Surgeons must do better job ‘policing themselves’ regarding retirement

A majority of neurosurgeons believe aging members of their field should undergo additional testing or evaluation beyond standard Maintenance of Certification examinations, according to results of a survey published in Mayo Clinic Proceedings.

Members of some professions — including pilots, air traffic controllers and certain judges — face mandatory retirement ages, but there is no specified age cutoff for surgeons.

Maya A. Babu, MD, MBA, fellow in the department of neurological surgery at Ryder Trauma Center at Jackson Memorial Hospital in Miami, and colleagues surveyed neurosurgeons about their attitudes toward ceasing practice and skill testing in later stages of their careers.

Babu said her observation of more senior peers who continued to perform operations prompted her to think about how careers in medicine evolve, and the questions that arise related to the timing of when surgeons should think about transitioning from practice.

“If we were going to consider imposing restrictions on the field, it is important that we know what the field thinks — and now we do,” Babu told Healio.com. “Neurosurgeons do not think there should be an age cutoff. The flipside is that there is a responsibility of the neurosurgeon community to do a better job at policing itself.”

Babu and colleagues sent surveys to 4,899 practicing and retired neurosurgeons to assess their perceptions of testing aging members of the field. Investigators received 1,449 responses (30% response rate). The majority (65%) of neurosurgeons who participated were aged 50 years or older.

Two-thirds (67%) of respondents indicated there should be no absolute age cutoff at which neurosurgical practice should be forced to end.

However, half (50%) of respondents indicated neurosurgeons aged 65 years and older should undergo additional testing; 59% suggested maintenance of certification exams should include a review of individual case logs and patient outcomes; and 42% indicated maintenance of certification exams should be tailored to accommodate aging neurosurgeons.

It is not surprising that most neurosurgeons support allowing members of the field to decide when their clinical practice should cease, Babu said.

“There are some surgeons who think that — even in their 50s — they might begin to lose their technical or cognitive skills,” Babu told Healio.com. “At the same time, some surgeons practice well into their late 70s and are still technically adept. Surgeons may have a very small repertoire of cases that they perform, but they have developed so much expertise in volume that they do quite well clinically.”

Still, the field would benefit from more guidance regarding when surgical practice should cease, Babu said.

“We need parameters to review cases more frequently when a surgeon is of a certain age,” she said. “We will need more peer involvement so that the burden of the decision is not on one person, but rather a group of experts to decide when someone needs to start scaling back.

“We also need to do a better job outlining pathways,” Babu added. “For a lot of older surgeons, there is a tremendous amount of knowledge that can be shared with residents and medical students. Perhaps an educational or mentorship role would be a good idea for some surgeons after retiring from the operating room.”

 

‘When is enough enough?’

The study examined a sensitive but clinically relevant issue, Kerry D. Olsen, MD, professor of surgery in the division of medical otolaryngology at Mayo Clinic in Rochester, Minn., wrote in an editorial that accompanied the study.

“Many surgeons have their entire identity and waking hours almost completely consumed by their practice,” Olsen wrote. “Some can just walk away, but stopping too early or too late or making a decision based on ill planning can be highly detrimental to both the patient and the surgeon.”

Olsen added that the research by Babu and colleagues helps to begin an important discussion for aging surgeons: “When is enough enough?”

The answer to that question often falls in a “grey zone,” Olsen wrote.

“A surgeon may decide not to operate out of wisdom gained from a long career or from an inner voice that seeks to avoid a lengthy, potentially complicated procedure with a possible unfavorable outcome,” he wrote. “The factors in evaluating competency go way beyond current medical knowledge or existing reported surgical outcome measures. This is an area of assessment that needs accuracy and completeness.”

Olsen offered the following advice to surgeons to guide their decision-making process:

All surgeons aged older than 60 years should select a younger colleague they trust and ask him or her to honestly assess and inform them if there are concerns raised by staff or others related to their surgical performance or decision making;

All surgeons, regardless of age, should undergo periodic reviews of their outcomes and decisions about surgical intervention and planning; and

Surgeons nearing the end of their careers should seek help with retirement planning beyond finances and benefits.

Also, hospitals and clinics should identify ways to use older surgeons’ knowledge and talents in capacities other than as “captain of the operating room,” Olsen wrote.

Options include performing less complex surgical procedures, helping others in the operating room, teaching inside and outside the surgical suite, and working in a medical practice that primarily assesses patients for surgery.

“One of my mentors told me that: ‘After 30 years of head and neck surgery — with its complications, cancer recurrences and patient deaths — get out. It takes a toll that most will not recognize until they stop. Do it before it is too late,’” Olsen wrote. “I did not exactly follow his advice but I did stop my surgical practice after 35 years. At least my younger surgical colleagues never had to tell me it was time to quit.”

 

Implications for oncology

The issues Babu and colleagues addressed in their study — and the feedback they received from survey respondents — are valuable to surgical oncology and other disciplines, according to experts with whom Healio.com spoke.

“[The researchers] have provided important information as to what mechanisms can be created to fairly evaluate aging surgeons,” Nicholas J. Petrelli, MD, FACS, Bank of America endowed medical director of Helen F. Graham Cancer Center and Research Institute and HemOnc Today’s associate editor for surgical oncology, said in an interview.

