About eight years ago, at the age of 78, a vascular surgeon in California operated on a woman who then developed a pulmonary embolism. The surgeon did not respond to urgent calls from the nurses, and the woman died.

Even after the hospital reported the doctor to the Medical Board of California, he performed operations for four years until the board finally referred him for a competency assessment at the University of California, San Diego.

“We did a neuropsychological exam, and it was very abnormal,” said Dr. William Norcross, director of the physician assessment program there, who did not identify the surgeon. “This surgeon had visual-spatial abnormalities, could not do fine motor movements, could not retain information, and his verbal I.Q. was much lower than you’d expect.”

Yet “no one knew he had a cognitive deficit, and he did not think he had a problem,” Dr. Norcross continued.

The surgeon was asked to surrender his medical license.

One-third of American physicians are over 65, and that proportion is expected to rise, with many under increasing financial pressures that make them reluctant to retire.

Experts warn that there are too few safeguards to protect patients against those who should no longer be practicing. “My guess is that John Q. Public thinks there is some fail-safe mechanism to protect him from incompetent physicians,” Dr. Norcross said. “There is not.”

In 2006, a study found that in complicated operations, patients’ mortality rates were higher when the surgeon was 60 or older .

“The profession of medicine has never really had an organized way to measure physician competency,” said Diane Pinakiewicz, president of the nonprofit National Patient Safety Foundation, based in Boston. “We need to be systematically and comprehensively evaluating physicians .”

Some experts are calling for regular cognitive and physical screening once doctors reach 65 or 70, and a few hospitals have instituted screening for older physicians. Some specialty boards already require physicians to renew their certification every 7 to 10 years and have toughened recertification requirements. But such policies have met resistance.

“I do not believe that diminished competence attributable solely to age is a significant factor in the underperformance of most poor-performing physicians,” said Dr. Henry Homburger, 64, professor of laboratory medicine at the Mayo Clinic in Minnesota . Mental illness like depression, substance abuse and a “failure to maintain competence through continuing education far outweigh age as causes of poor performance .”

Others doubt that a single type of exam can assess the performance of doctors from a variety of specialties.

“More research is needed for us to define what combination of cognitive and motor issues are important,” said Dr. Stuart Green, a member of the ethics committee of the American Academy of Orthopaedic Surgeons.

The tougher new policies adopted by some specialty boards usually do not apply to older physicians, who, because of “grandfather” clauses, are not required to renew their certification . They are being encouraged to do so voluntarily, but few do.

Doctors with mild cognitive impairment may not be aware they have a problem .

Medical professionals are supposed to report colleagues’ unsafe practices and bad behavior. But doctors are reluctant to confront their fellow physicians, especially their seniors, who may have trained them.

“Sometimes we empathize too much and have difficulty making the hard calls when we need to,” Dr. Norcross said.

Doctors often cover for physicians who are becoming less sharp, Dr. Green said.

Dr. John Fromson, associate director of postgraduate medical education at Massachusetts General Hospital, cited a case at another medical center in New England, where physicians noticed cognitive changes in the 77-yearold chairman of internal medicine.

He was highly respected and had trained most of the physicians at the center, so they were reluctant to confront him. Instead, they gave him a retirement party, hoping he would take the hint.

“But he didn’t,” Dr. Fromson said. “He kept on working.”

Dr. Fromson staged an intervention, at which four or five of the doctor’s close colleagues confronted him as compassionately as they could. “We reaffirmed our concern and caring for him, and asked him to hand over his medical license,” he said. “He became quite tearful, but he did.”


By LAURIE TARKAN