As oncology workforce ages, need for objective assessment of competency increases

Although members of some professions — including pilots, air traffic controllers and certain judges — face mandatory retirement ages, there is no specified age cutoff for cancer specialists.

Older oncologists may be susceptible to burnout, which, in turn, may lead to mistakes and risk patient safety. Other concerns include cognitive dysfunction and worsening dexterity. For example, tremors, poor eyesight and reduced stamina may compromise the careers of oncologic surgeons.

Some institutions have their own way of assessing physicians’ performance as they age — such as through chart or peer review, or video recordings of operations — whereas others lack formal assessment protocols.

“The American College of Surgeons proposes that — somewhere between the ages of 65 and 70 years — there is a gradual decline in overall physical dexterity and cognition for some surgeons,” David P. Winchester, MD, FACS, FACR, medical director of cancer programs at the American College of Surgeons, and principal investigator for the National Cancer Database, told HemOnc Today. “Surgical oncologists are not immune to age-related decline or decline in cognitive skills.”

Still, cognitive impairment is not an automatic consequence of aging, and the American College of Surgeons does not favor a mandatory retirement age due to individual variation in such decline.

“Instead, they believe that objective assessment of fitness surpasses mandatory retirement,” Winchester said. “There is no objective set age when we can say it is time for an individual oncologist or surgeon to stop practicing. Instead, there are ways to stop someone who objectively cannot carry on treating patients, even though they may want to. There are mechanisms that can be used if any doubt arises about ... a particular oncologist or surgeon and their competency for taking care of a patient, which is their primary role.”

HemOnc Today spoke with medical oncologists and surgeons about whether a mandatory retirement age is appropriate, ways the clinical community can “police” itself regarding competency, how older clinicians in practice can stay current given the pace at which new research is published and treatments are developed, and how oncologists can ready themselves for retirement.

An aging workforce

The issue of retirement age is particularly relevant to the oncology community given the aging workforce and a projected shortage within the next couple of decades that could have a considerable impact on quality of care.

ASCO’s 2017 State of Cancer Care in America report states that an increasing number of oncologists in active care are nearing retirement. Nearly one in five (18.4%) oncologists is aged 64 years or older, whereas 13.3% are aged younger than 40 years.

More than one-fourth of oncologists practicing in Delaware, Hawaii, New Mexico, Nevada and West Virginia are nearing retirement, with Hawaii and Nevada having far fewer new, younger oncologists available to replace those nearing retirement, according to the report.

In addition, results of a 2007 ASCO survey showed the expected retirement age of respondents was 64.3 years, and most oncologists who were still working after age 64 planned to retire within the following 3 to 4 years.

Although there are some aspects of practice that improve as an oncologist ages and gains more career experience, other issues become more of a challenge. Physician burnout often is cited as a reason that could prompt early retirement, thus impacting the oncologist shortage, although some research suggests rates of burnout are lower for older oncologists than for other medical professionals.

“There is an increased risk for burnout as one ages, in addition to the fact that our ‘energy of youth’ becomes increasingly diminished and our ‘enthusiasm of youth’ becomes increasingly depleted as one faces cutbacks, challenges and the wider introduction of the electronic health record system, which has led to more stress and less time spent with actual patients,” Mark J. Clemons, MBBS, MSc, MD, professor of medicine in the division of medical oncology at The Ottawa Hospital Cancer Centre, and the department of medicine at University of Ottawa, told HemOnc Today.

The 39% rate of burnout among those in the field of oncology is largely due to the emotional and intensive workload that often is unique to oncology, according to George P. Canellos, MD, professor at Harvard Medical School and medical oncologist at Dana-Farber Cancer Institute.

“Some of our patients who we care for are quite unwell and may die of their disease,” Canellos told HemOnc Today. “This, of course, takes a toll on the emotions of the oncologist. In this sense, the oncologist may gladly welcome retirement to be free of this. I am not aware of too many community oncologists who see a downside to retirement, as most busy oncologists have welcomed retirement if it was indeed possible and comfortable financially for them.”

Surgeons’ skills

A survey on retirement among neurosurgeons conducted by Maya A. Babu, MD, MBA, fellow in the department of neurological surgery at Ryder Trauma Center at Jackson Memorial Hospital in Miami, and colleagues revealed a majority of neurosurgeons believe their older colleagues should undergo additional assessments beyond standard maintenance of certification examinations.

However, two-thirds (67%) of 1,449 respondents indicated there should be no absolute age cutoff at which neurosurgical practice should be forced to end.

Fifty percent 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.

“If we are going to consider imposing restrictions on the field, it is important that we know what the field thinks — and now we do,” Babu told HemOnc Today when the study was published. “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.”

Some surgeons believe they start to lose their technical or cognitive abilities as young as in their 50s, Babu said.

