Should neurosurgeons retire?
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.258036
Source of Support: None, Conflict of Interest: None
Keywords: Aging in neurosurgeons, neurosurgery and retirement, operating privileges for seniors
An advertisement issued by the Tamil Nadu Medical Council and also notified in the Tamil Nadu Government Gazette mandating minimum requirements for continuing medical Education (CME) set the author thinking. As per the notification, a neurosurgeon who provides evidence that he has attended approved programmes for 30 credit hours from 2012 to 2017 is deemed to be competent to practise. If in this block of 5 years, there is shortage of credit hours, the deficit can be carried over to the next block of 5 years if Rs. 50 is paid per hour of shortfall. If the neurosurgeon is over 65 years, 15 h of learning will do for every 5 years, and once 70 is reached, there is 100% exemption. This implies that soon the author and his contemporaries will be branded as “know-it-all.” The so-called mandatory CME credits itself leave much to be desired. As one Vice-Chancellor remarked, “You can sleep through a session, in fact not even be inside the hall and if you sign your name, you will get the certificate and CME credit.” Interestingly, the American Board of Plastic Surgery and several other boards recognize that senior surgeons may be “grandfathered” and receive time-unlimited credentials.
Becoming a neurosurgeon implies a substantial commitment of time, energy, and making multiple “sacrifices” at multiple times. Throughout their careers, neurosurgeons are recognized as professionals who practice a complex “craft” which requires them to maintain their skills and constant continuing education.
Making difficult, often quick, and sometimes life-and-death decisions that demand high and complex levels of cognitive functioning even at the seventh and eighth decade may not be possible for all. The cliche, “It is not brain surgery… it is not rocket science...” clearly shows the awe in which the public regard the neurosurgical community.
Retirement - a general overview
Retirement is synonymous with stepping down and giving up work, which one has been doing for several decades. Although this is mandatory in government services and most organizations after a certain age, the neurosurgeon can always be self-employed from the very beginning or after formal retirement. In the public sector, the retirement age in most countries including India and Japan is 65 years. In Russia and China, it is 60 years. Commercial airline pilots by law must undergo regular health screenings, in addition to mandatory preflight tests. They are not allowed to fly after the age of 65 years. Federal Bureau of Investigation (FBI) agents, fire fighters, and air traffic controllers must retire at the age of 57 years from their specific jobs. Worldwide, it is generally accepted that there has to be a mandatory retirement age in occupations where the public will be directly affected, due to an age-related erroneous decision. It is conceded that there will always be outliers and all do not fit into the bell curve. Exceptions can be accepted but rules and regulations need to be formulated, which can be reviewed and modified when deemed necessary. Self-discipline, though theoretically attractive, is in practice, not doable.
The Aging Process
It is an undeniable fact that the aging process cannot be arrested. It is also true that chronological age is not synonymous with functional age, Exceptions only prove the rule. A decrease in overall muscle strength (25% loss by the age of 65 years), joint mobility, and tissue elasticity are common. The signal/noise ratio delivered from sensory organs is reduced. Increasing difficulty in swiftly retrieving stored information and in switching attention from one task to another is common among senior citizens. Neurosurgeons need to recognize and accept that personality changes, confusion, tardiness, and forgetfulness may occur so slowly that it is even overlooked. Individual adaptation ensures that when these changes are subtle, they are often unrecognized by colleagues and patients until a specific problem occurs. Knowledge, experience, and reputation compensate for the decline of physical strength and skills for a long time. Age-related changes vary considerably from individual to individual. A decrease in the working memory and the ability to store and process information could reduce one's ability to take quick correct decisions. Cognition, attention span, verbal and performance intelligence quotients, recall, manual dexterity, and visuospatial capability, which normally ensure procedural competence, decrease with age. Decreased visual acuity and accommodation results in the necessity for a 100% increase in illumination.
