A growing number of complaints against older doctors has prompted the Medical Board of Australia to announce today that it’s reviewing how doctors aged 70 or older are regulated. Two new options are on the table.

The first would require doctors over 70 to undergo a detailed health assessment to determine their current and future “fitness to practise” in their particular area of medicine.

The second would require only general health checks for doctors over 70.

A third option acknowledges existing rules requiring doctors to maintain their health and competence. As part of their professional code of conduct, doctors must seek independent medical and psychological care to prevent harming themselves and their patients. So, this third option would maintain the status quo.

Haven’t we moved on from set retirement ages?

It might be surprising that stricter oversight of older doctors’ performance is proposed now. Critics of mandatory retirement ages in other fields – for judges, for instance – have long questioned whether these rules are “still valid in a modern society”.

However, unlike judges, doctors are already required to renew their registration annually to practise. This allows the Medical Board of Australia not only to access sound data about the prevalence and activity of older practitioners, but to assess their eligibility regularly and to conduct performance assessments if and when they are needed.

What has prompted these proposals?

This latest proposal identifies several emerging concerns about older doctors. These are grounded in external research about the effect of age on doctors’ competence as well as the regulator’s internal data showing surges of complaints about older doctors in recent years.

Studies of medical competence in ageing doctors show variable results. However, the Medical Board of Australia’s consultation document emphasises studies of neurocognitive loss. It explains how physical and cognitive impairment can lead to poor record-keeping, improper prescribing, as well as disruptive behaviour.

The other issue is the number of patient complaints against older doctors. These “notifications” have surged in recent years, as have the number of disciplinary actions against older doctors.

In 2022–2023, the Medical Board of Australia took disciplinary action against older doctors about 1.7 times more often than for doctors under 70.

In 2023, notifications against doctors over 70 were 81% higher than for the under 70s. In that year, patients sent 485 notifications to the Medical Board of Australia about older doctors – up from 189 in 2015.

While older doctors make up only about 5.3% of the doctor workforce in Australia (less than 1% over 80), this only makes the high numbers of complaints more starkly disproportionate.

It’s for these reasons that the Medical Board of Australia has determined it should take further regulatory action to safeguard the health of patients.

So what distinguishes the two new proposed options?

The “fitness to practise” assessment option would entail a rigorous assessment of doctors over 70 based on their specialisation. It would be required every three years after the age of 70 and every year after 80.

Surgeons, for example, would be assessed by an independent occupational physician for dexterity, sight and the ability to give clinical instructions.

Importantly, the results of these assessments would usually be confidential between the assessor and the doctor. Only doctors who were found to pose a substantial risk to the public, which was not being managed, would be obliged to report their health condition to the Medical Board of Australia.

The second option would be a more general health check not linked to the doctor’s specific role. It would occur at the same intervals as the “fitness to practise” assessment. However, its purpose would be merely to promote good health-care decision-making among health practitioners. There would be no general obligation on a doctor to report the results to the Medical Board of Australia.

In practice, both of these proposals appear to allow doctors to manage their own general health confidentially.

The law tends to prioritise patient safety

All state versions of the legal regime regulating doctors, known as the National Accreditation and Registration Scheme, include a “paramountcy” provision. That provision basically says patient safety is paramount and trumps all other considerations.

As with legal regimes regulating childcare, health practitioner regulation prioritises the health and safety of the person receiving the care over the rights of the licensed professional.

Complicating this further, is the fact that a longstanding principle of health practitioner regulation has been that doctors should not be “punished” for errors in practice.

All of this means that reforms of this nature can be difficult to introduce and that the balance between patient safety and professional entitlements must be handled with care.

Could these proposals amount to age discrimination?

It is premature to analyse the legal implications of these proposals. So it’s difficult to say how these proposals interact with Commonwealth age- and other anti-discrimination laws.

For instance, one complication is that the federal age discrimination statute includes an exemption to allow “qualifying bodies” such as the Medical Board of Australia to discriminate against older professionals who are “unable to carry out the inherent requirements of the profession, trade or occupation because of his or her age”.

In broader terms, a licence to practise medicine is often compared to a licence to drive or pilot an aircraft. Despite claims of discrimination, New South Wales law requires older drivers to undergo a medical assessment every year; and similar requirements affect older pilots and air traffic controllers.

Where to from here?

When changes are proposed to health practitioner regulation, there is typically much media attention followed by a consultation and behind-the-scenes negotiation process. This issue is no different.

How will doctors respond to the proposed changes? It’s too soon to say. If the proposals are implemented, it’s possible some older doctors might retire rather than undergo these mandatory health assessments. Some may argue that encouraging more older doctors to retire is precisely the point of these proposals. However, others have suggested this would only exacerbate shortages in the health-care workforce.

