How and why is the age demographic of physicians changing? Does this affect their ability to practice and treat patients? What can be done about it? Cardiovascular surgeon Dr. Todd Rosengart weighs in.
Todd Rosengart, M.D., is professor and chair of the department of surgery and a professor of molecular and cellular biology at Baylor College of Medicine. He is also a professor of heart and vascular disease at the Texas Heart Institute and current president of the national Society of Surgical Chairs.
See more information on the Michael E. DeBakey Department of Surgery at Baylor College of Medicine.
See below for more of Dr. Rosengart’s research:
- Transition Planning for the Senior Surgeon: Guidance and Recommendations From the Society of Surgical Chairs
- Informed consent for cardiac procedures: deficiencies in patient comprehension with current methods
- Completeness of coronary revascularization and survival: Impact of age and off-pump surgery
Nothing but a Number: Our Aging Physicians | Transcript
Erin: Welcome to Body of Work, an exploration of health topics in the news and important issues facing science with experts from Baylor College of Medicine. I'm Erin Blair, and my guest today is cardiovascular surgeon and surgical chair, Dr. Todd Rosengart.
How is the age demographic of physicians changing?
Dr. Rosengart: Well, it's an important issue at the age demographic is actually going to create a significant burden on the healthcare delivery in the United States. A number of, an increasing number of surgeons and physicians overall, are reaching the age where they're going to be functioning as physicians who are 60 years and older. The number right now is about 25,000, and that is going to at least quadruple and then in the next decade.
Erin: So, what does it look like in previous decades?
Dr. Rosengart: The number of surgeons who are retiring at a reasonably early age had been significantly higher than now. The number surgeons were looking to continue working into their 70s, 60s and 70s, is beginning to increase. There are a lot of different reasons for that, some very good. The functionality of physicians and surgeons who are older continues to improve. Some of it is, quite frankly, financial. That concerns about their ability to retire.
Erin: Do you have a sense of what the current average age of a retiring surgeon is?
Dr. Rosengart: I don't, that number is not really available. However, what's very interesting is surgeons, in particular, there has been a survey on this, usually do not have a good sense of when they should retire based upon their cognitive skills, even their clinical competency. So what would be desirable is to give them good feedback about whether or not it's time to start switching into activities that take them out of the operating room, and into other very important roles, be it teaching, research, mentoring, administrative support, or the like.
Erin: What will it look like in the future? Do you see physician surgeons practicing even longer?
Dr. Rosengart: I do. I think there is a significant shortfall in the physician workforce. There’s an estimate that there will be a gap of at least a hundred thousand physicians in the coming decades. So clearly that is going to put a lot of strain on the physician manpower, or physician human power, ability, or availability. So, there's going to be an increasing need and push to have surgeons and physicians who are 60s, or even 70s, continuing to practice.
Erin: What aspects of aging, in particular, would directly affect a surgeon's ability to operate?
Dr. Rosengart: Well, on the positive side, as we get older, hopefully, we've all gained a lot of experience and learned from that experience. So the older surgeon, or physician, for that matter, tends to do better on the basis of their experience. That’s obviously not a surprise. On the other hand, there's very clear data that beginning, really in the late 40s, early 50s, there becomes a significant decline in cognitive function and overall capabilities, again not necessarily a surprise. That can be as much as 20% when you perform standardized cognitive testing on physicians. Interestingly, in general, physicians and surgeons tend to do better than the general public. Perhaps not a surprise, and that does negate or counterbalance some of this change in cognitive function. Experience plays an important part the expression “older and wiser” exists for a reason. The importance of what we really need to do is figure out where those different factors balance out. The Society Surgical Chairs feels that that is on the basis of competency and cognitive testing, beginning at an appropriate age so we can make sure that the right, capable, and competent physicians and surgeons continue to practice, but conversely that we make sure those who may not be balanced in terms of that experience versus cognitive abilities are kept abreast of and are properly transitioned into non clinical or non-operative roles.
