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Late-career orthopaedic surgeons may consider shifting to a nonsurgical practice; the question for many is when to make the change.
Courtesy of iStock\Thinkstock

AAOS Now

Published 10/1/2015
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Angus M. McBryde Jr, MD

The Senior Physician: Acknowledging Age and Ability

Is it possible for us to “retire gracefully”?

Recent efforts to identify quality care have put a spotlight on the relationship between aging and competence in medicine. Women and men who are age 50 to 80 years today are, on average, living longer and with greater quality of life, physical skills, and cognitive abilities than previous generations. But is there a point at which a clinician should expect to “retire” from performing surgery or practicing medicine?

This is a question that the Governing Council of the Senior Physicians Section (SPS) of the American Medical Association (AMA) has discussed at length. The council directs the programs and activities of the section for AMA Physicians 65 years of age and older, whether working full time, part time, or fully retired. At the House of Delegates meeting in June 2015, the SPS recommended and the AMA approved a resolution to convene—rather than simply encourage—organizations to develop assessment guidelines to ensure that senior/late-career physicians are able to provide safe and effective care for patients. This much more active position highlights the following three overall needs:

  • strong data regarding etiology/physiology of cognitive change, which has documented age-related variations
  • testing/evaluation methodology for individual physicians, whether related to proceduralist or nonproceduralist skill sets
  • ways to mute variables such as fatigue, “burnout,” practice environment, health status, and other factors while still producing valid outcome research

The late-career orthopaedist
Orthopaedics and the AAOS have long been on the cutting edge of early- and mid-career teaching and testing principles, but the late career is yet another pivotal point where age and competence intersect. “Phased retirement” is the lay term for the process.

Should an orthopaedist have a nonsurgical practice only after age 75? Or should the cut-off be age 70? Who should be responsible for testing, examining, or evaluating late-career physicians? The University of Virginia, for instance, conducts a first screening when the physician is age 70; at age 75, the physician must undergo annual screenings.

Pilot studies from numerous areas and different perspectives are emerging, but none addresses the specialty-specific variations that are required. Nor can self-evaluations alone answer the question. For the physician, the decision to shift from an active surgical practice to a nonsurgical practice can be stressful and confusing. That stress is due in part to the need for planning a late-career move and to the continued obligation the physician may feel to remain involved in patient care.

This “generational” evolution intersects the increasingly tech-dependent medical practice, as well as the changing socioeconomics of medical care. Significant physical and mental demands may bring to the surface previously unrecognized demotivation and practice shortcuts.

At this point, self-evaluation should occur, supported by information or advice, but this rarely happens. Self-evaluation is a necessity, but can it work in our litigious society? The answer is yes, it must work. Comparative (or reasonably comparative) occupations like airline pilots, air traffic controllers, and fire fighters have strict protocols and mandatory retirement ages. But what is the validity of those comparisons?

Although some complications after surgery may be due to a surgeon’s age and declining competence, others are inevitable risks that may occur regardless of the care taken by the surgeon. For this reason, it may be difficult to draw comparisons between surgery and other fields.

If—justified or not—a surgeon’s age is tied to complications, the result may be a risk management nightmare. It is all too easy for perceptions to be seen as realities and for senior physicians to experience discrimination and to be misjudged.

As proceduralists, orthopaedists may become fair game for generic, nonindividualized, and possible discriminating policies, especially if the evaluation is being conducted in part by the nonprocedural world. The AAOS could bring much-needed leadership to this burgeoning milieu and to discussions of age and competency. The AAOS should play an aggressive and active role as more quantification and stiffening of guidelines occur. At the state level, orthopaedic associations and the AMA, with their strong infrastructures, also may be able to devote resources to this encroaching issue.

Addressing competence
Cognitive deterioration is incredibly hard to quantify from the vascular and multisystem perspective. Research that totally eliminates the variables and matches patient outcomes to physician age is nearly impossible. Furthermore, patient outcomes are only partially affected by the physician, especially in the nonprocedure environment. Generic criticism and prior studies related to “physicians not keeping up” are anecdotal and lack validity. But as the evidence-base broadens, age itself may not be the crux of the issue.

In 2008, Stuart A. Green, MD, then a member of the AAOS Ethics Committee, addressed this issue. (See “Clinical Competence and the Aging Surgeon,” AAOS Now, September 2008.) Today—seven years later—his comments are still pertinent. He noted then the seven steps necessary to ensure that the medical profession itself identifies incompetent physicians. Although detection is important, the medical/orthopaedic community must be proactive on the front end and go beyond it to provide assistance and support for the impaired physician after recognition occurs.

This necessary early recognition can prevent embarrassing exposure and enable quietly proactive measures to be taken that preemptively and gently disallow practice. Physicians have rights, but if their practice puts patients at risk due to their personal and professional shortcomings, then steps must be taken to identify and address the issues.

Retirement is becoming a stepwise process in society but is often difficult for us as physicians, particularly since many of us live an “all-or-none” practice lifestyle. Volunteerism, home or urban work, or humanitarian efforts abroad are multiplying and enable both gainful employment and medical productivity. The recent AMA decision to be a convener for culling the best resources available prompts all of us to move ahead with this issue that will visit each of us at some point in our future.

Angus M. McBryde Jr, MD, is a member of the AMA Governing Council, elected by the membership of the Senior Physicians Section.

References:

  1. Cooper KH: Grow Healthier as You Grow Older. Address to the AMA–SPS Clinical Meeting, Dallas, TX, June 2014.
  2. Waljee JF, Greenfield LJ, Dimick JB, Birkmeyer JD: Surgeon age and operative mortality in the United States. Ann Surg 2006;244(3):353–362. doi: 10.1097/01.sla.0000234803.11991.6d (accessed Aug. 31, 2015)
  3. Weinstein L: Is it time to take a “REST”? Obstet Gynecol 2004;104(3):623-625. (accessed Aug. 31, 2015)
  4. Personal communication from Dr. Angus McBryde
  5. Blazer DG, Yaffe K, Karlawish J: Cognitive aging: A report from the Institute of Medicine. JAMA 2015;313(21):2121-2122. doi:10.1001/jama.2015.4380. (accessed Aug. 31, 2015)
  6. Hershberger PJ, Bricker DA: Who determines physician effectiveness? JAMA 2014;312(24):2613-2614. doi:10.1001/jama.2014.13304 (accessed Aug. 31, 2015)
  7. Green SA: Clinical competence and the aging surgeon. AAOS Now, September 2008. (accessed Aug. 31, 2015)