Doctors Recertification /Retirement in the Digital Health Era

They have a tremendous responsibility. Hundreds of lives depend on their skill and each time they take off, they are in sole charge of something worth hundreds of crores of rupees.

“None has his/her skills tested so frequently. Every year we undergo six checks, where we are in danger of losing our licenses and our jobs. There are two route checks where an examiner flies with me and checks what I am doing, how I behave with others, and how I take my pre-flight test. While in the air he will ask me a hundred different questions about hypothetical problems that can arise. Two other checks are in the simulator, where I am put through the works. I do two theory refreshers each year. The pass mark is 70 % ” This is what my patient - a pilot - told me many, many years ago indicating the inbuilt checks to ensure the continuing competency, of a pilot to fly a plane.

These measures are for those who cater, to an insignificant microscopic segment of the population. Commercial airline pilots by law must undergo regular health screenings, in addition to mandatory preflight tests. They are generally not allowed to fly after the age of 60 and certainly not after 65.

On the other hand, the medical doctor in India who caters to the entire population of the country is presumed to be omnipotent once he/she qualifies.

It is 49 years since I enrolled as a Registered Medical Practitioner in the Tamil Nadu Medical Council. It is taken for granted that I continue to be competent to practice medicine. Probably 60 to 70% of the diagnostic armamentarium and therapy available today, was nonexistent even when I qualified as a neurosurgeon in 1980. 60-75% of medical practice today involves developments in the previous decade. What I taught a few years ago may be inapplicable today.

With 30,000 peer-reviewed  medical journals publishing 1.8 million articles annually, the annual growth rate of 8-11% is resulting in the medical database literally doubling every 7.5 years. Even if one reads two new published papers every day, within one year one would be 5,600 years behind!

No doubt Digital Health (DH) has changed this scenario completely. Using Perplexity, Gemini, ChatGPT, or Co-Pilot anyone on the planet can have instantaneous access to precise, relevant focused information, which just 2 years ago would have taken a University Professor several days to obtain!

It is assumed that just to survive in the rat race, the RMP will always attempt, to be up to date. As the rats are getting bigger, and the stakes get higher and higher, there should be enough motivation for self-study, argue the powers that be.

Perhaps that was not untrue in the 20th century. The world has since turned upside down. DH when fully implemented will democratize healthcare and level the playing field.

In the DH era clinical judgement and medical skills are no longer synonymous with white hair. A dedicated student in today’s DH era can acquire in a few months, the “wisdom “that took several years for his/her mentor to acquire. Previously, it was believed that with greater experience, that is with increasing age, one would be more competent and proficient. Several scientific studies have shown that the learning curve is a parabolic curve rather than a straight line. In other words, if one has not learned how to operate on a hydrocele after 30 or 40 cases, it is unlikely that it will be learned after 75 cases.

The added benefits of further experience after a point of time is limited. Accepting this, in the advanced countries professors chair departments at younger ages not just before their superannuation. Our traditional beliefs would scoff at such concepts.

For tomorrow’s trainee starting his education with DH, Computer-assisted simulations will ensure that “patients” with a variety of illnesses are readily and consistently available, “Patients” progress can be simulated at any time point, and the trainee doctor proceeding at his own pace can assume full responsibility for patients care without jeopardizing the “patients” safety. Would septuagenarians be adept in using AR, VR, AVR, XVR, and Digital Twins in their daily clinical practice, to keep up with the present generation

Even doctors trained two decades ago, may now have to unlearn and relearn, what was once considered irrevocable truths written in letters of stone!!

I would never have passed the MBBS exam if I had  argued that ABO incompatible kidney transplant is possible or that some nerve cells in the adult brain can divide or that Parkinsonism could perhaps be diagnosed with a skin biopsy and risk of stroke quantified by looking at the fundus of the eye!!

Considering all this, should senior doctors accept the fact that it is very difficult for an aging brain to comprehend recent developments?

Thanks to the internet, patients in 2025, familiar with tomorrow’s developments, will have very high expectations, For an elderly doctor to fulfill these expectations requires quickly learning totally new skills in a very short time, competing with his mentees!

Is the senior doctor’s brain wired differently than normal age-related challenges in being receptive, registering, and reinforcing to recall any new information that does not apply to him/her?

Today it is left entirely to my personal sense of judgment to decide if I am a menace to society as a medical practitioner. 5 years ago in a provocative article “Should neurosurgeons retire” (Ref “Ganapathy K. Should neurosurgeons retire? Nerol India article.2019 Mar-Apr;67(2):370-374. doi:10.4103/0028-3886.258036. PMID: 31085838) I had reviewed the world literature and discussed at length, the consequences on patient care, if septuagenarians, continue to directly treat patients. This is particularly relevant in India where the so-called mandatory CME credits are an absolute farce.

Worldwide, it is generally accepted that there has to be a mandatory retirement age in occupations where the public will be directly affected, due to an age-related erroneous decision.

Cognition, attention span, recall, manual dexterity, and visuospatial capability, which normally ensure procedural competence, decrease with age. Increasing difficulty in swiftly retrieving stored information and in switching attention from one task to another is common among senior citizens. Doctors need to recognize and accept that forgetfulness may occur so slowly that it is even overlooked by them.

I strongly feel that it should be made mandatory, that all doctors above 65 desirous of continuing practice, should have their license to practice reviewed once in 2 years. In the USA  36% of neurosurgeons planned to completely retire between 65 and 69 years and an additional 33% at 70+When is enough enough? Making difficult, often quick, and sometimes life-and-death decisions that demand high and complex levels of cognitive functioning will be difficult in the seventh and eighth decades.

It is conceded that there will always be outliers and all do not fit into the standard bell curve. Exceptions can be accepted but rules and regulations need to be formulated, which can be reviewed and modified on a case-by-case basis when deemed necessary. Self-discipline, though theoretically attractive, is in practice, not doable as there will always be a “conflict of interests”, assistance of DH notwithstanding!!