Erin: Has any research shown that older surgeons have poorer outcomes than younger ones?
Dr. Rosengart: Yes, that's a great question. It actually, there is research that cuts both ways. They’re clearly studies that would suggest overall, surgeons who are older do not do as well on things like incorporation of current guidelines, medical knowledge, even some outcomes. On the other hand, there are studies that show just the opposite that they do better than younger, less-experienced surgeons. So I think the takeaway from that is you can't generalize in any, in one way or the other, about clearly there's an age cutoff and in terms of who may or may not be credentialed or continued to a practice. But it's important on the other hand on an individualized basis to make sure we're keeping an active eye out, and alert out, to make sure that when there is a change in capability that we pick up on this. At the end of the day, the most important thing is to make sure our patients are well taken care of.
Erin: Can years of experience and judgment compensate for a modest physical and cognitive decline?
Dr. Rosengart: I think absolutely so, and there's no metric to measure that a priori, or prospectively, and again another reason why making sure that we test physicians, so we don't second-guess that that issue is going to, I think, be very, very, important, especially going back to your first question, “is the percentage of physicians and surgeons who are older and continuing to practice in the workforce increases proportionate to the total number of physicians.”
Erin: So, you're a surgical chair at Baylor, what's that mean to a layperson?
Dr. Rosengart: Sure, I guess the framework for that is at any institution, a college, a university, or the like, typically there are different departments in a regular University. That might be the Department of History, the Department of English, and usually, the leader of that department and the particular faculty of that department is called a chair. In the old days, we used to say, chairmen. Thankfully those days are behind us, now we just say chair.
In a medical school, those departments and chairs become a little bit more specific, of course, for the practice of medicine. So you have chairs of medicine who take care of the medical specialties, like gastroenterology or the like. Then you have a chair of surgery which obviously takes care as oversight of the faculty involved in surgeries. That could be general surgeons, cardiac surgeons, vascular surgeons of the like. So at Baylor, I'm the Chair of Surgery, the Michael E. DeBakey Department of Surgery, of about a hundred and seventy faculty members in our department. Then we also have oversight, in our case, of about a hundred and twenty resident trainees, and of course, the education and medical students who will rotate through our services and practices.
Erin: Does that translate into a national role for you as well?
Dr. Rosengart: Yeah, so back in about 1965 interestingly, the chairs, the surgery chairs all said it would be useful to compare notes and so the Society of surgical chairs, which I’m president of for this year, was formed. And it was really just an opportunity to get together, compare notes, look at opportunities to improve the profession. About two or three years ago we asked the question, “How do you deal with the challenge of a senior surgeon who may or may not feel like he or she is ready to retire and you as a surgeon chair feels that they might be?” So that was sort of an exploratory session and interestingly, everyone who's involved in this peer group session, they thought it was a very significant problem. Almost all of us had different war stories to share and compare. All of us felt that not enough was being done to deal with that.
Erin: Why is this topic challenging?
Dr. Rosengart: There's a lot of reasons. They're very sensitive, and one reason why we wanted to tackle this as the group of surgery chairs is to avoid those sensitivities. In particular, if there are no general guidelines, then all of these interactions seem very ad-hoc. Potentially a personal, potentially a retaliatory in some way, and certainly arbitrary. So what we want to do is proactively engage physicians as they get older in a long-term process so that the expectations are clear, there's a clear runway ahead of each of us, and so that we understand our expectations.
Fascinatingly, if you look at the airline industry, where there is a mandatory retirement age, which is fairly young, it's at 65, I'm almost 60, so that's very young to me. It appears from what we've read and what we've heard, that the airline pilots actually do very well with that mandatory age. Mostly because they know it's coming. It's well done, it's well known, it's out there, and they have years and years to prepare in advance, so that when that date comes, again there's not that one-off where it's uncertain what their future is going to be. So the key on all this to avoid it being sensitive, is to plan well ahead, even mid-career, so that what comes after you transition out of the operating room, or the clinic, as well communicating in advance and there's a plan in place be it financial, practice patterns, or even the cultural and psychological elements of not tagging your self-worth, self-value, self-perception to being in the operating room, or at the bedside, but being able to understand that you can contribute in a valuable and significant way in other important activities. When you think about it, the experienced physician has so much to offer to students to residents, to trainees, in terms of that accrued knowledge, information, experience that you mentioned. There would be a shame to waste that talent contributed to a younger generation, but we want to make sure it feels valuable to that physician as they transition as well.
