Letters to the Editor

This month, it is a pleasure to share letters to the editor from old friends I have not seen in years. These letters, all in response to my Commentary “The aging orthopedic surgeon: An area we need to address before others do it for us," bring back fond memories of discussions and presentations we have shared when we were much younger. Personally, it has always been a real benefit in my thinking to publish my work and thoughts and then hear the thinking and criticisms of others. The comments are usually constructive and this is a wonderful tradition in our profession. It is how we all get better and how our thinking evolves.
— Douglas W. Jackson, MD
Chief Medical Editor

To the editor:

I wanted to comment on the Commentary “The aging orthopedic surgeon: An area we need to address before others do it for us," as I have had some personal experience in the area.

I have been trying for some time to have the leaders in the American Academy of Orthopaedic Surgeons consider a group called “Orthopedic Physicians” rather than “Orthopedic Surgeons.” If this could be done, I think it would help a great deal. The group could have their own sub-meeting, like the sports medicine group and other groups have. When Bob Hensinger was president, we put on a few events. I am not talking about retirement, but how orthopedic surgeons can continue to practice. We might add some of the items discussed in the editorial.

— G. Dean MacEwen, MD
New Castle, Del.

To the editor:

The aging orthopedic surgeon is an interesting and meaningful topic. I ended my work as a medical education director for The Colorado Personalized Education Program that had contracts with 20+ states. We evaluated physicians for state medical organizations and hospitals. It avoided conflicts of interest for our organization to evaluate the physician rather than hospital physicians where the physician worked. The aging physician was the toughest problem, especially if they were a surgeon. As you noted, the evaluations were often done too long after the physician was noted to be having trouble because of the interval between staff evaluations and the onset of the problem. I have an orthopedic problem now and have an orthopedist in his 70s. He stopped doing surgery in his 60s, but he is sharp and has kept up with the changes in practice and is a great one for the proper direction for treatment.

— Ralph Hall, MD, FACSM, FACP
Retired Vice President for Medical Affairs
Long Beach Memorial Hospital
Long Beach, Calif.

To the editor:

I read your Commentary about the problem of the aging orthopedic surgeon with a lot of attention. It is an issue that is addressed in different medical subspecialties because every discipline has its own “problem” with this subject. On the whole, however, it is something that is beyond the medical profession and has to do with mental and physical health and society in which we live. In Sparta, the old were thrown over the cliffs.

Why can a Pope be a Pope well in the mid-80s? In my country, why does a university get rid of a Noble prize winner in chemistry at age 65, which forces him to go to the United States to open a new lab and activity at a famous institution? Why do they get rid of you when you have reached the official age limit and call you in again when there is shortage of a successor in your field or when the elected successor walks away after 6 months because the patients have followed the previous chief of the clinic in the private clinic? Isn’t there a free market that should be allowed to function — where patients decide whether a given surgeon is still capable and thus let him feel when the moment of retirement is coming?

Can it not be that the fellows and residents whom “an aging surgeon” has taught embrace him at the moment they find correct and ask him to continue as a mere consultant and not as active surgeon? Is it not like a natural flow of transition? Isn’t it a problem that in countries, like in the United States, surgeons in some disciplines stop earlier because the malpractice insurance in their age category is so high that they cannot afford it to pay it? And in some countries, like in the Middle East, where there is virtually no medical legal threats, physicians practice until 75 or 80 years old just because there are not enough young trained orthopedic surgeons?

So, on one side it is a question of offer and demand. On the other side, why, despite the presence of many young surgeons, patients prefer to go to the old ones? Obviously, there must be something around the magic words of “experience and wisdom” that moves those patients. Patients know that young surgeons, until they are very busy, tend to grab the knife much earlier. They must make a living and have high costs, and like to recommend the “definite” solution (eg, the “total arthroplasty”) while the old one likes to recommend the “wait-and-see” policy and the “natural way” with preservation of the joint.

Or should we only do like Cicero who recommended that old people should plant a garden. Certainly, this is great because it brings you close to earth where anyhow you shall, the sooner or later, be integrated. You learn, if you have not been taught before, to look at and talk to trees and flowers, beetles, squirrels and birds with their uniqueness of difference of life span yet expressing joy, luxury and love to communicate to others. Shame on you that you worry, that you feel about the proximity of change and end of your earthily existence. And this allows you to realize that Earth has changed and should become again a constant “Nature Garden” and that only renewable energies should be “wasted” and an end should be made to burying natural sites under concrete.

