physical, psychological, and social change of aging and its implication in patients and surgeons

1. The Ageing Patient and Surgeon
Mr Vaikunthan Rajaratnam
MBBS(Mal),AM(Mal),FRCS(Ed),FRCS(Glasg),FICS(USA), Dip Hand Surgery(Eur),
MBA(USA), Dip MedEd(Dundee),MIDT(OUM),FHEA(UK),FFST(Ed),FAcadMEd(UK).
Senior Consultant Hand Surgeon
Alexandra Health, SINGAPORE
This work is licensed under a Creative Commons Attribution 4.0 International License.
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2. Declarations
• I am not an expert in the field of cognitive decline in healthcare
professionals
• I am a full time surgeon with 35 years of clinical practice
• Early retirement from NHS, UK age 55
• I have no financial arrangement with any commercial organization
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3. Ageing
• physical,
• psychological, and
• social change
http://www.americusumterobserver.com/category/archive/2014/july2014/
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4. http://www.pureepitalon.com/fr/epitalon-research-article-part-4/
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5. Surgery in aged (>65)
• growing health care costs
• growth in the utilization of surgical
services
• cost-effectiveness of medical care
• advances in surgery and medicine
- expanded scope and safety
• cost-effectiveness of medical care
• age-based rationing of health resources
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6. Surgical risk factors, morbidity, and
mortality in elderly patients.
• Although several risk factors for postoperative morbidity and
mortality increase with age, increasing age itself remains an
important risk factor for postoperative morbidity and mortality
• Age was statistically significantly associated with morbidity (wound, p
= 0.021; renal, p = 0.001; cardiovascular, p = 0.0004; respiratory, p <
0.0001) and mortality (p = 0.001).
J Am Coll Surg. 2006 Dec;203(6):865-77. Turrentine FE1, Wang H, Simpson VB, Jones RS.
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7. Predicting Success for Geriatric Surgery
- frailty score model
Increased risk of surgical death
• malignant disease and low serum
albumin levels were more common
among the patients who died.
• dependence in activities of daily
living,
• dementia,
• risk of delirium,
• short mid-arm circumference, and
• malnutrition Kim S-W, Han H-S, Jung H-W, et al. Multidimensional Frailty Score for
the Prediction of Postoperative Mortality Risk. JAMA Surgery. 2014
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8. Surgeons are ageist
Doctors in Britain regularly discriminate against older patients by
denying them tests and treatments they offer to younger people,
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9. We should not hesitate to offer surgical procedures to those beyond
the age of 80. Instead, we should continue to improve all facets of
preoperative and post-operative care, anesthetic agents, surgical
skills, and rehabilitation units so that the widening frontier may ever
extend. For who can say what the upper limit of life may be?
(Wilder and Fishbein 1961b, 551)
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10. “advances in surgical and anesthetic techniques” have made “the risk
associated with surgery . . . somewhat less of a concern than the need
to provide maximal medical management of disease”
(Dardik, Berger, and Rosenthal 2012, 328).
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11. Ageing Surgeon
• skills will decline
• a properly planned retirement
• retired surgeon has much to offer the medical and teaching
community
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12. The Problem of the Aging Surgeon
• Knowledge, experience, and reputation
can compensate for a long time. The
declines are gradual. The surgeon and
his or her colleagues may not notice the
changes until the deficits become
serious.
• Quantity, remoteness , and
obsolescence of knowledge
• Skills and technique gained 25 years
ago is outdated
The Problem of the Aging Surgeon - When Surgeon Age Becomes a Surgical Risk Factor
Ralph B. Blasier MD, JD
Clin Orthop Relat Res (2009) 467:402–411
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13. Psychomotor domain of ageing surgeons
maintain old skills,
develop new skills, and
grow through experience
• vision, hearing, motion, and dexterity
Greenfield LJ, Proctor MC. When should a surgeon retire? Adv Surg. 1999;32:385–393.
70 years old had retired, but strikingly, of surgeons aged older than
70 years who had not yet retired, only 40% had made any
retirement plans, and more than half were performing operations
at a rate self-estimated to be their ‘‘normal’’ workload
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14. 22% believed age conferred greater credibility and respect,
21% a more mature life perspective, and
49% greater actual confidence and competence.
27% reported fatigue interfering with work,
12% difficulty keeping up with advances in knowledge, and
10% poor memory
281 responded to a survey of the influences on and of the effects of age and retirement. Of
these, 223 were still working full time after age 55
Draper B, Winfield S, Luscombe G. The older psychiatrist and retirement.
Int J Geriatr Psychiatry. 1997;12:233–239.
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15. Ageing in surgeons
Maximum strength is generally achieved during the third decade of life,
with a 25% loss of strength by age 65 years. … As we age, visual
acuity and accommodation decrease in association with hardening and
yellowing of the lens [of the eye]…and pupillary shrinkage. Optimal
performance requires…100% more [illumination] in workers older than
55 years
three reasons why surgeons resist retiring:
(1) lack of self-esteem;
(2) fear of death; and
(3) resistance to change.
Rovit RL. To everything there is a season and a time to every purpose: retirement and the neurosurgeon.
J Neurosurg. 2004;100:1123–1129. Creative Commons Attribution 4.0