“At the same time, some surgeons practice well into their late 70s and are still technically adept,” she added. “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.”

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 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.

Source: Christiana Care Health System.

“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 told HemOnc Today. “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.

‘Policing’ strategies

In their paper, Babu and colleagues discussed the need for the clinical community to “police” itself regarding when retirement is appropriate.

However, this may be virtually impossible for the general oncology community to do, because there is no tribunal system that appreciates the issue of an oncologist slowing down and retiring, Canellos said.

“I do not think that this is a broad societal or state process at the moment but could be something that is decided at the local hospital level where the oncologist practices,” he said. “If the local hospital feels as though the physician is slowing down and has received patient complaints, then these factors get communicated to the hospital and there is a system that is already in place that evaluates these types of situations.”

In instances where there is concrete evidence showing a physician is making regular mistakes for any reason, then one can expect to have a conversation with administration. The individual physician should accept this recognition from their colleagues and agree to slow down their practice or retire, Canellos said.

ASCO, ASH and other oncology professional societies do not have guidance in place on retirement age, and legal restrictions prevent institutions from “harassing” a physician who is aging and slowing down with no concrete evidence to back up these types of claims. Still, the reality is that physicians are surrounded by colleagues who may notice deterioration in work performance and most hospitals have quality officers who monitor this, Winchester said.

“There is always a focus on physician performance and, if there is deterioration, it will be recognized by one or several of those who monitor performance of the more senior staff,” he said. “It also is suggested that surgical oncologists who are reaching the age of 70 years should undergo regular health evaluation to monitor their health and vision. This is something that can be done by their personal physician in a confidential manner and is something that I did at that age.”

Robert F. Ozols, MD, PhD, who served as senior vice president and chief clinical officer at Fox Chase Cancer Center until his retirement in 2008, said that although there is concern regarding increasing age and the risk for medical errors, he is unaware of data showing a correlation between the two. Also, medical malpractice companies do not increase premiums due to the age of the physician.

“There is no doubt that medical errors occur and should be addressed and prevented,” Ozols told HemOnc Today. “It is essential that we have a culture where physicians do not hide possible mistakes and where their colleagues are able to raise questions about the care they are providing.

“We should be open about our errors,” he said. “We do already have strict credential procedures that have been in place for years where physicians that practice at hospitals are re-evaluated every year or every 2 years and patient- or staff-reported errors are evaluated.”

As physicians age, there will always be the potential for mistakes, but this is countered by the experience an older oncologist has, according to Ian F. Tannock, CM, MD, PhD, DSc, professor emeritus of medical oncology at Princess Margaret Cancer Centre in Canada.

“In Ontario, all physicians who continue to practice are reviewed in their 70th year. The licensing agency at College of Ontario sends a physician to a respective institution to review charts of about 20 patients or so [who] an aging physician has treated, as well as a review of any emergencies they were a part of,” Tannock, who retired from clinical practice in 2014, said during an interview. “On average, about 70% of physicians are absolutely fine, but roughly 15% are recommended continuing education and the other 15% are advised to retire or go through additional routine training.”

In an editorial that accompanied the study by Babu and colleagues, Kerry D. Olsen, MD, professor of surgery in the division of medical otolaryngology at Mayo Clinic in Rochester, Minnesota, suggested an additional way for the clinical community to monitor itself regarding retirement.

“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,” Olsen wrote.

Experts with whom HemOnc Today spoke agreed this is a moot point for oncologists.

“Asking a younger colleague about failing ability is not viable, but can instead be challenging, because who is to say that the younger colleague knows more or is correct?” Clemons said.

“One of the things that comes along with having gray hair is the experience with toxicity,” Clemons added. “As we age, we have inadvertently harmed our patients with toxicities and the threshold for avoiding this harm decreases with increasing age. If anything, it should be the other way around — older colleagues should look after our younger colleagues.”

Evolving practice

It has been suggested that, as aging physicians spend more time invested in administrative work and less time in clinical care, they may be at risk for being out of touch with current practices and research.

“Although I agree it can be concerning if a physician is only taking part in a very small amount of intimate clinical work, this tends not to happen at most institutions. We have time-limited terms for administration at Princess Margaret Cancer Centre,” Tannock said. “I avoided being out of touch with current practice by conducting the maximum amount of administrational work during my mid-50s and then later went back into clinical practice and research work at a later age.”

Given the pace at which new research is published and presented and new treatments — some of which are extremely effective but carry risk for unique and severe toxicities — are developed, the need to stay current in practice is key for every oncologist.

“The pace of innovation of novel therapeutics for the field of oncology is moving quite rapidly,” Canellos said. “If one is to stay abreast of this in practice and treat the new metastatic melanomas, for example, or any of the other diseases for which new treatments exist, we have to re-educate ourselves by attending medical meetings, reading the medical journals, and attending postgraduate courses that are now available across many institutions. Re-education is a must at any age and should be routine for oncologists if they want to continue treating patients.”

