Age-Old Debate: When Does the Senior Surgeon Put the Scalpel Away?

NEW ORLEANS, LA—To be the optimal cardiothoracic surgeon, what matters more: age or experience? And should there be mandatory retirement or cognitive testing at certain age?

Mirroring conversations taking place in real-world practice as the surgeon workforce ages, several physicians grappled with these questions during a debate session at the 2020 meeting of the Society of Thoracic Surgeons (STS). Their conclusion: there are no easy answers.

“The definition of the expert cardiac surgeon is the one that has made all the possible mistakes, or I prefer to say the one that has seen all the possible mistakes,” session co-moderator Mario Gaudino, MD (Weill Cornell Medicine, New York, NY), told TCTMD. “In any case, there is for sure truth in the fact that experience is really important. There's no doubt that you can compensate for the reduction in your manual skills and speed of thinking with experience just because you have been there, you have seen that specific scenario, [and] you know how to manage—and that's very important. The key is to find the balance between the two.”

Surgeons are not alone in facing this issue—interventional cardiologists have also considered when to stop, at minimum, performing procedures.

The crux of the problem is the lack of evidence regarding what’s normal cognitive decline among physicians and how that affects outcomes, Gaudino said, noting that all of the available studies in this arena are small with “major methodological limitations.”

Looking at the Evidence

Presenting in the session, Marc Moon, MD (Washington University School of Medicine, St. Louis, MO), outlined the existing data on surgeon age and operative mortality, showing a slight association for CABG but not necessarily aortic valve replacement. The two studies looked at older physicians, one only at congenital heart surgeons, and Moon said this link could potentially be due to the fact that the surgeons studied were not trained in multiarterial grafting, which could alone affect CABG outcomes.

To learn more, he looked at outcomes associated with reoperative cardiac surgery and surgeon age at his institution over 33 years. Moon’s team identified “change points” in the career of a surgeon showing increased outcomes at 5 years of experience, again at 9 years, and with the best outcomes at 18 years. But at 29 years of experience, surgeon outcomes begin to decline such that observed/expected mortality rates were lowest for surgeons with 18-28 years of experience.

“There's evidence of a learning curve, at least our data suggests there might be,” Moon explained. “That being said, the late-career surgeon may in fact be the most appropriate member of the team to tackle a complex reoperation. However, it requires preoperative planning and a checklist for the team.”

Some solutions might be performing complex reoperations earlier in the day and potentially teaming early career with late career surgeons to improve outcomes. “It may actually improve both of their experiences,” he suggested. “These data do not suggest that early career or senior surgeons should not tackle complex reoperations, but they do suggest there's room for improvement for many if not all surgeons. With the best circumstances, events will occur, but with adequate team planning and surgical preparation, hopefully failure to rescue will remain low for surgeons in any career phase.”

Age vs Experience

Robert Guyton, MD (Emory Healthcare, Atlanta, GA), a self-described “senior surgeon” at 73 years old, argued in the debate that while age “of course” matters, so long as a surgeon’s risk-adjusted outcomes are desirable he or she should continue to operate.

“Why have mandatory testing for cognitive skills when we in cardiac surgery are blessed with risk-adjusted outcomes?” he asked. “Why use the surrogate when we have outcomes?”

“Early in your career, your physical skills and your ability to focus are strong, but knowledge, planning skills, and repertoire for rescue will be stronger later. You commit to dedicated longitudinal care and compulsive attention to detail to give the patient the same outcome,” Guyton asserted. At the mid-career level, he continued, physical skills are strong and experience and knowledge are “robust but still growing,” but the surgeon’s risk adjusted outcomes are still good.

Finally, as a senior surgeon, Guyton acknowledged that his own physical skills and stamina have weakened, but he said he compromises by doing one complex case a day and starting early. At this point, any lack in function is “balanced by the strongest experience and knowledge base” and backed up by risk-adjusted outcomes, Guyton stressed.

Early in your career, your physical skills and your ability to focus are strong, but knowledge, planning skills, and repertoire for rescue will be stronger later. Robert Guyton

Taking the opposite tack but arriving to similar conclusions, Todd Rosengart, MD (Baylor College of Medicine, Houston, TX), argued that age should be the primary factor in whether a surgeon is able to continue operating. He gave examples of three surgeons who continued to operate through their 80s and even 90s, saying “these are either alarming cases depending on your perspective or actually very encouraging cases about the ability of surgeons to continue on for many years.”

Rosengart was the co-author of a 2019 white paper published in JAMA Surgery looking at career planning for senior surgeons. “We were struck with the dearth of information and good data in terms of this issue of cognitive outcomes and performance,” he said. “In fact, we struggled very hard to find primary-source data.”

