Katz, Jonathan D. MD
The practice of anesthesiology is a demanding and potentially hazardous occupation (1). Much of the literature to support this claim reflects research involving medical students, residents, or young physicians. However, little attention has been directed toward the challenges faced by older anesthesiologists.
The successful practice of anesthesiology requires a high degree of knowledge and skill, as well as mental and physical stamina. Those who fail to maintain these standards are at risk of causing serious injury to their patients. Many other professions that place similar demands on their practitioners have been more aggressive about monitoring the health, well-being, and competence of their aging practitioners. The airline industry has set a good example. Commercial pilots are required to take regular examinations to demonstrate their continued good health and professional skills. Contractual and legal age limits determine whether a pilot can remain active. These practices are in sharp contrast to the relative laissez-faire attitude of anesthesiology’s professional organizations and licensing boards with regard to older practitioners.
The purpose of this review is to examine some of the issues that challenge practicing anesthesiologists as they age and to suggest some remedies to assist them, their colleagues, and, ultimately, their patients.
There are more older Americans now than ever, both in absolute numbers and as a percentage of the total population. Since 1900, the number of Americans older than 65 yr has increased 11-fold (from 3.1 million to 33.5 million), and the percentage of Americans older than 65 yr has tripled.
Although it remains a relatively young workforce, the population of anesthesiologists is also aging. In 1994, 22.8% of members of the American Society of Anesthesiologists (ASA) were age 55 or older (2). As of 2000, 25% of ASA members were age 55 or older (3).
Physicians in general tend to have a life expectancy as long or longer than that of the general population (4). In Goodman’s report (5) covering the years 1969–1973, the death rate among male physicians was 75% that of the general population. The mortality among female physicians was 84% that of the Control group.
Studies of the mortality risks among anesthesiologists have provided conflicting conclusions (6–10). In the earliest study of mortality among anesthesiologists, Dublin and Spiegelman (6) found a mortality ratio among anesthesiologists that was 88% that seen among all male physicians. In a prospective study on mortality, Bruce et al. (7) reported that the overall death rate among anesthesiologists was 72% that of the control population. More recently, Alexander et al. (8) have reported that the overall mortality risk, as well as mortality caused by cancer and heart disease, did not differ between anesthesiologists and a Control group of internists. However, they also reported that the mean age at death of anesthesiologists (66.5 yr) was significantly younger than that of the internists (69.0 yr) (8). A similar finding was reported from an analysis of the obituary columns of the British Medical Journal, in which anesthetists died significantly younger (mean age, 66.4 ± 19.9 yr) than did other specialists (9). A series of letters to the editor took issue with the latter report on the basis of methodologic flaws in study design (11,12).
Suicide is the one recurring exception to the general observation of favorable mortality experiences among anesthesiologists. In the report of Bruce et al. (7), suicide was the only cause of death that exceeded that found in the general population. Lew (10) further confirmed this observation. He concluded, “The high mortality rate from suicide. . .appears to be the only major health problem among American anesthesiologists.” Carpenter et al. (4) studied mortality among physicians employed in the British National Health Service. They found suicide among anesthesiologists to be four times that found among other consultants. In the report of Alexander et al. (8), American anesthesiologists had an increased risk of suicide (relative risk = 1.45) and drug-related deaths (relative risk = 2.79) as compared with the Control group of general internists. These two factors accounted for the lower age of death of the anesthesiologist decedents. Suicide rates among anesthesiologists decreased with increasing age (8).
A number of explanations have been offered for this consistent observation of excessive suicide among anesthesiologists. Occupational factors such as chronic fatigue, dealing with sick and dying patients, and fears of litigation are likely contributing factors (13,14). The high rate of substance abuse reported among anesthesiologists is likewise a significant factor. In many cases, suicide in an anesthesiologist is a direct result of planned or accidental drug overdose in a substance abuser (15).
The Physiology of Aging
Aging is a universal and progressive physiologic phenomenon characterized by degenerative changes in the structure and functional reserve of organs and tissues. The accumulation over time of these changes results in increased susceptibility to disease and death. Aging begins at conception and continues throughout all stages of an organism’s life history. Senescence is a more precise term and refers only to postmaturational physiologic deterioration. There are two general theories that attempt to explain the biologic basis of aging. The genetic theories argue that aging is just one component of the universal process of cell growth and differentiation. The injury/error models contend that environmental influences cause damage to the gene transcription and protein synthesizing mechanisms, which produce the many manifestations of aging. These two competing theories actually share in common many assumptions and are in fact complementary (16).
