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- Mark Katlic, MD, MMM, FACS
Welcome to Safety Net, a patient safety podcast with news, trends and ideas…from CRICO, the insurance program for all of the Harvard medical institutions and their affiliates; bringing a data-driven approach to reducing medical error through clinical analysis of malpractice claims.
Thank you for listening. I’m Tom Augello with CRICO, and today we have a special guest, Dr. Mark Katlic. Dr. Katlic is the Chair of the Department of Surgery at LifeBridge Health System in Baltimore, and he’s also the coauthor of a recent Viewpoint article in JAMA, titled Assessing the Performance of Aging Surgeons.
Dr. Katlic, thank you for joining us.
A.) My pleasure, Tom.
Q.) Let’s start with why people are interested in the issue of aging surgeons. Why is it coming up now and what are people concerned about?
A.) Well, I think the whole aging of society has reached the national consciousness. If you look every day in the papers, on the news, there’s something about our aging population. And I think it’s finally striking people that it’s the natural human condition that things deteriorate with increasing age. It’s nothing to be ashamed of, but surgeons are human. We don’t think that we’re human but we are human, and our cognitive and physical faculties diminish with age as any other human. And so, I think that’s finally beginning to reach the national consciousness and the consciousness of the medical profession.
Q.) You’re here to speak to a group of surgeons in the Harvard system through CRICO. Why is this an issue for patient safety?
A.) Well, as our cognitive and physical faculties diminish over time, there’s the potential for problems, potential for cognitive errors particularly, even more than physical errors. Surgeons particularly are at risk because if you think about it, we have to make fast decisions in emergency situations. And often, we don’t have the luxury of calling on help immediately. And so, it’s important for the surgeon to have his or her wits about them. We know that one of the first things that diminishes with increasing age is the ability to make decisions during so-called noisy conditions, not auditory noise, but distractions. And that’s exactly what happens in an operating room or a trauma bay when things go bad. And so, particularly for surgeons, unlike maybe some other specialties, it’s important. Also, one’s physical abilities are important for surgeons, probably more so than any other specialties.
Q.) What’s the data telling us about bad outcomes based on or caused by cognitive decline?
A.) Well, there is very little published data and a large amount of anecdotal data. And so, if one looks at the publications about older surgeons and results, the results are mixed. Most of the errors that do occur—there’s a recent study just published online that showed when errors do occur around the time of an operation, 60-some percent of them are cognitive rather than physical errors. So, there’s very little published data. However, any chief of surgery, any hospital president sometime during his or her career encounters a surgeon who should have stopped operating before he or she did. And when I lecture about this to groups of medical students even, and other doctors, when I ask the audience, ‘how many of you have encountered a surgeon who should have stopped operating before he or she did?’ the majority of hands in the room go up. And these are nurses, medical students, other doctors, and hospital administrators. So, little published data, it’s mixed, but a great deal of anecdotal data.
Q.) What kinds of stories come out of this kind of a situation where we’re seeing aging surgeons who should have retired?
A.) Well, I’ve heard quotes. When I polled the Society of Surgical Chairs a few years ago, asking them for anecdotes, I heard quotes such as, “fell asleep during the part of the operation,” “had to be shown back to his office by one of the residents after the procedure,” “became slovenly in hygiene and appearance.” So, those are obviously some of the bad things. Now, I also heard good quotes, such as, “seventy-five-years-old and still excellent,” And so, again, there are good comments and bad. But it’s those bad few surgeons—and it’s not the majority, but it’s those surgeons that we need to identify and help them. Help them hopefully transition to some other part of their career, but not in the operating room.
Q.) It’s not something that might really show up in a malpractice claim, but it could still kind of be an underlying thing?
A.) I think we all fear—hospital presidents and chairs of surgery—fear having the older surgeon get into trouble. And that’s why we would like to do some sort of screening probably, to identify those problems before they become problems.
Q.) In most hospitals, that doesn’t take place. At LifeBridge you guys are doing something. Can you talk about that a little bit?
