The aging anesthesiologist: a narrative review and suggested strategies

Abstract

PurposeTo address an aging anesthesia workforce, we review the relevant changes and implications associated with age in order to stimulate discussion at the individual, local, and national levels regarding appropriate changes in practice aimed at protecting patient safety.Principal findingsIn a 2013 survey of Canadian Anesthesiologists, 22% were aged 55-64 yr, 7% were aged 65-74 yr, and 3% were older than 74 yr. Clinical abilities decline with age, making older anesthesiologists more likely than their younger colleagues to be associated with adverse patient events. Anesthesiologists older than 65 yr in Ontario, Quebec, and British Columbia had 50% more cases involving litigation and almost twice the number of cases involving severe patient injury compared with anesthesiologists younger than 51 yr of age. In the absence of overt deterioration in skills, decisions about reducing activities and retirement are left largely to individuals despite their limited ability to self-assess competence. This state of affairs may contribute to the increased incidence of adverse events and poor patient outcomes.ConclusionsProvincial regulatory bodies have peer assessment programs to evaluate physicians at random, following a complaint, and at certain ages, but all have limitations. Simulation has been used widely for training and assessment in the aviation industry as well as in automobile driving exams. Simulation can assess crisis recognition and management, which is crucial in anesthesiology and not well assessed by other methods, and could assist elderly anesthesiologists during the pre-retirement phase of their careers. A standardized schedule for winding down would have advantages for physicians, their department, and their patients. A suggested schedule might include no further on-call duties for those aged 60 yr and older, no further high-acuity cases for those aged 65 yr and older, and retirement from operating room (OR) clinical practice (with possible continuation of non-OR clinical or other non-clinical activities, if desired) at age 70 yr. These timelines could be extended with satisfactory performance in annual simulation sessions involving assessment and practice in crisis management.

Occupational Health: additional support for the aging anesthesiologist

“…The authors also offer proposed assessments and possible solutions to ensure patient care is not compromised. 1 This paper reflects broader concerns over a lack of preparedness among professional bodies associated with a range of liberal professions where their members may continue practice into later life without support from formal occupational health services. 2 This is particularly important for medical specialities where there is a heavy reliance on psychomotor skills and rapid responses to emergent situations and where senior specialists are frequently required to attend out of hours to deal with complex clinical cases.…”

The aging anesthesiologist: Are we asking the right question?

“…When a satisfactory answer to a complex question is not readily available, a common intuitive human response is to find a related question that is easier to answer. In this issue of the Journal, Baxter et al 2 address an important topic that relates to the professionalism of anesthesiologists in dealing with age-related decline in clinical performance. The authors offer a ''proactive'' strategy that hospital departments and practice groups should consider for managing this issue.…”

“…For example, Campbell et al 5 reported that 52% of patient complaints to the General Medical Council in the United Kingdom (UK) involved anesthesiologists qualified for more than 20 years, whereas only 39% of the cohort were over the age of 45. Baxter et al 2 have asked an important, yet complex, question that requires serious analysis. We cannot, and should not, deny that there may be an unrecognized problem pertaining to some anesthesiologists that is related to an age-related decline in clinical abilities.…”

“…Before adopting the strategy suggested by Baxter et al, 2 we should ask whether their proposal reflects the correct question (i.e., a concern for overall patient safety) or whether it reflects an easier question (i.e., competence of aging anesthesiologists working in hospitals), as Kahneman 1 suggested was our natural inclination. It should be emphasized that all studies show that the absolute number of adverse events (attributed to anesthesiologists) that lead to complaints or litigation are greater in younger anesthesiologists, although the frequency is relatively higher in those older than 65.…”

“…Tessler 3 was correctmore work is needed. It is somewhat ironic that our specialty in Canada is moving toward competence-based assessment of residents, 8 yet Baxter et al 2 focus on an agebased (time-based) model for continuing professional competence. The idea may be intuitively appealing, but is it the answer to the correct question with respect to patient safety?…”