Clinical Scenario
Archibald Fitch, MD, is a senior, highly respected, experienced, and innovative head and neck surgeon at your medical center. Tall and lean, with a full head of white hair and a robust disposition, he has a commanding presence. He was the first otolaryngologist in your community to practice the full scope of head and neck oncologic and reconstructive surgery, adding a number of innovations of his own to the field, including several textbooks and a host of journal publications. Beyond those credentials, he is considered a compassionate and meticulous surgeon with keen judgment and discernment, serving as a role model to many in the community and beyond.
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August 2015Dr. Fitch, now in his mid-70s, has continued to practice head and neck surgery and is always willing to give formal or informal counsel when consulted regarding a colleague’s patient. His general health appears good, and he is an avid golfer and tennis player. His attendance at committee meetings and participation in medical center affairs is consistent and admirable. He is very active in several national charities of his passion.
Because of his prominence in the medical community, as well as his experience and expertise, there are often observers in his operating rooms, including yourself. On a recent occasion, you stopped by Dr. Fitch’s operating room to observe a few minutes of him performing bilateral modified neck dissections. You were close enough to hear this verbal exchange between Dr. Fitch and the scrub technician:
Dr. Fitch: “Sandra, may I have … uh… you know, that long instrument with the blunt tips that you cut tissue with … it’s a pair of scissors, I just can’t think of its name, right now. But you know what it is.”
Sandra: “Dr. Fitch, are you thinking of the Metzenbaum scissors?”
Dr. Fitch: “Of course, Sandra, thank you. How could I forget that old friend?”
A few minutes later, the same scenario was played out with an automatic clip applier and a Penrose drain. At other times, you noted that Dr. Fitch preferred to find an instrument himself on the instrument tray rather than ask for it. His technical performance of the procedures was flawless, however, and the blood loss was minimal. You were impressed, as usual.
Verification
These brief memory lapses concern you, and you feel you should verify your observations with other colleagues—discreetly. Over coffee in your office, you describe your observations to two fellow otolaryngologists whose opinions—and discretion—you trust. Both colleagues did remember recent incidences when they were either observing or assisting Dr. Fitch and he experienced such memory lapses, but these involved names of medications and names of personnel. Neither had observed any breach of technique or of patient safety.
As chief of otolaryngology-head and neck surgery at the medical center, a position previously held for many years by Dr. Fitch, along with his tenure as chief of the medical staff, you feel a professional obligation to monitor the capabilities of every otolaryngologist in the department. You have, in the past, dealt with issues such as disruptive behavior and other unprofessional activities. In this particular situation, your concerns involve a highly regarded senior surgeon who continues to practice within the standards of technical capability, but with a possible early deterioration of memory.
Again, in confidence, you request a separate meeting with Dr. Fitch’s regular anesthesiologist and his circulating nurse. Both are initially wary of where you might be headed with this line of inquiry, but after you assure them that you are interested only in the welfare of both Dr. Fitch and his patients, they do acknowledge having observed an increasing frequency of memory lapses, although he compensates cleverly using his sense of humor and warm personality. As a model of professional propriety and decorum, Dr. Fitch simply does not get flustered or act inappropriately in the healthcare setting.
You review Dr. Fitch’s medical staff privileges and the letters of recommendation and support for their renewal; there is no evidence of concern being passed on by those endorsing his continued staff privileges. There are no documented complaints about his behavior or interactions with colleagues, staff, or patients. In short, he is what everyone feels he is—a consummate professional. In more than 40 years of surgical practice, he has had no medical liability suits, and there have been no complaints filed with the state medical board.
You feel very conflicted about raising this issue with Dr. Fitch—on one hand, he shows no deterioration of dexterity and motor skills, and his clinical judgment appears intact. On the other hand, your observations and those of others raise the concern that subtle cognitive deterioration might be present that could worsen over an unknown period of time. This surgeon has devoted his professional career to excellence and innovation in patient care, medical education, and community service and, at age 75, continues his dedication to clinical work. You are aware that, over the past several years, there has been increasing national discussion regarding the issue of the “aging surgeon,” a topic previously side-stepped in many regards with respect to a surgeon’s prerogative to decide when is the proper time to retire.
Is it time to initiate this discussion at your medical center, and should you be the one to initiate it? What should you do?
