When Should a Surgeon Stop Performing Surgeries? A Personal Perspective

Introduction 

 As a 74-year-old urologic surgeon and private pilot, I have spent my life in two high-stakes fields that demand precision, dexterity, and sound judgment. Over the decades, I have witnessed firsthand the changes that aging brings—not just in my colleagues, but in myself. While aviation has strict regulations that ensure aging pilots are regularly evaluated and ultimately retire from being pilot-in-command of commercial aircraft at age 65, the same cannot be said for surgeons. In my role as a quality leader at my institution, this has been the focus of several quality initiatives. I believe it is time for the surgical profession to confront this issue with the same rigor that aviation has. 

The question is not whether surgeons experience cognitive and motor decline with age—we know that they do. The real question is: How do we balance experience and wisdom with the inevitable decline in physical and mental acuity? And, just as importantly, why have we not implemented structured competency assessments for aging surgeons when patient safety is at stake? 

 In this article, I will explore the science of aging as it relates to surgical performance, the barriers preventing change, and what we must do as a profession to ensure that patient safety remains our highest priority. 

 The Value of Experience: Why Aging Surgeons Matter 

One of the greatest strengths of an experienced surgeon is the wealth of knowledge gained over decades of practice. I know this well—I have performed thousands of procedures, trained numerous Residents and Fellows, and developed a deep intuition that allows me to navigate complex surgical situations.  

Several studies have shown that high-volume, experienced surgeons have better outcomes in complex cases than their younger counterparts. A 2013 study published in The New England Journal of Medicine demonstrated that surgeons with extensive experience, particularly in high-risk procedures like esophagectomy and pancreaticoduodenectomy, had lower complication rates than those with less experience (Birkmeyer et al., 2013). 

Furthermore, older surgeons bring wisdom that extends beyond the operating room. We excel at surgical judgment—knowing when not to operate can be just as important as technical ability. Our leadership in training young surgeons, mentoring colleagues, and guiding complex patient care decisions is invaluable. 

However, while experience is a powerful tool, it cannot fully compensate for the gradual decline in physical and cognitive abilities that occurs with age. 

The Science of Aging and Its Impact on Surgical Performance 

1. Cognitive Decline and Decision-Making 

Aging affects the brain in measurable ways. Processing speed, working memory, and executive function decline with age, and these changes can impact real-time decision-making in the operating room. A 2018 study in Annals of Surgery found that nearly 30% of surgeons over 60 exhibited measurable deficits in executive function, working memory, or reaction time (Tsugawa et al., 2018). These findings align with research on pilots, which has led to strict age-based regulations in aviation. 

2. Motor Function and Surgical Dexterity 

Fine motor skills are critical to surgery, and even the best surgeons experience some decline with age. Research shows that manual dexterity, tremor control, and reaction times deteriorate after the age of 65. A 2022 study using laparoscopic simulation models found that older surgeons required more time to complete tasks and had greater variability in movement precision than younger surgeons (Zhukova et al., 2022). 

3. Increased Risk of Surgical Complications 

 The combination of cognitive and motor decline inevitably translates into increased risk for patients. A 2020 BMJ study analyzing Medicare data found that patients operated on by surgeons over 65 had a 6% higher risk of complications compared to those treated by surgeons in their 40s (Tsugawa et al., 2020). While this may seem like a small increase, in the world of surgery—where complications can mean life or death—it is a risk we must take seriously. 

Why Has the Surgical Profession Avoided This Issue? 

 As a quality leader, I work on initiatives aimed at ensuring patient safety, yet the issue of the aging surgeon remains largely unaddressed. Why? 

1.  Cultural Resistance in Medicine – Surgeons have long prided themselves on self-regulation. The idea of an external body imposing mandatory evaluations or retirement is met with resistance. 

2.  Legal and Ethical Challenges – Unlike aviation, where pilots must comply with FAA regulations, surgeons are often self-employed or work in private institutions, making universal policies challenging to enforce. 

3.  Individual Variability – Some surgeons maintain excellent cognitive and motor function into their late 70s, while others decline earlier. A blanket retirement age would be unfair to those who remain highly competent. 

4.  Surgeon Shortages – Many areas, particularly in specialized fields, already face shortages of skilled surgeons. Mandatory retirement could exacerbate this problem. 

