Clock ticks down as ag­ing sur­geons con­tem­plate skills

Santa Fe New Mexican - - HEALTH & SCIENCE - Some hos­pi­tals eval­u­at­ing com­pe­tency of older doc­tors By Paula Span

In the fall of 2015, Dr. Her­bert Dardik, chief of vas­cu­lar surgery at En­gle­wood Hospi­tal and Med­i­cal Cen­ter in New Jersey, nod­ded off in the op­er­at­ing room.

Note that Dardik, then 80, was not per­form­ing the op­er­a­tion. He’d un­der­gone a mi­nor med­i­cal pro­ce­dure him­self a few days ear­lier, so he’d told his pa­tient that an­other sur­geon would han­dle her carotid en­darterec­tomy, in which plaque is re­moved from the carotid artery to im­prove blood flow.

But when she begged Dardik at least to be present dur­ing the op­er­a­tion, he agreed to sit in. “I was re­ally an ac­ces­sory,” he re­called. “It was so bor­ing, I kind of dozed off ” — where­upon an alarmed nurse anes­thetist re­ported the in­ci­dent to ad­min­is­tra­tors.

Within days, the hospi­tal’s chief of anes­the­si­ol­ogy and chief med­i­cal of­fi­cer were in Dardik’s of­fice, prais­ing his sur­gi­cal skill while urg­ing him to re­duce his work­load. “I got so an­noyed, I stood up and opened the door and said, ‘Get out,’ ” Dardik said. “Who knows bet­ter what I can do but I my­self ?”

He also re­sisted the sug­ges­tion that he un­dergo test­ing at Si­nai Hospi­tal in Bal­ti­more, which had es­tab­lished a two-day pro­gram to eval­u­ate whether older sur­geons could safely con­tinue prac­tic­ing.

Not long after­ward, Dardik was on a plane when its older-look­ing cap­tain came aboard. (Fed­eral reg­u­la­tions man­date a re­tire­ment age of 65 for com­mer­cial pi­lots.)

“I hope this guy’s still OK,” Dardik re­mem­bered think­ing. At which point, “it hit me like a ham­mer — this is what other peo­ple think when they look at me.”

A few weeks later, he be­came the first doc­tor eval­u­ated by Si­nai Hospi­tal’s ag­ing sur­geon pro­gram.

The physi­cian work­force, like the rest of the pop­u­la­tion, has grown sub­stan­tially grayer in re­cent years. Al­most a quar­ter of prac­tic­ing physi­cians were 65 or older in 2015, ac­cord­ing to the Amer­i­can Med­i­cal As­so­ci­a­tion. In 2017, more than 122,000 physi­cians in that age group were en­gaged in pa­tient care.

Health care re­searchers and an­a­lysts are de­bat­ing what, if any­thing, to do about this tide of ag­ing prac­ti­tion­ers. “We know that hu­man fac­ul­ties decrease with age,” said Dr. Mark Katlic, the tho­racic sur­geon who founded Si­nai Hospi­tal’s pro­gram.

De­clin­ing vi­sion, hear­ing and cog­ni­tion can af­fect any health pro­fes­sional (or any per­son). But Katlic has ex­pressed par­tic­u­lar con­cern about sur­geons, who need to re­tain ex­cep­tional vi­sion, man­ual dex­ter­ity, re­ac­tion speed and stamina.

Past age 70, “can you grab a tiny lit­tle blood ves­sel with a for­ceps and not grab some­thing else?” he asked. “Or use very small in­stru­ments for su­tures?” Some op­er­a­tions, he pointed out, go on for six or seven hours, even longer.

Stud­ies haven’t pro­duced clear-cut an­swers to such ques­tions. Cog­ni­tion and other abil­i­ties decrease with age — but the vari­abil­ity be­tween in­di­vid­u­als in­creases.

At 75, “there are sharp, won­der­ful doc­tors, and those who need to stop,” said Dr. E. Patchen Dellinger, lead au­thor of a re­view on ag­ing physi­cians pub­lished in JAMA Surgery.

Whether older sur­geons have poorer out­comes than younger ones also re­mains de­bat­able, be­cause decades of ex­pe­ri­ence and judg­ment can com­pen­sate for mod­est phys­i­cal or cog­ni­tive de­clines.