Is there a way out of the dilemma? Is there room for both?

Two years ago, just 1½ year after retiring from my position as chief and professor of a major orthopedic unit in Switzerland, I got the diagnosis of acute myeloid leukemia. The way from chemotherapy to a lucky cell transplant from one of my sisters was not easy. Now, 2 years later, I have a normal blood count and relatively excellent life quality and no pain or limitation of relevance.

I am doing my gardening work as Cicero advised and as I always did. I even built a new French baroque garden of 1,000 square yards planting 2,000 boxwood trees and a lot of fruit trees during the summer when I was diagnosed the disease. But soon my interest in orthopedics “woke up again,” with reading a lot of literature, also on research and in communication with my pupils. At first, my pupils sent me clinical cases by mail asking for an opinion. Then they invited me to look at patients and help them with surgery.

I also took up again some teaching activity. Why should we not enjoy the feeling of still being worthwhile to colleagues and to patients who feel relieved by one’s presence at surgery? There, in my opinion, lies the miraculous combination of the young surgeon’s strength and endurance with the old surgeon’s 40 years of experience and wisdom. This secret tandem, by the way, functions well in private industry, too. That would have potentially avoided the dramatic development in finances that almost ruined our world in the past 2 years.

The following examples could serve as words of warning from the experienced to younger people – “Do not make this specific surgical error because once when I was young I did the same”. Collecting during your clinical years a “private selection” of epicritic patient’s data written down immediately after the surgery is what all surgeons should do. Writing notes in a book about what really happened during surgery and not what you dictated in the cabin of the operating which may have been edited and “neutralized” to meet the format. You do this, so that before next time you have a similar case, you can just go to re-read these “secret notes” so as to be well prepared. Follow the rule to only “perform” each possible complication once in your life. Even better, show young surgeons who invite you how to avoid that complication at all.

Here are my personal recommendations for aging orthopedic surgeons:

Many orthopedic surgeons have lived a healthy life with a lot of outdoor activity, attempting to stay fit find themselves in an excellent cardiovascular condition. With age, you know you shall loose a bit of mental capacity and you feel that already. You shall forget things more easily; you have to learn a few programs and tricks to overcome these deficits for a few more years. You may still be physically competent into the mid-70s, and it is important that your brain meets your excellent physical skills. The opposite may also be the case. But that comes usually later in your 80s when there is no room for this type of discussion anymore.
Giving up your profession just because they threaten you (age, medical legal, and hospital policy) may not be a good remedy against the other threat of senescent depression.
Face the fact and admit that you get older. You may be the cause of age-related or unrelated complications with your patients and you may find that you cannot easily cope with it. You may be wake in the middle of the night, unable to fall asleep again because of the worries about patients, lawyers and fundamental questions that you need not be worrying.
Build a faculty of aging surgeons in your area who are of similar age and good health enjoying their orthopaedic hobby. They may be of university or non-university faculty origin, but they are in the same situation and would still be willing to teach young surgeons who have just opened a private practice yet lack practice. Your niche is teaching and discussing cases with surgeons of any age. They know that the topic in which a given patient’s problem is situated fits among your main interest and age-unrelated competence which on top is even more enriched by your wisdom.
Be consultant for industry partners who are in a desperate need for sound advice. Never keep this relationship a secret. Industry may come to you because they know you are an honest person.
Be research consultant to an institution or to your previous partners who have not thrown you overboard. They will like your judgment and care for your ideas on new projects.
Be gentle with those who have thrown you overboard. They are young and will need your willingness and generosity to forgive them when they come to you.
Go to developing countries, provided you are in good enough health. Do something for those who are in the greatest need.
Do not be concerned exclusively with yourself and your worries.
Do not have financial issues. You may get a little salary, and that is all right. It is not too late to follow the Hippocratic laws and guidelines that a doctor should never become an economist.

— Roland Jakob, MD
Former Chief of Orthopaedics
Hopital Cantonal de Fribourg
Fribourg, Switzerland