Relationship between age and performance
This correlation is complex and cannot be generalized based on a number. One size does not fit all. Stamina, cognition, and fine-motor skills generally decrease with age, but not uniformly across populations. Some learned tasks and physical memory are remarkably preserved over time. Specific cognitive testing of surgeons, however, showed that a decline in reaction time was less than that of the other groups compared with them. Most practicing surgeons older than 60 years performed as well as younger colleagues in all areas of cognitive testing. When driving licences are issued only for 4 years after the age of 65 years, and one cannot even apply for a driving licence after the age of 75 years in India, it is surprising that no regulation mandates physical and mental reassessment at any age for any clinician. Neurosurgeons above the age of 65 years need to undergo voluntary, confidential baseline physical and cognitive examination every 2--3 years.
Factors influencing decision to retire and the reasons for retirement
How does one determine the proper time for retirement from the operating theatre? How should this be enforced? Is one justified in continuing to work 70 h a week without spending time with at least one's grandchildren. What is the purpose of life? Is anyone truly indispensable? Many neurosurgeons are hesitant to plan for their retirement and are unable to accept huge and abrupt changes. As surgery is satisfying and rewarding, this is often continued even if skills may be decreasing. Retirement is often forced due to (a) rules mandating age-specific retirement in government service and the inability to start “private practice” for the first time in a totally different environment; (b) an intense competition from the younger generation; and, (c) a passionate interest in a second career. Financial insecurity is an important factor influencing retirement decisions, and many extend their careers for this reason.
Time to retire
When is it time to put the scalpel down?, Is self-evaluation of skills and judgment enough? How reliable is self-appraisal? Is objective assessment of surgical skills and judgment feasible or practical? Will a surgeon's age itself be a risk factor, as considered by some? With increasing life expectancies and changing attitudes towards retirement, when 23% of clinicians in developed countries are over the age of 65 years, and there are clinician shortages, what should a neurosurgeon do? A report from Pakistan refers to studies indicating that one-fifth of surgeons older than 70 years continue to operate. No one can stay fit forever. Neurosurgeons may be able to work into their “old” age, but there has to be a tipping point? Every study on the aging clinicians has concluded that, at the very least, clinicians should make more of an effort to assess themselves and their peers more regularly, whether the process is legally mandated or not. If they do not experience physical or cognitive decline, they can continue to do the most good, by working as long as they can. At some point, every neurosurgeon must retire from clinical practice before their actions turn into an unnecessary risk for their patients. When a neurosurgeon chooses to retire from active practice, which to a large extent is a personal decision, the action is influenced by many factors. The skills that neurosurgeons have developed even decades ago may sometimes still hold good at least to some degree. The basic conundrum still remains-when should one retire from a professional career and what should one do with the remaining years until death inevitably occurs. Retirement is more palatable for those who are able to choose when they retire. It has been pointed out that retirement should be gradual–a series of events and not a single event. Recently, many neurosurgeons are choosing a second career before the traditional retirement age of 65 years, for personal and financial reasons.
Views on retirement
In 1905, Sir William Osler, then 55 years of age, spoke about the “comparative uselessness of men above 40 years of age.” He asserted that men should retire when they are 60 years old. His remarks provoked an outburst of controversy. Age-related compulsory retirement continues in many professions. Is it relevant in neurosurgery as patient safety is involved? Scarrow et al., reporting on a Congress of Neurological Surgeons Consensus Conference in 2009 noted that neurosurgeons at that time strongly opposed the government that was trying to implement uniform retirement age regulations. Older neurosurgeons wanted to maintain the status quo. Local flexible regulations by hospital privileging bodies rather than national age-based thresholds were deemed to be acceptable. Rovit pointed out that neurosurgeons define themselves primarily by what they do and not who they are. A neurosurgeon who has attained success, recognition, and a sense of self-worth because of what he or she does may experience a profound sense of deflation when forced to relinquish surgical procedures. That is the time for the second career, time for the old dog to perform new tricks! The reasons for retirement offered by 22 globally renowned neurosurgeons included decreasing personal satisfaction and decreasing financial rewards, a desire to pursue other activities, local ground rules mandating age-specific retirement, the general sense that enough is enough, and, overall, a strong desire to stop performing surgery while at the top of one's game. According to a survey published in Mayo Clinic Proceedings, a majority of neurosurgeons opined that aging members should undergo additional testing or evaluation beyond standard “maintenance of certification” examinations; 67% of 1,449 respondents (30% response rate from 4,899 surveyed, 50% of whom were older than 50 years) indicated there should be no absolute age cutoff at which neurosurgical practice should be forced to end. However, 50% of respondents indicated that neurosurgeons aged 65 years and older should undergo additional testing; 59% suggested “maintenance of certification” exams should include a review of individual case logs and patient outcomes; 42% indicated that “maintenance of certification” examinations should be tailored to accommodate the aging neurosurgeons.
