From the Editor

From the Editors: Hanging up the scalpel


 

The decision to stop practicing surgery is a monumental one when you have been a surgeon for almost 40 years, have loved operating, and have defined yourself by the word “surgeon.”

The decision to cease operating should at best be a personal one that the surgeon makes, rather than one imposed by others. The “others” could be an institutional policy mandating retirement at a given age, the results of a series of psychomotor examinations, or even a kind department chair’s suggestion that you should stop operating because your complications have increased and it is in your patients’ best interests. As we approach “a certain age,” I suspect that most surgeons would prefer to decide their own fate and, especially, to avoid the last of the three above options.

Dr. Karen E. Deveney, professor of surgery and vice chair of education in the department of surgery, Oregon Health & Science University, Portland

Dr. Karen E. Deveney

An arbitrary retirement age for surgeons is an option that is unlikely to be optimal. Since the decline in physical and cognitive ability is so notoriously variable across the age spectrum, using an age cutoff would eliminate from practice many who remain hearty and competent, just at a time when the physician shortage is becoming more acute.

Literature is emerging about the aging physician and how best the decisions should be made about ceasing practice. A recent such article published online by some dear and respected colleagues (JAMA Surg. 2017 July 19;doi:10.1001/jamasurg.2017.2342) proposes that institutions and professional organizations develop policies to address the aging physician that leave “flexibility to customize the approach” lest regulators and legislators impose “more draconian measures.” Their suggestions include mandatory cognitive evaluation, voluntary annual physical examinations, and confidential peer evaluations of wellness and competence as physicians reach a certain (unspecified) age.

I most certainly concur with the authors’ well-reasoned arguments. As they relate, only a handful of institutions to date have developed policies that require assessments of physician wellness and competence at a given age. Most institutions still rely on physicians’ voluntary submission to physical examinations, cognitive testing, or peer referral of a colleague if declining function is observed. Yet we all know that individuals tend to overlook signs of declining physical and cognitive function both in themselves and in colleagues. Moreover, we all know that even the most carefully designed and implemented tests have shortcomings and may fail to identify the exact nature of an individual’s malady or fail to identify a remediable issue early. And just as individuals’ physical and cognitive abilities decline at different chronological ages, problems with burnout, mental illness, and substance abuse have no reliable age threshold and may be difficult to diagnose accurately.

Whatever the age of the individual, it is critical that a decline in function of a practitioner be addressed promptly and effectively, for the benefit of the affected individual, his or her patients, and the institution. It is therefore most appropriate for every institution to develop a firm policy to deal with concerns of competency of all staff members, regardless of age.

It is also appropriate for peers to pay attention to a colleague’s stumbles and have the courage to first initiate a dialogue directly with that person, referring the issue to an individual in authority if the direct approach fails. A culture that promotes responsible self-policing protects patients and the reputations of both the affected individual and the institution.

Most of us with “seniority” will recall situations during our training when surgeons with diminished physical or cognitive capacity continued operating well beyond their prime. In those days, it was not unusual for a chief resident to be told, “Your job is to scrub with Dr. X and keep him out of trouble.” As inappropriate as that was, we complied, all the while vowing that we would never let ourselves be in the same position when we aged.

It therefore became my habit as I aged to “listen to my body” and pay attention to evidence that my skills might be declining and perhaps it was time to hang up the scalpel. As an almost lifelong runner, I marked my athletic decline by noting an increase in minutes per mile from 7 to 14 over 40 years and wondered whether my cognitive decline might be comparable, if not so obvious. I had to admit to a bit of lost hand dexterity, less sharpness of eyesight, and slowed memory for the names of people and even of surgical instruments. Although I believed that my diagnostic acumen and decisions were unaffected, I weathered a sleepless night on call less well, requiring two or more full nights of eight hours’ sleep to recover my energy completely.

Part of the reluctance to cease surgical practice that I share with many colleagues my age is the fear of becoming irrelevant and unproductive. It was therefore critical to prepare for retirement from practice by identifying activities that I considered both meaningful and also challenging: writing and editing, teaching students and residents in surgical skills labs, teaching residents “open” surgical techniques on cadavers, advising younger colleagues when they have a challenging case in my area of expertise, and filling a myriad of needs in our department that match my skill set but that my younger counterparts are too busy to attend to.

I now also have the freedom to pursue activities for which I had little time during the years of intense practice, including service on nonprofit boards and other community activities. There may even come a day when my definition of self has fully accepted the word “retired,” even though I hope that day is many years in the future.

Dr. Deveney is professor of surgery and vice chair of education in the department of surgery, Oregon Health & Science University, Portland. She is the coeditor of ACS Surgery News.

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