The aging surgeon: A geriatrician's perspective

Hal H. Atkinson, MD, MS

Atkinson is a professor of internal medicine in the section on gerontology and geriatric medicine at Wake Forest School of Medicine, Winston-Salem, North Carolina.

As a champion for maintaining function and purpose with aging, I am always delighted to meet physicians and surgeons who have continued to practice and hone their craft into their senior years. As an academic physician and educator, I also recognize the advantage of years of clinical experience in refining clinical judgment and skill. Yet, not all changes that accompany the aging process lead to better care, and some frankly threaten the ability to practice safely.

Senior clinicians have much to offer in medicine and surgery—they have often seen more and done more than the rest of us. They can apply that experience to the care of their patients and use it to advise junior colleagues. In the absence of cognitive diseases, the aging process is associated with improved judgment in general even though normal cognitive aging is associated with declines in other areas of fluid intelligence. Changes due to aging alone may affect some aspects of cognitive/neurologic function; namely, cognitive processing speed, reaction time, and declines in sensory inputs. However, in my opinion, none of these in and of themselves is likely to lead to inability to practice medicine or surgery when balanced with the degree of experience that an older surgeon brings to the operating table. In fact, even among younger people, there can be variability in cognitive performance in all these areas. Additionally, older physicians without cognitive impairment who are experiencing physical or sensory declines often self-regulate or adapt their practice.

The higher likelihood of cognitive illnesses among aging physicians most certainly can affect the capacity to practice safely, and often these illnesses rob individuals of the insight to self-regulate. A 2020 study at Yale New Haven Hospital demonstrated that among 141 clinicians over the age of 70 who underwent mandatory neuropsychological testing, 12.7% demonstrated cognitive difficulties that would preclude independent practice.¹ This is a sobering fact, and some have advocated for mandatory neuropsychological testing above a certain age for all physicians to screen for unrecognized impairment. As a geriatrician, I worry that blanket policies targeting certain age groups run some risk of being ageist and discriminatory toward older adults, although I appreciate the rationale of screening where risk is expected to be highest. At a minimum, the professional community should be aware and willing to act when there is concern for cognitive impairment.

In all fields of medicine, older physicians are essential in the understaffed medical work force to maintain access and quality of care for patients. Balancing the benefits of experience with the risk of impairment is a fine line to walk, and we do not yet have a clear path forward. As a former program director for a much younger group of internal medicine residents, I recognized that assurance of clinical skill to practice competently should be the most important goal of medical education. However, the concept of certifying ongoing clinical competence among practicing physicians, irrespective of age, has been met with a great deal of resistance among many specialties. In my opinion, many things can affect the ability to practice effectively and safely, and a robust system to assess clinical competence, including testing and formal peer assessment, is in order for all of us, regardless of age. We all need to revisit meaningful methods for ongoing assurance of competency specific to our fields of medicine and surgery across the physician career span. Until consensus is clearer on how best to assure competence, we should value and respect our colleagues regardless of age but not be afraid to say something when we have concerns about their practice.

Reference

1. Cooney L, Balcezak T. Cognitive testing of older clinicians prior to recredentialing. JAMA. 2020;323(2):179-180. doi:10.1001/jama.2019.18665