According to the American Medical Association (AMA) in 2006, 42% of the 1 million doctors in USA were older than 55 years, and 21% older than 65. In 2015, nearly one in four clinicians were 65 years or older. In Canada and Australia, it was 17.6 and 19%, respectively. In 2015, AMA took a step toward changing the absence of nationwide age-related assessments or guidelines to make sure doctors can do their jobs safely. A group of physician members were asked to come up with guidelines for assessing the skills and abilities of late-career doctors. The AMA cited research from its “Council on Medical Education” indicating that after the age of 60 years, there are “differences in performance” that “may become apparent.” The AMA report also cites recommendations from a variety of sources that cognitive and physical screening should begin between the ages of 65 and 70 years. The AMA purports that screening of senior doctors is important for patient safety and that typical age-related decline in hearing, eyesight, memory, and motor skills could affect the physician competence. Would age-based assessments be considered discriminatory? Shouldn't surgeons be treated as individuals, not as numbers? The steps of forming laws advocating the cessation of practice have been controversial. A mandatory retirement age could be discriminatory and take many competent neurosurgeons out of practice adding to the existing shortage. Increasing evidence that suggests that the surgeons' age and performance are related has led many organizations, such as the American College of Surgeons (ACS), to revisit this challenge. Since 1975, the number of practicing physicians older than 65 years in the United States has increased by 374%, and in 2015, 23% of the practicing physicians were 65 years or older. A recently published study revealed that surgeons (general and all specialties) planned to stop all clinical work at 70 years and stop operating at 65 years. Career satisfaction (97%), a sense of identity (90%), and financial need (69%) made them to continue operating. Enjoyment of work (79%), camaraderie with surgical colleagues (66%), and financial need (45%) were the other reasons.
Technology and management gap
The older a surgeon is, the more likely is the fact that what had been learnt during the initial education and training has truly become history! Healthcare, particularly in neurosciences, is growing exponentially. The transformation has truly been disruptive not only with respect to technology but also patient expectations. To paraphrase Rudyard Kipling's often repeated statement: “What do they know of England, who only England know.” White hair hopefully will lead to introspection and the realization that it is not all old dogs who can learn new tricks. What got you there will not keep you there. One may fail to remember that the patient will do better with one's student or even one's student's student.
Recertification for Seniors
As one whose formal training and certification was completed in the BC (before Computers !) era, (the computed tomographic (CT) scan was introduced a few months before I appeared for my final exam in 1980), I would indeed be a menace to society if I had not attempted at least to know what is happening in some fields of neurosurgery. As per the Central Motor Vehicle Rules, all private vehicles are to re-register the vehicle after 15 years. This needs to be renewed every 5 years, subject to confirmation of roadworthiness by the department. Old cars are not exempted from evaluation and re-evaluation. Readers may look askance and consider this analogy inappropriate. At present, a neurosurgeon who was trained 20-55 years ago does not have to be formally re-evaluated. When he is 65 years old, he/she can even pay Rs. 750 and have the 5-year requirement of 15 h postponed to another 5 years. One would have thought that any doctor, family physician, specialist, super-specialist, sub-specialist in government service, solo private practice, and in corporate group practice above 60 years would have to be re-certified every 2--3 years following a proper re-evaluation. We should never forget that we are primarily directly responsible for the patient's well-being.
