The ageing anaesthetist: lessons from the North American experience

Key points.

• •Demand for anaesthesia services and provider shortages will increase in the next 15 yrs.
• •The proportion of anaesthetists in the UK practising after age 55 yrs is much lower than in North America.
• •Retention of older anaesthetists may partially alleviate shortages of providers.
• •Competency and cognitive testing are major issues for older anaesthetists.
• •Some departmental practices make it easier for older anaesthetists to remain in the workforce.

Learning objectives.

By reading this article, you should be able to:

• •Discuss the workforce characteristics of older anaesthetists in the USA, Canada and the UK.
• •Explain the problems associated with assessing cognitive issues and clinical competency.
• •Relate the practices in the USA and Canada that promote utilisation of older anaesthetists in the workforce.

Clinical anaesthesia practice in today's medical environment is an acute, procedure-oriented discipline. As such, it requires a combination of manual dexterity, sound vision and hearing, vigilance, focus, intact cognition, stamina, multitasking and the ability to utilise working memory to draw on one's medical knowledge and experience to make rapid and appropriate decisions under conditions of uncertainty. Anaesthetists have these characteristics and skill sets to varying degrees. When they are young, most clinicians can compensate for deficiencies in one or more of these areas to the point where clinical competency is not significantly compromised. However, as anaesthetists age, these attributes progressively decline in varying degrees for different individuals. This decline raises the question of whether some or all older practitioners are capable of rendering the same level of safe and effective anaesthetic care as their younger counterparts. This is particularly important for complex cases requiring a high degree of current knowledge and advanced technical skills at which they may not be proficient.

At the same time, demand for anaesthetists is growing because of an ageing and sicker general population who need more surgical procedures, and secondly, an increased number of procedures being done outside the operating theatre that require monitored sedation or general anaesthesia.¹ The Association of American Medical Colleges projected a shortage exceeding 100,000 physicians by 2030. They also stated that the percentage of the US population aged 65 and older is expected to increase by 55%, and the number of people aged 75 and older will grow by 73% during the same period.² The World Federation of Societies of Anaesthesiologists (WFSA) workforce survey of 153 countries reported a global shortage of anaesthetists and predicted continued shortages in the near future.^3,4

Increased utilisation of older anaesthetists in both clinical and administrative roles may help to alleviate some of the pressure from this shortage. In the UK, only 17.2% of anaesthetists work clinically beyond the age of 55, whereas in the US and Canada, 40% and 41%, respectively, continue working.

This article begins by delineating the age-related demographics of the anaesthesia workforce in the USA, Canada and the UK, and then discusses how the North American experience with ageing anaesthetists provides valuable lessons in both recognising problems associated with ageing and how anaesthesia departments can harness the expertise of their older staff to expand their clinical productivity.

Workforce characteristics of anaesthetists in the USA, Canada and the UK

Most descriptive statistics of older anaesthetists in this article come from two large-scale surveys in the USA and Canada in 2018 and a census of the workforce in the UK in 2015.5, 6, 7 Figure 1 shows the percentages of qualified practicing clinical anaesthetists, excluding residents in training, in different age cohorts in these three countries. Data from the WFSA and the Canadian Medical Association from 2017 to 2018 provide the number of anaesthesiologists per 100,000 of the populations.^3,6,8

Fig 1.

Distribution of anaesthetists by age and country.

Although there is no precise definition of the term ‘older anaesthetist’, the age range quoted in most of the literature is 55–70 yrs of age.⁹ An earlier survey of anaesthetists in the USA noted that this cohort also constitutes the segment of the anaesthesia workforce considering retirement.¹⁰

United States

The 2018 ASA survey of the anaesthesia workforce in the USA reported 51,283 physician anaesthetists, 40,140 nurse anaesthetists, 7,200 residents and 1,931 certified anaesthesiology assistants. The US data come from the American Medical Association Masterfile and exclude physicians who are aged 90 yrs or older, retired, or inactive and residents. The average age of active anaesthetists was 46.5 yrs. However, 40% of the overall anaesthesia workforce was over 55 yrs old and 12% were aged >65 yrs. The overall number of anaesthetists per 100,000 population was 14.4.³

The gender distribution changed with age. In the over age 65 cohort, 18% were females, but in the under age 35 cohort, the proportion of female anaesthetists increased to 38%.