Some research has shown that cognitive decline starts around age 60, but “physicians in general perform better than their lay public counterparts,” he noted. While some professions like air traffic controllers and pilots have age retirement mandates and seem happy with them, Rosengart said he’s not so sure something like this should be applied to physicians.

“As you get old, the variability in terms of decline in cognitive function actually begins to increase quite dramatically. Actually the increase is in the variability rather than the actual decline [itself],” he said. “The other issue certainly in our environment . . . is we do have a growing patient population of need and a relatively declining number of physicians and surgeons available to support the care of those patients. So to arbitrarily mandate everyone's retirement regardless of abilities would obviously seem to be unwise.”

A test cannot [measure] experience in the OR and the ability to deal with complex scenarios, which in the end is really, really important for a cardiothoracic surgeon. Mario Gaudino

Rosengart highlighted a Medicare database analysis showing that older surgeons in fact have better outcomes for nonelective cardiac and noncardiac cases, especially among high-risk cases. “The more you've done over the course of your career, perhaps the more you have built your skills to avoid problems,” he said.

Yet, data show that older surgeons are less likely to adopt new technologies and tend to have little self-awareness of true cognitive declines. In the aforementioned white paper, Rosengart said results from a 2018 survey of 80 Society of Surgical Chairs members show that less than 25% have any kind of mechanism in place to deal with cognitive decline issues and none felt that mandatory retirement was appropriate.

“Perhaps realistically we need to accept the fact that physicians themselves may not necessarily be the best judge of those declines in performance,” he said, adding that the writing committee didn’t recommend mandatory cognitive testing “but that there should be cognitive testing performed in a standard fashion beginning at the age of 65, so a baseline could be established.”

If a surgeon is faced with cognitive issues big enough to support a step back from the operating room, Rosengart said there are still options to remain in practice, whether as an assistant surgeon or even a nonoperative role. These roles are  “not at all a pejorative,” he commented. “Of course, there's a lot that senior surgeons can contribute—their experience teaching, guiding research, guiding younger faculty members and students and of course leadership outside of the operating room or in some cases even the clinic room.”

Call for Society Guidance

“It’s great to see that in the end the debaters found agreement,” Gaudino said after the debate ended.

Audience member William Caine, MD (Intermountain Healthcare, Salt Lake City, Utah), shared how he works with a 76-year-old senior partner and has no qualms. It used to be that his institution required routine biennial neurocognitive testing after about age 68, a good idea since self-awareness can be a problem, Caine said. However, the Utah State Legislature passed a bill in 2018 identifying this practice as age discrimination. “That then makes the burden fall back on us as partners to monitor, which is sort of an awkward situation to be in, but nevertheless we'll take that on,” he explained. “I'm wondering, is there some way to reconcile these two things so that it's not so awkward?”

Rosengart said while he was aware of that legislation, he pointed to the Age Discrimination in Employment Act of 1967. Federal law “has a significant carve out for things like patient safety, so were it to come to litigation, [Utah’s stance is] probably not a justified law,” he assured. “The institution would be protected.”

Another audience member called upon surgical societies to take more of an active role in guiding what should happen to senior surgeons nationally. “Ultimately the societies are a good place to get some recommendations, but realistic credentialing is an institutional matter,” Rosengart argued. “This will probably have to occur at the institutional level.”

Peer Feedback, Public Reporting

Gaudino told TCTMD that his institution does not have a formal age for surgeon retirement, but Italy, where he practiced until recently, requires surgeons to retire at age 70. “I can tell you that I think an age cutoff doesn't really work very well, because you have people who should have retired probably at 60 and people that at 70 are perfectly functional,” he said. “They are actually mentoring junior colleagues and they are the resources for the national health system and for the patients. It's a complex question, and it's good that we are discussing that.”

Moving forward, he would like to see more studies in this field. “The first thing is we do not have background information, we don't have really a comparator because we have no data of what happens to surgeons when we age,” Gaudino said. “The very first thing would be to prospectively collect standardized data on surgeons over the course of their career and then potentially correlate those data with the outcomes and see what is the threshold—if there is a threshold. We really do not know. We are really at the very beginning.”

In the meantime, anonymous peer feedback—like what is done for physicians impaired by alcohol or drugs—will be important, he said. “That's a good mechanism that's in place. It's a difficult question that cannot be simply assessed or decided based on the results of a test because, again, a test can measure motor ability or eye-to-hand coordination, but a test cannot [measure] experience in the OR and the ability to deal with complex scenarios, which in the end is really, really important for a cardiothoracic surgeon, probably as important as dexterity and speed.”

Also, Gaudino said, public reporting will continue to identify outliers in terms of outcomes, “and that doesn't necessarily happen [only] when you are old.”