When Are Neurosurgeons Too Old to Perform Surgery?

Christine Lehmann, MA

November 27, 2017

Should neurosurgeons have a mandatory retirement age to protect public safety?

In a survey of US neurosurgeons, most disagreed with an absolute cutoff age and favored adapting the maintenance of certification (MOC), a regular assessment administered by the American Board of Neurological Surgery (ABNS) to reflect daily patterns of practice, whether case-based or individual case logs.

Dr Maya Babu

The study is the first to survey ABNS neurosurgeon diplomates about their attitudes toward ending a surgical practice and related assessments later in their career.

“Most of the respondents don‘t believe in firm age cutoffs but want more community policing. They believe that the surgical profession is best suited to police itself, although the surgical community has to do a better job of determining alternate pathways these surgeons can transition to.  It‘s challenging to have that conversation with older colleagues so they don‘t feel criticized or forced out,“ principal investigator, Maya Babu, MD, MBA, told Medscape Medical News.

Dr Babu, a neurotrauma fellow from the University of Miami in Florida, agreed it would be a shame to have a firm age cutoff because she has worked with very senior neurosurgeons with impressive cognitive and technical abilities. 

“Patients want experienced and highly skilled surgeons and place tremendous confidence in them,“ she said.

The study was published online November 15 in Mayo Clinic Proceedings.

Individualized Approach

According to the American Medical Association, many surgeons continue to practice beyond the standard retirement age of 65 years.  More than 40% of the 800,000 actively practicing physicians in the United States were at least 55 years of age in 2010, according to the Association of American Medical Colleges.

Previous research has shown that the rate of cognitive and physical decline affecting the practice of medicine varies by individual. For example, a study published in the October 2002 issue of Academic Medicine  exploring aging physicians and cognitive processing found that “one of the more robust findings in aging research is that the variability across the scores individuals receive tends to increase with age.“

Another study, published in the September 2010 issue of Journal of the American College of Surgeons, showed that most surgeons older than 60 years performed as well as their younger counterparts in aspects of cognitive testing.

However, the challenge for neurosurgeons practicing into their 70s and 80s is to know when to stop. Compared with doctors in other subspecialties, neurosurgeons tend to start their careers later, often in their mid-40s, and practice longer.  After completing residency training, they spend another 8 to 9 years in subspecialty training, Dr Babu noted.

Dr Babu and coauthors developed and sent an online confidential survey to 4899 neurosurgeons composed of 2435 ABNS diplomates participating in MOC, 1440 diplomates certified before 1999 (grandfathered), and 1024 retired diplomates. The survey was conducted from March 1, 2016, to May 31, 2016, and the overall response rate was 30%.

Most respondents (65%) were age 50 years and older; 92% were male. Thirty-six percent had been in practice for 11 to 20 years, and 45% had been in practice for 21 to 35 years. Most were in private practice or academic practice, followed by a combination of the two and employed practice.

Respondents were split on whether neurosurgeons aged 65 years and older should undergo additional testing. Fourteen percent of respondents believed that older neurosurgeons should undergo cognitive testing, 26% agreed with a review of cases, 24% agreed with both cognitive testing and case review, and 40% felt that neither type of testing should occur.

In addition, 42% believed that the MOC should be tailored to accommodate the aging neurosurgeon, and most respondents (59%) believed that the MOC should consist of a review of individual case logs and patient outcomes for the aging neurosurgeon. 

“It‘s important to have an awareness of what your colleagues think is appropriate as well as translate this knowledge into a call to action.  How can neurosurgical societies and professional boards do a better job of providing education and support for older colleagues so that we can have these conversations and make transitions?“ said Dr Babu.

Work/Life Balance

Alex B. Valadka, MD,  president of the American Association of Neurological Surgeons, who was not involved in the study, told Medscape Medical News that it‘s “really hard to have a black and white retirement age because we need a system that allows a healthy vital 72-year-old physician to practice while weeding out a 60-year-old with obvious health issues who should stop practicing.“

Dr Valadka, from Virginia Commonwealth University in Richmond, said he noticed many physicians aged 65 or older “almost unconsciously start to limit their practice by handling only certain types of cases or, in the case of surgeons, performing less complicated procedures than before.“

However, for those who refuse to acknowledge any decline or impairment, most local hospitals have systems in place to detect red flags among the medical staff, said Dr Valadka.

He agreed with the recommendations to tailor the MOC with a review of cases "to have a safety net in place for those hospitals that don‘t follow the rules," adding that it was important for younger colleagues of surgeons to provide feedback. Dr Valadka said the American Board of Medical Specialties is considering asking all physicians, regardless of age, for a random sample of their cases during a specific timeframe.

Nonetheless, Dr Valadka questioned whether it‘s legal to require cognitive or vision testing for people aged 65 or older and wondered how the data would be interpreted.

“Some highly functioning people may be off in a few categories on standard cognitive or vision tests but not be impacted clinically,“ he said.  

To prepare for retirement, Dr Valadka recommended surgeons create a work/life balance throughout their career, including hobbies they enjoy, to develop an identity outside of work.

“When physicians reach age 65 or 70, they can decide whether they can afford to retire but also what they want to do with their time. Would they like to keep working but have a lighter load, such as teaching rounds or mentoring students or residents? Would they prefer to stop working completely but volunteer in the arts or with charities in their communities?“

Dr Babu participated in the American Board of Medical Specialties Visiting Scholars Program, which funded the study, but the Board was not involved in other aspects of the study. Study coauthors Drs Liau and Meyer serve on the Board of Directors of the ABNS. Dr Valadka, in his role as American Association of Neurological Surgeons president, also serves on the board of ABNS.

Mayo Clin Proc . Published online November 15, 2017. Abstract

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