One large study of Medi­care pa­tients found sur­geons over age 60 had higher mor­tal­ity rates for sev­eral kinds of op­er­a­tions, in­clud­ing coro­nary by­passes, but not for other pro­ce­dures. And the dif­fer­ences were small, oc­cur­ring mostly among doc­tors who per­formed few op­er­a­tions.

Last year, con­versely, re­searchers re­view­ing records for nearly 900,000 Medi­care pa­tients re­ported that op­er­a­tions by older sur­geons re­sulted in lower mor­tal­ity than those by younger physi­cians.

“It’s prob­a­bly a small per­cent­age of sur­geons in their 70s who have trou­ble, maybe 5 or 10 per­cent,” Katlic said. “But they’re the ones we want to iden­tify.”

That has proved daunt­ing. “The pub­lic be­lieves we po­lice our­selves as a pro­fes­sion,” he added. “We don’t, at least not very well.”

A 2016 state­ment from the Amer­i­can Col­lege of Sur­geons, for in­stance, rec­om­mended phys­i­cal, vis­ual and neu­rocog­ni­tive test­ing for older sur­geons — but on an en­tirely vol­un­tary ba­sis, with no re­quire­ment that they dis­close the re­sults.

Be­com­ing a sur­geon is dif­fi­cult, a gru­el­ing marathon. But re­main­ing one isn’t very de­mand­ing, ex­perts say. Reg­u­lar hospi­tal re­cer­ti­fi­ca­tion tends to be per­func­tory. Peers of­ten fail to re­port trou­bling be­hav­ior, es­pe­cially since se­nior physi­cians can be pow­er­ful, re­spected fig­ures.

A manda­tory re­tire­ment age could solve such prob­lems. But it also could vi­o­late dis­crim­i­na­tion laws, side­line per­fectly com­pe­tent doc­tors and leave ru­ral com­mu­ni­ties even more un­der­served.

Ad­vo­cates ar­gue that manda­tory screen­ing at older ages rep­re­sents a bet­ter ap­proach, a way to dis­tin­guish able se­nior pro­fes­sion­als from those who should re­tire, re­duce their re­spon­si­bil­i­ties, or tran­si­tion to teach­ing and other roles.

A hand­ful of hos­pi­tals have al­ready adopted that tac­tic, in­clud­ing the Univer­sity of Vir­ginia Health Sys­tem, Tem­ple Univer­sity Hospi­tal and UPMC in Pitts­burgh.

Late-ca­reer prac­ti­tioner poli­cies, as they’re of­ten called, kick in at age 70 or older and typ­i­cally cover not only physi­cians but nurse-prac­ti­tion­ers, physi­cian as­sis­tants and other pro­fes­sion­als.

The So­ci­ety of Sur­gi­cal Chairs, rep­re­sent­ing lead­ers at aca­demic med­i­cal cen­ters, may boost such ef­forts in the next few months when it pub­lishes a new white paper, “Tran­si­tion­ing the Se­nior Sur­geon.” Dr. Todd Rosen­gart, the so­ci­ety’s pres­i­dent, ex­pects the re­port to spur wider dis­cus­sions.

But for now, the num­ber of in­sti­tu­tions that have taken any for­mal ac­tion re­lated to age re­mains tiny. In its fifth year, Si­nai Hospi­tal’s as­sess­ment pro­gram has screened a grand to­tal of eight sur­geons, ages 55 to 81.

As the first, Dardik found the test­ing ar­du­ous but did well. The pro­gram’s re­port in­di­cated that he could ca­pa­bly con­tinue op­er­at­ing.

When the as­sess­ment team dis­cussed his per­for­mance, “most peo­ple said, ‘If I needed a short vas­cu­lar surgery, like a carotid en­darterec­tomy, I’d have him do it,’ ” Katlic re­called, though for ex­tended op­er­a­tions, they might opt for some­one younger.

STEPHEN SPERANZA NEW YORK TIMES

‘The clock ticks,’ said Dr. Her­bert Dardik, 80, a sur­geon at En­gle­wood Hospi­tal and Med­i­cal Cen­ter in New Jersey. ‘And I’ve be­come an ad­vo­cate for eval­u­a­tion.’

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