Canada

The 2018 Canadian Anesthesiologists' Society survey reported a total of 3,321 anaesthetists, 9 per 100,000 population, 423 (13%) of whom were over 65 yrs. As in the USA, 40% of the workforce was aged 55 yrs or older.

The gender distribution in Canada was also similar to that in the USA. In the over 65 cohort, 18% were females, but in the cohort under 35 yrs, the proportion of female anaesthetists increased to 42%.

United Kingdom

The 2015 census report of the Royal College of Anaesthetists for the UK showed a workforce of 7,439 consultant physician anaesthetists registered with the UK General Medical Council specialist register, and 2,047 staff and associate specialist (SAS) grade physicians (i.e. those without board certification). The overall number of physician anaesthetists per 100,000 population was 17.8.³ Consultants over the age of 65 yrs who were still practicing clinically comprised only a small portion, 0.66%, of the total consultant workforce, and SAS grade doctors over 65 were only 0.9% of the total SAS workforce.

This 2015 UK census was the only survey to report the number of older members of the anaesthesia workforce (250) who retired and returned to work. Of these physicians, 202 (81%) were consultants and 48 (19%) were SAS doctors. Retired men (3.1%) were more likely to return to work than retired women (1.7%).

The census noted that there had been an increase in consultants of 2.3% a year from 2007 to 2015, and an increase of 2.9% per year in the number of SAS doctors, but to fill the projected need for anaesthetists, there would have to be an increase of over 4% a year.

Competency issues

Older anaesthetists become subject to the same physical, cognitive and behavioural issues confronting older individuals in the general population, many of which can affect their ability to engage in safe practice.^11,12

Physical issues

These include cardiac and respiratory issues, metabolic disease, visual issues, hearing loss, arthritis and tremors, impaired balance, fatigue and loss of stamina, medications that could affect performance and judgement and the cumulative effects of sleep deprivation interfering with the ability to function normally after being on call.

Cognitive issues

Cognitive difficulties include loss of working memory leading to diminished ability to make multiple decisions in a rapid fashion and a decreased ability to maintain the knowledge base and skill sets necessary to be up to date for clinical practice. Older clinicians also may resort to pattern recognition and heuristic thinking rather than analytical judgement when confronting acute situations.

Behavioural, personality and substance abuse issues

These include depression, alcohol and substance abuse with prescription and recreational drugs and burnout, a major environmental stressor that can interfere with motivation and desire to continue practice.¹³

Other workplace challenges confronting older anaesthetists include increasing workloads and production pressures as hospitals and practice groups push for greater efficiency, computerisation and the introduction of electronic medical records. The transition from paper to electronic records can be extremely stressful for older anaesthetists who did not have to deal with computers in their earlier years of practice, and who have to learn to use and master these systems in relatively short periods.¹⁴

With all these problems, it is not surprising that the incidence of litigation stemming from adverse outcomes has been found to be higher in older anaesthetists compared with their younger counterparts.¹⁵

Maintenance of competency and acquisition of skills for contemporary practice

During the last 5–10 yrs, there has been a significant increase in the number of anaesthetic procedures outside the operating theatre, in interventional cardiology, interventional radiology, endoscopy suites and the emergency department. Many of these require general or regional anaesthesia in very sick patients who require elaborate, sophisticated monitoring and intraoperative manipulation of complex electromechanical devices, such as pacemakers and computerised i.v. dosing devices while highly potent medications with relatively low margins of safety are given. In addition, many operative procedures in neurosurgery, interventional pain management, cardiothoracic, orthopaedic and trauma surgery, in addition to complex general surgical procedures, such as liver transplants and radical cancer surgery, require that anaesthetists handling these procedures have highly developed contemporary skill sets.

As opposed to today's anaesthesists in training, many of whom do fellowships in anaesthesia subspecialty areas, many older anaesthetists who did their training 30–50 yrs ago were not taught these skills. Some, of course, acquired them over the years through observation, practice and instruction by their younger colleagues, but many have not. If such individuals wish to continue practice involving these highly technical skills, they may have to acquire them through formal retraining, including simulation, didactic sessions and dedicated time in the operating theatre devoted to particular specialty areas.