Erin: So, what were some of the recommendations of your survey?
Dr. Rosengart: Our survey first all showed that the Society of Surgical Chairs really was very, very, supportive of early career counseling, mentoring, career planning, retirement planning, and then thinking about ways to transition. So those ways are again fairly obvious is an important role, an opportunity for physicians and surgeons to be involved in mentoring trainees and students, be involved in peer review and administrative leadership roles, teaching education, even research roles than other hospital, or medical school, or other institutional roles in an administrative support basis. The other part is it's also okay to retire.
Erin: Do you think the surgeon lifestyle makes it difficult to retire?
Dr. Rosengart: Oh, absolutely. The surgeon, I think, in general. Every surgeon I know views their value, their worth, and even their raison d'être, so to speak, based upon their being in the operating room, doing what they love, being able to take care of patients to the point where I would actually think that surgeons in particular almost feel guilty if they're not, and not lose their value of self-worth, if they're not doing those things. So I think we need to educate our colleagues that there are valuable and important ways to contribute that go beyond being in the operating room.
Erin: Why do you think that these surgeons resist suggestions to slow down as they get older?
Dr. Rosengart: Again I think it's how we place self-worth and value on that activity that's in the operating room. If some of that is financial, we pay surgeons to operate. We don't necessarily pay surgeons to be mentors and leaders. And so it's important that we recalibrate that in a way that surgeons and physicians, in general, can contribute in a way that they feel that is valued and supported, that goes beyond the operating room, again, expanding to physicians in general, taking care of patients at the clinic or in the bedside as well.
Erin: What does the current transition process look like?
Dr. Rosengart: Basically, there is none, and that's the problem. This often becomes an emergency when there's a bad clinical outcome. All of a sudden that physician is under review, this was not telegraphed in advance. One day everything is fine, in the next, there is a catastrophe. So that, of course, is about the worst way you can possibly do this, and again one reason why we think this is important and excited about this initiative, we're actually going to try to collaborate with the American College of Surgeons on this effort, because there is no process. It has been a very sensitive issue, there's always concerns about age discrimination, even though legally there's a clear precedent that when it comes to patient safety, these measures are very appropriate. But we need to put something together, so in an organized, proactive way spanning years, if not decades, again so that this does not become an ad hoc, catastrophic moment where emotions are high, and the ability to plan in advance is least applicable.
Erin: What do you think of a mandatory retirement age?
Dr. Rosengart: I think mandatory retirement age, and this is supported by not only outside studies but by our Society of Surgical Chairs, a survey as well, does not make sense, and I think that's a very, very, important point. We clearly know that there's a lot of heterogeneity between how one 65 year old might function versus another. One, in fact, it may be very appropriate to consider retirement either voluntary or even supported by a review process. Other 65-year-olds are well within their capabilities to go on for a significant number of years, and that's again why we advocate for an individualized, competency, and cognitive, as well as a physical testing regimen so we can certify and make sure that physicians as they get older, continued to be credentialed and appropriate for continuing their practices. This will probably move forward working with individual hospitals to create credentialing, or reappointment criteria that likely would, it would involve things like cognitive testing, peer review, and even outside testing counseling if necessary.
Erin: Rather like getting your driver's license.
Dr. Rosengart: Yes, exactly. Why should it not be much different than that? That's exactly right, it's a great comparison. If we need to get tested to get our driver’s license, I certainly think to get tested to fly an airplane, run a nuclear reactor, or take care of patients should be taken with equal seriousness and care, and perhaps it's inappropriate that we're not already doing so
Erin: At what age could late career practitioner policies start?
