such as electronic health record systems,³⁰ hence this finding may relate to delays in modernising a range of practice management tasks. The elevated risk we observed in relation to report writing may result from increased involvement in expert witness roles among senior doctors; however, this cannot be verified within the scope of this study.³¹

Study strengths and limitations

A key strength of our study is its comprehensiveness. The data and analysis covered every registered doctor in Australia in the two age groups of interest. The detailed demographic data linked to notifications profiles allowed us to undertake complex and varied analysis in a way not previously done. Partnerships between researchers and regulators can enable new insights into patient safety risks and inform regulatory practice.

Our study has four main limitations. First, notifications are an imperfect marker of quality of care with previous research suggesting most instances of poor performance, impairment or unethical conduct do not result in a formal notification of concern.¹⁶

Second, medical regulators coded the issues involved in notifications when they were received, based on the information known at the time; this coding does not reflect new information revealed during subsequent assessment and adjudication processes.

Third, we were unable to access information regarding practice setting. While there is some evidence that older practitioners in isolated or solo practice³² may be at increased risk of notification, we were unable to confirm in this study.

Finally, we were unable to control for systematic differences between older and younger doctors in the nature of clinical work being done by doctors. Our inclusion of an exposure measure that accounted for differences in working hours among older and younger doctors helps to address this concern and goes further than almost all other studies of medico-legal risk. However, some findings, such as the lower rate of notifications about procedures among older doctors may reflect differences in the nature of clinical work being undertaken.

Conclusions and implications

This analysis of nearly 13,000 notifications about doctors lodged with Australian regulators over a four-year period found that, overall, ‘older’ doctors (>65 years) had a 37% higher rate of notification than ‘younger’ doctors. However, the type of notification varied between the two groups. Health-related notifications were two times higher among older doctors than younger doctors, 40% higher for conduct-related notifications and 10% for performance-related notifications. Within all domains (health, performance and conduct), there were clear ‘hot spots’ of risk. Older doctors were at higher risk for notifications relating to physical or cognitive impairment, records and reports, prescribing or supply of medicines, disruptive behaviour and treatment. Older doctors were at lower risk for notifications about mental illness or substance misuse, and problems with procedures.

Medical regulators must balance their primary role of protection of the public with the need to respectfully partner with the medical profession and avoid unlawful and unjustified age-based discrimination. Knowledge of areas of heightened risk for older doctors, as outlined in this research, could be used to inform ongoing professional assessment, education and support with a view to ensuring public safety, and, where this is no longer possible, facilitate transition into retirement.

Footnotes

Acknowledgements

We thank Martin Fletcher, Deborah Brown, Ameer Tadros and Jennifer Morris for their contribution to the manuscript. We also thank patient advisors Jennifer Morris and Susan Biggar, and patient complaints commissioners Grant Davis and Rae Lamb for their contribution to our expert advisory group.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Appendix 1. Predicted working hours for each medical specialty

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