Senior citizenship in neurosurgery
The concept of 'senior citizen' helps those aged more than 60 years utilize facilities beyond those made available to others. Queues are considerably shorter at the special counters set up to help ageing individuals at railway stations and airports. In Mumbai, BEST (the Brihanmumbai Electric Supply and Transport Undertaking) buses have seats reserved for senior citizens. Lower berths in long-distance trains are preferably allotted to older citizens.
The other side of the coin shows the decay of faculties with age. In the field of medicine, such deterioration may result in harm to patients.
This essay attempts to review events as they unfold for senior neurosurgeons and provides a personal narrative.
You are only as old as you feel
There appears to be truth in this old axiom. A study at University College, London, showed that over an eight-year period, of those who felt younger, 14% died whilst 25% of those who felt older had died. Dr. Andrew Steptoe felt that that the judgement of a person on how old he was based on many factors, including the state of physical health, peace of mind and social activity  Frequent and happy interactions with friends and loved ones, freedom from pain and illness, ability to engage in desired activities, unhampered mobility and goals in life helped engender a feeling of persistent youth.
Advice to senior citizens includes such statements as 'Do not regret growing older. Many are denied this privilege,' 'Young at heart, slightly older in other places' and 'Age is simply the number of years the world has been enjoying your presence.' Compensations are highlighted. 'As you get older, your secrets are safe with your friends because they can't remember them either.'
Besides, in the broad field of medicine, ageing is accompanied by greater experience. Dealing with patients under a wide variety of circumstances, often with Yama hovering in the background, sharpens medical skills and enables sterling performance. When combined with teaching and continued interactions with young, enquiring minds, age confers wisdom.
The physical changes accompanying ageing
Anatomical and physiological changes make their presence felt. Muscles of the face sag and wrinkles make their appearance. The north pole of the adult male shows reduced foliage with silver colour. Ocular lenses opacify and need corrective surgery. Bones soften and joints creak. The senile loss of hearing is a real entity, as is the reduced ability to appreciate taste that necessitates increasing addition of ingredients that lend flavor to food.
Unless continuous efforts are made, muscle bulk withers and a feeling of tiredness seeps in. Certainly, the incessant movements of the young child and the vigour and bounce with which the child explores the world around, have given way to a more sedate form of physical activity.
The loss of neurons – noted even during foetal life, as the brain jettisons those that are superfluous – is accelerated and now involves cells that are needed in activities of daily living. Intention tremors are one consequence.
These factors have led cynics to conclude that only wine and cheese improve with age.
And yet, there are those who appear to show no signs of ageing.
Fauja Singh, called the Turbaned Tornado by Khushwant Singh (2011), is a striking example. When one realizes that he had spindly, weak legs and did not start walking until he was five years old, one's admiration for him is heightened. He ran his first marathon in London at the age of 89 years. At the age of 93 years, he completed 26.2 miles in 6 hours and 54 minutes – a record for those aged more than 90 years.
In Mumbai we have the example set by Dr. Shirish Bhansali. Born on 21 September 1929, he gained eminence as a surgeon and continued to operate all day on his many patients with undiminished vigour almost till his death at the age of 80 years. His clinical acumen, as well as his ability to operate and retain the loyalty of his patients showed no decline with age.
When should neurosurgeons retire from the field?
Surgeons, as a tribe, are reluctant to bid adieu to the operation theatre. The adrenaline rush preceding surgery and the satisfaction on completing a difficult operation successfully are addictive.
Logic suggests that a neurosurgeon must retire when he is past his prime and shows deterioration in function that is inimical to the best interests of the patient.
Studies have used criteria such as accurate and valid judgement, especially in critical situations; sustained attention; the ability to learn and remember; excellent vision; short reaction time; corrective reflexes; dexterity; smooth purposive movements free from tremor and excellent, undiminished functional abilities, to determine the capabilities of the individual ageing neurosurgeon. The surgical outcomes in patients under the neurosurgeon's care and the observations of anaesthetists, operation theatre nurses and other colleagues in the operation theatre must form additional inputs during such an evaluation.
