Commercial airline pilots are required to retire at 65 under Federal Aviation Administration regulations. It’s not ageism; it’s safety. Yet physicians, whose decisions can be just as life-or-death, face no such requirement. As a former internist, chief medical officer, and hospital CEO, I have seen what happens when physicians practice past their prime. The results can be dangerous, heartbreaking, and entirely preventable.

When “going out on top” doesn’t happen

During my tenure as CEO, multiple reports of concerning behavior crossed my desk about a respected physician. Nurses told me he wandered the unit searching for a patient who had been discharged days earlier. Colleagues described confusion during routine tasks. Though I was not there to diagnose him, I suspected early dementia. I urged him to retire gracefully, protecting both his patients and his reputation. He refused. What followed was painful: tense meetings with his family, escalating safety concerns, and ultimately a precautionary suspension of his hospital privileges. This scenario is not rare. Families often don’t recognize the decline (or don’t want to) until harm is imminent. Hospital leaders are left with an impossible choice: protect patients and risk humiliating a beloved doctor, or delay action and endanger care.

The data are clear

Physicians are not immune to aging. Research shows age-related declines in memory, processing speed, and dexterity, all of which affect diagnosis, decision-making, and procedural safety.

• In one study of 356 U.S. physicians aged 65 and older, 9 percent showed measurable cognitive impairment.
• In a multi-hospital screening program, 14.4 percent of actively practicing physicians over age 70 screened positive for impairment.
• A systematic review of sixty-two studies concluded that performance (including adherence to evidence-based guidelines) generally declines with years in practice.

We cannot leave this to chance, families, or ad hoc committees.

A fair, practical solution

I am not advocating mandatory retirement. The Age Discrimination in Employment Act rightly prohibits forcing physicians out based solely on age. But we can and should require regular competency evaluations for older physicians. Here’s what I propose:

• Standardized testing: Cognitive, motor, and physical assessments every two years for physicians 65 and older as part of license renewal.
• Oversight: Administered by state medical boards to ensure fairness and consistency.
• Due process: Clear appeals and review mechanisms for physicians who fail.

Why this helps everyone

• Patients get assurance that their clinicians are safe to practice.
• Physicians receive a fair, objective process rather than facing quiet pressure to step down or public embarrassment.
• Hospitals gain legal clarity and protection from liability.

Respect, not punishment

When physicians work past the point where they can practice safely, everyone loses. Their reputations, built over decades, may be tarnished in their final years. Patients may suffer preventable harm. Competency testing is not about pushing physicians out; it is about preserving dignity, protecting patients, and honoring the profession we love. Pilots undergo regular checks to keep passengers safe. Our patients deserve nothing less.

Joseph Pepe is a physician executive and author with decades of experience across the continuum of care, from home health aide to hospital system chief executive officer. As president and chief executive officer, he led a 330-bed acute care hospital, a heart and vascular institute, physician practices, urgent care centers, and a joint venture ambulatory surgery center, navigating the business of health care while remaining grounded in clinical medicine. Dr. Pepe is the author of the forthcoming On All Sides of the Bed, an 80,000-word memoir that blends gripping bedside stories with lessons on leadership, ethics, and resilience. He has published on health care ethics in the Cambridge Quarterly of Healthcare Ethics, speaks on moral leadership, and mentors clinicians and executives. He writes a popular Substack newsletter and shares reflections on Instagram at @jack_and_homer, exploring mortality, meaning, and the human side of medicine. Through his work, Dr. Pepe invites readers to reflect on how we live, how we heal, and how we lead.