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224 J.F. Waljee and L.J. Greenfield
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The Effect of Age on Physician Skill
Several studies have looked specifically at the effect of aging
on physicians. In 1994, Powell et al. demonstrated a progressive decline in cognitive function among aging physicians,
with a notable decline after age 65. These authors assessed
physicians and age-matched controls using the Assessment
of Cognitive Function (ACF) test, a series of neuropsychological tests assessing one’s ability to process and retrieve
new information, attention and language ability, visuospatial
operations, and reasoning [13, 14]. The study demonstrated
that age-related declines occur in both physicians and nonphysician control subjects affecting verbal memory, reasoning, attention span, and visuospatial ability.
Bieliauskas et al. recently surveyed 359 surgeons over a
6-year period to identify an association between aging and
cognitive functioning. Unlike previous studies addressing
the effects of physician aging on performance, this study is
longitudinal in design. These authors used the Cambridge
Neuropsychological Test Automated Battery (CANTAB)
instrument to assess several aspects of physician performance. First, surgeons were tested on measures of rapid
visual information processing (RVIP), which also assesses
stress tolerance. Surgeons were also tested on reaction time
(RTI), and visual learning and memory (paired associates
learning, PAL). The authors found age-related declines
across all domains. Figure 18.1 demonstrates the effect of
age on the RVIP task. There was a nearly linear decline in
mean rapid visual processing response with advancing age.
Additionally, older surgeons had notably slower movement
and reaction time with response to stimuli (Fig. 18.2). Finally,
with respect to visual learning and memory, older subjects
experienced more incorrect responses per trial, and a lower
proportion of correct responses on the first attempt of each
exercise (Fig.
18.3). Of note, these effects were more pronounced among those surgeons who had voluntarily
decreased their operative caseloads compared with higher
volume surgeons, implying that procedural volume may be
an important factor in the correlation between aging and
technical skill (Fig. 18.4).
Interestingly, recent data suggest that physicians may
adapt to the aging process differently due to the technical
and cognitive demands of their profession. Physicians may
retain some skills that decline faster in age-matched counterparts. Boom-Saad et al. used CANTAB to determine the
effect of age on psychomotor functioning among surgeons
and trainees, specifically looking at efficiency of motion,
reaction time, sustained visual attention, and visuospatial
memory [15]. These authors also demonstrated a linear
decline in functioning with respect to RTI, RVIP, and the
visual paired associates learning test (PAL). However, compared with age-matched controls, surgeons outperformed
age-matched controls despite the decline in age. Surgeons
had greater efficiency of movement, shorter response time,
and greater accuracy with PAL tasks compared with agematched controls (Figs. 18.5–18.7), despite the overall
decline with age.
To what extent these phenomena represent innate abilities
compared acquired skill through the practice of surgery is not
clear. However, it is encouraging that studies have shown that
many cognitive and motor tasks can be learned and modified
with practice. Wanzel et al. and Risucci et al. have studied the
relationship between visuospatial ability and competency to
perform surgical procedures. These authors have shown that
visuospatial ability is easily tested and improves with practice
and feedback. Such observations suggest that these and similar tasks could be an important tool for systematically assessing physician competence and skill [11, 12].
Fi g u r e 18.1 Correlation between
subject age and rapid visual
information processing (reprinted
with permission from
Bieliauskas et al. [31]).
Fi g u r e 18.2 Correlation between
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subject age and five choice
movement and reaction time
(reprinted with permission from
Bieliauskas et
Fi g u r e 18.3 Correlation between
subject age and paired associate
learning to assess visual learning
and memory (reprinted with
permission from Bieliauskas
al. [31]).
et
al. [31].
22518 The Effect of Advancing Age on Physician Performance
Fi g u r e 18.4 Correlation between surgeon case volume and paired
associate learning (reprinted with permission from Bieliauskas
et al. [31]).
Fi g u r e 18.5 Comparison of movement time between surgeons and
normative controls stratified by age (reprinted with permission from
Boom-Saad et al. [15]).
226 J.F. Waljee and L.J. Greenfield
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age was not correlated with recurrence among patients undergoing open herniorrhaphy.
