Ferdinand Sauerbruch (1875–1951) was one of the world's greatest surgeons. As a brilliant diagnostician and exquisite technician, he attracted to his clinic and operating theaters at Charité Hospital in Berlin a stream of students and patients from across Europe, Russia, and the United Kingdom.
In his late 60s, however, Sauerbruch began to change. Colleagues noted that he “had sudden changes in mood and periods of forgetfulness.” He “struck assistants with instruments during operations”—operations, which were “performed with growing clumsiness, dragging tissues and tearing blood vessels.” The faculty and administration of the Charité, warmed by the reflective glow and financial flames of his international fame, failed to act; individual efforts by his friends suggesting retirement were met with flat refusal. A prominent actor died from bleeding during a simple herniorrhaphy; a child succumbed when Sauerbruch failed to restore gastrointestinal continuity after a stomach resection. He finally relented in 1949, at age 74, when threatened with a humiliating public dismissal.
Even then, Sauerbruch had little insight. He continued to operate at his home, with disastrous results. His 1953 autobiography is titled Master Surgeon.
IS THE AGING SURGEON STILL A PROBLEM?
Sixty years after Sauerbruch's dismissal, there is overwhelming anecdotal evidence and some published evidence that the aging surgeon remains a problem.
Hartz et al1 found that mortality rates of surgeons performing coronary artery bypass grafts increased with increasing years of practice. Older surgeons performing carotid endarterectomy had higher mortality rates than younger surgeons in the study of O'Neill et al.2 Laparoscopic inguinal herniorrhaphy led to higher hernia recurrence rates when performed by older surgeons when compared with younger surgeons.3 Waljee et al4 examined the files of 461,000 Medicare patients and reported that older surgeons did have higher operative mortality rates for pancreatectomy, coronary artery bypass grafts, and carotid endarterectomy relative to younger surgeons, but the difference was small and limited to surgeons with low procedure volumes. She concluded that “surgeon age is a relatively weak predictor of operative mortality in aggregate and certainly much worse for discriminating performance among individual surgeons.”
Those few individual surgeons, however, are the problem, a problem encountered by nearly every chief of surgery, vice-president of medical affairs, and hospital president sometime during his or her tenure. One of us (M.R.K.) sought anecdotes from members of the Society of Surgical Chairs and was told, “he fell asleep taking down the internal mammary artery,” “had to organize an ‘intervention’ led by other senior/retired surgeons,” “operating room nurses were in tears in my office, saying ‘you must stop him.’”
Compounding the problem, a lack of self-awareness is common, though not exclusive to, this small group of problematic senior surgeons. A survey of 995 surgeons by Greenfield's group5 found that most senior surgeons reported no changes in perceived cognitive abilities with age. A review of this subject in 2006 concluded, “the preponderance of evidence suggests that physicians have a limited ability to accurately self-assess.”6
How large a potential issue is this? The American College of Surgeons lists 5763 senior fellows older than 70 years, a category defined as “actively practicing but no longer required to pay dues.” Given that only 25% to 30% of surgeons are fellows at all, the total number of septuagenarian surgeons practicing approaches 20,000.
ARE SURGEONS HUMAN?
As is true of everyone else, surgeons face the inexorable deterioration in cognitive and physical faculties that accompanies increasing age. Decrements in sensory function such as vision and hearing are expected by all. Similarly, we all experience varying declines in visual-spatial ability, inductive reasoning, verbal memory, and other areas of cognition.7 An elderly physician's vast fund of knowledge and experience is not sufficient to mitigate the inevitable change in cognition. Habitual memory is better preserved than controlled analytic memory,8 but the surgeon needs both.
Greenfield's group9 studied surgeons specifically, testing visual sustained attention, which also addresses stress tolerance, reaction time, which addresses psychomotor abilities, and visual learning and memory, which also addresses visual-spatial organization. Although surgeons performed better than the general population in psychomotor areas, there was nevertheless “considerable decline with age” in virtually every test.
IS A MANDATORY RETIREMENT AGE THE ANSWER?
Establishing a mandatory retirement age for surgeons would be a straightforward solution but would be inappropriate and unfair due to the vast variability in function among older individuals of a given age.
The Age Discrimination in Employment Act of 1967 outlawed forced retirement based on age; this is enforced by the Equal Employment Opportunity Commission, an agency of the Department of Justice. Congress has approved fixed retirement ages for a number of professions that impact public safety: commercial airline pilot (65 years), Federal Bureau of Investigation agent (57 years), National Park Ranger (57 years), air traffic controller (56 years), lighthouse operator (55 years). Mandatory retirement for surgeons does exist in many countries, but not in the United States.
Nor should there be a mandatory retirement age for surgeons. There is impressive variability in the rate of cognitive and physical decline—variability which increases with age. Eva's review8 of changes in cognitive processing among aging physicians concluded that “one of the more robust findings in ageing research is that the variability across the scores individuals receive tends to increase with age.” Only 7 of 108 senior surgeons performed significantly below the younger surgeons on more than 1 of 3 tests administered by Drag et al.10 They concluded, “age alone is not a sufficient predictor of cognitive performance.” A number of Chairs of Surgery lauded surgeons who “are still excellent at age 73” and “continued to operate until 80 and was superb.”