Different individuals age at varying rates and in very different fashions. Even within any one individual, different cells, organs, and organ systems age according to their own characteristic patterns and rates. It is difficult to distinguish pure physiologic changes from chronic disease states that progress with time.
Despite these limitations in the ability to generalize about the aging process, certain common processes are universally observed in humans as they grow older:
1. Distinctive changes in the chemical composition of the body.
2. A broad spectrum of progressive and irreversible deteriorative changes.
3. Reduced ability to respond adaptively to environmental change.
4. Increased vulnerability to many diseases.
5. Increased mortality.
As a general rule, almost all physiologic systems show decline with chronologic age. The one notable exception is the stability of an individual’s personality throughout life. This variable is measured by such observations as openness to experience, neuroticism, extroversion, and agreeableness. In the absence of disease- or drug-related alteration, an individual’s personality remains consistent and can provide a useful yardstick to measure suspected cognitive impairment (17).
Some commonly observed age-related physiologic changes specifically have the potential of affecting an individual’s ability to practice anesthesiology.
Neuronal density and brain weight diminish with age such that the average brain weight decreases from 1375 g at age 20 yr to 1200 g at age 80 yr (18). Aging also affects the morphology and biochemistry of brain tissue. Neurons are diminished in size, with a reduced number of synapses containing a decreased concentration of neurotransmitters (18).
There are characteristic changes in psychological and cognitive function that are associated with aging. The complex processes involved in cognition diminish in healthy individuals as they age (19). However, there is considerable variation in this regard (20). Also, there are many differences between observations made in the controlled environment of a test room and the complex environment of the workplace. Performance in the operating room relies on additional skills, based primarily on experience and judgment, which often permit older anesthesiologists to compensate for any cognitive deterioration (21). In fact, age may impart enough advantages that under certain circumstances, older professionals enjoy a definite advantage over their younger colleagues (22). Experience and wisdom fail to compensate only in advanced stages of cognitive impairment, as seen in Alzheimer disease.
Predictable age-related decrements in taste, smell, sight, and hearing have the potential of imposing serious handicaps on an anesthesiologist. Aging of the sensory/perceptual system probably provides the closest correlation between chronologic and biologic age and is least susceptible to antiaging interventions such as lifestyle changes (23). Visual disturbances associated with aging include presbyopia, reduction of static visual acuity, impaired dark adaptation, decreased depth perception and visual field, and reduced color discrimination. Cataracts and glaucoma are more frequently seen among older individuals. Fortunately, most of the visual impairments are readily compensated with glasses or minor surgical procedures.
Hearing impairment can be particularly troublesome for an anesthesiologist. Most individuals more than 40 yr old have some degree of hearing loss (24). The percentage is higher among anesthesiologists, among whom 80% of those older than age 45 yr have abnormal audiogram results (2). Commonly observed hearing difficulties include presbycusis, abnormal loudness perception, tinnitus, and impairment of sound localization. The hearing impairment most frequently observed among anesthesiologists is typically in the higher frequencies and is exacerbated by background noise, such that conversation in the operating room and detection of equipment alarms can be difficult. Lip reading is often used to supplement hearing loss, but surgical masks obscure these hints. In the report of Wallace et al. (2), 40% of anesthesiologists older than age 65 were unable to detect one or more of the standard equipment alarms.
Other psychomotor and perceptual processes that deteriorate with age and are specifically important to anesthesiologists include the ability to perform complex tasks rapidly, to adapt to new and quickly changing conditions, to process incoming information and make complex decisions, and to perform effectively in a stressful environment (21).
Perhaps the greatest challenges to aging health care professionals are in the psychosocial realm. Several reports have documented a relatively frequent rate of psychological morbidity among physicians in high-intensity specialties who are in the middle and late stages of their careers (25,26). These report such problems as decreased job satisfaction, increased anxiety, depression, and burnout. The practice of anesthesiology has been specifically identified as stressful for middle-aged people (27). Evidence for this observation is drawn from the increased incidence of suicide (8,10) and substance abuse (28) among anesthesiologists as compared with other physicians.
Fatigue resulting from prolonged duty cycles, night call, and disturbances of the sleep/activity cycle is a frequently cited challenge for all anesthesiologists (29–31). Long work hours and 24-h on-call periods are particularly stressful for the older anesthesiologist (32). Nevertheless, older anesthesiologists often work long hours. Among respondents 60 yr and older, 40% worked 50–59 h/wk, 24% continued to work 24–30-h shifts, and 15% reported work weeks >80 h (31).
