How can cognitive decline be accurately measured in physicians?

Question

The average age of physicians in the US is increasing, and there is ample evidence that cognitive impairment increases with age, as well as do adverse patient outcomes. It has been suggested that physicians of a certain age undergo periodic screenings for cognitive decline.

However, Primary Care Physicians (PCP), as well as many highly trained individuals, do better on Mini Mental Status Exams (MMSE) than their non-professional peers. I believe that's in part because PCPs use one of the many mini-mental status exams frequently enough to have the answers and the mechanics of the questions memorized.

It is a test that has become one of the most widely used internationally for the diagnosis and clinical prognosis of cognitive impairment, mainly in elderly patients.

Yale requires cognitive testing in physicians 70 years old and above, but the (secret) test is only 16 items long. The MMSE and the Montreal Cognitive Assessment (MoCA) exams each have 30 items. Regardless of which one physicians use, they are basically the same. Having administered these tests for at least 5 years in practice, these tests were committed iron clad in my memory. I believe a physician would need to be severely impaired by the time they fail either of these tests. Extensive neuropsychiatric exams are just more of the same.

The best paper I could find had suggestions but no details.

Is there any exam that measures cognitive impairment in physicians sensitively?

_{Sorry about the tag; neither cognition nor competency is a tag here. Also, please know that I am totally in favor of mandatory testing. But it should be sensitive, i.e. detect cognitive impairment before patients start to suffer. There's a difference between malpractice caused by hubris and cognitive impairment.}

Answer 1

I had a bit of a search and found 3 papers of relevance. Only one of these indicate the tests used, but the others do indicate that there are tests available for use, though I suspect mostly in-house systems.

• Cooney L, Balcezak T. Cognitive Testing of Older Clinicians Prior to Recredentialing. JAMA. 2020 Jan 14;323(2):179-180. doi: https://doi.org/10.1001/jama.2019.18665. PMID: 31935030.

• Armstrong KA, Reynolds EE. Opportunities and Challenges in Valuing and Evaluating Aging Physicians. JAMA. 2020 Jan 14;323(2):125-126. doi: https://doi.org/10.1001/jama.2019.19706. PMID: 31935010.

• Del Bene VA, Brandt J. Identifying neuropsychologically impaired physicians. Clin Neuropsychol. 2020 Feb;34(2):318-331. doi: https://doi.org/10.1080/13854046.2019.1666922. Epub 2019 Sep 19. PMID: 31537179.

The Cooney et al. paper indicates that Yale uses a battery of tests (all secret) to administer to their physicians. The tests seem to test more than just memory, though mostly focussing on higher cognitive function:

The screening battery used consisted of 16 brief tests including rudimentary information processing (2 tests), visual scanning and psychomotor efficiency (2 tests), processing speed and accuracy under decision load (1 test), concentration and working memory (1 test), visual analysis and reasoning (2 tests), verbal fluency (2 tests), memory (1 visual test and 1 verbal test), “prefrontal” self-regulation (1 test), and executive functioning (3 tests).

The Armstrong paper is an editorial on the Cooney one, but has some very relevant links, including the following review, indicating that machine learning might be the objective way forward:

• Dias RD, Gupta A, Yule SJ. Using machine learning to assess physician competence: a systematic review. Acad Med. 2019;94(3):427-439. doi:https://doi.org/10.1097/ACM.0000000000002414

Finally, the Del Bene and Brandt paper indicates that they used the following tests:

I make no commentary on these tests, as it isn't my specialty at all, but they seem appropriate to me and to have similar aims as the Yale tests.