The day , turned 70 last year, the 240-member anesthesiology physicians group that employed him since 1989 said his time was up.
That's because decades ago, Anesthesia Service Medical Group, Inc. () imposed an age-related hard stop, forcing all doctors his age to move on.
"The next day, I went on an Alaska cruise," Pue said.
He soon got a part-time job in outpatient surgery at the University of California San Diego Medical Center with a schedule he described as "not nearly as stressful," and without the high risk obstetric cases he had before.
Although setting a firm age to stop seems "arbitrary," Pue said -- some doctors should retire earlier and some later -- "I completely understand why ASMG does this." The policy began "because they'd had some old folks who weren't doing a very good job and caused some problems, and they couldn't get rid of them."
ASMG general counsel Glenn Buberl elaborated. As one of the largest specialty groups in California, ASMG self-insures for malpractice and wanted to have "a bright line" for doctors to call it quits, he said. "It avoids a situation leading to something that could be humiliating for the physician."
"We have call obligations at night, on weekends, and that's until the end of a career. And as you get older, you tend to slow down and then everybody else has to pick up the call slack, making it harder on everybody," he said. Also, "It's very hard for people to see if they start to have trouble as they age."
It seemed a lot tougher to decide who remains fit on a case-by-case basis, he said. Moreover, under , physician groups may legally establish a mandatory retirement age of 70. (California healthcare attorney told 鶹ý that the state appears to be alone in allowing it.)
How have doctors reacted? A few doctors "were a little grumpy about it and wanted the board to reconsider. We still believe it's a good policy; everyone has plenty of warning," Buberl said.
, is a family physician with 6,500-member Southern California Permanente Medical Group, whose rules dropped him as a partner on Dec. 31, the last day of the year he turned 65.
The partnership, which works in seven counties, allows doctors like him to continue working on contract as partners emeritus or on per diem, and some do, he said. But they give up their share of annual partner distributions, vacation, educational time, and dental insurance that were previously provided under the partnership.
When his colleagues turn 65, "most doctors retire and not work," he said in an e-mail.
Ray said he and several fellow SCPMG doctors are pushing back, asking for a membership vote to extend the policy to age 70.
The medical group did not respond to a request for comment.
The issue of senior or "late career" physicians maintaining credentials and status is of increasing concern to hospitals, medical groups and others as more doctors practice long past their 60s, and some develop memory lapse, intention tremor, or other issues that strain relationships with colleagues or, potentially, harm a patient.
According to a June report from the American Medical Association's , 241,641 doctors, or about one in four, are 65 or older, four times the number in 1975, and about 96,000 of those are actively treating patients.
That's why several hospitals or health systems have launched programs to screen older doctors for cognitive skill or physical health, or both as a condition for renewal of staff privileges. The University of Virginia Health System in Charlottesville and Driscoll Children's Hospital in Corpus Christi start screening at age 70, while Stanford Health Care in Palo Alto starts at age 75.
Attorney Barton, who helped write a recent on how organizations might set guidelines for age-based physician screening, emphasized the issue of liability.
"Let's say a 72-year-old doctor injures a patient. Would the hospital be liable for not having a screening policy?" he asked. "My guess is, the more prevalent it becomes to have these policies -- and I think the AMA report is going to spur a lot of activity in this regard -- the more hospitals that don't will be at risk because somebody will say it's the standard."
Now, however, policies are all over the map, Barton said. "Some do a physical exam, some do physical and cognitive exams, some do a physical exam with peer review process, and there are variations in what they're looking for. That adds more uncertainty in predicting what might happen in a lawsuit," he said.
In California, the issue is pronounced, with an estimated 26% of licensed physicians now over age 60. California Medical Board statistics say of 130,726 physicians with active licenses -- the most of any state -- 21,460 graduated from medical school between 1970 and 1979; 10,043 between 1960 and 1969, 2,166 between 1950 and 1959, and 213 prior to 1950, which probably makes these doctors at least 90 years old. It's not known how many still treat patients, but some do.
There's a need to standardize policies for screening these older doctors, said , chair of non-profit California Public Protection and Physician Health, which has drafted to guide peer review committees equitably and legally. "Doctors working with their well-being committees and their medical staffs were coming across these problems and saying, 'What do we do with this guy who is 89 years old and can't remember how to get to the OR anymore?' "
It's not just a California thing.
At the University of Virginia Health System, , clinical staff president-elect and credentials committee chair, said an older provider screening policy adopted four years ago -- which he said may be the first such hospital policy in the country -- applies to any of the system's more than 800 physicians and 300 advanced practice nurses, nurse anesthetists, and physician assistants after they turn 70 at the time they would come up for their two-year staff privilege review.
