For everything there is a season and a time to every purpose

By Christopher Wilson
Consultant Trauma and Orthopaedic Surgeon at the University Hospital of Wales NHS Trust

Corresponding author e-mail: [email protected]

Published 03 March 2022

There was recent excitement at the announcement of the first xenograft heart transplant in the USA. The lead surgeon in this outstanding achievement, Bartley Griffith, is 72.

As a surgeon in the UK, when you reach 60, there are amiable mutterings and casual enquiries about your intended retirement age but I observe that when surgeons get to around 65, these enquiries become more focused and more urgent.

The handful of surgeons I have seen still practising in the UK in their late 60s crossing into the 70s have actually provoked the ire of their colleagues, who appear to think it irresponsible of them to be continuing to practice, irrespective of their abilities and the clinical outcomes from their surgery. A reluctance to retire can be seen as clinging on.

Rovit¹ proposed that there are three reasons that surgeons resist retirement: 1) lack of self-esteem; 2) fear of death, and 3) resistance to change. But is this fair?

The situation appears to be different in the USA. I am interested by the cultural difference here in the UK and by the assumption that surgeons over 60 are approaching their sell-by date.

The picture is complicated by the need to officially retire from the NHS contract in order to gain access to the NHS pension and, as it makes no fiscal sense to let the pension contributions drag on into the mid to late 60s, most surgeons do this.

This produces a class of surgeons who are retired-and-returned but the fact is that they have been forced down this route by financial arrangements and, in many cases, are in no mood to retire at all. Certainly, even if they want to reduce to fewer NHS sessions, many of them are keen, willing and able to continue to make a contribution to their departments as well as continuing their own practice, both public and private, as long as they feel able. And as far as the Trusts are concerned these retired-and-returned surgeons are a much cheaper proposition on reduced rolling contracts without pension contributions and possibly making fewer errors without any appreciable decline in output.

We are all aware of a decline in cognitive function from the 50s onwards². Articles based on studies in other specialities³ have generated sensational headlines in the popular press regarding surgeons ageing but of course it’s much more difficult to equate this decline in cognition with an actual decline in surgical performance⁴. Certainly there is every reason to suppose that decision-making and softer factors such as patient contact and trainee contact actually improve with age once all the sharp corners of hubris, often seen in the younger practitioner, have been knocked off by experience and, let’s be honest, a few mistakes.

Whilst it is evident that surgeons should be prevented from practicing into extreme old age⁵, evidence from other fields supports an individualised approach rather than an assumption of critical age related decline into the 60s⁶.

In my own field of knee surgery I seem to learn new things most of the time. My practice in the last few years has expanded to include procedures with which I was completely unfamiliar 10 years ago, for example robot-assisted knee replacement surgery, various types of meniscus root and body repair, new types of ligament reconstruction and repair etc. Osteotomy around the knee, which I started quite early in my career, has gone from being a minority activity in the UK to a common and standard technique which is expanding and generating more interest and indications all the time. 

My colleagues may beg to differ, but I detect no significant decline in my performance, and trainees coming to me experience new methods with a surgeon who is happy to let them operate as much as they can, with appropriate supervision.

And there are some techniques and methods that veterans, training as we did in an era of extreme rheumatoid knees, can pass on from long experience.

One has to supress the tendency to sit in an audience shaking one’s head and at ‘new’ ideas that you’ve seen before, but it’s not so difficult to remain open and receptive to novel methods and techniques, and it’s not written in stone that one’s practice can’t continue to evolve into the twilight of one’s career.

I often listen to a presentation or read a paper and think “I thought of that ages ago” or “I’ve been doing that for years” but with increasing age comes a sanguine state of mind that means that I simply admire the industry and application of the surgeons who have written up their ideas for the benefit of the rest of us.

And whilst I’ve done my bit as Clinical Director, and on the local training programme, and in various roles there are still holes to fill which means that retirement does not beckon just yet.

Perhaps it’s time for a change in our attitudes to older surgeons, as has been the case in Australia and Canada and New Zealand⁷. Supporting older surgeons would involve robust peer review of practice and performance, but that is probably what we need to improve across all age grades in any case, and at present there is no real evidence, apart from individual assessment, that surgeons in their 60s need to be heading for the exit if they don’t want to. We are going to need lots of orthopaedic surgeons in the coming years⁸ and our trainees need to be appointed into new posts rather than existing jobs vacated by healthy, effective surgeons dragged kicking and screaming through the revolving doors.

References

1. Rovit RL. To everything there is a season and a time to every purpose: retirement and the neurosurgeon. J Neurosurg. 2004;100:1123-9.
2. Boom-Saad Z, Langenecker SA, Bieliauskas LA, Graver CJ, O’Neill JR, Caveney AF, et al. Surgeons outperform normative controls on neuropsychologic tests, but age-related decay of skills persists. Am J Surg. 2008;195:205-9.
3. Duclos A, Peix J-L, Colin C, Kraimps J-L, Menegaux F, Pattou F, et al. Influence of experience on performance of individual surgeons in thyroid surgery: prospective cross sectional multicentre study. BMJ. 2012;344:d8041.
4. Drag LL, Bieliauskas LA, Langenecker SA Greenfield LJ. Cognitive Functioning, Retirement Status, and Age: Results from the Cognitive Changes and Retirement among Senior Surgeons Study. J Am Coll Surg. 2010;211(3):303-7.
5. Blasier RB. The Problem of the Aging Surgeon: When Surgeon Age Becomes a Surgical Risk Factor. Clin Orthop Relat Res. 2009;467(2):402-11.
6. Bhatt NR, Morris M, O'Neil A, Gillis A, Ridgway PF. When should surgeons retire? Br J Surg. 2016;103(1):35-42.
7. Sherwood R, Bismark M. The ageing surgeon: a qualitative study of expert opinions on assuring performance and supporting safe career transitions among older surgeons. BMJ Quality & Safety. 2020;29:113-21.
8. Alderson D. Waiting lists and the ageing surgeon. Bulletin of RCSEng. 2019;101(6):213.