Formal mechanisms for maintenance of competency in the USA

In the USA, the three principal mechanisms for maintenance of clinical competency are (i) the Maintenance of Certification in Anesthesiology (MOCA) examinations administered through the American Board of Anesthesiology (ABA),^16,17 (ii) satisfying continuing medical education (CME) requirements for re-licensure as a physician and (iii) the use of anaesthesia simulators.

MOCA examinations

The MOCA examinations, administered at 10-yr intervals, were restructured in 2016 as MOCA 2.0 and are designed to document that anaesthetists who received ABA Board Certification after year 2000 are current in their knowledge base. They are a fee-based requirement for ABA recertification and include a 200-question multiple choice examination administered electronically at an examination centre and a simulation session (Part 4) examination. Those who received their ABA certification before year 2000 are exempted from the examination and can maintain board certification without participating in MOCA. References 16 and 17 from the ABA contain detailed descriptions of the MOCA process, and interested readers are encouraged to examine these documents. As the years progress, the percentage of exempted MOCA candidates will steadily decrease, thereby closing a recertification loophole for older anaesthetists in the USA.

CME requirements for re-licensure

In the USA, older board-certified anaesthetists often attend regional or national anaesthesia meetings to help keep themselves abreast of current practice. Almost every state has CME requirements for license renewal, and the combination of CME courses and CME-granting anaesthesia meetings helps to keep the older anaesthesia population current with regard to both clinical anaesthesia and overall medical practice. Members of private practice groups in the USA also often attend didactic sessions at nearby academic departments of anaesthesia or at their regional or state anaesthesia societies. Most of these courses grant CME credits for attendance.

Anaesthesia simulators

Anaesthesia simulators are widely used in the USA to assess and improve competency in handling crisis situations and to improve teamwork and task delegation in the operating theatre setting. The most frequent application is simulation of untoward emergency events, such as malignant hyperthermia, anaphylactic reactions, severe hypotension, sudden cardiac arrest and anaesthesia machine malfunction. Baxter and colleagues, in their review article, state that ‘simulation serves both formative (assessment for learning by identification of weaknesses and deficiencies for correction) and summative (assessment of learning for achievement of an adequate standard of practice) purposes. Importantly, it facilitates assessment of crisis resource management, which is crucial and not well addressed by other assessment methods’.¹⁵ The American experience with simulation bears this out, and the MOCA examinations now include a simulator session. It is expected that anaesthesia simulators will proliferate and become more available, particularly to evaluate older anaesthetists.

Some older anaesthetists, particularly those in their mid-to-late 60s and early 70s, may find that they are unable to take the necessary steps to achieve contemporary competency in specialised areas and accordingly confine themselves to anaesthetic administration and supervision of less complex cases.¹⁵ In a later section, we discuss strategies for departments to utilise older anaesthetists in a variety of capacities outside the operating theatre, resulting in a win–win outcome for both older anaesthetists and the departments in which they work.

Methods used by anaesthesia practice groups to determine clinical competency

In the USA, judging the clinical competency of older anaesthetists involves a combination of several measures.

Medical evaluations

For clinicians who experience significant physical or mental illness, a comprehensive medical evaluation is often performed to determine fitness to continue in clinical practice. This is a reasonable course of action and, in most cases, temporary or permanent inability to continue is compensated by disability insurance.

Peer observation and clinical competency committees

Many departments have clinical competency committees whose members review the clinical performance of their colleagues. These reviews are periodically discussed and action taken if a significant pattern of impairment is detected. Peer observation can detect glaring issues, such as acute early onset Alzheimer's disease; strokes; dementia; working while under the influence of alcohol, narcotics, or illicit drugs; and similar issues. However, marginal deficits are much harder to deal with. Rather than have peer review performed by a departmental clinical competency monitoring board, some older anaesthetists request trusted clinical colleagues to inform them privately if and when they feel that their clinical abilities have deteriorated to the point where an intervention is needed. This would seem to be a kinder and gentler way of assessing marginal deficits, and allows affected clinicians to take the initiative to modify their clinical responsibilities or even retire rather than being forced to do so. A two-step process involving initial informal discourse followed by a more formal inquiry if the clinician is unwilling to act upon his or her colleague's counsel is another avenue utilised by a number of practice groups.