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Discussion
The number of U.S. physicians who are aged 65 and older has quadrupled since 1975, reaching 240,000—one fourth of all physicians.
Image Credit: gualtiero boffi; kurhan/shutterstock.com
As with the general population, physicians born during WWII and later constitute an inflated “blip” in the physician population in the United States. While the net flux of senior physicians leaving practice, continuing to practice, limiting practice, or still fully practicing is not completely understood, financial and health considerations have certainly played a role in the decision of when and how to stop practicing. This generation of physicians has been characterized by a keen dedication to the profession and their patients and a desire to continue to practice as long as possible, however. Whether this is a salutary philosophy rests with the capabilities and health status of the individual physician. In this scenario and discussion, the senior/aging surgeon is the focus of consideration.
The issues with the aging surgeon appear to be twofold: Does the surgeon have the mental and physical capabilities to serve the patient well and safely, and can the aging surgeon adequately assess her/his own competency to practice? In addressing the former, you must consider the fact that practicing at an advancing age requires the continuation of those capabilities that are expected of the competent surgeon, including a high level of cognitive functioning, exceptional eye-hand coordination, stamina for long hours of surgery, adequate vision, superb judgment, and a persistent capability for discernment. In short, practicing at an advancing age requires continued competence as a surgeon and physician who serves and protects one’s patients.
Much of the current discussion on the topic of the aging surgeon has to do with the proper balance of competence and experience—that is, maintaining the skills of surgical performance and judgment while serving as an experiential resource and role model for younger surgeons. To date, the decision of when to retire or stop operating has been left to the individual surgeon, with external influence being exerted only after some egregious or near-mishaps have been identified. This generation of surgeons, many of whom have served in the military and in combat situations, can be characterized by a fierce independence and confidence in their capabilities, both cognitive and surgical. These traits could both help and hinder the aging surgeon in deciding when to stop operating or retire.
Due to the skills required to perform surgical procedures, it seems logical that there is a differential in the performance requirements for senior surgeons versus nonsurgical senior physicians. A decrease in visual capabilities, an intention tremor, musculoskeletal maladies such as arthritis of the hands, and cardiovascular problems can all potentially affect the safety and care of the surgical patient. Thus, it would seem that the competency of the aging surgeon carries more burdens of proof than does the competency of the nonsurgical physician with regard to procedural performance. Both types of physicians still must perform their cognitive and assessment responsibilities adequately and at a high standard of care.
Recently, the American Medical Association announced plans to create model guidelines for assessing the competency of aging physicians to provide safe and effective care of patients. While these guidelines are likely to be fairly generalized, subsequent discussions by surgical associations should also address the special skills required for the safe and appropriate conduct of surgical procedures. Surgical skills are clearly important to maintain, but so are proper judgment and discernment, maintenance of knowledge base, and proper use of medical technologies. It will not be an easy task to develop assessment instruments that are valid, fair, and can adequately evaluate shortcomings that can be potentially remediated.
Healthy and successful aging can allow a surgeon to perform well and competently for an extended period of time. Experience, maturity, and perspective are important benefits resulting from a long surgical career, and the aging surgeon can be a tremendous resource for young surgeons and nonsurgeons, as well as hospitals and other community institutions. While a physician’s physical health might decline, personal traits such as resilience, optimism, wisdom, and compassion seem to remain intact and strong. Surgeons tend to become more risk-averse with experience and tend to consider alternatives to surgery more frequently than younger surgeons. Taken in the whole, senior/aging surgeons can be a valuable resource in the profession, and their potential continued contributions should be considered in any effort to assess competency and capability.
Assessment Tools and Remediation
Yet, because of its fiduciary responsibility to the public (patients), the profession must develop the tools that are needed to assist in the identification of not only the impaired aging surgeon but also the surgeon who continues to operate and practice at a high level of competence. Additionally, those tools or instruments should provide the capability to identify areas for remediation and/or improvement that might prolong the practice longevity of aging surgeons, should they decide to
participate in available programs. The most effective competency assessment instruments and remediation programs would be nonthreatening and voluntary, as well as inviting to the surgeon who wishes to assess her/his own skill and competency level. Mandatory testing of surgeons over a certain age would likely be met with an unfavorable response and would be inappropriate.