Chronological age has been deemed to be of secondary importance and can be ignored if the above appraisal showed no decay.
Many neurosurgeons will bristle at the suggestion but the interests of patients make it imperative that warning signals prompt tests and corrective action. Most neurosurgeons past their prime welcome the allocation of emergency surgery at odd hours of the night to their younger colleagues. Such allocation to competent young neurosurgeons assures the welfare of the patient. It also helps the older neurosurgeon avoid the increasingly evident threat of summons to face a judge in court.
Why do some neurosurgeons fail to recognize the need to retire?
A prominent reason appears to be the loss of personal esteem. The acknowledgement of a failing in oneself is always difficult, and here, the individual admits to an inability to perform what was hitherto a crucial part of his repertoire. As neurosurgeon, he commanded attention, respect and obedience in the operation theatre. Once he stops his operations, he is stripped of much of the aura that surrounded him and is reduced to a position of relative insignificance.
A major component of the earnings of neurosurgeons is from charges for operations. Abstain from coming to the operating theatre and your earnings plummet.
Finally, as a senior neurosurgeon, now no more, told me, 'If I do not operate, what am I to do? Neurosurgery is my life. I have no other interests, hobbies or activities.'
Can older surgeons be assisted as they retire?
It would be a shame to let go of the wisdom and experience of senior neurosurgeons. There is much they have to offer outside the operation theatres.
Their assessment of patients, their use of rapidly disappearing clinical tools such as history-taking and examination of the patient, their ability to develop rapport with patient and family and discuss thorny aspects of diagnosis, treatment and prognosis, their methods of dealing with the dying patient and the grieving family – all these and more can be passed on to students and residents in outpatient clinics, during ward rounds and at bedside clinics.
Their personal narratives incorporating ethics and the history of medicine, especially as witnessed and practiced by them, can further enrich younger colleagues.
Continuing in neurosurgery after withdrawal from the operation theatre
There is also scope for neurosurgeons past their prime to work in the broad field of neurosurgery and the neurosciences.
The Neurological Society of India has developed several programs for the education of young neurosurgeons. Some of these are held in different parts of India to enable local resident doctors to attend and benefit from them. The participation of senior neurosurgeons and the help and guidance they would provide would augment the utility of these meetings. Their vast cumulative experience would enable moderation of claims by young and enthusiastic professors, place recent advances in perspective and prompt trainees to question and evaluate claims made on conference platforms and in print.
Dr. Ajit Banerjee and the Society have long been advocating changes in the pattern of training in the neurosciences, especially in neurosurgery., Of necessity, this has to be a continuing effort. Senior neurosurgeons could participate in these efforts and help in the standardization and betterment of education throughout the country.
Editors of journals such as Neurology India, Annals of the Indian Academy of Neurology and National Medical Journal of India should welcome constructive criticism of the present trends and advocate policies and advocacies of change for the the better. They should also welcome personal views on vexing problems such as the care of individuals diagnosed as being in a persistent vegetative state, and accounts of personal experiences that resulted in better care of patients.
Finally, senior neurosurgeons, especially those with leverage in the corridors of power, can work for the elimination of barriers to academic progress and misguided policies. Their experiences would be of great benefit to institutions such as the Indian Council of Medical Research and committees that award grants as well as select senior staff for our national institutes.
Do we need training in planning for our retirement?
Yes, there is such a need.
Self-assessment needs to be developed as part of our psyche. Keeping the welfare of patients as our prime consideration will help develop this faculty. Skills in managing finances are not the forte of medical personnel, and yet these are crucial to well-being as we age. Planning for retirement must include means for the provision for income during the twilight years. This income must enable a continuation of comfortable living and cater to needs, including those occasioned by accident or illness, in the face of rising inflation.
Few of us have been encouraged in our strenuous profession to develop second careers. Dr. Wilder Penfield's essay bearing this title should be a required reading for all of us.