16. Assuring Competence in Surgery
• Revalidation , recertification and appraisal
supporting information that doctors will be expected to
provide and discuss at their appraisal at least once in
each five year cycle. They are:
1. Continuing professional development (CPD)
2. Quality improvement activity
3. Significant events
4. Feedback from colleagues
5. Feedback from patients
6. Review of complaints and compliments
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17. Aging Surgeon Program
• comprehensive, multidisciplinary, objective and unbiased evaluation
• physical and cognitive function
• identify potentially treatable or reversible disorders
• protect patients ,surgeons and hospitals/employers
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18. Protocol
• General physical examination; hearing screen
• Neurology examination
• Physical/Occupational Evaluation
• Neuropsychology Evaluation
• Ophthalmology Examination
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19. Simulation - Objectively measuring
• technical skills
• performance,
• setting proficiency ”benchmarks”
minimum standard is measured and achieved
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Use of a standardized patient protocol to assess clinical competency: The University of Colorado Denver
Comprehensive Clinical Competency Examination.
Masters, Kevin S.; Beacham, Abbie O.; Clement, Lacey R.
Training and Education in Professional Psychology, Vol 9(2), May 2015, 170-174.
The Role of Simulation in Continuing Medical Education for Acute Care Physicians: A
Systematic Review. Critical Care Medicine:
January 2015 - Volume 43 - Issue 1 - p 186–193

20. Reasons for retirement included
(1) an adverse malpractice experience;
(2) ‘‘just wanted to retire’’;
(3) ‘‘age’’; and
(4) ‘‘fear of loss of competence.’’
Miscall BG, Tompkins RK, Greenfield LJ. ACS survey explores retirement and the surgeon.
Bull Am Coll Surg. 1996;81:18–25.
The average gross income declined 36% on retirement, but 90% of the survey responders believed
their income was at least adequate
11% of these retired surgeons had made no preretirement plans at all; 59% had instituted financial
retirement plans; and 9% had taken on new hobbies, new interests, or a new occupation
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21. Teaching in four areas
(1) preclinical teaching to medical students, particularly
anatomy
and physiology;
(2) clinical teaching to medical students, particularly
coaching them in learning to take a patient history and
perform a physical examination; (3) acting as an
experienced surgical assistant to a registrar in
training; and
(4) teaching basic surgical skills in workshops.
Kirk RM. The retired surgeon: a potential teaching resource.
Ann R Coll Surg Engl. 1997;79(Suppl):73–74.Creative Commons Attribution 4.0

22. Personal Strategy
• Intellectual challenge –
Masters, PhD
• Skills – Clinical work -
reengineer, train, innovate
• Emotional – passion, mentor,
educational technology,
volunteerism
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23. References
1. Dardik, A., D.H. Berger, and R.A. Rosenthal. 2012. Surgery in the Geriatric Patient. In Sabiston Textbook of Surgery. 19th ed., ed.
C.M.Townsend, R.D. Beauchamp, B.M. Evers, andK.L.Mattox, 328–57. Philadelphia: Saunders
2. Wilder, R.J., and R.H. Fishbein. 1961b. The Widening Surgical Frontier. Postgraduate Medicine 29:548–51.
3. Shamliyan T, Talley KM, Ramakrishnan R, Kane RL. Association of frailty with survival: a systematic literature review. Ageing Res Rev
2013;12(2):719- 36. Epub 2012 Mar 12.
4. Bagshaw SM, Stelfox HT, McDermid RC, Rolfson DB, Tsuyuki RT, Baig N, et al. Association between frailty and short- and long-term outcomes
among critically ill patients: a multicenter prospective cohort study. CMAJ 2014;186(2):E95-102. Epub 2013 Nov 25.
5. Farhat JS, Velanovich V, Falvo AJ, Horst HM, Swartz A, Patton JH Jr, et al. Are the frail destined to fail? Frailty index as a predictor of surgical
morbidity and mortality in the elderly. J Trama Acute Care Surg 2012;72(6):1526-30.
6. Leopold SS, Morgan HD, Kadel NJ, Gardner GC, Schaad DC, Wolf FM: Impact of educational intervention on confidence and competence in the
performance of a simple surgical task. J Bone Joint Surg Am 2005;87:10311037.
7. Tessler MJ, Shrier MD, Steele RJ. Association between anesthesiologist age and litigation. Anesthesiology 2012; 116: 574-9.
8. National Clinical Assessment Service. Concerns About Professional Practice and Associations With Age, Gender, Place of Qualification and
Ethnicity – 2009/10 data. London: NCAS, 2011.
9. Drag LL, Bieliauskas LA, Langenecker SA, et al. Cognitive functioning, retirement status, and age: results from the Cognitive Changes and
Retirement among Senior Surgeons study. J Am Coll Surg 2010; 211: 303-307
10. Waxman BP. Caring and sharing: strategies for recognizing and surviving burnout in surgeons. ANZ J Surg 2011; 81: 493-494.
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