Aging Surgeons

The surgical workforce is aging. According to the American Medical Association, 18% of practicing physicians are older than 65 years. In Australia 19% of active surgeons are 65 years or older. The age at which surgeons retire is also increasing. In the commercial airline industry, commercial pilots face mandatory retirement at 60 years of age; similarly, the retirement age of British Surgeons is 65 years from institutional practice and 70 years from private practice.

At age 60 years, most surgeons continue to work, and 17% continue to operate even after 70 years of age. Decisions about surgical competency should be based on functional age and abilities rather than chronologic age. This argues against a mandatory retirement age for surgeon. When questions arise regarding the competence of an older surgeon, there should be an objective evaluation of functional age. Reason not to pursue mandatory retirement age is that treatable causes of poor performance may be found such as medication adverse effects, depression, disease, sleep apnea,and correctable vision problems. Age-related decline in hearing, visual acuity, depth perception, and color discrimination all  may impact surgeon’s performance. The development of chronic medical illnesses, cardiovascular disease, depression, and excessive alcohol use all complicate the normal decline in neurocognitive function. Verbal skills and semantic memory (knowledge of facts and meanings) remain intact. Clinical wisdom is also preserved.

The practice of medicine in general, and surgery in particular, is both physically and mentally challenging. Prolonged, repetitive exposure to stressors is bound to have consequences. The physical nature of surgical work also takes its toll. For example, up to 87% of laparoscopic surgeons reported physical complaints, of which the strongest predictor is high case volume. However, even low case volume surgeons experience eye and back complaints. Mental or emotional exhaustion may also take a toll. As one progresses through a career, symptoms of burnout may appear. A host of other medical conditions, such as anxiety, depression, substance abuse, sleep disturbance, lowered immunity, and possibly ischemic heart disease, may further impair the aging surgeon’s performance. The incidence of burnout in surgeons of all age groups is as high as 40%. One of the major contributing factors to burnout is chronic sleep deprivation. Women are be more vulnerable to burnout.

The presence of mental and psychiatric disease has an increased incidence in the elderly medical professionals. In a study of impairment in older doctors 12% had dementia; 22% had depression and 29% had some form of substance abuse (of which, 20% had alcohol abuse and 17% had opiate abuse , and 20% had a high likelihood of a minor psychiatric disorder). Several tests have been developed that could be used to monitor cognitive function of the aging surgeons. Playing chess has several similarities to surgery, such as complexity, time pressure, and rewards or penalties for decisions made. Game of chess may slow down deterioration in surgeon’s neurocognitive function.

Most difficult aspect of retirement is the loss of the role as a surgeon. There is lack of self-esteem, fear of death, resistance to change, loss of financial security, and fear of boredom.  Further, some surgeons feel that their advanced age confers greater credibility, more respect, and better perspective, and nearly one-half feel advanced age gives them greater clinical confidence and competence. Most surgeons enjoy retirement. There is a common saying among surgeons, ‘‘Surgery is for patients, not for surgeons”. Some believe surgeons enter the occupation of surgery out of a need to struggle with and defeat death and disease. When a surgeon stops doing surgery, he or she becomes more like a patient, susceptible to death and disease. So, the decision to retire resembles the decision to die. Being a surgeon is perhaps the most privileged of all occupations. To be so burdened and simultaneously so honoured is a privilege like no other. One reason surgeons may persist in their craft is there is no other activity that is nearly so rewarding.

Recent systematic review found that increased volume and greater surgeon experience with specific procedures did result in improved outcome. Older physicians and surgeons allocate more time to each patient, and increasingly seek second opinions. But surgeons do not adequately look after their own physical health. For example, despite hepatitis B being a major risk of the profession, vaccination rates may be as low as 49%. Aging surgeons should take care of their health: (1) controlling weight and diet; (2) reducing or eliminating smoking, drinking, and illicit drugs; (3) exercising; and (4) practicing safe sex.

The workplace should also adapt to meet the needs of the aging surgeons. Ceasing all night calls and reducing overall duty hours after a specified age may be a good option.

As surgeons progress toward the end of their operative career, they continue to need intellectual stimulation and feel the obligation to continue contributing. An experienced surgeon may have seen many patients with a certain diagnosis. If a patient comes anew with a rare diagnosis, the experienced surgeon, having seen it so often before, will far more easily and accurately recognize the problem than a novice would. The novice may learn in theory how patients should respond to treatment, whereas the experienced surgeon would have learned in fact how actual patients have responded to operations actually performed on them. The theory and the practice may not coincide. One potential outlet for the surgeon emeritus is teaching. Sir William Osler once said: “The teacher’s life should have three periods, study until age twenty-five, investigation until forty, profession until sixty, at which age I would have him retired on a double salary”.

Dr.A.K.Dewan
Director-Surgical Oncology