The ageing cardiac surgeon—neither a bane, nor a boon, but a problem that needs to be addressed

“We don’t stop playing because we grow old. We grow old because we stop playing.”—George Bernard Shaw.

“I would not mind being operated on by a surgeon of 91.”—Dr. Michael DeBakey at the age of 91 years.

The recently published editorial by Dr. Yadava [1] calls for a healthy debate as regards advancing age in cardiac surgery. A brief Google search reveals that life expectancy for India in 2020 is 69.73 years. The life expectancy for the USA, on the other hand, is 78.9 years in 2020, a difference of nearly a decade. What about Indian surgeons? Pandey et al., state the life expectancy for Indian doctors of just 59 years, much lesser than an average Indian [2]. Thus, “ageing” for an Indian cardiac surgeon may not mean the same as his counterpart in the USA, and thus, planning well and planning early might help in the Indian context.

The ageing surgeon and the surgeon being an added risk factor have been studied often. Anderson et al. [3] observed that patient outcomes for surgeons with the fewest years of experience were comparable to those of their mid-career and senior counterparts. Very senior surgeons had higher risk-adjusted odds of major morbidity/mortality. They concluded that contemporary approaches to training, referral, mentoring, surgical planning, etc. could contribute to such outcomes.

Patient safety should be the most important factor that should determine ending professional surgical practice in cardiac surgery. Age has an impact on one’s physical and cognitive skills but individual variation remains. Old age heralds disease like hypertension and diabetes mellitus, presbyopia and tremors, even coronary artery disease. Acuity and stamina take a hit. Dementia sets in. According to the World Health Organization, about 15% of those aged 60 suffer from a mental disorder. Cardiac surgeons cannot be immune to burnout in a long surgical career. Again, frequent complex cases, re-operations and deaths have a bearing. But then, does not the experience count? A senior surgeon may be way ahead in decision-making while choosing not to operate, weighing the risk benefit ratio far more accurately than his younger counterparts, thus avoiding a lengthy, complicated procedure, which could have otherwise led to possible morbidity and mortality.

In a recent study by Sherwood et al. [4], 52 experts across four countries participated and perceived the need for a staged approach to assessing the performance of older surgeons and tailoring interventions. Most older surgeons made decisions regarding career transitions with self-awareness and concern for patient safety. Some older surgeons may benefit from additional guidance and support from employers and professional colleges. A few poorly performing older surgeons, on the other hand, who are recalcitrant or lack insight, may need regulatory action to protect patient safety. Participants perceived that personal fulfillment from work, lack of hobbies, financial pressures and poor retirement planning all contribute to delayed transitions to retirement. Two key roles for employers were identified: (1) appraising performance through annual performance reviews and credentialing activities and (2) managing performance through career planning and an active and timely response to concerns. Participants spoke about the lack of validated tools for assessing surgical performance. The most commonly mentioned remedial approaches were multisource feedback, direct observation of procedural skills, data analysis to identify outliers or changes over time, self-evaluation and cognitive assessment.

Ageing must be recognized as a normal phenomenon which affects both physical and cognitive function, on attaining a certain age. Appropriate authorities should mandate practicing cardiac surgeons in India to have regular physical examinations to assess physical health, vision, and cognitive function.

Holding on to chairs and money and power, therefore, which comes with it, is a trait common to all professions. If it was not for the age limit and physical constraints in several professions (judges, firefighters, pilots, air traffic controllers, professional sports), many would rather choose to go on.

An elderly surgeon, after a day performing surgery, turns to his younger colleague and asks, “Bill, please take me to my office. I don’t know where it is” [5].

Educating surgeons to three facts [5] may reduce the problem: Physical and cognitive functions will gradually fade and as Dr. Yadava rightly pointed out [1], including junior colleagues in the surgical team with better skills and dexterity may help; adequate planning may make retirement quite satisfying; and retirement does not have to bring in its wake the loss of all self-esteem and the feeling of an imminent death. Surgeons nearing the end of their careers should be provided with help with planning their retirement beyond finances and benefits. The private sector still does not recognize the role of senior surgeons as teachers and guides to juniors, as key decision-makers in complex cases and leaders in management, beyond their role in the operating theatre.

To conclude, more studies on Indian cardiac surgeons in a similar context are the need of the hour to address their needs. Unless we have the data, we cannot debate. Most importantly, the problem needs to be recognized at the earliest, not just for the surgeons’ sake but for patient safety, addressing future litigation concerns and improving quality in the long run.

Funding

Nil.

Compliance with ethical standards

Ethical approval and consent

Since this manuscript does not involve human or animal participants, ethical approval or consent was not required.

Conflict of interest

The authors declare that they have no conflict of interest.