Dr. Rosengart: Well, that depends both on how early you want to go into creating a baseline for measurement, clearly beginning at age sixty to sixty-five, that cognitive performance levels begin to change significantly. By the age of seventy, there's again, about a 20% decrease in cognitive function compared to baseline. So in our view, at a minimum, you want to capture that beginning of change, so again age sixty to sixty-five, but ideally you'd even be do cognitive testing at an even earlier age, perhaps as early as 40 or 50, to again to establish that baseline. The other part that's interesting is you can do exercises to improve your cognitive function. That may be something as simple as playing backgammon, or cribbage, or something like that. Then other tricks that you can learn memory games memory tricks memory exercises to again, help yourself if there is a cognitive decline. So you avoid even checklist for that matter, to avoid deficits that translate into a adverse clinical outcome.
Erin: So you talk about evaluations, both cognitive and physical, sort of getting a sense of where an older physician is. What would evaluations of older physicians look like?
Dr. Rosengart: Yes, so there's two components. One is a simple cognitive test, one test, for example, is called micro cog. It’s a very basic, it's about a 15 or 20-minute test. it's memory function, simple arithmetic, sylloge and the like. Then there's also which we've talked about a bit as the psychomotor function, so peg games, drawing, simple drawing exercises, and the like. Again, these are fairly standardized. They've been well established, not particularly complicated, so a hospital for example in an HR department could easily execute deliver these tests in a well-documented way, so there could be comparison to your own baseline which is perhaps most important, as well as a population norm.
Erin: Do you think these kinds of transition strategies could be used in other areas of healthcare careers or other industries even?
Dr. Rosengart: Yes, so mostly we are learning from other industries in this the medical profession is late to the game, so to speak. And there are a lot of lessons, for example from nuclear power industry, or the military. We mentioned the aviation industry and the FAA, so we probably can teach others, but we first need to be taught how to do this ourselves and implement our own strategies, which again I think is with the aging physician population, is going to be important. I do think this is something that we want to be ahead of. There are now stories actually, coincidentally, there is a story in The New York Times recently, a fairly high-profile event where a surgeon who was involved in an institution with bad programmatic outcomes was a senior physician, and there was some question about whether or not that that age-related deterioration and outcomes was perhaps a contributor to these issues. So again I think the more we're ahead of the curve on this, and maybe even a little late for that to be ahead of this curve, the better we'll be in a better service we can provide to our patients in the population in general.
Erin: Do you think it would be fair to have different standards for different kinds of medical practice?
Dr. Rosengart: Yeah, that's a great question. I don't know the answer to that. I certainly, something like surgery where there is a motor function a technical ability is going to be appropriate for surgeons, as opposed to a cognitive field, like internal medicine or Rheumatology so to speak where the obvious those technical skills may not be relevant at all. So I do think different specialties will need different assessments of actual ability to deliver a clinical care. That makes a lot of sense.
Erin: How have your colleagues responded to this survey?
Dr. Rosengart: So the fascinating part is, as far as I can tell, everyone has embraced this as an important area. I've even gotten some calls from 65-year-olds who have thought about this, and said, “boy this is important work and glad you're doing it, and am I okay?” Not so much the last part, but yeah it's actually been very encouraging when we first took this on about a year ago. We’re quite apprehensive about the politics and the atmospherics of it. But it's been very heavily supported embraced and championed actually by every colleague that we've encountered so far. So encouraging good start, sure not completely won't be smooth sailing all the way through.
Erin: It almost sounds as though you spoke what others had privately been thinking kind of brought it into the light.
Dr. Rosengart: I think that's true, I think that's true. And again ego that speaks well both for the opportunity to accomplish this. And again I think the ethos of a physician and the medical community at large that they are trying to do the right thing, and appreciate what would be fair and reasonable support and continuing to provide good care for our patients.
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