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The aging orthopedic surgeon: An area we need to address before others do it for us
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We have educated ourselves and improved our ability to recognize the signs of substance abuse in our colleagues. We also realize our responsibility to offer help to and report impaired colleagues. Partly as a result of these efforts, many physicians in crisis have been encouraged to seek help and now have the opportunity to participate in excellent rehabilitative programs and functionally return to their practices. A somewhat-related area in which we need more research and education is evaluating the retention of surgical privileges for the aging orthopedic surgeon.
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The aging physician has the potential to have significant losses in cognitive and/or motor skills. Recertification every 7 to 10 years and hospital credentialing every 2 years allows for significant windows that may not detect diminishing skills. Recent American Academy of Orthopaedic Surgeons (AAOS) surveys have shown the average full-time practicing orthopedic surgeon is 49.2 years old and the average age of part-time orthopedic surgeon is 66.7 years. This disparity may represent self policing, individuals slowing down and choosing a less stressful practice setting or a combination of both.
More than one-third of physicians in this country are older than 60 years. The number of physicians older than 65 years will increase as the baby boom generation continues to age. I recently informally surveyed orthopedic surgeons practicing beyond age 70. There were three main reasons they were working: choosing to continue doing something they enjoyed and that gives them meaning; having to continue as a result of financial pressures related to past decisions and choices; and some said they were still working to support their hobbies and other outside activities.
An example that made me acutely aware of these issues occurred more than 35 years ago. I remember an older orthopedic surgeon whose motor skills were failing quite rapidly primarily related to multiple sclerosis. He had noticeable impaired dexterity in his hands and strength in his upper extremities. His gait was affected. He was loved by his patients and colleagues. I was amazed how many patients would still consent to, and schedule surgery with him, even as they could see his obvious physical impairments. As his colleagues, we agreed he should not be operating and would take turns doing his surgeries. I remember having short discussions at the beginning of every case to get him to give me the knife and to have him be the first assistant. As his health failed rapidly, he stopped his practice. It would have been hard for his colleagues to step in earlier and with help and close supervision; he was able to go 1 year longer doing what he loved.
That was not the best example of aging, but more so of a progressive neurologic disability in an older surgeon. We all have seen many examples of physicians retaining their skills and mental acuity well into their 70s, 80s and even 90s. However, we as medical professionals are not immune to the ills and diseases that increase with aging. Early onset Alzheimer’s, dementia, Parkinson’s and other neurologic and degenerative conditions touch the lives of orthopedic surgeons as often as they do our patients.
Cognitive and motor skills testing
There are those in society and within our medical communities who suggest that we need more formal screening processes to protect patients from physicians who may become impaired through the aging process before a catastrophic occurrence requires removal of their license. The question we must answer: Are there currently too few safeguards to protect patients against those who should no longer be practicing?
There have been studies that show physicians who have been out of their training more than 40 years have more disciplinary actions then those out less than 10 years. There are some explanations for those finding in addition to age. Other studies have suggested increased patient mortality and complication rates when the surgeon was 60 years old or older in large and complicated surgeries. However, those differences have not held up, in routine operations.
Proposed screening
Many critics of our current screening and credentialing related to their appropriateness for the aging physicians suggest we should have a system similar to commercial airline pilots. They are similarly entrusted with people’s lives. However, they have forced retirement at age 65. They undergo frequent physical and mental exams starting at age 40. Should physicians have some sort of physical and mental competency test? Are our recredentialing and recertification processes addressing these issues?
Testing the cognitive and motor skills in young physicians to eliminate those who will not be good doctors is not the same science we would like to use. Can you imagine annual screening of doctors who reach 60 or 70 years of age? Poor performance and competence can be attributed to a multitude of factors other than aging. Currently, physicians have to meet requirements to continue to practice. To renew a medical license in most states, doctors must complete a certain number of hours of continuing medical education (CME). Action is only considered when a doctor’s behavior or their medical complications starts to become noticeable by other physicians and nurses. Mild impairments often start subtly and may become more apparent and aggravated in stressful situations. This is an area in which we need much more meaningful research, involvement of our profession and education material on what we do know and how to react.
Researchers have evaluated, studied and written volumes on the competency and training of young physicians, but we know much less on how aging affects a physician’s performance. When should an orthopedic surgeon lay down the scalpel and stop evaluating patients in the clinic?
Refusing to employ or allow capable aging physicians to practice would be a travesty and at least an illegality. We all are placing another candle on the birthday cake each year; that alone is no reason to limit privileges. On the other hand, allowing a few physicians to work after their skills are compromised endangers the public. If we do not take this on in a meaningful way; I can see more legislators and regulators getting involved in aspects confronted by some aging physicians.
Editor's note: Read some of the responses to Dr. Jackson's Commentary in Letters to the Editor.
- Douglas W. Jackson, MD, is chief medical editor of Orthopedics Today. He can be reached at Orthopedics Today, 6900 Grove Road, Thorofare, NJ 08086; e-mail: OT@slackinc.com.