Patient safety, ethical considerations must be respected

When is a surgeon too old to operate or a physician too old to practice medicine? We could pose the same query about any profession. The question is difficult to answer because it involves a person’s sense of self-worth, society’s needs and expectations, and many complex legal issues.

Some surgeons have successfully practiced medicine and surgery into their 80s and beyond. On the other hand, we all know of surgeons whose judgment began to decline in their mid-60s.

Although all states have a minimum age to practice medicine, no maximum age exists in any jurisdiction. In spite of the obvious need to consider the matter of the aging surgeon, scientific literature on the subject is limited. Nobody has done a definitive study matching surgical outcomes to surgeons’ ages.

A body of literature does exist, however, that compares, in a roundabout way, clinical outcomes with physician age. An analysis of literature relating clinical experience to quality of care found that chronologic age and clinical experience are closely related (for obvious reasons). Of the 62 articles that were reviewed, the following results were reported:

• about half of the articles reported a decline in performance with increased experience (meaning older doctor)
• 21 percent showed a decline in some, but not all, outcome criteria
• 3 percent showed first an increase and then a decrease
• in outcomes with increasing experience
• 21 percent showed no relationship between age and outcomes
• 2 percent showed some improvement in outcomes with experience
• 2 percent showed improvement in all outcomes with experience

The authors of these diverse studies used different criteria to measure outcomes, but for the most part looked at failure to keep up with (or “believe in”) the latest recommendations for such things as blood transfusion criteria or the use of beta-blockers, aspirin, thrombolytic agents, and so forth. The articles reviewed did not, as far as I could determine, look at surgical outcomes related to age or “experience.”

Like driving a car?
Without any literature comparing surgeon age to surgical outcomes, how can we even begin to make recommendations that have any validity? Research on fitness to drive a car may have some applicability. In 2001, a short battery of standardized psychological tests was developed as an initial panel for fitness-to-drive screening. Researchers compared the results of these written tests with a more comprehensive, computer-based test battery and validated both approaches with the reports of two driving instructors who independently assessed the subjects in the field—that is, while driving a car.

The written tests, which measured several cognitive functions thought to be important for safe driving, were fairly reliable; the computer-based testing had even better accuracy. According to the researchers, “Most of the time, its [driving’s] complexity is not experienced because many aspects of driving are highly automated.

“When a cognitive problem arises, however, a distortion of the complex information processing system can produce very dangerous situations. This may be the reason why several researchers could demonstrate that cognitive variables are an important causal factor in crashes of older drivers.” These words could easily apply to surgical situations as well.

The researchers chose tests that measured “visuo-sensory, visuo-perceptual, and visuo-spatial functions, the different basic attention functions, the useful field of view, automatic versus controlled processes, cognitive flexibility, the psychomotor system, and executive planning functions.” They were satisfied that their short screening battery could serve as a useful first step in assessing driving ability in an aged population. They pointed out in a companion paper that, in most jurisdictions, driving assessment begins with a court order, usually after an accident or other encounter with authorities. The authors implied that this isn’t good enough to protect society.

A similar situation exists in medicine when certain practitioners are put out of business because they’ve had so many malpractice suits that they can no longer obtain liability coverage. This postinjury type of control is suboptimal in today’s world. Instead, a proactive anticipatory scheme to protect patients is needed.

Surgical skill assessment
Could a screening test be developed for surgery that would do the same as the fitness-to-drive battery? I suspect so. In fact, considering the nature of the question at hand, the identical group of tests might do. After all, the screening battery did not have questions related specifically to driving a car; instead, it used standardized psychological tests that measured a variety of cognitive, motor, and visual functions.

Testing actual surgical skill—as opposed to cognitive functioning that would apply to surgical skill—might be trickier to do. Although some surgical specialties and orthopaedic residency programs have motor skills labs and standardized tasks for training and assessment, the validity of such measures has yet to be proven. They would also be far more difficult to administer than a written or computer-based assessment.

As with the fitness-to-drive analysis, a motor skill assessment might be limited to those individuals who fail to make the grade on an initial written or computer-based screening test. Alternatively, a motor skill assessment could be administered when some entity raises a disputed question of competence.

Before we begin judging the competency of our fellow orthopaedic surgeons, however, the existence of an age-related competency issue must be established. Although the scientific literature now contains abundant volume-related outcome studies involving surgical procedures, age-related analysis of outcomes in surgery doesn’t exist. Performing such a study, however, wouldn’t be any more challenging than doing volume outcome studies. Medicare data that look at indicators of “good” and “bad” care, such as clean surgery infection rates, perioperative mortality, readmission rates, length of stay, and so forth could be massaged to compare groups of surgeons based on age.

Is age the issue?
Before making any recommendations about testing competency, we should first define the problem and get a grip on its magnitude. Although some members of the AAOS might argue that an unfavorable report would hurt the membership—and perhaps even lead to lawsuits against older orthopaedic surgeons—if we don’t do such a project ourselves, no doubt biostatisticians from the Harvard School of Public Health will.

