February 5, 2019

Can a surgeon be 'too old to operate'? Here’s how top hospitals are making the call.

Daily Briefing

    The medical workforce is aging, but to date, there's no clear guidance surrounding when a physician is too old to practice—leaving the often uncomfortable task to hospitals and the physicians themselves to self-evaluate, Paula Span reports for the New York Times.

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    An aging workforce

    In 2015, almost 25% of practicing physicians were 65 or older, and over 122,000 physicians ages 65 or older cared for patients in 2017, according to the American Medical Association.  

    While some patients might be reassured by seeing an older, and presumably more experienced doctor, "human faculties decrease with age," Mark Katlic, a thoracic surgeon who founded an aging surgeon program at Sinai Hospital, said.

    A person's vision, hearing, and cognition decline with age—and Katlic noted those effects of aging raise very important questions providers. Do older doctors have the stamina to perform operations that are six or seven hours long? "Can [older doctors] grab a tiny little blood vessel with a forceps and not grab something else? Or use very small instruments for sutures?" Katlic asked.

    But researchers to date have not been able to identify clear answers to those questions because the effects of aging affect everyone differently. In a JAMA Surgery article, E. Patchen Dellinger, a physician, wrote that at 75, "there are sharp, wonderful doctors, and those who need to stop."

    Research on patient outcomes also is split. One large study of Medicare beneficiaries found that surgeons over age 60 had higher mortality rates for several procedures, such as coronary bypasses, but not for other operations. But another study of Medicare beneficiaries revealed that older surgeons had lower morality rates than younger surgeons, Span writes.

    How to tell when a physician is too old to practice

    Currently, there's no universal guidance on when a physician should consider retiring. Instead, many hospitals rely on a peer- and self-reporting system, and request providers undergo an exam to test their skills.

    However, Glen Gabbard, a psychiatrist at Baylor College of Medicine whose work has focused on providers, said many doctors are not receptive when their medical abilities are questioned. "Being a physician is at the core of their identity. ... They can't imagine retiring." Gabbard said, adding that many providers worry what would happen to their patients.

    That was the case for Herbert Dardik, chief of vascular surgery at Englewood Hospital and Medical Center in New Jersey. In 2015, Dardik, who at the time was 80, nodded off in a surgery he was observing (not performing), and an alarmed nurse-anesthetist reported the incident. Shortly thereafter, the hospital's CMO and chief of anesthesiology visited Dardik and urged him to reduce his workload and take a two-day program at Sinai Hospital in Baltimore that evaluates older surgeons.

    "I got so annoyed, I stood up and opened the door and said, 'Get out,'" Dardik said, adding, "Who knows better what I can do but I myself?"

    But Dardik had an eye opening revelation after that meeting. He was on a plane when the captain, who looked older, came onboard. Dardik recalled thinking, "I hope this guy' still OK." The irony of the situation "hit me like a hammer," Dardik said. "This is what other people think when they look at me."

    So, he decided to undergo Sinai's aging surgeon program.

    The assessment team at Sinai agreed that Dardik could continue operating, but said they said he may want to re-consider longer procedures. But when Dardik returned to Englewood, he experienced intense back pain and exchanged practicing surgery for research and teaching.

    How some hospitals are navigating the issue

    Approaching retirement conversations with physicians can be tricky, Span writes. While older physicians may be physically frail, they generally have a wealth of knowledge and years of experience that hospitals would be loath to lose.

    "It's probably a small percentage of surgeons in their 70s who have trouble," Katlic said. "But they're the ones we want to identify." He added, "The public believes we police ourselves as a profession," Katlic said. "We don't, at least not very well."

    Some experts have floated mandatory retirement ages for physicians, but Span writes such an action could violate discrimination laws and force out doctors who are perfectly capable of practicing medicine at an older age.

    Instead, others have called for a mandatory screening that could determine whether older doctors should reduce their responsibilities, retire, or transition to different roles would be a "better approach," according to Span.

    In addition to Sinai, some hospitals, including University of Virginia Health System, Temple University Hospital, and UPMC, have already implemented these "late-career practitioner policies," to screen health professionals who are 70 or older. But the programs' reach so far has been small, Span writes. Sinai's five-year-old program has evaluated only eight surgeons.

    But as a participant, Dardik said these programs have value. "You think you're invincible. But the clock ticks, and I've become an advocate for evaluation" (Span, New York Times, 2/1; Javed Warraich, New York Times, 1/6).

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