On July 1, 1928, William J. Mayo, MD, a very highly regarded surgeon and co-founder, along with his brother, Charles, of the fabled Mayo Clinic, operated on a patient like he had done on many occasions in his career. Afterward, he returned to his office and announced to his secretary that he had performed his last surgical case. Dr. Will, as he was fondly known, was 67 years old at the time and, as he : "I want to stop while I'm still good. I don't want to go on like some others I've seen, past my prime, doing the surgery that younger, surer men ought to be doing." While there is nothing to suggest Dr. Will's abilities were waning, historical writings indicate this eventual occurrence was of concern to him. Simply put, Dr. Will wanted to quit on his own terms and while still at the top of his game.
Nevertheless, this was probably not an easy decision for Dr. Will to make. He truly embraced his medical profession and was passionate about the practice of surgery. This undoubtedly holds true for many physicians. We embark on this professional journey and spend several years in school and in training, learning our chosen specialties, and developing a dedication to our calling. We anticipate practicing for many years afterward. How long physicians practice is generally a matter of personal choice, since in the U.S., there is no mandatory retirement age for physicians.
However, skills and competency can decline with age and as a result of various medical conditions. Studies have found that mean cognitive abilities decline by in individuals between 40 and 75 years of age. Physicians in procedure-intensive specialties like surgery may be particularly affected by these changes. We would hope most of our colleagues would recognize the signs and know when to scale back from practice or to gracefully bow out. And yet, we still hear stories about aging surgeons becoming increasingly forgetful of instruments, paperwork, and schedules, or, in the worst case scenarios, making easily avoidable mistakes that put patient safety in jeopardy.
Given increased attention toward high quality healthcare and patient safety in the last 2 decades, should there be a mandatory retirement age for physicians, and in particular, surgeons and other proceduralists? Other industries have certainly done this in the interest of public safety. The Federal Aviation Administration (FAA) is a good example, with its for airline pilots. and other also have retirement age requirements. Some have established required retirement ages for physicians, including India, China, and Russia.
However, setting a mandatory retirement age fails to account for the fact that physicians "age out of their skills" at different points in their lives. Some may still be at the top of their game at an arbitrarily set retirement age, while perhaps others should consider retiring even sooner. Is there a better answer?
Several of my colleagues and I think so. We recently published in Hospital Topics on the subject of when surgeons are "too old" to practice surgery. In the article, we note that one-third of practicing surgeons are over the age of 55 and the average age at which they opt for retirement is increasing. We examine how other industries and professions deal with aging workers and discuss legal safeguards that protect against age discrimination. At the same time, we emphasize the imperative to balance these with attention to public safety. After considering recommendations from various professional organizations and mechanisms to protect patients from harm -- such as medical staff credentialing and licensure actions -- we recommend against a mandatory retirement age. Instead, we favor mandatory testing of physical dexterity, cognitive skills, and hand/eye coordination for surgeons beginning at age 65 and at least every 2 years thereafter. Licensing agencies should be able to delegate authority for testing to physician peer review organizations and should work with medical societies to ensure surgeons' rights to due process are upheld.
In fact, some hospitals are already performing cognition and skills testing. Take for example the Aging Surgeon Program sponsored by Sinai Hospital of Baltimore and Lifebridge Health, and the Physician Assessment and Clinical Education (PACE) program at the University of California San Diego. Both provide comprehensive physical assessments and cognitive skills testing, among other services. They are available to physicians around the country. Similarly, many state medical societies offer assistance and evaluation through affiliated entities. Two examples include the Committee for Physician Health of the Medical Society of the State of New York, and the Physician Assistance Program through the Indiana State Medical Association. Both provide evaluation and monitoring for impairment related to substance abuse, other mental health disorders, and medical illness.
However, all of these programs are typically used in a reactive fashion, once a potential impairment or competency issue becomes apparent.
What we need is a more proactive approach involving screening at a certain age to identify potential age-related cognition and skills problems before they result in patient harm. Obviously, there are many details to work out and many questions to answer. Some of these include: What would be the reference standard for such testing, and who would set those standards? Should generic psychomotor testing be performed or should there be specific surgical procedure evaluation? How accurate are the currently available tests for cognitive skills and hand/eye coordination? What about testing for physicians other than surgeons?
While the details need to be figured out, there are obvious benefits to age-related testing. In addition to preventing possible patient harm, such assessments could lead to identification of underlying medical conditions at an early, treatable stage. This would enable surgeons to remain in practice either during or following treatment. Having physicians involved in the development process of the testing standards would allow us to monitor our own profession rather than having more mandates unilaterally forced on us. Finally, testing of cognitive skills, coordination, and physical dexterity seems a better alternative to a mandatory retirement age; it would provide a green light to those surgeons with no adverse findings to continue practicing for as long as they desire and are able. For those surgeons who are deemed no longer able to skillfully practice, the development of alternative roles -- such as teaching, mentoring, and non-clinical and modified clinical opportunities -- would allow aging surgeons the option to stay active and remain as valued contributors to our profession.
In fact, Dr. Will did just this at Mayo Clinic. He, along with his brother (who retired a year and a half later), continued to serve on the Clinic's Board of Governors until the end of 1932. They then formed an advisory committee and continued providing guidance to the Clinic until they both died in 1939. Dr. Will was thus able to remain active as a physician for 11 more years after he quit operating...while still at the top of his game.
is a pathologist and former hospital executive, and a member of the graduate teaching faculty in the Master of Health Administration Program, School of Health Sciences, in the Herbert H. & Grace A. Dow College of Health Professions at Central Michigan University in Mount Pleasant.