A.) So, there is a medical staff policy called Late Career Practitioner Policy, and a number of hospitals around the country have such a policy, although it’s not many hospitals. There may be as many as one or two dozen hospitals of the 4,000-some hospitals in the country. But we have it at our three hospitals in LifeBridge Health in Baltimore. And a Late Career Practitioner Policy would say, for example at a certain age, say 75 years old, every doctor, every nurse practitioner, every physician assistant when he or she comes up for recredentialing, typically every two years, must have a neurocognitive screening evaluation, a physical examination, and an eye examination. And we do that on every 75-year-old every two years when he or she comes up for recredentialing. Now, I believe every hospital in the country should have such a policy. That’s my bias having studied this subject for a number of years. But they are controversial, and some hospitals have tried to institute these policies and there’s been pushback by some of their influential doctors.
Q.) Based on your experience, what kind of advice would you give to an institution or a system that wants to implement something like this? What were the challenges that you had to overcome?
A.) Well, I think doctors are logical and they will look at data. And so, I would recommend that they look at, for example, a review article I wrote of the whole subject a few years ago that lays out logical argument for why we need some sort of screening. And that is, doctors are human too, and we know that cognitive and physical faculties diminish with increasing age. Mandatory retirement age is not the answer because of the enormous variability among individuals. And by the way, the variability among individuals actually increases with increasing age. So, there’s more variability among 80-year-olds than there is among 40-year-olds. We know 80-year-olds who can play vigorous tennis, other 80-year-olds can’t walk to the mailbox. So anyway, mandatory retirement age would not be scientific nor would it be fair.
So, if we don’t have mandatory retirement age, we do need to do something. And the reasonable step is some sort of screening, just a simple screening test. If you’re cognitively great, then you have nothing to fear from the screening test. And if we identify somebody, we can either help them transition to a different role. Or, in the case of surgeons, sometimes just taking them off the call schedule so they get more sleep at night, or review the medications that they’re taking, or make sure they don’t have sleep apnea, or move them into an assisting role or a teaching role rather than as the primary surgeon. So there are things we can do, and we as a profession really need to do it.
Q.) One of the issues that you have to face is balancing the benefit of experience against this decline in cognition. How do you describe that?
A.) So, one argument has always been that the vast experience of the surgeon particularly, or a physician, who has been in practice for 30 or 40 years, will more than compensate for these decrements in cognition and physical function. The reality is that that experience just simply cannot totally make up for the deterioration in normal human functions. That has been studied, not so much in surgery, but it has in other fields of medicine. And the conclusion has been that the experience just can’t make up for everything.
Q.) How do we keep this from turning into something that could be considered age discrimination or something that’s used in a way that’s not appropriate?
A.) Well, that question does come up, Tom, and that’s actually one of the arguments that some doctors use who push back against these Late Career Practitioner Policies. What I would say is this: it is illegal in the United States to make hiring and firing decisions based upon chronologic age, based upon an act way back in 1967. Consequently, it’s taken acts of Congress to impose mandatory retirement on airline pilots and national park workers and lighthouse workers and FBI agents and a few others. There have been age discrimination suits brought against hospitals for hiring and firing, some of which have been successful. But the idea of screening has never been tested in court. Our hospitals and our hospital lawyers felt that they were willing to take that tiny chance with this Late Career Practitioner Policy, feeling that the overwhelming weight of evidence is that this will help patients more than harm patients and will not also harm respected doctors either.
Q.) When we think about how to manage this issue with aging surgeons, what would be the ideal? What’s your vision for healthcare in order to address this?
A.) Well, I think that every hospital in the country should have one of those Late Career Practitioner Policies and it can be specific to that hospital. They can pick one age, 70, 72, 75 even 80. They can pick whether they want to do cognitive screening or physical screening or peer evaluations or something. But I think it’s reasonable to do some basic screening and then to help the few doctors that are identified. And by the way, we’re talking about maybe five percent. It’s not a huge number or percent, but help those folks transition to something more productive and safer for patients.
Q.) Thank you, Dr. Mark Katlic. Dr. Katlic is Chair of the Department of Surgery at LifeBridge Health System in Baltimore, and coauthor of a recent Viewpoint article in JAMA, titled Assessing the Performance of Aging Surgeons.
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