Old Surgeons Not a Problem

Robert Blanchard

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When you need complex cardiovascular or cancer surgery, you have to choose a surgeon and many patients may select an older physician, assuming his experience may be needed. New research says they are right - experience helps. A study designed to address this issue used approximately 461,000 Medicare records to assess the association between age of the listed operator and surgical mortality. For some operations, such as pancreatectomy, coronary artery surgery, and carotid endarterectomy, surgeons aged 60 or older had higher mortality rates than younger surgeons. However, for other equally complex operations, such as esophagectomy, effects of the age of the surgeon were not observed. Surgical volume must also be taken into account when considering the impact of the age of the surgeon.
The conclusion of the study is that the age of the surgeon is not a major factor to surgical complications. It is unusual that an age effect was observed for a few difficult procedures but not for others of equal complexity. However, if you have to chooose a surgeon, the conclusions are reassuring: The results after surgery performed by an older surgeon are comparable to outcomes of similar procedures performed by a younger surgeon.

But, older surgeons - those over age 60 - who do not maintain a high surgical volume as they age are more likely to have high patient mortality rate than younger surgeons.
The researchers at the University of Michigan Health System say patients should be less concerned about the age of their surgeon and more focused on other factors that really count - like surgical volume.
These findings, published in the September issue of the Annals of Surgery, reveal that for some complex cardiovascular and cancer surgical procedures, older surgeons who continued to maintain higher surgical case loads were found to have comparable outcomes to peers ages 41 to 50.
The study also dispels the belief that younger, less experienced surgeons are more likely to have poor surgical outcomes. Instead, the researchers say young surgeons, ages 40 and under, had similar patient mortality rates to those of their more experienced peers for the eight surgical procedures studied.
"This study's results should be very encouraging not only for patients, but also for younger and older surgeons whose operative skills may previously have been the subject of scrutiny," says lead author Jennifer F. Waljee, M.D., M.P.H., general surgery resident in the Department of Surgery at the U-M Medical School.
"The bottom line is that for most procedures the age of the surgeon is not an important predictor of operative risk for a patient. The effect of surgeon age was largely limited to those surgeons with lower procedure volumes."
Previous studies that focused on primary care have suggested an inverse relationship between a surgeon's age and his or her clinical performance. They've found that older physicians are less likely to know about new treatments and medications, and tend to perform poorly on recertification exams.
Based on these recent studies, Waljee and her colleagues wondered if some of the common mental and physical affects of aging might affect older surgeons' performance in the operating room, as well.
Using data from the National Medicare Inpatient Files, the team reviewed eight major cardiovascular procedures and cancer surgical resections that were performed from 1998 to 1999 on patients between the ages 65 to 99.
For the study, surgeons were placed into three age groups: 40 years and younger, ages 41-50, and 60 years and older.
A total of 460,738 Medicare patients who underwent one of the eight surgical procedures - coronary artery bypass grafting; elective abdominal aortic aneurysm repair, aortic valve replacement, carotid endarterectomy, pancreatectomy, esophagectomy, lung resection and cystectomy - were used for this study. These procedures were chosen because they are some of the more commonly-performed procedures among Medicare patients, says Waljee.
Patient operative mortality - death before discharge or within 30 days of surgery - was reviewed for each patient. Additionally, factors such as surgeon procedure volume, hospital surgery volume and the hospital's teaching status were evaluated.
Overall, surgeons over age 60 were found to have higher patient mortality rates when compared against the rates of surgeons ages 41-50, for three of the eight procedures: pancreatectomy, coronary artery bypass grafting, and carotid endarterectomy. Surgeon age was not related to mortality for elective abdominal aortic aneurysm repair, aortic valve replacement, exophagectomy, lung resection or cystectomy.
More surprising to researchers, however, was that the younger surgeons - those under age 40 - had comparable mortality to surgeons between the ages of 41 and 50, for all eight procedures.
"We expected to see a significant difference in patient mortality at the extremes of surgeon age, but instead found very little variation among younger and older surgeons," says Waljee, a Robert Wood Johnson Clinical Scholar. "Based on these finding, we'd encourage patients not to focus on age when selecting a surgeon. Instead, other characteristics of the provider and practice setting, such as operative volume, are likely better predictors of patient outcome than surgeon age."
Waljee hopes to further explore this topic through future research to determine if specific mechanisms of aging (physical and mental stamina, vision and motor skills) affect low-volume surgeons' performance in the OR.