Other arguments against a mandatory retirement age include the fact that treatable causes of poor performance may be found (eg, medication adverse effect, severe depression, neurologic disease, sleep apnea, vision problems) and the tendency in society as a whole toward ageism, prejudice based purely on chronologic age.
BUT DOES THE SURGICAL PROFESSION POLICE ITSELF?
The public believes that we police ourselves, but this is illusory. Initial certification to be a surgeon is difficult but recertification is relatively easy. Ongoing professional practice evaluations, mandatory in all hospitals every 6 months, are hospital-specific and highly variable. Our malpractice system is neither constructed nor capable of hobbling bad doctors. We are left with the scrutiny of our peers, and, with respect to the aging surgeon, many barriers to this exist.
Senior surgeons are the most respected members of their community. They have been the teachers and mentors of their younger colleagues, some of whom may now be their chief. These younger colleagues may even become “enablers,” assigning senior residents to assist, the best scrub nurse, the most experienced anesthetist. The senior surgeons have brought fame to their hospital and have been the “rain-makers” for surgical volumes. Few medical staff bylaws contain any provision for dealing with an aging staff physician. Some changes in performance may be hard to document, falling into a gray zone of worrisome-but-within-standard-practice. It often takes a patient death or a sentinel event to force action.
We must do better, or others will impose arbitrary rules such as mandatory retirement. We are a profession (from the Latin, “to speak forth”), and it is ethically imperative. Ironically, in many states, it is more difficult to maintain one's driving privileges than one's surgical privileges. Two states, Illinois and New Hampshire, require a road test at age 75 and 10 states require a vision test at a specific age.
What can we do that balances patient safety and liability risk with respecting the dignity of a committed surgeon and his or her value to society? (Fig. 1)
THE AGING SURGEON PROGRAM
The Aging Surgeon Program is a 2-day comprehensive, multidisciplinary, objective, and confidential evaluation of a surgeon's physical and cognitive function. It is one option for striking that balance illustrated earlier.
Ironically, this was advocated by the American College of Surgeons 20 years ago. In a monograph published by the newly formed Committee on the Impaired Physician of the Board of Governors (now the Workforce on Physician Competency and Health), the authors wrote, “Specific mechanisms must be developed to address issues of age-related decline in skills” and “The review procedure must include an assessment of physical, psychological, and intellectual functions.”11 Greenfield wrote 2 years later, “Both cognitive and functional test results should be evaluated under controlled circumstances so that objective as opposed to subjective criteria for performance can be established.”12
Developed over 12 months of literature review, expert consensus, rigorous debate, and reiteration, The Aging Surgeon Program at Sinai Hospital of Baltimore opened on February 1, 2014. The goals of the program are as follows: protect surgeons from arbitrary or unreliable methods of assessing competence or cognitive capacity; identify potentially treatable or reversible disorders that, if treated, could restore or improve functional capacity; aid surgeons in deciding when to retire; protect patients from unsafe surgeons; protect surgeons and hospitals from liability risk; rely on existing structures for using results to make credentialing and privileging decisions; and provide objective, comprehensive, unbiased evaluation.
Our multidisciplinary team includes experts in Surgery, Geriatric Surgery, Neurology, Neuropsychology, Physical Medicine and Rehabilitation, Ophthalmology, Internal Medicine, Legal Services, and Ethics. The program includes a pre-visit screen of medical history and appropriate recent radiographs (eg, magnetic resonance imaging), and then travel to Baltimore. Day 1 begins with general physical and neurologic examinations, physical therapy/occupational therapy evaluation (reaction time, distance judgment, coordination, dynamic visual-spatial acuity, fine-motor function, and more), and then lunch. The afternoon comprises neuropsychology testing (attention, memory, executive functioning, emotional status, and more), and then dinner and sleep. Day 2 encompasses a morning of neuropsychology, lunch, physical therapy/occupational therapy, ophthalmology, and an exit interview.
The resulting report will be sent as an encrypted locked electronic file to the individual who contracted and paid for the program, likely a chief of surgery, hospital president, or the surgeon him- or herself. The report will include only objective findings; decisions about privileges, retirement, or even lifestyle changes must be made by those who receive the report.
Triggers for the program may include the following: every surgeon 70 years or older at each hospital recredentialing cycle (typically every 2–3 years), failure of ongoing professional practice evaluation, failure of focused professional practice evaluation, a sentinel event, worrisome malpractice history, discretion of chief of surgery, or discretion of hospital president. Possible hospital actions may include: full privileges, no privileges, no operating privileges, assisted by another surgeon (routine, only complex cases), assistant privileges only, focused review of cases (all, certain number), or decreased work hours (eg, no on-call duties).
Human faculties—even those of surgeons—deteriorate with age, but there is great variability. Decisions about competency, therefore, should be based on functional age rather than chronologic age. This argues against a mandatory retirement age and argues for an objective evaluation of functional age. Such an assessment would balance the dignity of a committed practitioner and his or her value to society with patient safety and liability risk. One way to do this is presented, namely The Aging Surgeon Program, a comprehensive, multidisciplinary, objective, and confidential evaluation. Both the surgeon and society deserve no less.