How Can Orthopaedic Surgeons Know When It Is Time to Retire?

When should a surgeon retire? That question has been quite vexing and debated for many years. Recognizing when it is time to retire can be difficult. Objective measurements of cognitive and manual skills may help individual surgeons recognize that the end is coming and plan accordingly, but methods to properly assess these skills remain elusive.

In the sports world, we have seen many examples of athletes who retired at the top of their game and some who stayed well past their prime. In my younger days, my favorite football team was the Dallas Cowboys. I remember with great sadness when my favorite player, Roger Staubach, retired after the 1979 season. He was still at the top of his game but felt that it was time to retire to protect his health and, I suspect, go out on top. Many other athletes have done the same. Professional sports teams constantly assess cognitive and physical skills, and players who do not measure up are cut, retire of their own volition, or are forced to retire. Can we apply the same standards to surgeons?

Cognition and surgical skills
The airline industry has set rigorous standards for commercial airline pilots. The maximum age for airline captains to command an aircraft in the United States is 65 years. There are no exceptions. In addition, pilots must pass rigorous physical examinations and spend time in simulators. There are likely commercial airline pilots aged older than 65 years who retain a level of skill high enough to still fly a commercial aircraft. However, the mandatory retirement age remains at 65. I suspect that many of us are familiar with orthopaedic surgeons aged older than 65 years who still retain a high level of cognitive and physical skill. In life, there are always exceptions to the rule. Should orthopaedic surgery have a mandatory retirement age of 65? That would likely end the argument of when a surgeon should retire, but I suspect that it may not stand up to court challenges. What is the best way to fully assess the capabilities of the aging orthopaedic surgeon?

Ralph B. Blaser, MD, JD, addressed this in his 2008 article titled “The Problem of the Aging Surgeon: When Surgeon Age Becomes a Surgical Risk Factor.” Dr. Blaser noted that essentially every treatment technique taught 25 years prior to the publication of his article had been abandoned and replaced. Orthopaedic surgery is constantly changing. The amount of new technology that emerges on an annual basis is mind boggling. The American Board of Orthopaedic Surgery has instituted board recertification as one measurement to ensure cognitive competence amongst orthopaedic surgeons. However, the recertification requirements do not objectively measure manual skills.

Airline pilots can be assessed quite rigorously with in-flight simulators. How does one properly simulate the OR environment? Or for that matter, is it even possible to objectively measure the surgical skill of each individual surgeon?

Donald D. Trunkey, MD, and Richard Botney, MD, addressed this issue in their paper from the Journal of the American College of Surgeons, published in 2000. At that time, they indicated that there were no simulators that could completely mimic the operative environment and accurately measure the physical and cognitive skills to complete an operation. They suggested a substitute solution of proctoring, recommending that any surgeon aged older than 59 years could potentially be proctored by an observer to assess surgical skill. In addition, they suggested that beginning at age 50, surgeons should undergo rigorous physical and cognitive examinations every 2 years until age 60, at which time that examination should be repeated on an annual basis. They did not recommend a mandatory retirement age for surgeons.

In addition, they cautioned against a federal bureaucracy (comparable to the Federal Aviation Administration) to oversee surgical competence. Ultimately, the federal government may step in and impose what some may view as punitive guidelines upon the medical specialties. In my opinion, many medical specialties may take a very dim view of the federal government imposing its will over surgeons’ ability to practice and care for patients. Cognitive ability has taken center stage this past election season. At some point in time, the public may demand more rigorous assessment of surgeons. Government intervention is likely to follow.

Emotional and personal impact
In his 2008 article, Dr. Blaser concluded by urging for the need to properly assess manual surgical skills. He also suggested that educating surgeons on three basic facts may help to reduce this problem:

• First, recognize that surgical skills will fade over time.
• Second, planning can make retirement quite satisfying.
• Finally, retirement does not have to bring loss of all self-worth and imminent death.

The risk of losing a sense of self-worth may be an important factor keeping aging orthopaedic surgeons in the workforce. As orthopaedic surgeons, we enjoy successful and rewarding careers. We are used to being in command. Think of the environment in the ORÑattending surgeons are at the top of the pyramid and are ultimately responsible for the lives of their patients. It is a burden that we have chosen. With that comes great responsibility and hopefully respect. When retirement comes, many orthopaedic surgeons have trouble dealing with that abrupt ending. Financially planning for retirement is not that complicated. But how does one fill free time with rewarding endeavors that can match the amount of satisfaction that comes from a full-time career as an orthopaedic surgeon?

I vividly remember a surgeon I once knew who was so despondent at the thought of retirement that he took his own life. It was a sobering moment, one that served as a wakeup call for all of the orthopaedic surgeons in my community.

Orthopaedic surgery is a challenging and rewarding specialty. It is also mentally and physically demanding. Going from that environment to one of a retiree can be a difficult transition. Staubach recognized when it was time for him to retire from professional football. One would hope that many orthopaedic surgeons would also have similar insight into their own lives and recognize when it is time to move on from the day-to-day challenges of orthopaedic surgery. If only every surgeon had that type of insight, the problem would be solved. Assessments of cognitive skills, although not perfect, have been in place for many years to measure clinical and decision-making capabilities. A way to objectively measure surgical skill needs to be clarified. At some point, we as a specialty may need to make difficult decisions to maintain the high level of care that we owe to the public and our patients.

Cassim M. Igram, MD, FAAOS, is a clinical professor in the departments of orthopaedic surgery and neurosurgery at the University of Iowa. He is a member of the AAOS Now Editorial Board, treasurer of the Political Action Committee of the American Association of Orthopaedic Surgeons, and a member of the AAOS Committee on Professionalism.