Letters: Surgeons’ Zone of Focus May Not Signal Cognitive Decline

Steven M Houser, MD
Associate Professor of
Otolaryngology, CWRU
MetroHealth Medical Center
Cleveland, Ohio

Response: I appreciate Dr. Houser taking the time to read and comment on the “Everyday Ethics” presentation on “The Aging Surgeon.” Dr. Houser is a highly respected, excellent academician, educator, and surgeon, and I value his perspective. As I understand his comments, Dr. Houser was indicating that, on occasion, when a surgeon is in the “zone” of focus during a procedure that is going exceptionally well, it would not be a concern if he/she might not name a particular instrument or prefer to reach for the instrument (safely, of course) so as not to be distracted from the smooth flow of the operation. I do get that and may have had the same experience from time to time over the 45 years of my surgical life. I am aware of the athlete’s “zone” and the writer’s “groove,” so what Dr. Houser is describing is likely a similar situation for surgeons.

However, by way of explanation, when I develop the scenarios for the Everyday Ethics presentations, they are partly based on real-world situations, and partly on a writer’s script, to emphasize certain points that are a prelude to the important part of the article—the discussion. In this particular scenario, I opted to have Dr. Archibald Fitch, the fictitious senior surgeon, exhibit a few behaviors that were equivocal for impairment, including the occasional forgetfulness of an instrument’s name, but which could indicate either an early memory loss or a variant of normal surgical actions. Then, based on the observations that other surgical capabilities appeared to be just fine, the reader was led to a discussion of how one knows when there is a concern for patient safety with a decline in a surgeon’s cognition and dexterity and what resources are available to a surgeon for identifying a problem. The American Medical Association and the American College of Surgeons are both addressing this issue, so it appeared to be a timely topic to me.

As a 71-year-old surgeon who still supervises residents in the clinic and operating room, it is, of course, an issue to which I am obliged to pay attention. As part of a large group of “baby boomer” surgeons, I welcome the national medical enterprise’s attention to this issue and look forward to the guidelines and recommendations that will surely be provided to assist us in a self-awareness assessment of our skills and competencies. I tried to emphasize in the article that, while external oversight is important for patient safety, it remains the primary responsibility of the surgeon to have a keen sense of awareness of his/her skills and mentation, and to seek additional assessments if there is a concern.