On Patient Safety: When Are We Too Old to Operate?

I am lucky to say that I once had a great senior partner. Seasoned in the ways of orthopaedic surgery, he offered me encouragement, advice, and help when I needed it. He took me under his wing when doing complex procedures, and he bailed me out when I got into trouble. I could not have asked for a more supportive person to mentor me in my early career.

As often is the case in mentor-protégé relationships, he was considerably older than I was. One day I asked him about the future. “Jed [not his real name], how many more years are you going to keep operating?” And he told me, “Mike, I’m going to keep operating until you tell me that it’s time to stop.” Seeing my confusion, he explained that he expected there would come a time when he would no longer be as effective in the operating room or in the clinic as he felt he ought to be. When that day would come, he wanted me to tell him it was “time.” He wanted me to assume that role because he thought he might not have the self-awareness to make that call himself. He wanted me to do it.

While I was impressed with Jed’s modesty and insight, I immediately began dreading the day I would have to tell my colleague, mentor, and friend that it was time to hang it up. Who would I be to tell this expert that he is no longer good at what he’s done his whole adult life? Jed stopped operating years later in his 70s, having made his own decision. Thankfully, I did not have to play the awkward role he envisioned for me.

The Age Discrimination in Employment Act of 1967 prevents discrimination based on age [10], but there are a few exceptions that are in the interest of public safety. Airline pilots are mandated to retire at 65 [4]. FBI agents have to sign off at age 57 [9]. Lighthouse keepers are required to retire at by age 65 [6]. There is no mandated retirement age for surgeons in the United States. Should there be?

I do not think so. Age is just a number. There is a wide spectrum of health, ability, and cognitive ability among individuals in their 70s, 80s, and even 90s. World-renowned cellist Pablo Casals continued to practice 5 hours to 6 hours a day well into his 80s because as he once stated: “I think I am making progress” [8]. To judge someone’s ability and mental acuity solely by age is at best, a blunt measure.

Though age may not be a wholly accurate measure of ability, we cannot ignore it entirely. It is reasonable to pay attention to a surgeon’s ability as he or she ages. Health, physical ability, and cognition decline with advanced age. But they decline at different rates in different surgeons. We all have known maestros making magic in the operating room well into their 70s and even 80s. Forcing these surgeons would do no one any good.

If a mandatory retirement age is not the solution, how else can this be approached? In Jed’s case, he wanted to rely on his junior partner to tell him. Even if he were to delegate such an important responsibility to me, I would have faced some real barriers in helping him make his decision, at least if I wanted to base it on good data. The most obvious indicator of decreased clinical ability is a change in the frequency and severity of complications. In fact, one of the most commonly cited reasons for surgeon retirement is an adverse malpractice experience [7]. But nobody (especially patients) wants us to wait for that to happen. Even if we were to wait, how much of a change in the frequency of our complications should it take? If an aging but expert arthroplasty surgeon’s hip dislocation rate increases slightly but remains low relative to community or published benchmarks, what then? There must be a better way. And, again, who is going to make this assessment? In Jed’s case, his junior partner (me) was horribly conflicted. In fact, every individual in a position to assess his skill would have been likewise conflicted—he was beloved by all. Certainly the hospital was pleased with him, and would have been unlikely to show him the door; he was a high producer.

Even so, Jed’s idea of outsourcing had some merit. Self-assessment of one’s abilities is flawed [1, 3]. Jed just picked a conflicted guy who had no idea of how to do it. What about the American Board of Orthopaedic Surgery? Orthopaedic surgeons are encouraged to recertify after passing their boards, but that happens only once every 10 years. A lot can happen in between recertifications. Additionally, in a relatively recent review of the aging orthopaedic surgeon, Dr. Blaiser [2] noted no orthopaedic surgeon had ultimately failed recertification, meaning that (1) all surgeons are competent, or (2) surgeons who are not competent chose not to attempt recertification, or (3) recertification standards are too low.

Are there other possible mechanisms that can help identify when a surgeon has lost a step, before he or she loses it on a patient with a bad complication? In response to this concern, Stanford University implemented the Late Career Practitioner Policy in 2012 [11]. This mandatory screening every 2 years for all physicians older than 75 included: (1) peer review, (2) history and physical and, (3) neuropsychology cognitive screening [11]. This policy was initially poorly received by faculty. The Stanford Faculty Senate voted by a 2 to 1 margin that university leadership advise the medical centers “that patients be safeguarded by a process that is the same for all faculty age groups” [5]. However, despite some continued opposition, this policy has remained active at Stanford and has passed a vote of the medical staff. Ann Weinacker MD, Vice Chair of Medicine and Quality Implementation at Stanford Medical Center, in an email communication, informed me that with their experience thus far, evidence is mounting that “we are doing the right thing and the policy is working.” This certainly seems like a reasonable process with minimal burden on the physician. As most institutions already have some kind of peer-review process, and as most people have a history and physicals from primary care physicians, the only real addition would be the cognitive screen.

Another more surgeon-specific solution is the Aging Surgeon Program at the Sinai Hospital of Baltimore [6]. The program is a 2-day process that involves neurological, neuropsychological, ophthalmologic, and general examination by a third party. At the conclusion of this process and the Stanford screening process, an assessment is made, but there is no specific recommendation on whether the individual should continue to practice. “There really is no standard for evaluating the judgment and neurocognitive hand eye coordination of the aging physician,” JoAnn Coleman, DNP, ANP, ACNP, AOCN, Clinical Program Coordinator of the Sinai Center for Geriatric Surgery and Nurse Practitioner for the Aging Surgeon Program at LifeBridge Health, told CORR ^®.

Such a comprehensive program is likely to provide a greater in-depth, surgeon-specific analysis than the simpler Stanford policy, but at substantially greater cost. According to Dr. Coleman, not only would the surgeon have to commit 1 to 2 days for one site examination, the price has been estimated to exceed USD 10,000. As of this publication, the program is still under development, and no individual has actually undergone the formal testing, though there has been much interest. The comprehensive nature of this program makes it suboptimal as a routine screening program, however it may be beneficial as a secondary process.

Ideally, when each of us eventually decides to stop operating for good, we should do it because we decide to—not because it was forced upon us. As my former senior partner told me, “I would rather choose to pick the train station to get off than be thrown off the train.” I suspect that for the vast majority of surgeons, this is the case. However, for the small minority that continue to operate into their 70s and 80s, it would be reasonable to at least consider formalizing some kind of neurocognitive testing. There is no doubt that surgeons’ psychomotor skills—like those of all other people—will decline with advanced age. As our profession directly affects patient safety, we should implement steps that recognize this fact. While all of us may not need to go through an exhaustive expensive 2-day series of various examination, certainly we can all tolerate a simpler screening process after a certain age. After all, airline pilots undergo much more rigorous screening to maintain their ability to fly planes at much younger ages. And while much still needs to be defined on how one interprets neurocognitive testing results, at least it introduces an age-appropriate conversation about when and how to retire.