Older surgeons offer advice on evolving one’s career over time
Aging surgeons may face diminution of physical strength, visual acuity, and coordination that gradually impair performance. Drawing the curtain on surgery can be one of the most difficult decisions affecting an orthopaedist’s life. In this roundtable discussion, Antonia F. Chen, MD, MBA, speaks with Richard H. Rothman, MD, PhD, and Lawrence D. Dorr, MD, on maintaining skills, monitoring one’s own performance, and finding value outside the operating room.
Dr. Chen: How would you describe your own career trajectory, and what would make you stop operating?
Dr. Rothman: My view has changed as I’ve gotten older, because I continue to feel well and be productive. I’ve always felt that even if you’re 5 percent or 10 percent off your game, you should step aside in terms of patient safety. But I try to be introspective in terms of my abilities. I look at objective statistics such as blood loss, operative times, mortality rate, and readmissions, and I ask my partners to watch me operate and evaluate my skills. Despite being 80 years old, I feel great and the statistics indicate that I do a good job, so it seems to me it would be a waste of my capacities to stop operating. But these days, I generally perform less demanding cases, and I carry a lower case volume, all of which makes my task easier.
Dr. Dorr: I always thought that when I reached age 55, I’d retire, but when I reached that age it was the best part of my life. When you’re still experiencing the rewards of accomplishment, there’s little incentive to stop as long as your hands and brain are still working.
Dr. Rothman: Retirement is a very difficult decision, and it’s certainly multifactorial. For me, the number one issue is patient safety. Over the years, I’ve had to counsel four or five people to retire, and it’s a very painful, difficult, and sensitive experience. For most surgeons, our identity is so tied up with our ability to operate and care for people, there’s a very strong identity that you lose when you retire.
There’s also an economic component, which should be low on the list, but it’s a fact of reality that very few people plan for their retirement in a sound, economic way. And realistically, there is a shortage of good surgeons. There’s no magic age at which one should stop operating, because you risk losing that resource of skill and wisdom.
Dr. Dorr: There is another important point regarding the older surgeon’s ability to train younger surgeons. We can still contribute in that manner. In my prime, I performed eight or 10 cases a day. Now, some days I only do two, and the most I do in a day is four or five. But I spend more time training younger surgeons. There’s joy in that, and I feel like I have a lot of wisdom and experience to offer.
Dr. Chen: You’re both very self-aware, but how do you tell a colleague that he or she should do fewer cases? How do you explain that slowing down would benefit their practice and their patients?
Dr. Rothman: I try to approach the issue as their friend, rather than as an adversary. “Look, you’ve had a distinguished career, and you want to preserve your image. Focus on the things you’re really good at and try to minimize your stresses.” I try to give the advice I’d want someone to give me. And if you can ikeep it at that level, people are much more open-minded, as opposed to saying, “I’m your boss and you need to cut your volume in half.” However, even with the best of intentions, it can sometimes become adversarial, and, in that case, you must follow a very careful procedure to protect everyone’s rights.
Dr. Dorr: My volume has reduced in part because my energy is a little less than when I was younger. Years ago, 4 hours sleep was all I ever needed. Now I need 8 hours. As you get older, your energy diminishes and patient safety can be impacted. You’re not going to be on top of the eighth case in a day like you once were. For both patient safety and your own health, you may need to reduce your volume.
Dr. Rothman: That leads into a discussion of what parameters one should look at as a maturing surgeon. At a certain age, surgeons should be regularly evaluated by an internist or neurologist to assess general health and neurologic status.
Second, our eyesight gets worse as we get older, so an ophthalmologist should be part of a matrix of ongoing examination after a certain age.
A third factor is to have an impartial surgeon watch you operate. The usual peer-review process, along with statistics like blood loss, time, mortality rate, and readmission rate should all be considered. Those are good, independent markers.
As surgeons, we’re examined very carefully when we start our practice. We have our cases reviewed, we have to take written and oral boards. What we’re talking about now is the age-related diminution of skill, and it’s important to evaluate that in a fair, open, and honest way.
Dr. Dorr: As one gets older, it’s also important to understand that you have to maintain your health. A regular exercise program strengthens your physical health and your mental capabilities, too. It’s incumbent on those who want to keep practicing to stay in shape, because surgery is stressful and you need endurance in the operating room. Physical endurance and mental attentiveness are critical factors to sustain excellence.