Assessment of senior neurosurgeons
This poses unique challenges. Effects of aging cannot be precisely quantified. Nor can it be extrapolated to everyone. There are too many variables to implement specific rules and regulations. Age is after all a number. Its influence on clinical competence and operative performance in practice cannot be standardized. Fatigue, stress, burnout, and health issues unrelated to aging can also affect clinical performance. As neurosurgeons grow older, hospitals should begin requiring them to prove that they are still fit. Ensuring that older neurosurgeons continue to be competent to treat patients is now on the radar of patient safety experts and hospital administrators. Gross negligence will be obvious, but subtle lapses of judgment or technique are harder to detect. On some occasions, senior neurosurgeons often wish that something else had been done or that the same management had been done differently. A 2006 report found that patient mortality in complex operations was higher when surgeons older than 60 years operated. Older doctors could be mentors and leaders, as well as teach and advise on medicolegal issues. However, they often have less factual knowledge, have different standards of care, and may in fact achieve poorer patient outcomes.
Several publications discuss what a neurosurgeon can do one with the rest of his life.,, Rapport even calls it “How to recycle a used brain surgeon.” Complete retirement is not always appealing. Often there is more to learn, more delight to be found, more care to be rendered. Retirement is, in fact, more difficult than work! Senior surgeons play an important role in their hospitals and communities. Their knowledge and years of experience can be valuable resources. Non-operating neurosurgeons can contribute significantly to teaching, mentoring, writing, research, and administration. It is unrealistic to anticipate personal fulfilment when there is an abrupt transition from a very busy surgical practice to “plenty of time for relaxation.” However, developing a second passion for a second career in a related area without cutting and stitching is often the answer. Meaningful endeavors and relationships are essential to continue one's professional life, Once they had made the decision to retire from active neurosurgical practice, approximately one-half continued, at least on a part-time basis, in medical practice with reduced work hours and flexible scheduling or in paramedical activities. Experience notwithstanding, reduced factual knowledge and knowledge of present standards of care may be of concern.
When is old old?
Ausman commented on Prof. Ramamurthi's celebrating the silver jubilee of a second Department of Neurosurgery, which he started after his superannuation at the age of 58 years from the Government of Tamil Nadu. There are several instances of nonagenarians and even centenarians continuing to see patients. The rheumatologist, Ephraim Engleman, who practiced rheumatology at the University of California at San Francisco (UCSF) Medical Center had said that he plans never to quit. Surgeons are reluctant to plan for retirement. “I would not mind being operated on, by a surgeon of 91,” said Dr. Michael DeBakey when he was 91 years old. Dr. Padmavathi, the senior cardiologist, still sees patients at the age of 101. Prof. Sharadha Menon, the oldest alumnus of the Madras Medical College, at the age of 95 years, continues to see patients with mental health problems, in Chennai. “Am I too old to do this anymore?” Perhaps George H.W. Bush asked himself that question just before being pushed out of the helicopter for his 90th birthday parachute jump. How do we know when we are “too old” to continue, what we love doing? The captain of a ship is seldom told that his compass has failed and that the ship is headed for the rocks. Paradoxically, the surgeon with the greatest experience may be the one putting patients at the greatest risk.
The author recollects being asked several years ago by the Founder Chairman of the largest corporate hospital group in India to identify neurosurgeons for upcoming tertiary care hospitals. “They should be between 35 and 45,” he added. It is said that only wine and cheese improve with age. However, senior neurosurgeons are an embodiment of clinical wisdom and understand that the whole is greater than the sum of its parts. They would be able to take a holistic view which the younger superb craftsmen would take years to acquire. Youngsters need to respect white hair. Neurosurgeons on the wrong side of 80 still operating will no doubt take comfort in the recent World Health Organisation (WHO) statement that 66-79 years age would now be considered the new middle age. Sunil Gavaskar and Sachin Tendulkar called it a day at the peak of their career. When asked why they were stepping down when they were physically and mentally fit, both replied that they would rather retire when people asked “why is he retiring,” instead of when they would start commenting, “why has he not yet retired.” Perhaps the comparison is not totally appropriate. At the same time, neurosurgeons above the age of 65 years need to seriously introspect regarding their primary role in the ultra-modern operating theatre and be willing to be recertified periodically and objectively by those biologically younger, if they still wish to continue their prima donna role. My 7-year-old grandson described the situation most aptly when he remarked, “Grandpa you are a brain surgeon, but are you a brainy one?”
I am thankful to Ms Lakshmi for secretarial assistance.
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Conflicts of interest
There are no conflicts of interest.