The federal Age Discrimination in Employment Act of 1967 outlaws compulsory retirement based on age. It provides protection against discrimination in the workplace and would most assuredly be invoked if mandatory testing of senior surgeons were considered by hospitals or medical schools. The better course is to educate senior surgeons about the benefits of undergoing professional competency testing voluntarily, to assess their own cognitive skills, and perhaps even dexterity, as an aid to their career decision-making process. Some medical schools, such as Stanford University in California, have developed assessment programs to help physicians identify their weaknesses and strengths, with the goal of potential remediation or assistance in career planning. Very likely, more assessment instruments will be developed and implemented for the use of senior surgeons.
The issues involved in assessing aging surgeons are more complex than cognitive testing—proper maintenance of surgical skills would be more difficult to assess out of the operating room setting. Simple dexterity testing can be performed, but the conduct of surgical procedures is quite complex and may require direct observation by impartial observers. Plans for procedural capability determination must be developed carefully, taking the dignity of the senior surgeon into full consideration.
Competency and its effect on clinical outcomes should be the primary objective of any assessment process. Concomitantly, the development of educational programs for remediation of potentially improvable deficits should have equal emphasis of effort. The identification of early signs of impairment should trigger counseling and facilitation of assessment and remediation. It is far better to identify competency concerns early on, so that patients can be protected and the dignity of the aging surgeon protected.
The profession of medicine in general, and the surgical specialties in particular, are in the early stages of understanding the issues of the aging physician and developing the appropriate processes for identifying impairments and the options for addressing them. The specialty of otolaryngology-head and neck surgery has the opportunity to lead the surgical specialties in this regard and is encouraged to do so. The Code of Ethics of the American Academy of Otolaryngology-Head and Neck Surgery addresses the issue of “impairment” and provides guidelines for addressing concerns, both by the otolaryngologist and the otolaryngologist’s colleagues; however, much more needs to be done in providing assessment tools and any indicated remediation. Lifelong learning is an excellent deterrent to loss of competency, and the specialty of otolaryngology-head and neck surgery excels in this capability.
Back to the Case
Regarding the specific case of Dr. Fitch, there are certain signs of early memory loss that may or may not be harbingers of something more serious. Certainly, within the normal aging process, minor forgetfulness of names is common and is usually of no real concern. More concern would be warranted by disorientation during surgery, improper or dangerous performance of surgical procedures, and judgment deficits. These issues warrant an intervention, albeit a dignified one.
Because Dr. Fitch shows no signs of loss of dexterity or improper conduct of surgical procedures, it would be appropriate for you to have an informal, private discussion with him about your observations and those of others (no names) regarding the mild memory lapses, in order to ascertain the level of his awareness and introspection. You might suggest that he consider voluntarily undergoing cognitive testing that might identify some areas that could be addressed by memory training or areas of early cognitive dysfunction that could herald possible future deterioration that might impact his practice decisions. You might need to have a series of discussions with him as the issues become clearer, and, as his friend and colleague as well as head of the department, help him understand the importance of addressing any issues of concern. It would also be appropriate to inform him that you plan to encourage the medical staff to study the issue of voluntary competency assessment of physicians, because this is an issue being addressed across the country. Give him time to consider your discussions, and work with him in identifying options for self-assessment and remediation. Above all, you want to protect Dr. Fitch’s patients, while still being his advocate and maintaining his dignity.
It is very important to understand that there is a wide range of capacity and competency in aging surgeons, and the approach to each surgeon should be individualized. Some surgeons will show no signs of cognitive or dexterity deterioration well into their late 70s and can continue to operate and discharge their clinical duties quite well. Others will identify their own shortcomings and make the decision to retire at an appropriate time. A few will attempt to practice beyond their competency limit and will need to be more closely monitored and assessed.
Mild cognitive deficits and motor skill deterioration need not precipitate retirement in all situations; many surgeons decide to limit themselves to working in an office practice or assisting colleagues in the operating room. Nonclinical opportunities for administration and teaching are also possibilities. It is not necessary to lose the experience and discernment of the aging surgeon totally, and efforts should be made, if possible, to continue to benefit from their maturity and perspective, for they are a clear resource to the profession.
Dr. Holt is professor emeritus in the department of otolaryngology-head and neck surgery at the University of Texas Health Science Center in San Antonio.