Anaesthesia simulators

Anaesthesia simulators as a tool to assess and improve clinical competency are discussed earlier.

Cognitive testing

In view of data showing that cognitive abilities decline with age in the general population and that physicians are not exempt from this decline, there has been a highly controversial move in a number of US hospitals, practice groups and state governments to institute cognitive testing of older physicians to determine their fitness to continue practice.^12,18 A number of articles consider the practice to constitute age discrimination.^19,20 In 2012, an estimated 5% of US medical centres developed age-related screening policies.²¹ In 2011, Kaups reported that the University of Virginia Health System implemented a system of mandatory physical and cognitive examinations every 2 yrs for physicians and some other members of the clinical staff, beginning at age 70, and in 2012, Stanford Hospital and Clinics instituted a late-career practitioner policy, including a peer evaluation of clinical performance, a cognitive examination and a comprehensive history and physical examination every 2 yrs for physicians aged 75 and older. ^19,22 . However, in 2015, the senior faculty at Stanford Hospital and Clinics voted to reject this late-career practitioner policy, citing that it constituted age discrimination.²⁰

Competency testing of older physicians may be problematic for a number of reasons, especially because of the lack of practical screening tools that are specific and easily used. Neuropsychological testing is expensive, highly demanding of departmental resources and often inaccurate in its conclusions. As described in the American Medical Association report on competency and the ageing physician, comprehensive neurocognitive and functional testing is not widely available, incurs travel expenses and requires time away from practice for testing procedures spread out over several days. The report also pointed out that there is a great deal of variability in how age-associated cognitive changes manifest themselves, coupled with uncertainty in interpreting psychomotor tests in physicians and in using the test results to predict care quality and patient outcomes.¹⁸ Three recent articles in JAMA further review issues and limitations in screening for cognitive impairment in older adults.23, 24, 25

Practice policies for older anaesthetists and how they vary

Although there has been an effort to encourage older anaesthetists who are no longer competent to stop their clinical practice, a number of departments make a concerted effort to utilise and accommodate older anaesthetists, especially with the realisation that their skills and experience constitute a valuable resource.

Practice policies in the USA

In 2012, the authors of the present article surveyed chairmen of academic departments in the USA about their practice policies for older anaesthetists (Table 1).⁹

Table 1.

Departmental policies for eight age-related issues and percentage of responding academic departments with such policies in place.⁹ Adapted with permission.

Issue	Proportion of departments with a policy (%)	Proportion of departments without a policy (%)
Mandatory retirement age	6	94
Limit hours that older staff may work	8	92
Direct older staff to non-clinical roles	17	83
Older staff assigned exclusively to preoperative clinic	17	83
Utilise part-time older staff for backup in clinic	21	79
Transition older staff to part-time status	23	77
Assign less complex cases for all older staff	5	95
Assign less complex cases for some older staff	48	52
(Each of these statements is an independent question, and therefore, the proportions in the columns do not add up to 100%.)
Age (yrs) for stopping overnight on call
55	7.9%
60	20.6%
65	11.1%
70	1.6%
No specified age	58.8%
Total of responses about stopping overnight on call	100.00%

The study included questions about whether the departments screened for six problem behaviours, including (i) critical incidents, (ii) errors in technique or judgement, (iii) substance abuse, (iv) emotional impairment, (v) fixation errors leading to performance issues and (vi) physical impairment. Almost all departments tracked critical incidents, almost three quarters tracked substance abuse, over half tracked physical and emotional impairment and fixation errors and a third of the departments tracked all six types of problem behaviour. However, only 12% reported having assessment tools for these problems in the clinic, and no department reported using these tools specifically for older anaesthetists. This may reflect the fact that these assessment tools lack precision and specificity, as discussed earlier.

The survey also asked whether the academic departments offered older anaesthetists alternatives to clinical practice. Only 17% specifically directed older anaesthetists into non-clinical roles, and the majority of older clinicians in these departments had teaching, mentoring, administrative and committee roles. Although 20.6% of the academic departments stopped overnight on call at age 60, most (58.8%) did not exempt older anaesthetists from call responsibilities, and only 6% had a mandatory retirement age.

