"When Is the Surgeon Too Old to Operate?" Heart Surgeons Respond
Earlier this month the New York Times explored an important question: “When is the surgeon too old to operate?”
Nearly 1 in 4 registered physicians in the United States is over 65, and 40 percent are actively practicing. But how do you determine when a surgeon can no longer be trusted with the scalpel?
We asked several cardiothoracic surgeons to weigh in, some of whom fall in the senior category of 65 and older. Their responses were quick to highlight the importance of developing accurate assessment tools and the difficulty behind successfully tracking the quality of a surgeon’s ability.
“This is an interesting topic and definitely controversial,” says Vinayak Bapat, MD, a cardiothoracic surgeon specializing in mitral valve repair. Dr. Bapat worked in Edinburgh and London before coming to Columbia. “In England, the mandatory age of retirement was 65 and now 67, but most surgeons retire at 60! In Germany the age limit is similar,” says Dr. Bapat. “In the U.S. there are two types of practices (broadly speaking), academic and private, but there is no mandatory retirement age in either unlike similar models elsewhere.”
Research indicates that existing voluntary policies to assess physician’s ability do not go far enough. First, most surgeons don’t willingly sign up. Second, there is no scientific evidence correlating the assessment results with surgical performance.
“I have little confidence that we have reproducible testing that really identifies overall surgical skill,” says Craig Smith, MD, a cardiothoracic surgeon and Chair of Columbia’s Department of Surgery. “ One study used metrics with which medical students outperformed practicing surgeons, which tells you those metrics have almost nothing to do with actual surgery. Many of the studies cited were done on MDs referred for evaluation, so a frightening frequency of problems is to be expected”
While Dr. Smith is aware that “as a member of the age group that’s in the crosshairs, anything I say will be viewed skeptically,” he is quick to note: “ I have no problem with the obvious notion that there is a time each of us should stop. Most proposals call for testing over some arbitrary age (65, 70). It seems to me it’s hard to have valid information without testing every surgeon at every age.”
“As a surgeon who retired at a relatively young age due to physical disability, I guess I have a weird perspective on the topic,” says Paul Kurlansky, MD, Associate Director of Columbia’s Center for Innovation and Outcomes Research, and a boarded cardiothoracic surgeon. “The truth of the matter is that there are many young surgeons who probably shouldn't be operating. The key is to continuously monitor the quality of your work, and if you cannot meet and/or exceed the standards of your profession, you should not have the privilege of performing surgery, regardless of your age.”
“Interestingly, in our specialty, each surgeon is closely (in public) monitored for their outcome,” says Hiroo Takayama, MD, Director of the Columbia Aortic Center. “There are professionally accepted metrics of quality [for cardiothoracic surgery] which are available on a relatively continuous basis updated quarterly through the Society of Thoracic Surgeons,” adds Dr. Kurlansky. “Other surgical specialties are gradually following suit.”
“Professionally, we tend to ‘judge’ people by their outcomes, which is appropriate. But what goes into arriving at those outcomes is a complex array,” says Dr. Kurlansky. “As for what makes a good surgeon, the list is long, but certainly involves manual dexterity, a fund of knowledge, ability to think and readjust on your feet, compassion, and most importantly, judgment.”
Experienced surgeons develop fine-tuned judgment that is invaluable to the global practice of medicine and training of future physicians. “It’s the ability to apply all of one's knowledge and skills to a nuanced understanding of the patient and the clinical scenario to determine what course is most likely to yield the best result,” says Dr. Kurlansky.
The ability to exert said keen judgement could lend itself greatly to the development of retirement assessment tools that are thoughtful, flexible, and standardized.