Previous studies have demonstrated a correlation between
physician age and procedural mortality. O’Neill et al. evaluated the association between surgeon characteristics such as
age, procedural volume and specialty training, and operative
morbidity and mortality following carotid endarterectomy
(CEA) [20]. Patients cared for by older surgeons, defined as
surgeons in practice longer than 20 years since licensure,
experienced a higher operative mortality rate following CEA
compared with patients treated by younger surgeons, after
adjustment for patient age and mortality risk. Hartz et al. also
identified a significant correlation between advanced surgeon
Fi g u r e 18.6 Comparison of response time between surgeons and nor-
mative controls stratified by age (reprinted with permission from BoomSaad et al. [15]).
age and higher operative mortality following coronary artery
bypass grafting (CABG) [21]. Waljee et al. examined the correlation between surgeon age and operative mortality following both cardiovascular and oncologic surgical procedures in a
sample of Medicare patients in the USA. In this study, patients
cared for by surgeons older than 60 years had a small but significantly higher risk of perioperative death following CEA,
CABG, and pancreatectomy (Fig. 18.8) [22]. Conversely, surgeon age was not correlated with operative mortality for elective aortic aneurysm repair, aortic valve replacement,
esophagectomy, cystectomy, and lung resection. Of note, for
those procedures in which older surgeon age was correlated
with higher patient operative mortality, this association was
limited to those surgeons with low procedural volumes
(Fig. 18.9). These findings suggest that procedural volume
may have a protective effect against age-related decay in performance, and those surgeons who remain active with high
Fi g u r e 18.7 Comparison of visual information processing between
surgeons and normative controls stratified by age (reprinted with permission from Boom-Saad et al. [15]).
operative caseloads may attenuate the effects of advancing age
on their skill set. Conversely, surgeons who recognize diminishing skills may begin to voluntarily reduce their caseload.
In contrast to these findings, other authors have demon-
The Effect of Physician Age on Patient
Outcomes
strated that increasing physician age confers better outcomes
for some procedures. Risucci et al. demonstrated that surgeon age and years since graduation were positively correlated with lower procedural times and better acquisition of
Clearly, age-related declines in functioning exist, but to what
extent these changes influence patient outcomes is less clear.
A recent systematic review demonstrated that older physicians may have less up-to-date factual knowledge and may
have poorer patient outcomes [16]. Older physicians are less
likely to adhere to established screening guidelines or to
laparoscopic skills [23]. Prystowsky et al. evaluated morbidity and mortality following complex alimentary tract procedures by physician age. In this study, patients of younger
surgeons were more likely to have higher morbidity and
mortality rates following highly complex alimentary tract
procedures compared with older surgeons [24].
standards of therapy use [17, 18]. Some authors have postulated that the effect of age may be related to difficulties in
adapting to new techniques, such as laparoscopy or endovascular therapies. For example, Neumayer et al. studied 1,629
patients who underwent laparoscopic herniorrhaphy [19].
Implications for Practicing Physicians
and Policy Makers
These authors found that surgeon age (³45 years) was correlated with a higher incidence of hernia recurrence following laparoscopic hernia repair, particularly among surgeons
inexperienced in laparoscopic repair. Conversely, surgeon
Although many studies have examined the relationship between
physician aging, professional performance, and patient outcomes, it is unclear how best to utilize these data with respect to
22718 The Effect of Advancing Age on Physician Performance
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Fi g u r e 18.8 Adjusted operative mortality among Medicare patients in
1998 and 1999, according to surgeon age, for four cardiovascular procedures (a) and four cancer resections (b)
health policy and guidelines for physicians approaching retirement age. We do not know the age limits of physician performance nor the role of other provider and practice setting
characteristics on the effects of aging, such as acquiring
subspecialty training or practicing in a teaching hospital.
Previous studies are often limited by a lack of longitudinal data
or reliance on administrative data which may not identify subtle
factors that influence the relationship of age and performance.
†
. (Reprinted with permission
from Waljee et al. [22].)
age, surgeon volume, hospital volume, and hospital teaching status.
*p<0.05.