The proposals are open for public comment until October 4.

Christopher Rudge, Law lecturer, University of Sydney

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Australia’s Therapeutic Goods Administration (TGA) recently issued a safety alert requiring extra warnings to be included with the asthma and hay fever drug montelukast.

The warnings are for users and their families to look for signs of serious behaviour and mood-related changes, such as suicidal thoughts and depression. The new warnings need to be printed at the start of information leaflets given to both patients and health-care providers (sometimes called a “boxed” warning).

So why did the TGA issue this warning? And is there cause for concern if you or a family member uses montelukast? Here’s what you need to know.

First, what is montelukast?

Montelukast is a prescription drug also known by its brand names which include Asthakast, Lukafast, Montelair and Singulair. It’s used to manage the symptoms of mild-to-moderate asthma and seasonal hay fever in children and adults.

Asthma occurs when the airways tighten and produce extra mucus, which makes it difficult to get air into the lungs. Likewise, the runny nose characteristic of hay fever occurs due to the overproduction of mucus.

Leukotrienes are an important family of chemicals found throughout the airways and involved in both mucus production and airway constriction. Montelukast is a cysteinyl leukotriene receptor antagonist, meaning it blocks the site in the airways where the leukotrienes work.

Montelukast can’t be used to treat acute asthma (an asthma attack), as it takes time for the tablet to be broken down in the stomach and for it to be absorbed into the body. Rather, it’s taken daily to help prevent asthma symptoms or seasonal hay fever.

It can be used alongside asthma puffers that contain corticosteriods and drugs like salbutamol (Ventolin) in the event of acute attacks.

What is the link to depression and suicide?

The possibility that this drug may cause behavioural changes is not new information. Manufacturers knew this as early as 2007 and issued warnings for possible side-effects including depression, suicidality and anxiousness.

The United Kingdom’s Medicines and Healthcare products Regulatory Agency has required a warning since 2008 but mandated a more detailed warning in 2019. The United States’ Food and Drug Administration has required boxed warnings for the drug since 2020.

Montelukast is known to potentially induce a number of behaviour and mood changes, including agitation, anxiety, depression, irritability, obsessive-compulsive symptoms, and suicidal thoughts and actions.

Initially a 2009 study that analysed data from 157 clinical trials involving more than 20,000 patients concluded there were no completed suicides due to taking the drug, and only a rare risk of suicide thoughts or attempts.

The most recent study, published in November 2024, examined data from more than 100,000 children aged 3–17 with asthma or hay fever who either took montelukast or used only inhaled corticosteroids.

It found montelukast use was associated with a 32% higher incidence of behavioural changes. The behaviour change with the strongest association was sleep disturbance, but montelukast use was also linked to increases in anxiety and mood disorders.

In the past ten years, around 200 incidences of behavioural side-effects have been reported to the TGA in connection with montelukast. This includes 57 cases of depression, 60 cases of suicidal thoughts and 17 suicide attempts or incidents of intentional self-injury. There were seven cases where patients taking the drug did complete a suicide.

This is of course tragic. But these numbers need to be seen in the context of the number of people taking the drug. Over the same time period, more than 200,000 scripts for montelukast have been filled under the Pharmaceutical Benefits Scheme.

Overall, we don’t know conclusively that montelukast causes depression and suicide, just that it seems to increase the risk for some people.

And if it does change behaviour, we don’t fully understand how this happens. One hypothesis is that the drug and its breakdown products (or metabolites) affect brain chemistry.

Specifically, it might interfere with how the brain detoxifies the antioxidant glutathione or alter the regulation of other brain chemicals, such as neurotransmitters.

Why is the TGA making this change now?

The new risk warning requirement comes from a meeting of the Australian Advisory Committee on Medicines where they were asked to provide advice on ways to minimise the risk for the drug given current international recommendations.

Even though the 2024 review didn’t highlight any new risks, to align with international recommendations, and help address consumer concerns, the advisory committee recommended a boxed warning be added to drug information sheets.

If you have asthma and take montelukast (or your child does), you should not just stop taking the drug, because this could put you at risk of an attack that could be life threatening. If you’re concerned, speak to your doctor who can discuss the risks and benefits of the medication for you, and, if appropriate, prescribe a different medication.

If this article has raised issues for you, or if you’re concerned about someone you know, call Lifeline on 13 11 14.

Nial Wheate, Professor of Pharmaceutical Chemistry, Macquarie University

This article is republished from The Conversation under a Creative Commons license. Read the original article.