Dr. Rothman: There are soft parameters as well that are harder to gauge, like courage, judgment, and wisdom. I’ve known brilliant surgeons who stopped operating suddenly. I asked them why, and they said they’ve lost their self-confidence and courage to go into the operating room and face five or 10 difficult cases. Those are factors that are hard to measure but important to address.
Working with other team members is very helpful to me as well. Dr. Chen works the same day I do, and I often ask her advice. I’m fortunate to have somebody else working with me to share problems and experiences and issues in the operating room. Sometimes two heads really are better than one.
Dr. Chen: You don’t realize that I’m the lucky one, not you. [laughs]
Dr. Dorr: I agree about the importance of collegiality among your associates. That’s very important for maintaining one’s enjoyment in medicine. One thing I’ve found that has shifted over time: There’s very little conversation these days about accomplishments and good work, just discussions about reimbursement and saving money. That gets old after a while. That’s not what drove most of us into medicine. What drove me was the romance of medicine and the rewards of helping people. When all that counts is how much money you’re making for the group or the partners, or how much you have to save to survive, it becomes a little bit depressing, and I think that contributes to burnout.
Dr. Rothman: I couldn’t agree more. I can only speak for myself, but I don’t feel any different about money now than when I was an intern earning a thousand dollars a month. That should not be the source of gratification. I believe we should encourage surgeons to have a broader scope of interest. There are so many things a surgeon can enjoy, such as philanthropy, research, administration, teaching, and even practice management. But you have to develop those interests throughout your career so that you’re not totally dependent on operating on people for gratification.
Dr. Dorr: Thank you for making that point, because I agree that having other interests can actually increase your interest in medicine. You begin to realize how much you contribute to other people’s lives and how much good you do throughout your medical career. My enthusiasm hasn’t changed much since I was a medical student. I still marvel at the fact that a patient trusts me enough; has enough confidence in me that they’ll allow themselves to be put to sleep and allow me to operate on them. All the activities that you do in life help you realize that what you do in medicine is just unmatched.
Dr. Chen: What advice do you have for young surgeons going forward? What should they do now to build for the future in terms of retirement?
Dr. Rothman: Maintain broad interest and values. Your values start when you’re 5 years old. Your parents teach you what’s right and wrong, and there’s no course in medical school that can replace good family values in terms of honesty and integrity.
But as our education progresses, we have to encourage young physicians to keep broad interests such as the liberal arts—as opposed to just focusing on worms and butterflies and premedical education—so they’re prepared to be better citizens.
Follow examples, like Dr. Dorr, and spend some time, energy, and resources serving the community and underserved countries. And those of us who are older should talk to our junior partners and students and explain to them that real happiness is more in service than in self-aggrandizement.
Dr. Dorr: Rabbi Harold Kushner author of the book, “When Bad Things Happen to Good People,” said that the soul is not hungry for fame and fortune and money; the soul is hungry for meaning. When you leave the earth, you will want to understand that you made a positive impact.
On the practical side, younger surgeons should understand the importance of setting aside some money each month, so when they get to an age where retirement is part of the discussion, they can make that decision without an economic crisis.
And a second factor is what we were talking about earlier: You need to develop some other interest besides medicine, so that you have some breadth to your life. It helps you be a better doctor, because you understand people and can connect with them better if you have a broader range of experience.
Dr. Rothman: All of those things are equally important as to how you cut and sew as well as make a diagnosis.
Dr. Dorr—One thing they don’t teach in medical school and residency is the art of living. Once you get into the medical field, everything is honed in on science and evidence-based medicine. If you want to be happy in your medical life, you’d better catch on to the art of medicine and the art of life.
Dr. Rothman—I don’t think there’s a day in the operating room that I don’t quiz the residents and fellows—and it drives them crazy—about art, literature, politics, or philanthropy. I just do it to provoke them to become better citizens and have a broader sense of interest. I’m astounded at how few physicians read broadly, or even read the newspapers every day. And I really fear the idea that some may become surgical technicians instead of good physicians and good citizens.
Antonia F. Chen, MD, MBA, is an orthopaedic surgeon at the Rothman Institute in Philadelphia and an associate professor of orthopaedic surgery at Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia. Richard H. Rothman, MD, PhD, is the founder of the Rothman Institute and professor of orthopaedic surgery at Sidney Kimmel Medical College at Thomas Jefferson University. Lawrence D. Dorr, MD, is the founder of Operation Walk and professor of orthopaedic surgery at the Keck School of Medicine at the University of Southern California.