Increasing age is generally associated with a decreased tolerance of shift-work cycles and a greater tendency toward late night errors (33). Older individuals tend to awaken earlier in the morning, to have difficulty getting to sleep and staying asleep at night, and to have a greater need for a late afternoon nap (34). This tendency toward “morningness” and difficulty with nocturnal sleep makes elderly people better suited for early morning shifts and less well suited for late work or 24-h calls. Older general practitioners report a decreased ability to recover after night shifts, with a disproportionate adverse effect on the next day’s work (35). Among older anesthesiologists, night call is the most stressful aspect of practice and the most frequently cited reason for retirement (32). In the majority of those retirees, early retirement would have been unnecessary if night call had been avoidable.
A major challenge for the health care system is how to ensure that the aging anesthesiologist maintains his or her base of knowledge and clinical competence. It is notoriously difficult to accurately ascertain clinical skills among experienced practitioners (36–38). Gaba (39) has made a strong argument for the use of simulators for the evaluation and training of both anesthesia residents and experienced practitioners. Others have advocated a series of performance-based clinical assessments to be conducted longitudinally over the physician’s entire professional life span (40). Regardless of the instrument chosen, the problem remains that programs for continuing education and evaluation of anesthesiologists are currently voluntary. The American Board of Anesthesiology has established a recertification examination, but this is currently optional except for the most recently trained anesthesiologists.
Aging is associated with an increase in peripheral vascular resistance and a consequent increase in systolic and diastolic blood pressure. More than half of Americans older than 65 yr are hypertensive (41).
Acute changes in cardiovascular dynamics have been observed among anesthesiologists at work. 1 In our study (42) reporting responses among anesthesiologists while they were administering an anesthetic, significant changes in heart rate and blood pressures were recorded. Heart rates >100 bpm, diastolic blood pressures >100 mm Hg, or both were observed in nearly 20% of the anesthesiologists.
However, there is no evidence of an excess of cardiovascular disease among anesthesiologists. In the study of Bruce et al. (7) of mortality among anesthesiologists, coronary and atherosclerotic heart disease was the leading cause of death (46%) but was less than for the control population. Cardiovascular deaths accounted for 57% of the mortality in Lew’s study (10), again not more than that experienced by the Control group. And in the study of Alexander et al. (8), cardiovascular disease was the most frequent cause of death in both groups studied but was less frequent in anesthesiologists (39%) than in the control population of internists (43%).
Other physiologic changes affecting the older anesthesiologist’s cardiovascular system have the potential of affecting his or her practice. A decline in ejection volume, cardiac output, maximum oxygen consumption, and maximal work rate can have an adverse impact on the physical stamina necessary for a busy anesthesia practice.
Arthritis and decreased psychomotor speed are often observed among the elderly. These together work to impede the manual dexterity necessary for an appropriate and rapid response to the many urgencies in anesthesia practices. Specifically affected are the fine motor skills important for anesthetic procedures. A portion of this handicap is compensated by years of repetitive practice and experience.
Aging among anesthesiologists raises a number of legal issues. Federal regulations and laws play a significant role in the decision of whether an older anesthesiologist is permitted to continue to practice. In general, state law and hospital bylaws conform to federal requirements.
The Age Discrimination in Employment Act of 1967 (ADEA) is probably the most important of the federal laws that pertain to the aging anesthesiologist. The ADEA, along with its subsequent amendments, extends to employees between the ages of 40 and 70 yr the same protections provided for race, color, religion, sex, and national origin by Title VII of the Civil Rights Act. The primary goal of the ADEA is to prohibit mandatory retirement rules based solely on age.
The ADEA proscribes only arbitrary age discrimination in employment practices. There are exemptions to its prohibition against age discrimination. In general, these exemptions are most clearly justified when the age discrimination claim involves public safety issues. The anesthesiologist’s employer, who would assert a public safety claim as the rationale for making age a factor in an employment decision, must prove that there is no alternative and that removal of the aged anesthesiologist will protect public safety.
Anesthesiology, similar to other high-stress practices, is regarded by many as a young person’s specialty. In general, anesthesiologists retire at a younger age than do physicians in other specialties (43,44). Anesthetists in the British National Health System have excesses in both ill-health and normal, early-age retirements (43). Within the British National Health System as of 1997, the median retirement age for anesthesiologists was 53.4 yr, as compared with 56.6 yr for other doctors (12).
