Source:Levine GN. Balancing Ischemic and Bleeding Risks of Prolonged Dual Antiplatelet Therapy. JAMA.2017;318(2):194-195. doi:10.1001/jama.2017.6698
Dual antiplatelet therapy (DAPT) combines aspirin with a P1Y12 inhibitor (clopidogrel, prasugrel, or ticagrelor) to decrease the risk of coronary thrombosis. [start-highlighting]Compared with antiplatelet therapy with aspirin alone, DAPT after a myocardial infarction (MI) or percutaneous coronary intervention (PCI) reduces the risk of spontaneous MI and coronary stent thrombosis[end-highlighting] (Audio).1However, the addition, intensification, or prolongation of antiplatelet therapy necessitates a trade-off between decreasing ischemic risk and increasing bleeding risk.1 In addition to this trade-off, consideration also must be given to the implications of ischemic or bleeding events, how patients are selected for treatment with DAPT and its duration, and what can be done to reduce bleeding risk.
Saturday, July 22, 2017
Importance The issue of the aging physician and when to cease practice has been controversial for many years. There are reports of prominent physicians who practiced after becoming dangerous in old age, but the profession has not demonstrated the ability to prevent this. A mandatory retirement age could be discriminatory and take many competent physicians out of practice and risk a physician shortage. An increasing body of evidence regarding the relationship between physicians’ age and performance has led organizations, such as the American College of Surgeons, to revisit this challenge.
Observations Since 1975, the number of practicing physicians older than 65 years in the United States has increased by more than 374%, and in 2015, 23% of practicing physicians were 65 years or older. Research shows that between ages 40 and 75 years, the mean cognitive ability declines by more than 20%, but there is significant variability from one person to another, indicating that while some older physicians are profoundly impaired, others retain their ability and skills. There are age-based requirements for periodic testing and/or retirement for many professions including pilots, judges, air traffic controllers, Federal Bureau of Investigation employees, and firefighters. While there are not similar requirements for physicians, a few hospitals have introduced mandatory age-based evaluations.
Conclusions As physicians age, a required cognitive evaluation combined with a confidential, anonymous feedback evaluation by peers and coworkers regarding wellness and competence would be beneficial both to physicians and their patients. While it is unlikely that this will become a national standard soon, individual health care organizations could develop policies similar to those present at a few US institutions. In addition, large professional organizations should identify a range of acceptable policies to address the aging physician while leaving institutions flexibility to customize the approach. Absent robust professional initiatives in this area, regulators and legislators may impose more draconian measures.