Author: Jonathan D. Katz, M.D.
ASA Monitor 12 2017, Vol.81, 18-20.
Jonathan D. Katz, M.D., is Clinical Professor of Anesthesiology, Yale University School of Medicine; Professor of Anesthesiology, Frank Netter School of Medicine; Attending Anesthesiologist, St. Vincent’s Medical Center, Bridgeport, Connecticut.
“Physicians are useless after age 60 and as such should retire to a college for a year and then be euthanized with chloroform.”a
– Sir William Osler, from a retirement address at Johns Hopkins University, 1905
The population of anesthesiologists in the United States is aging. In the year 2008, the average age of an ASA member was 47.b Currently, it is 50 years of age. And 37 percent of ASA members are age 55 years or older.
Changes that frequently accompany the aging process can provide both advantages and disadvantages to the ability of an aging anesthesiologist to successfully fulfill all of his/her clinical responsibilities. Decreases in motor strength and stamina make long work periods and night call responsibilities more onerous for older anesthesiologists.1 Hearing and visual impairments can impose difficulties as the senior anesthesiologist attempts to master new technologies such as ultrasound-guided regional anesthesia. Cognitive changes impact short-term memory, abstraction, and mental flexibility and can hinder the ability of an older anesthesiologist to multitask or to perform some of the complex duties required during many anesthetics. On the other hand, many important abilities are enhanced with maturation, most notably wisdom, judgement and the experience from a lifetime of clinical practice, which can impart definite advantages to senior anesthesiologists.
Fitness for Duty: Advancing physician age has been identified as a predictor of poor performance on several metrics frequently employed to judge professional competence. For example, older physicians tend, on average, toward lower scores on standardized tests of medical knowledge as compared to younger colleagues.2 However, there is typically a wide range of performances among the older physicians in these studies, and individual seniors can be found among the highest performers.3 As observed by Eva, “One of the more robust findings in ageing research is that the variability across the scores individuals receive tends to increase with age.”4 Continued participation in high-quality continuing medical education programs is one common denominator found among many top performers.
Other studies have attempted to identify a correlation between physicians’ age and more direct measures of professional ability, such as patient outcomes. In general, these studies reveal a biphasic curve, with increasing experience and case volume contributing toward improved outcomes as younger physicians mature but plateauing and becoming less of a factor as limitations imposed by older age become dominant. In one meta-analysis that examined the relationship between years in practice and various markers of quality of care, 73 percent of the included studies reported decreasing performance in all or most of the outcomes evaluated.5 Older physicians also experience an increased frequency of complications and of disciplinary actions by state licensing boards.6,7 A study conducted in Canada demonstrated a 1.5 times greater risk (after adjusting for exposure) for being implicated in malpractice litigation among anesthesiologists older than 65 years as compared to colleagues younger than 51.8 In addition, the severity of injury was two-fold greater among older anesthesiologists.
However, not all studies identify physicians’ age as an independent risk factor for poor patient outcomes. In the meta-analysis described above, 22 percent of the studies reported no association or improved performance with age for some or all of the outcomes measured.5 And in a study of operative mortality in a group of high-risk procedures, surgeon age (age >61 years versus <40 years) was not an important predictor in five of the eight surgeries studied.9 In those procedures where older surgeons did have a higher mortality rate, the effect of age was largely restricted to surgeons with low procedure volumes.
Many licensing agencies, health care organizations, medical societies, certifying bodies, regulators and policy makers are independently developing policies to address concerns about age-related physician impairment.10 ASA is relatively silent on the specific subject of age and the clinical anesthesiologist, but does provide guidance on the more general topic of fitness to practice in the Guidelines for Ethical Practice of Anesthesiologyc and the Guidelines for the Delineation of Clinical Privileges in Anesthesiology.d
Legal Considerations: Unlike many other industries in which public safety is potentially at risk (for example, the airline industry), there are no federal laws or regulations that impose age-related work restrictions such as regular health screenings or a mandated retirement age on health care providers (or Supreme Court Justices) in the United States. To the contrary, the pertinent federal laws, such as the Age Discrimination in Employment Act of 1967, and the Americans with Disabilities Act of 1990, tend to protect workers from discrimination in employment due to age alone and outlaw compulsory retirement solely on the basis of age. However, there are many exceptions to the broad protections afforded by these laws, including those who work in fields that directly impact public health and safety, such as many physicians.11
Most of the regulations pertaining to medical practice are found in individual state law. Many of these contain language which requires that physicians remain physically, mentally and emotionally competent to practice. There is also usually an explicit requirement that a physician and his/her colleagues report when there is substantial suspicion of professional impairment, including those resulting from advancing age.
“The mean age for retirement among American anesthesiologists is 63.3 years. The most frequent reasons cited for retirement are on-call responsibilities, followed by diminishing reimbursement, lack of professional satisfaction, personal health concerns and changes in the health care environment. Among those who continue to work after expected retirement age, 40 percent do so in a part-time mode.”
Employment Arrangements for Senior Anesthesiologists: The size, structure, and collective philosophy of an anesthesiology group are significant factors in determining if and how to employ senior associates. Especially important are polices for distributing night/weekend/holiday calls and vacations, assigning overhead expenses, dividing income and providing benefits.
Employment arrangements for senior physicians fall into three general categories: a shared position where two or more anesthesiologists combine to form one full-time equivalent, a part-time position in which one individual performs all of the functions of a full-time clinician at a reduced rate, and a part-time position that limits or eliminates some aspects of practice. The most challenging aspect of any of these arrangements is how to value the trade-offs. That determination is specific to each individual practice and must be made on a case-by-case basis.
Retirement: Unlike many professions that impact public safety (such as commercial airline pilots [65 years] and air traffic controllers [56 years]), there is no mandatory retirement age for physicians in the United States.
The mean age for retirement among American anesthesiologists is 63.3 years.1 The most frequent reasons cited for retirement are on-call responsibilities, followed by diminishing reimbursement, lack of professional satisfaction, personal health concerns and changes in the health care environment. Among those who continue to work after expected retirement age, 40 percent do so in a part-time mode. The most common reasons cited by those older anesthesiologists who decide to remain clinically active are career satisfaction, financial need and the requirement to maintain health insurance for family members.
Mortality Among Anesthesiologists: The great Hank Williams, Sr., observed that “I’ll Never Get Out of This World Alive.”e Death is the ultimate outcome of aging. Life expectancy among Americans has increased dramatically in recent years. A male who was 65 years old in 2017 can expect to live until age 84, up from age 72 just 25 years ago.f A female 65 years old in 2017 can expect to live to age 87, up from age 79 only 25 years ago. About 25 percent of 65-year-olds today will live past age 90.
Anesthesiologists are also living longer. Several early studies on mortality patterns reported that anesthesiologists, on average, died at a younger age than other physicians. This was attributed in large part to consequences of the stressful nature of the work and to exposure to potentially toxic substances such as waste anesthetic gases and radiation. Almost all studies cite a disproportionate number of deaths related to substance abuse and suicide.12 A more recent report has challenged the assumption of early deaths among anesthesiologists and instead concluded that the age-adjusted mortality rate among anesthesiologists is no different than among other physicians.13
Advancing age among anesthesiologists has implications for the quality of individual practices and for the workforce in general. Improvements in continuing medical education for this group along with objective assessment of competence benefit the individual anesthesiologist, the group and their patients.
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