1. Assessment Of The Aging Physician: The Ontario Experience
Bill McCauley MD, MHPE
Medical Advisor
Practice Assessment and Enhancement
College of Physicians and Surgeons of Ontario
QUALITY PROFESSIONALS | HEALTHY SYSTEM | PUBLIC TRUST

2. College of Physicians and Surgeons of Ontario
Provincial equivalent to State Medical Board
Sort of
Broader mandate
Complaints/Investigations/Discipline
Quality Management Division
Registration
Quality Assurance Program

3. Ontario
Population 13 million
It’s big
Really big
30,000 physicians

4. CPSO Physician Assessments
Quality Management Division
Peer Assessments
Registration Assessments
Physician Review Program (PREP™)
Specialties Assessment Program (SAP)
Out of Hospital Premises Inspection Program
Methadone prescribers assessments
Independent Health Facilities Assessments
Investigations and Resolutions
Complaints
Inspections
Registrar’s Investigations
Comprehensive Practice Assessment

5. Objectives By the end of the session participants will be able to…
…describe differences in outcomes of peer assessments for physicians over and under age 70 in Ontario
…describe differences in outcomes of complaints and investigations of physicians over and under age 70 in Ontario

6. Peer Assessment Program: A Brief History
1977 CPSO approved Peer Assessment Pilot
Pilot in ‘78-79
to identify physicians who are practicing at an unacceptable level
to designate methods of correcting the deficiencies
to ensure that these methods are effective
McAuley RG, Paul WM et al, CAN MED ASSOC J 1990; 143 (I 1)

7. Peer Assessment History
Program began in 1981
Data from first 5 years
923 physicians assessed
663 (72%) GP’s or FP’s

8. Table 1: Distribution of physicians in Ontario randomly selected for assessment of office practices
Year: No of physicians
Type of specialist
1981
1982
1983
1984
1985
Total
General Practitioner (GP) or
Family Physician (FP)
120
140
160 83
663
Internist 20 -- 60
Surgeon
Pediatrician
Obstetrician/Gynecologist
Psychiatrist 30 70
Ophthalmologist
Orthopedic Surgeon 10
Otolaryngologist 15
Dermatologist
Urologist
Neurologist 5
200
123
923

9. Number (and %) of physicians
Overall results …..
Finding
Number (and %) of physicians
GP’s and FP’s
Specialists
Total
No major deficiencies in records or level of care
510 (77)
239 (93)
749 (82)
Deficient records but no major deficiencies in level of care
55 (8)
13 (5)
68 (7)
Grossly deficient records or unsatisfactory level of care or both
97 (15)
4 (2)
101 (11)
662 (100)
256 (100
918 (100)

10. Results Based on Age, Membership in CFPC and Practice Type (1981 – 86)
Variable
Number assessed
No. (%) with grossly deficient records, unsatisfactory care or both  Χ2
p2 value
Age group
≥ 75 63
22(35)
50 – 74
324
51(16)
< 50
275
24(9)
Total
662
97 (15)
28.72
<
CFPC Membership
Nonmember
434
79 (18)
Member but not certificant
111
14 (13)
Certifcant
117
4 (3)
16.55
<
Type of Practice
Solo
453
78 (17)
Not solo
209
19 (9)
7.56
0.006

11. Relationship between quality of record keeping and quality of care
Level of Patient Care
Quality of Record Keeping
Unsatisfactory
Satisfactory
Total
Likelihood ratio
55 (43.6%) 71
126
7.8
4 (0.77%)
515
519
0.08 59
586
645

12. Peer Assessment Currently
An Educational Program
Provide feedback on performance
Occasionally find problems
Currently approximately 1400 per year
Target to get to 2000 per year
Every doc every 10 years
Current practice: Starting age 70, assessment every 5 years

13. Data Review Years 2005 – 2009 538 – 625 – 772 – 1076 – 1072
Total 4083 assessments over 5 years
2740 < age 70
680 = 70
663 > 70

14. Peer Assessment Categories
Category 1 = No problems identified
Generally NFA
Category 2 = Some issues, usually record-keeping only
Often record-keeping course with reassessment
Category 3 = Some care concerns OR severe record keeping deficiencies
Generally interview with committee +/- higher level assessment

19. PREP™ and SAP – High Stakes Assessment
PREP™: GP/FP’s
MCQ
Standardized Patients
Chart – Stimulated Recall
SAP - Specialists
Chart review
Interview stakeholders
Directly observe in practice (clinic, OR, office)
Patient surveys

20. PREP™ and SAP Categories 1 - 5
NO OR MINIMAL DEFICIENCY
MINOR DEFICIENCY
MODERATE DEFICIENCY
SEVERE DEFICIENCY – POTENTIAL RISK TO PATIENT SAFETY
CRITICAL DEFICIENCY – IMMEDIATE RISK TO PATIENT SAFETY

22. Observations for Peer/PREP
Compared to their younger colleagues, physicians 70 and older:
More frequently have serious record-keeping deficiencies
More frequently have care concerns
Once identified as potentially having concerns
Physicians older than 55 perform significantly more poorly than those < 55
Physicians > 70 may not be much worse than those

