Surgeons: Absolute cutoff age for retirement, mandatory skills testing is unnecessary

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.”

Deciding retirement for yourself

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 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.”

Retiring from practice

George F. Rapp, MD, of Indianapolis, who visited Sir John Charnley and Maurice E. Müller, MD, to learn how to perform total hip arthroplasty before he performed that procedure, invested in orthopedic implant companies during his tenure as an orthopedic surgeon, performed surgery right up until the time he retired at age 65. He did not cutback on his cases.

“I wanted to quit before someone told me I ought to quit and I thought I was competent enough to the end,” Rapp told Healio.com.

At the time he neared the age he retired, Rapp’s two younger partners and a first-year resident would assist on total hip arthroplasty cases, for example.

Similarly, orthopedic surgeon Douglas A. Garland, MD, retired at age of 70, said he was in the OR until the day he retired, although he stopped performing total knee arthroplasties the day he announced his retirement.

“Total knees I quit doing 3 months before, as soon as I notified [my colleagues], because it takes that long to get a knee rehabbed and be able to effectively sign-off,” Garland told Healio.com. “I did not want to, what we say, cut and run. Most of the other procedures I did up until a month before I quit, trying to make sure not any patient had a postop infection that I had to leave for somebody else to manage.”

He noted the decision to retire was completely his own, but for some surgeons the decision may need to be a group one.

“You just know there is no fire in the belly. You just know they are going through the motions and they maybe like making money and they just do not want to give it up,” Garland said. “I think when that happens, then the group has an obligation to do what we did with one of our senior partners. We helped show him the door, but we did it in a gentleman-like way.”

A similar approach might involve limiting the surgeon by removing him or her from emergency room call and taking them off rotation from seeing unreferred patients in the office.

Finding an identity

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, Minnesota, 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.”

Rapp told Healio.com that although he understands how surgeons might have an identity crisis once they retire, he did not have one when he retired because he was already active as a volunteer and involved in organizations in his area, like The Indiana Art Association.

“I think it’s good for them to be involved. If a person is religious, like most doctors, give to the church. But they’re not thinking much about the church. They are thinking about medicine. But, if they get out more, they can become involved in their church more,” he said.

Garland said retired surgeons may be able to find volunteer opportunities with county hospitals, universities and medical companies, a possibility he suggested they consider.

Although it may be difficult for some surgeons to let go of their identify as a physician, Garland said “it was a no-brainer” for him.

“I wanted absolute freedom from the encumbrances of private practice,” Garland said. “There is nothing better to do what you want when you want to do that. This is really the first time I have had that luxury in 50 years.”

‘When is enough enough?’

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.

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: ‘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.”

“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.

The aging surgeon staff

One guideline Rapp offered to hospitals that need to address the situation of an aging surgeon staff is to have orthopedic surgeons who are older than 65 years of age write down annually the procedures they would like to do so the team knows what to expect from a near-retirement orthopedist. That list can help start an appropriate conversation with an older surgeon about limiting or reducing his or her caseload.

A former chairman of orthopedics at St. Vincent Indianapolis Hospital who still sits on the board of Riley Hospital for Children at Indiana University Health, Rapp said surgeons should police themselves once they near retirement age to assess their skills.

Let them make the decision voluntarily first, he said.

The once-weekly practice when he was at St. Vincent’s of having staff meet to discuss everyone’s upcoming cases was effective for identifying cases that were perhaps too complex for an extremely senior surgeon to take on, such as a patient with severe scoliotic deformity. It helped everyone deal proactively with a situation that might end badly, according to Rapp.

No mandatory retirement age

However, Jamie S. Ullman, MD, FACS — professor of neurosurgery at Donald and Barbara Zucker School of Medicine at Hofstra/Northwell and director of neurotrauma in the Northwell Neurotrauma Institute — said she does not favor a mandatory retirement age for surgeons but agrees “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.

“I think you have to be careful to test. It is sort of like old people driving a car,” Rapp said, noting statistics show older drivers have fewer accidents than drivers in their 20s or 30s because the older drivers, in fact, drive more carefully.

“If they are elderly, maybe they can find themselves one or two operations they can probably do better” than a surgeon who perhaps does them only once a year, he said.

Other considerations before retirement

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, Susan M. Rapp and Casey Tingle

 

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.

Douglas A. Garland, MD, can be reached at 2111 Shoreline Dr., Pismo Beach, CA 93449; email: dougarland@msn.com; website: http://douggarland.com/.

George F. Rapp, MD, can be reached at 200 Forest Blvd., Indianapolis, IN 46240; email: rapp.20096@gmail.com.

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

Disclosures: The study was supported by the American Board of Medical Specialties Visiting Scholars Program. Babu, Garland and Ullman report no relevant financial disclosures. Rapp reports he was founder of the Sofamor Danek division of Medtronic.