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Challenges Facing the Aging Surgeon

  • Kerry D. Olsen
    Correspondence
    Correspondence: Address to Kerry D. Olsen, MD, Division of Medical Otolaryngology, Mayo Clinic, 200 First St SW, Rochester, MN 55905.
    Affiliations
    Joseph I. and Barbara J. Ashkins Professor of Surgery Division of Medical Otolaryngology Mayo Clinic Rochester, MN
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Published:November 15, 2017DOI:https://doi.org/10.1016/j.mayocp.2017.10.002
      The phenomenon of professional burnout among physicians is the focus of considerable and merited attention.
      • Shanafelt T.D.
      • Hasan O.
      • Dyrbye L.N.
      • et al.
      Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014.
      • Shanafelt T.D.
      • Mungo M.
      • Schmitgen J.
      • et al.
      Longitudinal study evaluating the association between physician burnout and changes in professional work effort.
      Such burnout, arising from a variety of stressors, has diminished professional satisfaction, and, indeed, it is predicted that substantial numbers of physicians will reduce their work hours in medical practice, entirely relinquish the practice of medicine, or switch careers, including to ones outside of medical practice (personal communication and cited with permission).
      • Sinsky C.A.
      • Dyrbye L.N.
      • West C.P.
      • Satele D.
      • Tutty M.
      • Shanafelt T.D.
      Professional satisfaction and the career plans of US physicians.
      These changes in medical careers, were they to occur, may exacerbate the anticipated shortfall in the physician workforce in the United States.
      • Sinsky C.A.
      • Dyrbye L.N.
      • West C.P.
      • Satele D.
      • Tutty M.
      • Shanafelt T.D.
      Professional satisfaction and the career plans of US physicians.
      Strategies to reduce physician burnout are under active consideration, including those that are organizational in nature.
      • Shanafelt T.D.
      • Noseworthy J.H.
      Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout.
      Surgical careers are also vulnerable to diverse stressors, some of which occur late in a career and may be age related. In this regard, in the current issue of Mayo Clinic Proceedings, Babu et al
      • Babu M.A.
      • Liau L.M.
      • Spinner R.J.
      • Meyer F.B.
      The aging neurosurgery: when is enough, enough? attitudes toward ceasing practice and testing in late career.
      have begun an important discourse on a topic that directly relates to patient safety and physician well-being. The authors studied input on the impact of aging on neurosurgeons and identified the challenges of evaluating and correlating competency with age. Because more than one-third of the surgeons in the United States are older than 55 years, the issues raised in this publication will likely be of equal import to other surgical disciplines.
      The article states that patient safety should be one of the main determining factors in continuing or ending a surgical practice. Additional factors are many, and their relationships to aging and practice remain complex. Age does alter one's physical and cognitive skills. There is, however, great individual variability in this occurrence. This variability led the authors to conclude that there should not be a mandatory age limit to a surgical practice. Accurately assessing physical and cognitive change remains important but incredibly challenging and incomplete.
      Visual problems, tremors, and lack of stamina all may be relatively easy to recognize. But, the assessment of necessary medical knowledge for making optimal surgical decisions currently does not exist. Patients do want an experienced surgeon. High-volume surgical practices have consistently been correlated with better outcomes. The value of surgical experience for dealing with anatomical variations, altered tissue conditions, unusual disease behavior, and rare findings is often essential to a favorable outcome. For certain complex difficult operations, the patient may unknowingly need a surgeon who, in “surgeons speak,” is not afraid of a little blood. Likewise, the patient does not want a surgeon who may elect to perform an operation beyond their skills or mainly for financial return.
      Throughout a surgical career, most surgeons will admit to a decline in stamina and reduced desire to be “late” in the operating room. Most are not immune to burnout or to the fatigue of a long surgical career. Over time, a surgical practice also brings more frequent difficult cases and reoperations and the increasing memory of accumulated complications and deaths.
      A gray zone not discussed in the article by Babu et al
      • Babu M.A.
      • Liau L.M.
      • Spinner R.J.
      • Meyer F.B.
      The aging neurosurgery: when is enough, enough? attitudes toward ceasing practice and testing in late career.
      is the decision to operate or not as this relates to age. 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. 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.
      Deciding when to end one's surgical practice can be an extremely difficult decision. Many surgeons have their entire identity and waking hours almost completely consumed by their practice. 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.
      So what should be done?
      • I agree with the authors that owing to individual variability there should not be an age cutoff for performing surgery.
      • Recognizing that aging does impact both physical and cognitive function, at some age (>65 years?) credentialing/privileging bodies should require surgeons to have regular physical examinations to assess health, vision, and cognitive function.
      • All physicians should be encouraged and provided assistance to maintain overall good health through optimal lifestyle behavior. They should also be encouraged to continually address preventive healthy activities and ergonomics to mitigate work-related injuries.
      • All surgeons 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. As the authors report, the surgeon may not be aware this is happening.
      • All surgeons, regardless of their age, should have periodic reviews of their outcomes and decisions concerning the areas of surgical intervention and planning.
      • Surgeons nearing the end of their career should be encouraged to seek and be provided help with retirement planning beyond finances and benefits. Although some individuals can just quit, many would benefit from exploring ahead of time other activities or opportunities and/or gradually reducing their surgical practice.
      • Finally, as the authors point out, hospitals and clinics do a very poor job of using the knowledge and talents of many surgeons who want to continue in some work capacity other than being “captain of the OR suite.” Options include doing less complex surgical procedures, assisting others in the operating room, teaching in and out of the surgical suite, and working in a medical practice mainly for assessing patients for surgery. Some may also select administrative work. There is team value in having a “surgical decision maker” as part of the group's voice in management or strategic planning.
      One of my mentors told me that “after 30 years of head and neck surgery, with its complications, cancer recurrences, and patient deaths, you get out! It takes a toll on you that you will not recognize until you stop. Do it before it is too late.” I did not exactly follow his advice but I did stop my surgical practice after 35 years. At least my younger surgical colleague never had to tell me it was time to quit.
      Babu et al
      • Babu M.A.
      • Liau L.M.
      • Spinner R.J.
      • Meyer F.B.
      The aging neurosurgery: when is enough, enough? attitudes toward ceasing practice and testing in late career.
      should be congratulated on seeking the opinions of current and retired neurosurgeons in beginning this important discussion on the aging surgeon: When is enough, enough?

      References

        • Shanafelt T.D.
        • Hasan O.
        • Dyrbye L.N.
        • et al.
        Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014.
        Mayo Clin Proc. 2015; 90: 1600-1613
        • Shanafelt T.D.
        • Mungo M.
        • Schmitgen J.
        • et al.
        Longitudinal study evaluating the association between physician burnout and changes in professional work effort.
        Mayo Clin Proc. 2016; 91: 422-431
        • Sinsky C.A.
        • Dyrbye L.N.
        • West C.P.
        • Satele D.
        • Tutty M.
        • Shanafelt T.D.
        Professional satisfaction and the career plans of US physicians.
        Mayo Clin Proc. 2017; 92: 1625-1635
        • Shanafelt T.D.
        • Noseworthy J.H.
        Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout.
        Mayo Clin Proc. 2017; 92: 129-146
        • Babu M.A.
        • Liau L.M.
        • Spinner R.J.
        • Meyer F.B.
        The aging neurosurgery: when is enough, enough? attitudes toward ceasing practice and testing in late career.
        Mayo Clin Proc. 2017; 92: 1746-1752

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