†
Adjusted for patient severity, race, gender,
Regardless, there have been efforts to improve healthcare
quality through assessment of physician performance
throughout one’s career. Many fields in medicine today
require recertification examinations at periodic intervals to
ensure competence and test medical knowledge. However,
written evaluation may not suffice for those in proceduralbased fields. In recent years, the Society of American
Gastrointestinal and Endoscopic Surgeons (SAGES) has
228 J.F. Waljee and L.J. Greenfield
0.0
Low
volume
Medium
volume
High
volume
Low
volume
Medium
volume
High
volume
Low
volume
Medium
volume
High
volume
Low
volume
Medium
volume
High
volume
Elective repair of an abdominal
aortic aneurysm
Carotid endarterectomy Aortic valve replacementCoronary artery bypass grafting
5.7
4.6
2.9
1.9
1.4
1.3
10.0
8.3
6.7
5.7
4.4 4.4
2.5
1.5 1.5
8.8
10.2
7.0
6.4
5.6
4.6
6.5
3.6
3.1
5.0
10.0
15.0
20.0
25.0
Adjusted Operative Mortality (%)
41-50 years
>60 years
5.9
5.7
4.6
6.2
5.1
3.3
22.4
13.6
10.2
14.6
10.0
5.6
6.6
5.0
5.2
6.4
12.2*
3.3
20.9
10.1
8.3
22.8*
15.2
3.7
Low
volume
Medium
volume
High
volume
Low
volume
Medium
volume
High
volume
Low
volume
Medium
volume
High
volume
Low
volume
Medium
volume
High
volume
Lung resection Cystectomy Esophagectomy Pancreatectomy
Adjusted Operative Mortality (%)
41-50 years
>60 years
0.0
5.0
10.0
15.0
20.0
25.0
a
b
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Fi g u r e 18.9 Adjusted operative
mortality among Medicare
patients in 1998 and 1999,
according to surgeon age, and
stratified by surgeon volume.
†
(a) Cardiovascular procedures;
(b) cancer resections. (From
Waljee et
al. [22]).
†
Adjusted for
patient gender, race, admission
acuity, age, and Charlson score.
*p<0.05.
developed a standardized curriculum and assessment of surgical trainees acquiring laparoscopic skills, the Fundamentals
of Laparoscopic Surgery (FLS) curriculum. The FLS program is designed to teach both the cognitive and psychomotor aspects of laparoscopy through didactic teaching modules
as well as specific technical skill sets [25]. Early studies have
shown these programs to be successful in improving performance, and they are increasingly becoming a requirement
for surgeons seeking credentialing at certain hospitals [12,
26, 27]. Similar concepts could be applied to the recertifica-
tion process for surgeons in practice to assess both medical
knowledge and technical skill. However, there is no current
systematic assessment for the technical aspects of surgery
for surgeons in practice, and few guidelines for surgeons
considering or nearing retirement.
This research has also prompted debate regarding the optimal timing of and approach to retirement. A recent survey of
surgeons revealed that many surgeons in practice begin to
decrease their workload after the age of 60, but a substantial
number continue to operate well beyond the age of 70 [28].
The reasons for retirement commonly cited relate to the medical business climate and fear of malpractice, rather than an
innate sense of waning competence or inability to complete
tasks. In fact, younger surgeons may be more likely to consider
22918 The Effect of Advancing Age on Physician Performance
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retirement due to increased rates of self-reported burnout,
emotional exhaustion, depersonalization, and sense of reduced
personal accomplishment [29, 30]. In addition to variation in
timing of retirement, physicians also vary in their approach to
retirement. Many surgeons gradually taper off their clinical
practices and operative volumes [28, 31]. However, recent
data indicate that those surgeons who maintain high procedural volumes can preserve their technical skills and have
improved patient outcomes. It is well established that surgeons who perform certain procedures less frequently have
poorer outcomes compared with those who perform these
operations more frequently [32–34].
Physicians may lack self-awareness regarding the effects
of aging on their professional skills. Recent data indicate that
physicians do not report difficulties with memory recall or
name recognition, despite age-related changes demonstrated
on testing. Interestingly, self-awareness of cognitive changes
may be the marker surgeons expect to use for the decision to
retire. [31] Approximately 40% of surgeons report that they
will retire when they feel their skills are waning, but only
27% report that they will retire at a predetermined age. In
fact, there may be a significant delay between the onset of
cognitive changes and retirement, and the extent to which
this affects patient care is not known. It is also unclear what
mechanisms should be in place for those surgeons who may
not recognize deterioration in their skills. Greenfield and
Proctor found that the majority of surgeons believe that withdrawing operating privileges should be based on peer-review
measures or the onset of disability, and not on the basis of
age alone [28]. However, this approach may be problematic
for several reasons. In community hospital settings, senior
surgeon influence and medicolegal concerns regarding
disclosure of surgeon performance can inhibit objective peer
review. Although an external reviewer could provide an
objective viewpoint, the most appropriate method to assess
performance has not been established. Instead, data on adherence to best processes of care, length of procedures, length
of stay, and specific postoperative complication rates may be
more helpful to assess the quality of patient care and could
be used in conjunction with standardized tests of knowledge
and technical skills to guide retirement.