Penfield acknowledged the 'mood of melancholy that comes to any man on retirement… Most men who retire could and would, continue on in constructive work if they saw that they were needed… The time of retirement should be reorganized and renamed. It is the time for embarking on a new career, the last career perhaps, but not necessarily a less enjoyable one; not, perhaps, a less useful one to society… When a man reaches his sixties, he should be released from heavy harness, but should be given the opportunity of starting on a new and modified career. The nature of that career must depend on interest and ability. It should provide greater latitude of living, allow a variable or decreasing amount of physical labour… New jobs call for the use of previously unused nerve-cell connections in the brain. This is perfectly possible in the sixties. The old dog will increase his previous capacity by taking on a challenging new job…'
During the last 15 years of his life, Penfield wrote historical novels and medical biographies. At the age of 83, he wrote The mystery of the mind to explain his studies on the brain conducted over a span of 40 years, to lay readers.
Hallowed public sector medical colleges have always set an age limit for their professorial and other staff. In 1998, I retired as professor on superannuation from the Seth G. S. Medical College and King Edward Memorial Hospital in Mumbai at the age of 58 years. (The age for compulsory retirement has been advanced to 65 since then.)
If permitted then, I could have continued without difficulty in these institutions for several years but this would have resulted in stagnation for Drs. Atul Goel and Aadil Chagla in their posts of Assistant Professors. My retirement enabled them to rise in stature and take over greater responsibilities.
At the suggestion of Drs. Gajendra Sinh, my teacher in neurosurgery at Grant Medical College and Ranjit Nagpal, my colleague at Seth G. S. Medical College, I obtained a position at Jaslok Hospital and Research Centre. This was especially attractive as I would work with Drs. Gajendra Sinh, Homi Dastur, Ranjit Nagpal in neurosurgery and Noshir Wadia and Anil Desai in neurology, each of them renowned for ethical practice of high quality.
I developed a modest practice over time, with patients referred from the Bhabha Atomic Research Centre Hospital in Trombay and by others. I was content doing my best for them.
I resisted urging by a colleague to participate in the employment of a manager who would seek patients on my behalf and ensure that they were well looked after in the hospital. I followed my teachers in the belief that patients should seek treatment at my hands on the basis of my reputation and that I should not go in search of them.
All went well till 2011 when I had to undergo three spinal operations in rapid succession. I was unable to see or treat patients for almost six months.
This was followed by a drastic fall in the number of patients being referred to me. Perhaps a feeling had grown that after three operations, I was not competent or able to treat patients. I must confess I took no active steps to dispel this feeling and continued treating those patients who came to me nonetheless.
I did not feel the burden of years. My surgical results have not been assessed independently but I have not received any complaints from patients, colleagues, anaesthetists, operation theatre nurses or the hospital administration. The single patient who sued Dr. Noshir Wadia and me in the Consumer Court has been described elsewhere.
After I passed the age of 75 years, I have stopped performing operations on tumours in the base of the skull and cerebello-pontine angle, aneurysms and arteriovenous malformations. The possibility of injury to the brainstem, optic nerve and chiasm from inadvertent injury to small, perforating arterioles causes me increasing anxiety. Fortunately, we have young and expert neurosurgery colleagues in our department who are happy to treat such patients when referred to them.
I am now 77 years old. I feel I can do justice to some diseases – cerebral gliomas, surface meningiomas, spinal tumours, intervertebral disc protrusions and the like, but all references from BARC Hospital and colleagues in my own hospital have now almost come to a standstill. All emergencies are referred to my younger colleagues.
As a result, I may not enter the operation theatre more than once a month or so. This is welcome. When younger colleagues are able to treat patients better than I can, it is foolhardy to attempt competing with them.
I have had my day.
I would like to continue seeing patients and, where needed, treat them. I feel that my clinical senses do not betray me as yet. I am able to spend time with my patients and write clinical notes that remain informative and useful. I seem to be able to continue helping them. Most of all, I enjoy learning from colleagues and patients. When the time comes, I shall relinquish these responsibilities as well, but with some regret.
Since I have more time to myself, I indulge in reading and writing, travel and photography, music and films. Medical ethics, medical history and topics such as this, lend themselves well to my urge to reflect and communicate. I am fortunate in having editors who encourage me in these pursuits.
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Conflicts of interest
There are no conflicts of interest.