They undergo a 4-hour confidential battery of neurocognitive and physical tests, and do so again at age 75, and every two years thereafter.
"We want to make sure our care is appropriate and safe, so we check our equipment and make sure it's safe and up to date. Likewise, we check all our providers to make sure their skills are up to date," Syverud said.
During the program's first two years, 80 doctors were screened, and about 40 a year subsequently.
Why did UVA adopt this policy? It wasn't because older doctors were messing up, he said. Rather, the organization realized that "you can't take care of older people without realizing that as people age, their cognitive abilities may decline and they may not always be aware they've declined. It may be subtle; physicians are people. And for us not to look for that would be a disservice to our patients."
Syverud worried how older doctors would take this mandate, so "I personally called each of them and talked with them at length. These are department chairs and senior leaders who had practiced for 30-40 years. They had reputations for excellence. And these were not easy conversations."
The result was a surprise. Many of the doctors passed with flying colors "and came back to me saying they scored neurocognitively in the 90th percentile -- for a 50-year-old," Syverud said. "And for the vast majority it was a validation, a clean bill of health."
Problems uncovered, if any, he said, don't usually require the physician to stop practicing. "But maybe they should stop highly complex surgical procedures, slow down a little, do clinical practice, and make adjustments that make more sense."
Because of the program's confidentiality, Syverud says he doesn't know how many physicians who retired did so because of the screening, or were planning to anyway. "It would be rational to use the information they got out of this evaluation to influence their retirement planning," he said.
A program launched four years ago at Stanford has been far more contentious, prompting complaints and petitions from some physicians and a faculty resolution that resulted in a significant modification.
All Stanford physicians who reach their 75th birthday now undergo a two-part evaluation as a condition of staff privileges and again every 2 years, , vice chairman of medicine for quality implementation said in an e-mail.
One is a peer assessment by medical staff members, trainees, advanced practice professionals, nurses and other hospital staff. The second is a comprehensive history and physical exam with a focus on the ability to perform requested staff privileges.
An additional cognitive test, required in the initial policy and which several physicians underwent, was struck after a faculty committee concluded there wasn't enough evidence that such testing would reduce patient harm, said cancer specialist .
Stockdale, 79, is one of 15 physicians who strongly object to Stanford's age-based cutoffs for any kind of screening, calling it age discrimination and a violation of their academic freedom. If competency screening is done at all, they should be required of all physicians who treat patients, Stockdale said.
"Actually, if one looks at the data, the truth is most harms from physicians occur at mid-career, not in late career ... so we should have an assessment that covers the entire spectrum of physician practice, no matter what their age," Stockdale said.
Besides, many other layers of assessment, including the two-year review medical executive committees must perform as a condition of hospital accreditation for Medicare reimbursement, help check doctors who have problems providing appropriate, safe care, he said. "Hospitals have chiefs of various services ... monitoring quality on their service, and there are operating room nurses, and house staff and others reporting on adverse events."
Asked how physicians reacted, Weinacker said more than 30 physicians have been screened, "a small number of practitioners who were not very clinically active chose to resign from the medical staff," and concerns about competency have been raised in only one physician. For that doctor, further evaluation "is ongoing."
Weinacker said she couldn't say whether care is now safer at Stanford because the program is too new, and too few doctors have been screened.
"But based on the available data on the effects of aging, we believe this is an appropriate course of action," she said.
In Canada, the , which licensed 38,503 physicians as of 2013 and is the equivalent of a state medical board in the U.S., performs random assessments of all physicians. But when a doctor reaches age 70, if he or she has not been randomly selected for peer assessment in the previous 5 years, they must then undergo it, and every 5 years subsequently.
In 2013, 202 physicians underwent assessment at 70 under this policy. Of those, 165 passed and 37 others "were required to complete individualized remediation," Clarke said.
The physician is judged on ability to keep medical records, take an adequate patient history, conduct appropriate exams, order necessary tests, identify appropriate course of action, conduct necessary interventions, and monitor patients. The assessment includes a discussion between the doctor and the assessor. In 2013, 91% of physicians randomly selected passed, but 81% of physicians who were 70.
Of the 37 who didn't pass, concerns included poor, illegible or incomplete record-keeping, lack of knowledge of current guidelines, failure to keep current with immunizations and medications, concerns about cognition and clinical judgment, Clarke said. After remediation, most were able to improve.
Anesthesiologist Pue said that today, he is much more relaxed and is glad he gave up his hectic schedule. But what will be the upshot of this increased attention to the competency of older doctors? he asked rhetorically.
"I don't know. The government will probably come up with some way to evaluate people that doesn't work. That's probably what will happen."