It is possible for aging oncologists to become reasonably well-versed in the evolution of the practice of oncology, Canellos said.

“We have always had to do this throughout our careers as oncologists,” he said. “The only difference now is that the science is coming out at a rapid pace, and we now have to ‘bone up’ if we are to stay in clinical practice.”

Moving beyond oncology

Still, the time will come when retirement is necessary and, before then, fear may drive many physicians to stay in practice and work longer than they should.

“A lot of oncologists are afraid of transitioning out of working 60 hours per week to working zero hours per week,” Tannock said. “Many are not ready to retire for various reasons — I certainly was not ready when it came time to retire from practice. However, it was a bit easier for me to move out of clinical practice and into an advisory teaching role, as I have been quite fortunate to still be able to participate in international work. I still teach in various places around the world and chair data monitoring committees for clinical trials, among other things.”

For those who do not wish to retire entirely, transitioning into a mentorship role may be a viable option.

“Older oncologists who remain reasonably sharp mentally can mentor quite well, which is something that I personally enjoy doing,” Tannock said. “As the older generation, we have a wealth of experience and knowledge to offer our younger colleagues.”

Winchester agreed.

“Moving into a mentorship role is a common practice for many older physicians — if there is a role for mentorship, many older physicians thoroughly enjoy becoming mentors for the newer generation of physicians,” he said. “This role is widely accepted by most.”

In a 2013 paper published in The Oncologist, Clemons and colleagues wrote that, although “the practice of oncology demands a lot of time in close contact with anxiety, distress and premature death ... most oncologists manage to achieve a balanced life by maintaining an interest in research, teaching and the well-being of patients.

“Nevertheless, we should all plan for a future beyond full-time oncology,” they added. “Although we may have informal ‘corridor discussions’ about retirement, usually with older colleagues, there is little practical guidance for a successful transition into retirement.”

The authors additionally emphasized the importance of having a succession plan in place for the practice from which an active oncologist is retiring.

“De-escalating one physician will often lead to a higher workload for other practice members, if a replacement is not being incorporated,” they wrote. “A written plan can ensure a smooth transition. Such strategies also require the cooperation of many, including partners, patients, hospitals and professional liability insurers. Practices that report a crossover period of ‘shared care’ between the outgoing practitioner and the incoming practitioner report high patient satisfaction.”

Retirement is a process and not something that should be simply decided tomorrow, but rather it is something that should be planned for at length, Clemons said.

“Retirement for anyone in any career should be something that one plans toward with their financial planner, spouse and family members over a long period of time,” he said. “It should include what someone wants for the remainder of their life. Everyone should think about retirement at an early age, and it should be considered a positive thing.

“As oncologists, we spend our lives treating patients who die prematurely,” he added. “I believe this is something that we should all learn from as we know that the average age of death among physicians for the past 2 decades is 77 years. We have to make these decisions early on so that we can enjoy the ‘retirement stage’ of our lives that we have earned and worked hard toward for much of our lives.”

Tannock agreed.

“We have given a significant proportion of our lives to our profession and when suddenly faced with retirement, this can be quite frightening for some,” Tannock said. “We really need to make retirement more attractive. For me, retirement has not been difficult at all.” – by Jennifer Southall

Click here to read the , “Should there be a mandatory retirement age for surgical oncologists?”

References:

ASCO. J Oncol Pract. 2017;doi:10.1200/JOP.2016.020743.

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

Erikson C, et al. J Oncol Pract. 2007;doi:10.1200/JOP.0723601.

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

For more information:

George P. Canellos, MD, can be reached at Harvard Medical School, 25 Shattuck St., Boston, MA 02115; email: george_canellos@dfci.harvard.edu.

Mark J. Clemons, MBBS, MSc, MD, can be reached at The Ottawa Hospital Cancer Centre, General Campus, Room: C2321, 501 Smyth Road, Ottawa, ON, Canada K1H 8L6; email: mclemons@toh.ca.

Robert F. Ozols, MD, PhD, can be reached at Fox Chase Cancer Center, 333 Cottman Ave. # P2051, Philadelphia, PA 19111; email: robertozols@comcast.net.

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.

Ian F. Tannock, CM, MD, PhD, DSc, can be reached at Princess Margaret Hospital, 610 University Ave., Room 5-208, Toronto, Ontario M5G 2M9; email: ian.tannock@uhn.ca.

David P. Winchester, MD, FACS, FACR, can be reached at American College of Surgeons, 633 N. Saint Clair St., Chicago, IL 60611; email: dwinchester@facs.org.

Disclosures: Canellos, Clemons, Ozols, Petrelli, Tannock and Winchester report no relevant financial disclosures.