According to published research and anecdotal evidence, the aging surgeon remains a problem throughout hospitals and medical centers across the United States. Some studies have shown that patient mortality rates are higher for surgical procedures performed by older surgeons. However, other analyses have suggested that surgeon age is a relatively weak predictor of operative mortality in aggregate and should be taken into context when evaluating performance among individual surgeons.
“Dealing with the aging surgeon is a common problem that is encountered by nearly every chief of surgery, vice president of medical affairs, and hospital president at some point during their tenure,” explains Mark R. Katlic, MD, MMM, FACS. “Many surgeons lack self-awareness in their perceived cognitive abilities as they age. This is an especially important issue considering that the number of U.S. surgeons aged 70 and older still practicing approaches may approach 20,000.”
A Complex Issue
In the Annals of Surgery, Dr. Katlic and colleagues published an article that explored issues surrounding the aging surgeon. According to Dr. Katlic, it is important to remember that human faculties diminish with age but with great variability. “As is true with everyone, surgeons are probe to deterioration in cognitive and physical faculties that comes with increasing age,” he says. “However, functional age doesn’t equal chronologic age. It’s more important to evaluate functional age rather than to implement policies that mandate a specific retirement age for surgeons because each individual is unique.”
Several arguments have been made to support the case against mandatory retirement for surgeons based on age, including the Age Discrimination in Employment Act of 1967, which outlawed forced retirement based on age. In addition, studies suggest that age alone is not a sufficient predictor of cognitive performance. There may also be treatable causes of poor performance among surgeons. Furthermore, there is a tendency in society toward ageism. According to Dr. Katlic, it is critically important to balance patient safety and liability risk while respecting the dignity of committed surgeons and their value to society (Figure).
“The public believes that we police ourselves, but this isn’t necessarily the case,” Dr. Katlic says. “Although initial certification to being a surgeon is difficult, recertification is relatively easy. In some states, it’s more difficult for older people to keep their driver’s licenses when they reach the age of 70 than it is for similarly-aged surgeons to continue practicing.” Compounding the issue is that many senior surgeons have been teachers and mentors of younger colleagues, some of whom may become enablers by assigning others to assist them with their procedures. “It often takes a patient death to force action, but we need to make efforts to prevent these events before they occur,” says Dr. Katlic.
The Aging Surgeon Program
In an effort to address the issues surrounding aging surgeons, Dr. Katlic and colleagues at Sinai Hospital of Baltimore developed the Aging Surgeon Program. The program consists of a 2-day evaluation that is comprehensive, multidisciplinary, objective, and confidential and assesses surgeons’ physical and cognitive function (Table). There are several different triggers for the program, including every surgeon aged 70 or older at each hospital re-credentialing cycle, failure of ongoing professional practice evaluations, a sentinel event, or a worrisome malpractice history, among other reasons. There is also a wide array of possible hospital actions, ranging from full privileges to no privileges and other types of privileges in between.
The Aging Surgeon Program includes a pre-visit screen of medical history and appropriate recent radiographs (eg, MRI). On the first day, general physical and neurologic examinations occur in the morning followed by neuropsychology testing in the afternoon. The second day encompasses a morning of neuropsychology followed by physical and occupational therapy and ophthalmology, and then concludes with an exit interview. The resulting report is sent confidentially to the person who contracted and paid for the program. Reports include only objective findings. Decisions about privileges, retirement, or lifestyle changes must be made by those who receiving the report.
A Call to Action
“The Aging Surgeon Program is just one option for striking a balance between patient safety, liability risk, and the dignity of committed surgeons,” Dr. Katlic says. “Other similar programs are being initiated throughout the U.S. Ultimately, these programs are intended to ensure that decisions about competency are based on functional age rather than chronologic age. Considering the vast knowledge and experience that older surgeons have accumulated, both surgeons and society deserve no less.”
Readings & Resources (click to view)
Katlic MR, Coleman J. The aging surgeon. Ann Surg. 2014;260:199-201. Available at: http://journals.lww.com/annalsofsurgery/Citation/2014/08000/The_Aging_Surgeon.1.aspx or at: http://www.medscape.com/viewarticle/829600.
Neumayer LA, Gawande AA, Wang J, et al. Proficiency of surgeons in inguinal hernia repair: effect of experience and age. Ann Surg. 2005;242:344–348; discussion 348–352.
Waljee JF, Greenfield LJ, Dimick JB, et al. Surgeon age and operative mortality in the United States. Ann Surg. 2006;244:353–362.
Lee HJ, Drag LL, Bieliauskas LA, et al. Results from the cognitive changes and retirement among senior surgeons self-report survey. J Am Coll Surg. 2009;209:668.e2–671.e2.
Bieliauskas LA, Langenecker S, Graver C, et al. Cognitive changes and retirement among senior surgeons (CCRASS): results from the CCRASS Study. J Am Coll Surg. 2008;207:69–78; discussion 78–79.
Drag LL, Bieliauskas LA, Langenecker SA, et al. Cognitive functioning, retirement status, and age: results from the Cognitive Changes and Retirement among Senior Surgeons study. J Am Coll Surg. 2010;211:303–307.