In a recent survey of more than 500 retired orthopaedic surgeons that asked why they retired, the response “I no longer felt competent” was not listed by anyone. This may have been a result of self-selection bias, but the results are instructive nevertheless. Age itself is not the important issue. Instead, the matter is one of competency and its effect on clinical and surgical outcomes.

Licenses to practice medicine and surgery are the exclusive bailiwick of state legislatures. If we look to the way the individual states handle concerns about older drivers to gain insight into how those same entities might respond to proposed changes in medical licensure for older doctors, we find an astounding variation among states. The diversity of leniency ranges from Tennessee, where drivers 65 and older don’t have to bother renewing their licenses, to Illinois, where the usual four-year renewal cycle is shortened to two years for drivers 81 to 86 years old, and one year for drivers 87 years of age and older.

Many states make no distinction among drivers of different ages; some consider it unconstitutional to even acknowledge that an age difference in driving safety might exist. Therefore, any suggestion regarding older surgeons will likely have little or no impact on such legislatures.

Without mentioning the specific issue of the aging surgeon, we might consider the AMA’s position on physician competency as contained in its Ethical Guidelines:

To preserve the quality of their performance, physicians have a responsibility to maintain their health and wellness, construed broadly as preventing or treating acute or chronic diseases, including mental illness, disabilities, and occupational stress. When health or wellness is compromised, so may the safety and effectiveness of the medical care provided. When failing physical or mental health reaches the point of interfering with a physician’s ability to engage safely in professional activities, the physician is said to be impaired.

In addition to maintaining healthy lifestyle habits, every physician should have a personal physician whose objectivity is not compromised. Physicians whose health or wellness is compromised should take measures to mitigate the problem, seek appropriate help as necessary, and engage in an honest self-assessment of their ability to continue practicing. Those physicians caring for colleagues should not disclose without the physician-patient’s consent any aspects of their medical care, except as required by law, by ethical and professional obligation, or when essential to protect patients from harm. Under such circumstances, only the minimum amount of information required by law or to preserve patient safety should be disclosed.

The profession’s responsibility
The medical profession has an obligation to ensure that its members are able to provide safe and effective care. This obligation is discharged by the following steps:

• promoting health and wellness among physicians
• supporting peers in identifying physicians in need of help
• intervening promptly when the health or wellness of a colleague appears to have become compromised, including the offer of encouragement, coverage, or referral to a physician health program
• establishing physician health programs that provide a supportive environment to maintain and restore health and wellness
• establishing mechanisms to ensure that impaired physicians promptly cease practice
• assisting recovered colleagues when they resume patient care
• reporting impaired physicians who continue to practice, despite reasonable offers of assistance, to appropriate bodies as required by law and/or ethical obligations

Before taking any position on the matter of older surgeons, the AAOS might want to include some questions in its Annual Survey to shed light on the matter. Likewise, perhaps a query of physician liability carriers could provide information about how often malpractice litigation against orthopaedic surgeons hinges on the practitioner’s age at the time of an alleged tort.

Some surgeons, perhaps wondering if they are, in fact, “losing it” with respect to surgical ability might want a mechanism to assess their own visual-motor skills. Perhaps the AAOS could travel down this pathway, establishing a computer-based program that surgeons could access from their own offices (for a fee, perhaps) or at the Annual Meeting to see if they still have what it takes to do the job they were trained for so many years ago.

Alternatively, perhaps a surgeon facing a malpractice claim could utilize such a program to confirm that he or she still has an officially sanctioned skill set sufficient to perform surgical procedures. It’s been said that malpractice lawyers love to sue surgeons older than age 75 years, because victory in the courtroom is often a slam-dunk, regardless of the fact pattern in the case.

Stuart A. Green, MD, is a member of the AAOS Ethics Committee.

Articles labeled “Orthopaedic Risk Manager” are presented by the Medical Liability Committee under the direction of contributing editor Douglas W. Lundy, MD. Comments and input are welcome.

E-mail your comments to feedback-orm@aaos.org or contact the contributors directly.

References

1. Choudhry, Fletcher, and Soumerai. Systematic Review: The Relationship between Clinical Experience and Quality of Health Care. Annals of Internal Medicine 142 (4), 2005.
2. De Raedt, and Ponjaert-Kristoffersen. Short Cognitive/Neuropsychological Test Battery for First-Tier Fitness-To-Drive Assessment of Older Adults. The Clinical Neuropsychologist, 15:3, 2001.
3. De Raedt, Ponjaert-Kristoffersen. Predicting At-Fault Car Accidents of Older Drivers. Accident Analysis and Prevention 33, 2001.
4. Leopold, Morgan, Kadel, Gardner, Schaad , Wolf. Impact of Educational Intervention on Confidence and Competence in the Performance of a Simple Surgical Task. JBJS 87A, 2005.
5. Moorthy, Munz, Sarker, Darzi, Moorthy. Objective assessment of technical skills in surgery. BMJ 327, 2003.
6. Ritter, Austrom, Zhou, Hendrie. Retirement from Orthopaedic Surgery. JBJS 81A, 1999.