|Staying safe while working longer|
|Monday, 11 March 2013|
With surgeons in the NHS facing the prospect of working in acute specialties until 68, Elaine Griffiths reviews the implications of aging and stress on surgical skills
Safe surgical practise is a complex combination of technical and non-technical skills. Although fine motor skills and technical skills are essential, skills such as judgment; problem-solving; emergency response skills and decision making are central components of surgical expertise and are important factors in determining operative success.1,2
Currently, many surgeons retire either at or before they reach 65 but, with the Government changes to both pensions and the retirement age, in future many surgeons will be forced to work on until they are 68. This may pose a very serious problem, putting both surgical outcomes and surgical careers at considerable risk.
Aging affects both technical and non-technical skills, so the planned increase in retirement age for the medical workforce may have unintended adverse consequences for surgical outcomes. This paper examines the inherent problems surgeons can have which worsen with age and the direct impact of aging on surgical skills.
Manual tremor affects speed and accuracy, and is exacerbated by physical factors such as tiredness, psychological factors, drugs, and disease, but it also increases significantly with age. All surgeons feel the effects of fatigue, but older surgeons have less reserve.3,4 Reaction time increases with age, slowly until 60 years of age then more rapidly after 70. This age effect is more marked for complex reaction time tasks.5,6 This aging effect is exacerbated by deteriorating visual or auditory cues and joint related disease such as arthritis.5 Finally, stress effects cognitive processes involving memory, recall of knowledge, and attention.7,8,9
Wear and tear
Open surgical procedures often require standing in awkward positions and the occasional need to exert substantial forces on tissues. Industrial ergonomics show that static, as well as dynamic, postural stress can lead to fatigue and disability.11-14 Surgical Morbidity Syndromes, including the overuse syndrome, have been documented in open surgery but minimally invasive surgery has taken a major toll on the physical well-being of surgeons. Laparoscopic instruments in particular suffer from ergonomically inadequate handle designs and inefficient handle-to-tip force transmission, leading to surgeon fatigue, discomfort, and hand paraesthesiae.
Neck pain has been, and continues to be, a constant affliction for surgeons.15 Bagrodia found 43% of urologists who responded to his survey reported chronic neck and/or back pain.12 Park reported on 272 laparoscopic surgeons, 86.9% of whom reported physical symptoms or discomfort. This percentage was previously thought to be around 20-30%.16 Thoracic outlet syndrome, over developed muscles near the shoulders, compressing nerves and resulting in numbness of the hands and fingers is also well-recognised in surgeons.16 A recent study of orthopaedic spinal surgeons found the most common self-reported diagnoses included neck pain/strain/spasm (38%), lumbar disc herniation/radiculopathy (31%), and cervical disc herniation/ radiculopathy (28%).17 They concluded that their cohort underwent surgical intervention for lumbar (7.1%) and cervical (4.6%) disc disease at rates far exceeding disease estimates in the general population.
There are other common problems, such as rotator cuff disease (24%), varicose veins or peripheral oedema (20%), and lateral epicondylitis (18%).17
Visual acuity is subject to several age-related changes. Genetic factors appear to be strong determinants of sharp visual acuity and colour discrimination so not everyone will experience the same level of symptoms. However, we all recognise the problems of presbyopia as we age. Rod photoreceptors, specialising in vision at low light levels, are selectively vulnerable during the aging process so in older people lighting with higher intensity is required to maintain visual acuity. Other effects include a loss in colour discrimination, changes within the lens and reductions in the temporal resolving capacity of the visual system. Visual attention skills, including divided attention and selective attention, are also impaired in many older adults even when other cognitive skills are intact.
Mental capacity also reduces with age.18 Aging is associated with a reduction in the number of nerve cells in the brain; decreased blood flow (by an average of 20%) and a decline in the rate of processing information.
It has been shown19 that the age-related decline of three cognitive functions (working memory, visual attention, and planning) can impact adversely on laparoscopic surgery. However, the potential consequences of a decline in reaction times and slower problem solving capabilities affects all types of surgery, particularly specialties which require magnification.
From the start of a surgical career, a surgeon will be at risk from the impact of stress, environmental factors and aging. The critical factor may be physical or mental, or both, but a decline in surgical skills is inevitable. It is a question of when, not whether. The point of onset and rate of decline will vary depending on inherited factors, the degree of control over work and working environment and the effort made to minimise the impact of adverse factors. However, the above research also shows that, to date, strategies for combating both wear and tear and aging are very limited. Even if all of them were implemented, many surgeons’ skills will have deteriorated to potentially significant levels before the time they are eligible to retire.
Even a brief review of the literature demonstrates clearly that many surgeons will face a decline in their surgical skills – through no fault of their own – to potentially significant levels before they reach the official retirement age. However, the impact of age-related problems will vary significantly depending on the surgeon, and possibly depending on the specialty. However, identifying surgeons whose competencies are declining will be difficult without a battery of complex tests, which would be expensive to administer, and only provide a snapshot of the surgeons’ current capability. Furthermore, his/her capability could change significantly within a short time.
The Equality Act 2010 ensures that people should not be discriminated against on the grounds of age. However, age restrictions have been applied to many careers for years. Military personnel, the fire sevice and the police have been expected to retire, not at the retirement age, but after a specific period of service, usually around 25-30 years. In the medical world, psychiatrists have been allowed to retire at 55 because of the stress they experience. In paediatric surgery, which over the years has received a significant amount of adverse publicity, some surgeons have voluntarily stopped operating on very young children in their mid-50s because they felt they were ‘slowing up’. That is fine if the surgeon does both paediatric and adult surgery and has a sympathetic employer, but what if he or she is a full-time paediatric surgeon in a paediatric hospital? One option is to allow some surgeons, possibly in specific specialties, to retire early after an agreed number of years in post.
Early retirement could be a waste of a great deal of expertise and many surgeons would wish to work on, not necessarily recognising that their skills are deteriorating. So the alternative is to use the expertise and talents of the aging surgeon without placing patients at risk. For example, concerns are being expressed about the reduced training times and reduced operative exposure of the current generation of young consultants. A second option could be for older surgeons to be used to mentor and aid younger colleagues in their decision-making processes. Other possibilities include, helping to train surgical trainees in simulated settings.
There is also the option of redeployment outside surgery. Surgeons could support Trust management by providing advice and oversight. They could also use their inside knowledge to advise commissioning consortia (poachers turned gamekeepers!).
The stresses and strains of a surgical career need to be recognised and strategies developed for surgeons to lead fulfilling but safe careers for their sakes and, more importantly, for that of their patients. As surgery evolves, more research is needed to find ways of mitigating the stresses and strains associated with surgical techniques to minimise wear and tear. However, aging is inevitable and will affect surgeons differently. Inevitably for some, their surgical skills will deteriorate to a point where it is no longer safe for them to operate on patients. This must be recognised and reflected in job plans so that surgeons who identify deterioration in their skills or performance can be offered an acceptable alternative career, and those who don’t can be identified and managed with dignity rather than with disgrace. Such a successful transition in surgical roles later in surgical careers will need to planned and adequately resourced.