The largest number of ASA members in the year 2000 was between the ages of 35 and 44 yr (37%) (3); 26% were ages 55 yr or older (a transient but large increase in the number of anesthesia residents during the mid- and late 1980s has skewed the age demographics toward younger anesthesiologists). Among retirees in Connecticut, anesthesiologists were grouped within those specialties characterized by younger retirements (64–67 yr), in contrast to specialties such as dermatology and psychiatry, in which the age of retirement ranged from 70 to 74 yr (44).
We 2 found the average age of retirement among American anesthesiologists to be 64.1 yr, with a range from 49 to 77 yr. A number of factors influenced retirement age, but the most significant was defined by the nature of the individual’s practice. Those in private practice retired younger (age 62.5 yr) as compared with anesthesiologists in university practice (64.8 yr).
The decision to retire from the practice of anesthesiology is complex. A number of considerations—professional and personal—play a role in this monumental career move. In our study (32) of recently retired anesthesiologists, we found that “demands of night call,” “demands of work load,” “burnout,” and “economic factors” were the most frequently cited reasons for retirement. Travis et al. (31) point out that the majority of anesthesiologists retired when they “felt it was time” on the basis of a number of subjective observations.
Physicians in general tend to deny issues involving their own aging and delay retirement planning until late (perhaps too late) in their professional lives (45). Anesthesiologists as a group are relatively proactive about retirement planning. Eighty percent of anesthesiologists older than age 50 yr report that they have already planned for their retirement (31).
A growing number of anesthesia practices are establishing phased retirement plans (46). This type of arrangement, essentially a shared or part-time position, has proved to be practical and effective among anesthesia residents (47). These formal agreements permit senior members of the group to slow down by eliminating certain aspects of practice (for example, night call or open heart surgery) in return for specified considerations (typically a cut in pay). This agreement can be advantageous to both the group, which continues to benefit from the maturity and experience of its senior partner, and the senior partner, who is permitted to do what he or she does best, unfettered by some of the more disagreeable aspects of practice (48). In many cases, a phased retirement has permitted a valued member of a practice to continue for some additional years. The most challenging aspect of these agreements is to create a formula that equitably values various aspects of practice so all members feel that they are treated fairly (49).
There are major psychosocial ramifications to the decision to retire (50). For many physicians, work is their self- defining activity, and the loss of their identity as a doctor after retirement can be traumatic (37). This difficulty can be minimized if retirement is viewed as a final career move and is planned and implemented as meticulously as previous career moves (51).
Two other major areas of concern for the retiring anesthesiologist are financial and health security. Financial security in retirement depends on resources available from Social Security, pensions (deferred income), and personal savings. For most retiring anesthesiologists, the majority of their retirement income will come from pensions.
Adequate health care is critical to any retirement plan. Health insurance is notoriously expensive and difficult to obtain for older individuals. According to the provisions of the Consolidated Omnibus Budget Reconciliation Act of 1985, anesthesiologists who retire are entitled to continue to participate in their existing health insurance plan for 18 mo after they leave practice. Then the insurer is no longer obliged to underwrite health insurance for any retiree. For most retiring anesthesiologists aged 65 yr or older, the principal source of health insurance is Medicare.
Potential expenses incurred from long-term care and chronic health problems must also be considered in retirement plans. In general, private health insurance covers little toward long-term care. Similarly, Medicare pays little, if anything, toward prolonged hospitalization (beyond 90 days of hospitalization within one “spell of illness”) or confinement in a skilled nursing facility. There are also significant limitations on Medicare coverage of prescription drugs, physical therapy, and home health services. There is no Medicare coverage for intermediate care or for custodial facilities. Frequently, older people purchase long-term-care insurance to provide the needed coverage.
The medical specialty of anesthesiology has the potential to provide great benefit and great harm to the anesthesiologist, as well as the patient. The process of aging imparts some definite advantages and some disadvantages to a practicing anesthesiologist. From a purely biologic perspective, aging is associated with a predictable and progressive deterioration in mental, physical, and behavioral functions. However, healthy aging is associated with experience, mental growth, wisdom, and enhanced capacity for prudence, reasoning, and planning. By applying the same degree of forethought to this stage as has been brought to bear on previous transitions in professional life, the older anesthesiologist can continue to actively participate in a productive practice.
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