Adaptive strategies for older anaesthetists

Supervision of certified registered nurse anaesthetists by older staff

Although certified registered nurse anaesthetists (CRNAs) must pass both a specific curriculum and a certification examination to be registered and licensed to practice in the USA, there is considerable controversy amongst physician anaesthestists as to whether CRNAs should be permitted to practice independently. In 2020, this is allowed in 17 US states, with 33 where CRNAs must have physician supervision (https://www.aana.com/). In such settings, older anaesthetists often assume that role for surgical patients who undergo procedures of less complexity. The older anaesthetists oversee such procedures and are immediately available for clinical situations that demand their intervention. This is less intense than personally giving anaesthesia, and allows the expertise and judgement of older clinicians to be used effectively in these patients while freeing up staff with subspecialty training for highly complex surgical procedures. It also significantly increases the efficiency of an anaesthesia practice group by having one physician anaesthetist supervise several rooms staffed by CRNAs, and this practice is becoming more widespread. Collegial arrangements between older physician anaesthetists and CRNAs promote departmental unity, trust and productivity, and constitute a highly appropriate venue for utilisation of older clinicians.

Other clinical and administrative roles for older staff

Many larger departments find other roles for their older staff that do not require their presence in the operating theatre. One of the most frequent is working in the department's centre for preoperative evaluation, where older clinicians perform a valuable service while freeing up others to work in the operating theatres or other locations. Another important role for older departmental members is serving on hospital committees, such as the pharmacy and therapeutics committee and hospital ethics committee, and assisting in medical education and teaching of medical students when the practice includes student rotations.

Part-time status and retirement

Many older clinicians opt for part-time status, especially in activities outside the operating theatre, such as the preadmitting test center (PATC) where flexible work schedules can be implemented. Amongst anaesthetists, the number of clinicians in their 70s who give anaesthetics is very low compared with their younger colleagues, and most have roles outside the operating theatres. Part-time work is often a prelude to retirement and allows physicians to determine whether they consider retaining some of their professional activities to be an essential part of their lives.¹⁰

Using older anaesthetists in emergency situations

There is increasing recognition that older anaesthetists constitute a valuable resource for departments and the community at large. A vivid example from the USA is the COVID-19 crisis in New York City, where ICUs were inundated with patients suffering from severe respiratory complications. The public health authorities actively solicited retired anaesthetists and pulmonologists to help staff these facilities in view of their expertise in respiratory care and management of artificial ventilation, and granted exemptions if their medical licences were no longer active. A number volunteered, including retired anaesthetists from other parts of the USA, and this helped to ameliorate a devastating public health crisis.

Conclusions

Older anaesthetists face a number of challenges that threaten their ability to remain in the workforce, including physical and cognitive issues that can impair their overall clinical competence and their ability to handle highly complex anaesthetic and surgical procedures. The North American experience using older anaesthetists has revealed some of the problems in assessing their clinical competency, but has also shown that they can be used effectively to enhance the capacity and productivity of anaesthesia departments. Although there are no unified standards amongst departments as to how to deal with this segment of the anaesthesia community, a number of departments have policies in place to extend the careers of older anaesthetists and to use their years of experience. These practices in turn will increase the number of older anaesthetists remaining in clinical practice and help to alleviate projected shortages in the anaesthesia workforce.

MCQs

The associated MCQs (to support CME/CPD activity) will be accessible at www.bjaed.org/cme/home by subscribers to BJA Education.

Declaration of interests

The authors declare that they have no conflicts of interest.

Biographies

Joseph Garfield MD is an associate professor of anaesthesia at Harvard Medical School and faculty scholar at Brigham and Women's Hospital, Boston, MA, USA (where he was the former director of anaesthesia for gynaecological surgery and director of medical student teaching). Dr Garfield is a physician–scientist member of the Partners HealthCare Investigational Review Board. His research interests include medical education, opportunities for older physicians and biomedical ethics.

Frances Garfield PhD is a retired research social psychologist who has coauthored a number of research and review articles with her spouse on psychological effects of ketamine and nitrous oxide, clinical guidelines and clinical practice policies. Her interests are in outcomes research and survey design.

Matrix codes: 1B03, 2H01, 3I00