Gabriel M. Gurman, MD
‘It’s not how old you are, it’s how you are old.’ ― Jules Renard
‘Learning is an ornament in prosperity, a refuge in adversity, and a provision in old age.’ ―Aristotle
These were the quotations that came to my mind when I read, some years ago, Gialcalone’s paper1 about the impact of age on anaesthesiologists’ competence. Many of my age could witness that old age has no absolute significance. One is as old as they feel, and this is why Jules Renard, the famous French writer, is fully right in his famous observation about the subjective aspect of old age.
This is also the reason why in many countries the retirement age is postponed for various professions, among them medicine. A 2016 report2 mentioned the fact that some 10% of the practicing physicians in the USA were older than 70. In Israel more than 30% of the physicians 65 years and older are still active, most of them working part time; some 11% of the active Israeli anaesthesiologists are older than 65.3
True, older anaesthesiologists’ daily activity includes fewer on-calls and, often, fewer working hours and technical manoeuvres, since many of the manual procedures are done by younger colleagues. But Gialcalone’s paper implies that, in spite of the fact that ‘aging process may not necessarily go hand-in-hand with predictable patterns of decreased competence’, there is a need to check the impact of old age on the clinician’s abilities to face the daily demands of their profession. So, it becomes clear that age has a real and objective impact on older anaesthesiologists’ ability to cope with situations in which skills, but also clinical judgment, are impaired and this situation might negatively influence their daily activity.
Baxter et al.4 reported that in older anaesthesiologists manual dexterity and visual acuity are reduced, while physical and mental health problems are common. Besides, he mentioned that Canadian anaesthesiologists older than 65 have a greater incidence of medicolegal actions against them than younger colleagues. If so, we are facing a situation in which many of our peers are still active after the ‘normal’ retirement age, but their abilities to fulfil their usual professional obligations could be affected by the physiological and mental changes produced by the process of aging.
The results might be hard to accept, especially when one takes into consideration the patient’s well-being and safety.
In my opinion there is only one solution, the use of simulation, in order to achieve two aims: to assess the professional abilities of each of those who are still active after a certain age, but also to use the simulation tools for improving the older anaesthesiologist’s clinical performance.
Usually, simulation is used for education of young professionals and also for testing their professional competence. As per our knowledge, practical re-training of aging professionals has not been included in the description of measures to be taken regarding anaesthesiologists in the late period in their career.
But it seems to be evident that the average aging anaesthesiologist needs to be re-assessed and eventually re-trained, at least from the manual abilities point of view. This is more obvious when one thinks of the emergency situations, which might be a real challenge for the anaesthesiologist, even for the younger one.4
Initially, simulation was used in anaesthesia for training but also for assessing competence, without the risk of involving real patients.5,6 Soon, it proved to be very useful in the process of training young physicians, especially in those disciplines that demand a high manual ability, anaesthesiology among them. As a consequence, simulation centres showed up in the medical education field like mushrooms after rain. In many countries each medical school developed such a centre, and students and young residents became involved in the process. The results presented by Savoldelli et al.7 some years ago did not come as a surprise: the need and interest in simulation was much more evident among anaesthesia residents (96%) than among staff members (58%).
These results clearly indicated that enlarging the aim of simulation, from education of young physicians to older staff, might encounter barriers and obstacles. Most of them are of a psychological nature. Older physicians have the feeling that they possess all the necessary tools, intellectual and practical, to cover any specific problem related to patient care, and any question regarding their competence level could be understood as affecting their professional ego and status.
But simulation could be the answer to the question related to any single older anaesthesiologist who decided to continue and practice their specialty, close to or above the retirement age. First of all, it can be an objective tool in assessing the level of clinical judgment (based on both experience and knowledge) but also of the manual skills necessary for covering the requirements of the daily activity. But, at the same time, it can improve the older physician’s performance in relation to their patient, in an identical manner as in the case of young physicians at the beginning of their careers.
What can be done in order to make this possible? First of all, there is a need for a campaign of convincing both older physicians and their employers of the importance of simulation in the process of assessing and improving the quality of work. This concept has to be understood as a help, with the scope of offering the practitioner a chance to go on with their activity in the following years, and thus overcoming the inherent limits imposed by the process of aging. The participation in such a project could also offer a successful defence in the face of the increasing number of medicolegal complaints against anaesthesiologists all over the world. It would be much easier to justify a clinical decision or to explain a complication related to a manual procedure, when the involved anaesthesiologist has recently passed a series of tests through simulation and proved to be competent, intellectually and manually, at the same time.
In other words, the process of simulation has to be described as a help to the older anaesthesiologist, and not as a way to question their competence and remove them from the clinical practice.
But all of the above needs a serious infrastructure. The already existing simulation centres are supposed to enlarge their activities and include older practitioners, ready to test their clinical aptitudes. The simulation process is not to be restricted to manual procedures, but it must include case scenarios in elective and emergency situations, which would give the clinician a chance to discover those points in their practice that need to be improved. In some countries this is called ‘re-certification’, but in my opinion the proposed system has to be based on voluntary acceptance.
There is no question that the proposed system implies an important role for the hospitals and anaesthesia departments. It has no chance of success without full cooperation of the employers’ and departments’ leadership. It also needs funding, which can be partially covered by the clinicians themselves who would have, for a decent sum, full access to everything a simulation centre could offer from the assessment and education point of view.
Aristotle’s use of the word ‘provision’ could be interpreted as providing the knowledge and skills in an age which, even in the best cases, negatively affects the clinician’s ability to face the requirements of routine patient management. The success should be the result of full cooperation between all the factors involved in the process of education and re-education.
The European Society of Anaesthesiologists (ESA) has an important role in this process. An open discussion during the various scientific events organized by ESA could bring the item to the attention of older colleagues and convince them of the importance of taking part in the project.
ESA’s (and National Anaesthesiologists Societies Committee – NASC’s) positive attitude towards this project could influence national organizations to take the necessary steps for providing the necessary infrastructure and also for convincing older members to take part in it.
In the end, I would like to remind our readers of the old adage: If we will not do it, others would do it for us, and I have no doubt that this is not what we want.
- Gialcalone M et al. Eur J Anaesth2016;33:787.
- Federation of State Medical Boards Census on Physicians, 2016.
- Horovitz PK et al. Isr J Health Policy Res2017;6:31.
- Artyomenko VV, Nosenko VM. Rom J Anaesth Intensive Care2017;24:37.
- Cooper JB, Taqueti VR. Qual Safe Health Care2004;13 (suppl 1);i11-18.
- Tetzlaff JE. Anesthesiology2007;106:812.
- Savodelli GL et al. Can J Anaesth2005;52:944.