ARE OLDER ANESTHESIOLOGISTS LESS SAFE? ARE INEXPERIENCED ANESTHESIOLOGISTS LESS SAFE?

 

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You’re boarding a commercial aircraft. It’s raining hard outside, and visibility is limited. You catch a glimpse of the pilots in the cockpit. To your relief, both of them are gray-haired. You’re nervous, and you don’t want a young and inexperienced pilot.

How do you feel when you meet your anesthesia provider prior to a surgical procedure? Do you want a young and inexperienced anesthesiologist? Do you want a geriatric anesthesiologist only months from retirement? Is there any data to help answer these questions? This topic was reviewed in a recent issue of Anesthesiology News (December 2015, Volume 41:12).

In an abstract presented at the 2015 American Society of Anesthesiologists annual meeting, data from the 2014 National Anesthesia Clinical Outcomes Registry was compiled for every anesthesiologist of known age who performed at least 100 cases. (Chen LC, et al, Abstract A1012). The anesthesiologists were divided into three age groups: less than 45 years (36%), 45 – 54 years (31.5%) and 55 years and older (32.4%). There were nearly 4 million cases from 5,334 providers. The overall mortality rate was 3.6 per 10,000 cases.

There was no mortality difference related to the anesthesia provider’s age. Higher ASA physical status (i.e. sicker patients) was associated with poorer outcomes. ASA Physical status 4 and 5 patients were more likely to die compared to ASA status 1 – 3 patients.

The study also examined practice patterns, and significant differences were discovered. Older anesthesiologists were:

  1. More likely to perform anesthetics under monitored anesthesia care, and less likely to perform regional, spinal, or epidural anesthesia.
  2. Less likely to work evenings, weekends and holidays.
  3. More likely to work part-time, and with a nurse anesthetist care-team delivery system.
  4. More likely to do outpatient cases and nonsurgical obstetrical/gynecology cases.
  5. More likely to perform shorter surgical cases and be involved in simpler surgeries with lower base units.

Major complications occurred at a rate of 18.4 per 10,000 cases. The middle-aged group (provider ages between 45 and 54) had more major complications compared with older anesthesiologists. The authors believed that elevated ASA physical status played a part in this statistic, because the middle-aged anesthesiologists took care of sicker patients. The middle-aged anesthesiologists were also more likely to care for inpatients under general anesthesia for longer cases, and these longer cases resulted in more major complications.

In a separate study on the topic of aging anesthesiologists in Canada, a survey found 7% of Canadian anesthesiologists were aged 65-74 years, and 3% were older than 74 years old. Anesthesiologists older than 65 years in the provinces of Ontario, Quebec, and British Columbia had 50% more cases involving litigation and almost twice the number of cases involving severe patient injury, compared with anesthesiologists younger than 51 years of age. The authors of this paper proposed regulations to include: no further on-call duties for those aged 60 and older, no further high-acuity cases for those aged 65 and older, and retirement from operating room clinical practice at age 70. (Baxter AD, The aging anesthesiologist: a narrative review and suggested strategies. Can J Anaesth. 2014 Sep;61(9):865-75.)

A 2006 United States survey of physicians aged 50-79 years showed that the work week of anesthesiologists decreased with advancing age, and part-time work increased. (Orkin FK, et al. United States anesthesiologists over 50: retirement decision making and workforce implications. Anesthesiology 2012 Nov;117(5):953-63.)

I’m currently in the higher of the three age groups (age 55 years and older). In my years as an anesthesiologist, I’ve watched colleagues of my generation change their clinical workload in a pattern consistent with the data presented above. As anesthesiologists age, most of us do not desire to be working at 3 a.m. resuscitating trauma patients, or doing anesthesia for 24-hour liver transplantation cases. These are surgeries for younger anesthesiologists. The overwhelming majority of aging anesthesiologists migrate toward administrative roles, daytime work, patients who are less sick, and simpler surgeries that minimally alter a patient’s physiology.

In the United States the mandatory retirement age is 65 for commercial pilots. There are no rules or regulations that prohibit an anesthesiologist from working at any particular advanced age. Could an 80-year-old anesthesiologist give you a safe anesthetic? It depends. If the 80-year-old has a valid medical license, a valid certificate from the DEA (Drug Enforcement Agency), and medical staff privileges at the facility your surgery is scheduled for, then he or she could work there. You can expect the 80-year-old will fare much better on simple outpatient anesthetics, and will never be doing open heart surgery or brain surgery anesthetics.

The hospital I work in at Stanford University confronted this issue in 2012 by enacting a Late Career Practitioner Policy. Physicians aged 75 and older are required to undergo a physical examination, cognitive screening, and a peer assessment of their clinical performance. These evaluations must be completed every two years to retain hospital privileges. Stanford is one of very few academic medical centers to require this scrutiny regarding older practitioners, and the policy met significant resistance from medical staff members prior to the policy being passed and enacted.

It is my impression, based on my clinical career, my peer review work, and my expert witness work on medical malpractice cases, that newly trained and inexperienced anesthesiologists present an increased risk for patient complications and poor outcomes. During anesthesia residency there is always a faculty member nearby to save an inexperienced anesthesiologist when he or she gets into a clinical problem. After that inexperienced anesthesiologist graduates and transitions into a community clinical practice, they may have to care for a sick patient at 3 a.m. as the solo on-call anesthetist, or they may have to manage an emergency airway disaster by themselves. Will they think clearly under pressure and make correct decisions to prevent their patients from dying? Every new graduate has these fears regarding their transition to post-residency practice. There’s nothing like having a couple of years of practice experience and 1500 solo cases under your belt to make you a safer anesthesiologist.

Expect to see further research on the topic of an anesthesiologist’s age in the years to come. Older physicians have a wealth of experience, but may have geriatric limitations on their ability to safely care for patients. Younger anesthesiologists have limited experience, and may be at increased risk for complications and mortality. Further Big Data from the National Anesthesia Clinical Outcomes Registry will help answer these questions in the future. As of now, there is no convincing data that practitioners at either extreme of age present a risk factor.

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Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

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LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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