Petrelli said he is an advocate for ceasing surgical practice “at a certain age,” but he emphasized factors other than age play a role. He cited operating times, morbidity, mortality and hand-eye coordination demonstrated during surgical simulations.

“I hear all the time from my colleagues that there are 70-year-olds who run marathons, and I think that this is great. We are living longer than people did decades ago,” Petrelli said. “But if someone is 80 years old, their [coronary arteries] have been around for 80 years, and their circle of Willis has been around for 80 years. The worst thing to have is a surgeon who has a heart attack in the operating room while treating a patient. No matter what shape someone is in, as we age, we are at risk for all of these things. There has to be an age when we stop the active practice of surgery.”

Once a surgeon retires from the operating room, their experience can remain tremendously beneficial, Petrelli said.

“One can retire from the operating room, but this does not have to keep them out of the simulation operating room or one-on-one meetings with surgical residents and mentorship,” he said.

Sandra L. Wong, MD, MS, chair of the department of surgery and William N. and Bessie Allyn professor of surgery at Geisel School of Medicine at Dartmouth, agreed that the age of surgeons is a legitimate concern for surgical oncology and other medical fields.

“The solution does not necessarily have to do with a specific age — there is not a ‘magic retirement number’ for surgeons,” Wong said. “The difference in surgical specialties is that we start our actual practice at a later age than most because of the length of training. Many surgeons think they have trained for so long, they want to work longer. However, as a profession, we physicians need to do a better job at policing ourselves.”

Maintenance of certification examinations — and even additional cognitive testing — fail to accurately assess medical judgment and dexterity in the operating room, Wong said.

“[Neither] goes deep enough ... and, as we all know, maintenance of certification has faced a lot of criticism over the past 10 years,” she said.

Although much discussion focuses on career development for younger faculty members, conversations about the same topic — as well as succession planning — must be conducted for more senior faculty members.

“I am sensitive to the feeling of ‘being put out to pasture,’” Wong said. “People need career mentorship throughout their career. Although we sometimes struggle with how we mentor the next generation of surgeons, we do not necessarily have good plans in place for how we mentor or transition people in the later stages of their career.

“We assume that career mentorship is for when someone is getting started in the field, and this is the wrong tactic,” she added. “Our mid-level faculty need career mentoring, and our senior faculty need career mentoring, too. This, of course, will come in slightly different formats, and to say that all senior faculty would make good mentors is an assumption. Relegating all of our senior surgeons to teaching medical students is not the solution.”

Jamie S. Ullman, MD, FACS — professor of neurosurgery at Donald and Barbara Zucker School of Medicine at Hoftstra/Northwell and director of neurotrauma in the Northwell Neurotrauma Institute — said she does not favor a mandatory retirement age for surgeons but agrees that “age is a concern” when it comes to patient safety.

“Age is a consideration in terms of how well a surgeon functions, and we know that — over time — there is some decline in skills,” Ullman told Healio.com. “However, at the same time, I know a lot of surgeons who are operating well into their 70s and are doing just fine. It is all based upon the individual.”

Although she does not support mandatory cognitive testing, she said professional evaluations — which include case reviews, as well as analysis of surgical mortality and readmission rates — could serve as the basis for determining whether physical examination, visual testing or cognitive skills assessments are needed.

Financial stability and the role of professional fulfillment in maintaining cognitive abilities also should be considered, Ullman said.

“Some surgeons may not be able to retire financially, and some may be afraid that — by retiring — they will suffer cognitive and functional decline,” Ullman said. “Working keeps them active and able to engage and maintain their cognitive capacities.”

Physician burnout also should factor into retirement decisions, Ullman said.

“Historically, people have retired when they felt as though they had enough,” she said. “When we address the issue of when someone should retire, we need to be attuned to the signs of burnout.

“Considering all of this, there are ways to determine if a surgeon is still fit to practice,” she added. “Hospitals have to set up policies by which to review the practice of all surgeons, not just someone who is 65 years old or older. Nevertheless, the issue of the aging surgeon is an important and necessary conversation to have.” – by Jennifer Southall

 

References:

Babu MA, et al. Mayo Clin Proc. 2017;doi:10.1016/j.mayocp.2017.09.004.

Olsen KD. Mayo Clin Proc. 2017;doi:10.1016/j.mayocp.2017.10.002.

 

For more information:

Maya A. Babu, MD, MBA, can be reached at Department of Neurological Surgery, Ryder Trauma Center/Jackson Memorial Hospital, University of Miami, 1095 N.W. 14th Terrace (D4-6), Miami, FL 33136; email: mayababu@gmail.com.

Nicholas J. Petrelli, MD, FACS, can be reached at Helen F. Graham Cancer Center and Research Institute, 4701 Ogletown Stanton Road, Newark, DE 19713; email: npetrelli@christianacare.org.

Jamie S. Ullman, MD, FACS, can be reached at North Shore University Hospital, 300 Community Drive, Manhasset, NY 11030; email:jullman1@northwell.edu.

Sandra L. Wong, MD, MS, can be reached at Dartmouth-Geisel School of Medicine, 1 Rope Ferry Road, Hanover, NH 03755; email: sandra.l.wong@dartmouth.edu.

 

Disclosures: The study was supported by the American Board of Medical Specialties Visiting Scholars Program. Babu, Olsen, Petrelli, Ullman and Wong report no relevant financial disclosures.