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Aging Surgeons overestimate Decline in Skills
Study May Provide Key Insight As Workforce Concerns Intensify

Surgeons may overestimate the decline in their cognition as they age, results of a new study suggest.

“It’s fair to say that surgeons are cautious about the effects of aging. Their self-perception of their cognitive status is unreliable,” said lead author Lazar J. Greenfield, MD, professor of surgery and chair emeritus, University of Michigan Medical School, Ann Arbor. He presented the results of the study at the 2007 Clinical Congress of the American College of Surgeons (ACS).

The report indicates that surgeons retire or cut back their practice before they become uncomfortable with their performance, regardless of whether their skills are indeed worsening.

“That’s a good thing,” said Andrew Warshaw, MD, chief of surgery, Massachusetts General Hospital, Boston.

Surgeons older than 45 years of age who voluntarily underwent cognition tests showed gradual declines in attention, reaction times, visual learning and memory as they aged. The changes were similar to what would be expected in a group of nonsurgeons, said Dr. Greenfield. However, when the surgeons were asked to subjectively assess their cognitive skills, the specialists graded themselves much worse than the test results showed.

The study provides new insights into surgeons’ perceptions of their skills as they age, an issue that has become increasingly important in recent years. Like other Americans, many surgeons today work into their senior years, leading some health care watchers, patients and physicians to suggest that mandatory cognitive skills testing be instituted for older surgeons.

Results from this study suggest that surgeons would benefit from having cognitive tests available to help them decide whether to retire or continue practicing, said Dr. Greenfield.

Dr. Greenfield and colleagues assessed 359 surgeons who volunteered for testing at ACS meetings between 2001 and 2006. The group included 330 men with a mean age of 61.4 years and 29 women with a mean age of 53 years. Of these, 62 surgeons were retired, with a mean age of 70 years.

The subjects completed three tests from the Cambridge Neuropsychological Test Automated Battery (CANTAB), which measures memory and learning, attention, planning strategy and executive function. In addition, the participants were asked about their practice status, use of technology, retirement plans and recent use of drugs and alcohol.

Overall, the surgeons fared incrementally worse on the tests as they grew older, with the worst results reported among the oldest surgeons, aged 70 and older. Surgeons’ test scores were also linked to their case volume and practice status. Performance declined steadily as surgeons reduced the volume of their workload. Those who had retired or were considering retirement within five years also had poorer memory recall and worse name recognition than did surgeons who planned to retire at a fixed age or when their skills declined, results showed.

“In some ways, this data is reassuring,” said Murray F. Brennan, MD, Benno C. Schmidt Chair in Clinical Oncology, Memorial Sloan-Kettering Cancer Center, New York City.

Younger surgeons were more likely to plan to retire at a set age, whereas older surgeons planned to retire when their skills declined or within five years, he noted. “That seems to me to be appropriate selectivity.”

He pointed out that the retired surgeons in the study do not necessarily reflect the general population of retired surgeons. The researchers surveyed a motivated group of retired surgeons who, although no longer practicing, still attended the Clinical Congress of the ACS.

Dr. Brennan, a former chair of surgery who sometimes works 14-hour days in the operating room, made light of the fact that the ACS had asked him to review the study. “Why was I being asked to do this? I am not yet retired, or at least I do not think I am. Maybe I forget,” he joked.

The study has a number of limitations. The volunteers may not represent the general population of surgeons, and the tests, although recognized as valid measures of cognitive change, have never been correlated with clinical functions and surgical outcomes. In addition, a surgeon’s decision to retire is often more complex than the study survey allowed.

Dr. Warshaw said the study does not examine several important factors that may affect surgical outcomes and clinical practice as surgeons age. The investigators could not discern whether surgeons chose to retire because their cognition was waning or their cognition was declining because they were no longer practicing. The study also does not address a surgeon’s experience, which may compensate for certain limitations in cognition, he suggested. “A young buck may do very well on cognitive tests, but judgment and experience count for something,” he said.

“It really comes down to the individual,” said Dr. Warshaw. “Some people are old at 60, others are still vibrant at 75. It’s different for everyone. We need to be wary of this when we are talking about making policy.”

The study also revealed several dissimilarities between male and female surgeons. Women performed better on tests of learning efficiency but had slower reaction and movement times. There were not enough female surgeons included in the study for the results to be conclusive.

A study published in 2006 in the Annals of Surgery showed that surgeons older than 60 years, particularly those with low procedure volumes, have higher operative mortality rates than their younger counterparts for some complex procedures. For most procedures, however, there was no link between surgeon age and operative risk (Ann Surg 2006; 244:353-362).

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