23. What about public complaints/reports/investigations?
Coded investigations = 8030 (represents 53% of total of investigations)
Decisions
Percent
Frequency
Committee Action
26%
2047
No Action
35%
2839
Departmental Resolutions
19%
1558
Departmental Closures
20%
1586
Grand Total
100%
8030

24. Committee Actions - Categories
Issues divided into
Clinical – Treatment, documentation, consent, prescribing, narcotics, diagnosis
Conduct – Sex, confidentiality, unprofessional communication, ungovernability, fraud, disruptiveness, money
Capacity – substance abuse, mental impairment (psych and cognition), physical impairment

25. Complaints/ICRC Committee Options
Refer to:
Incapacity hearing
Discipline
Fitness to practice QA
SCERP
Undertaking
Cautions (written or in person)
Counsel

26. Physicians =/> 70 Years of Age
Clinical Issues Actions by Committee
Clinical
Physicians
Physicians =/> 70 Years of Age
< 70 Years of Age
Percent
Frequency
<70
=/>70
Treatment
25%
452
29% 76
Documentation
15%
263
16% 44
Assessment
11%
204 8% 21
Communication (patient care)
135 7% 19
Prescribing Controlled Substance 4% 70 16
Prescribing General 66 6% 17
Consent 3% 53 13
Diagnosis 2% 43 1% 4

27. Physicians =/> 70 Years of Age
Conduct Issues Considered by Committee
Conduct
Physicians
Physicians =/> 70 Years of Age
< 70 Years of Age
Percent
Frequency
<70
=/>70
Sexual Impropriety 4% 64 12
Breach of Confidentiality 2% 44 0%
Unprofessional Communication 37 9% 27
Ungovernability / Breach of Undertaking 36 5%
OHIP Billing / Fraud 26 1% 1
Disruptive Physician 28
Conflict of Interest
Money Issues 21

28. Physicians =/> 70 Years of Age
Capacity Issues Considered by Committee
Incapacity
Physicians
Physicians =/> 70 Years of Age
< 70 Years of Age
Percent
Frequency
<70
=/>70
Substance Abuse
3.0% 46
1.0% 2
Mental Impairment (Psychiatric)
2.0% 27
Mental Impairment (Cognitive)
0.0% 5
Physical Impairment 9

29. Physicians =/> 70 Years of Age
Committee Decisions by Age – 26% of all investigations
Committee Decisions
Physicians
Physicians =/> 70 Years of Age
< 70 Years of Age
Percent
Frequency
<70
=/>70
Refer to Discipline 8%
144
15% 42
Refer to Quality Assurance 1% 18 3
Accept PHP 3% 55 1
Accepted Undertaking
10%
184
19% 51
Caution In Person
345
18% 48
Caution In Writing
22%
388 53
Counsel
31%
552
23% 64

30. No Action Decisions by Age Physicians =/> 70 Years of Age
Percent
Frequency
<70
=/>70
No Action
31%
144 4% 42
No Action by Committee – 35% of all investigations

31. Departmental Resolution by Age Physicians =/> 70 Years of Age
Departmental Resolutions by Age – 19% of all investigations
Departmental Resolution by Age
Physicians
Physicians =/> 70 Years of Age
< 70 Years of Age
Percent
Frequency
<70
=/>70
Departmental Resolution
18%
1412 1%
146

32. Departmental Closure by Age Physicians =/> 70 Years of Age
Departmental Closures by Age – 20% of investigations
Departmental Closure by Age
Physicians
Physicians =/> 70 Years of Age
< 70 Years of Age
Percent
Frequency
<70
=/>70
Departmental Closure
18%
1395 2%
191

33. Observations about Complaints and physician age – types of issues
Physicians over age 70 for which an action is necessary are more likely to have complaints related to:
Treatment
General prescribing
Prescribing of controlled substances
Unprofessional communication
Ungovernability
Cognitive issues

34. Observations about Complaints and physician age – types of issues
Physicians over age 70 for which an action are necessary are LESS likely to have complaints related to:
Confidentiality
Fraud
Disruptiveness
Conflict of interest
Substance abuse
Mental health issues
Physical health issues

35. Observations about Complaints and physician age – committee decisions
Compared to younger peers, physicians > 70 who have a complaint that requires a committee decision are more likely to…
…be referred to a discipline committee
…sign an undertaking to restrict their practice

36. Observations about Complaints and physician age – General
Compared to younger peers, physicians > 70 who have a complaint that requires a committee decision are LESS likely to…
…have a No Action by the committee
…have departmental resolution of their complaint
…have departmental closure of their files

37. For Consideration Older physicians are… …at risk of poor performance
Should likely be assessed routinely
Probably younger than age 70
…in need of ongoing education and support
Professional communication
Professionalism/Professional regulation
Current management
Prescribing, including controlled sub’s
…at risk for cognitive difficulties
Should be screened

38. QUESTIONS?
Movember - Canada