In conclusion, current research has only begun to define
the effects of aging on physician performance, but has raised
important questions concerning physician competence and
quality of healthcare delivered. While current data may not
support the use of age alone as an indicator of performance,
understanding the effects of aging and the mechanisms behind
decline in performance can provide valuable insight for future
policy decisions regarding recertification and retirement.
Efforts to refine cognitive and procedural tests should continue with emphasis on confidentiality so that ultimately, surgeons will be able to track their own performance over time
facilitating appropriate decisions regarding retirement.
References
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Section III
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Perioperative Issues
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Chapter 19
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Invited Commentary
Ben Eiseman
Since the publication of the first edition of this book,
geriatric surgery has achieved recognition of its professional
independence. Like an adolescent youngster or an equivalent
recently liberated nation, it now faces a number of policy
decisions as it matures and seeks stability. This invited commentary is therefore for the founding mothers and fathers of
Surgical Geriacistan. It comes from a veteran of similar wars
of independence of Thoracic, Pediatric, and Vascular
Surgcalistan, and many years ago as an invited outside founding father of Family Practistan.
Defining the Borders of Your
Professional Turf
An essential early step in the maturing process for a person,
a nation, or a clinical specialty is to define where it differs –
and excels – from everyone else: to define its borders. This is
of practical importance if, as for Surgical Geriacistan, it is
surrounded by aggressive neighbors such as Intensivistan,
Hospitalistan, and the bearded mullahs of Fundamentalistan.
The political paradigm for Surgical Geriacistan resembles
the diplomatic Great Game of Central Asia, the Balkans, and
Central Africa.
Geriatric surgery has a unique focus: its primary concern
is the elderly and those near the end of life when operation
is under consideration. Such patients have a diminished life
expectancy, suffer multiple comorbidities and most of their
diseases are incurable and, therefore, palliation is the best
that can be expected. Their quality of life is limited; their
physiologic reserves and defensive mechanisms compromised, and they are uniquely dependent on support of family and society. Finally, their management is enormously
expensive. Skills required to provide operative care to such
B. Eiseman (*)
Department of Surgery, Denver Vetarans Affairs Hospital, University
Hospital, 1055 Clermont St., Denver, CO 80220-112, USA
e-mail: Ben.eiseman@va.gov
a population requires special training, which must be
codified by the founders of geriatric surgery.
Unique Skills
Essential skills for geriatric surgery are familiar to its practitioners but include familiarity with the following unique features of the elderly and the oldest old.
Response to the stress of operation. −
Cumulative effects of comorbidities. −
Risks of polypharmacy. −
Communication skills with the elderly and their families. −
Economic implication of the cost of care in this high-risk, −
high-cost, low-outcome benefit population.
Once requirements for achieving these and other essential
skills are identified, definition of the content and duration of
the required training period will follow.
Defending Your Borders
Leaders of geriatric surgery must be skilled practitioners and
good politicians because they are surrounded by acquisitive
competitors with whom they must work in harmony. Sharing
authority is seldom an inherent charm for most surgeons who
prefer unity of command but such are the rules of engagement in geriatric surgery. The fact that their neighbors are
often the source of patient referrals asserts a modulating
force on authoritarian instincts.
Geriatric surgeons like any good diplomat should be prepared to protect their turf when all else fails. Clearly defined
and accepted boundaries help avoid misunderstandings, but
inoffensive traffic through gates in the fence should be
encouraged. Poaching is unacceptable, but recent diplomatic
experiments involving hubris have clearly demonstrated its
destructive folly.
R.A. Rosenthal et al. (eds.), Principles and Practice of Geriatric Surgery,
DOI 10.1007/978-1-4419-6999-6_19, © Springer Science+Business Media, LLC 2011
233
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