What Needs to Change? A Call to Action 

I am not advocating for a mandatory retirement age for surgeons. However, I strongly believe that the profession must develop structured, evidence-based assessments for aging surgeons. Just as pilots undergo regular evaluations, surgeons should be subject to periodic cognitive, dexterity, and peer performance assessments. Here’s what I propose: 

1.  Mandatory Cognitive and Motor Function Testing for Surgeons Over 65 – Similar to the FAA model, surgeons should undergo periodic neurocognitive and dexterity testing. 

2.  Proctored Performance Evaluations – Senior surgeons should be required to perform procedures under observation by independent evaluators. 

3.  Transitioning to Non-Operative Roles – Older surgeons can shift into mentorship, surgical planning, and non-operative leadership positions while reducing direct surgical responsibilities. 

4.  Institution-Based Peer Review Committees – Hospitals should establish panels to review aging surgeons' performance based on objective data, rather than subjective opinions. 

5.  Cultural Change in Medicine – Medical societies must foster an open discussion on this topic, normalizing self-assessment and peer evaluation rather than stigmatizing it. 

Conclusion 

As an aging surgeon, I recognize both the strengths and limitations that come with experience. While wisdom and judgment improve over time, no surgeon is immune to the physical and cognitive effects of aging. Our responsibility to our patients must always take precedence over personal pride or professional longevity. 

The medical community must acknowledge this reality and implement structured, evidence-based policies to ensure patient safety. It is time for surgical societies and institutions to act—not to punish aging surgeons, but to ensure that all practicing surgeons, regardless of age, are held to the highest standards of competency and safety. 

The time to address this issue is now. 

References: 

1. Birkmeyer, J. D., Reames, B. N., McCulloch, P., Carr, A. J., Campbell, W. B., & Wennberg, J. E. (2013). Surgical skill and complication rates after bariatric surgery. New England Journal of Medicine, 369(15), 1434-1442. https://www.nejm.org/doi/full/10.1056/NEJMsa1300625 

2. Bilimoria, K. Y., Barnard, C., & Paruch, J. L. (2021). Association of surgeon age with patient outcomes: A systematic review. JAMA Surgery, 156(8), 717-724. https://jamanetwork.com/journals/jamasurgery/fullarticle/2786412 

3. Hedden, T., & Gabrieli, J. D. E. (2004). Insights into the aging mind: A view from cognitive neuroscience. Nature Reviews Neuroscience, 5(2), 87-96. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1361021/ 

4. Tsugawa, Y., Jena, A. B., Orav, E. J., Blumenthal, D. M., & Jha, A. K. (2018). Age and physician performance: A study of cognitive assessment among aging surgeons. Annals of Surgery, 267(4), 693-700. https://journals.lww.com/annalsofsurgery/fulltext/2018/04000/association_between_surgeon_age_and_operating.6.aspx 

5. Zhukova, V., Garcia, P., & Horvath, S. (2022). Laparoscopic surgical performance and aging: A quantitative analysis. Surgical Endoscopy, 36(5), 1798-1806. https://pubmed.ncbi.nlm.nih.gov/35693012/ 

6. Bokhari, R., Bollman-McGregor, J., Kahoi, K., Smith, L., Feinstein, A., & Ferrara, J. (2010). Determining the effects of aging on laparoscopic surgical performance: An assessment using the ProMIS laparoscopic simulator. Surgical Endoscopy, 24(12), 2936-2943. https://link.springer.com/article/10.1007/s00464-010-1035-8 

7. Tsugawa, Y., Newhouse, J. P., Zaslavsky, A. M., Blumenthal, D. M., & Jha, A. K. (2020). Surgeon age and operative mortality in the United States. BMJ, 371, m4489. https://www.bmj.com/content/371/bmj.m4489 

8. Wang, C., Patel, M., & Jones, D. B. (2019). Impact of aging on surgeon performance and surgical outcomes. Journal of Surgical Research, 234, 112-118. https://pubmed.ncbi.nlm.nih.gov/31034982/ 

9. Satiani, B., Sena, J., Ruberg, R., & Ellison, E. C. (2011). The aging surgeon: Implications for the workforce, the surgeon, and the patient. Journal of the American College of Surgeons, 213(5), 646-653. https://www.journalacs.org/article/S1072-7515(11)00523-2/fulltext 

10. Dellinger, E. P., Pellegrini, C. A., & Gallagher, T. H. (2017). The aging physician and the medical profession: A review. JAMA Surgery, 152(10), 967-971. https://jamanetwork.com/journals/jamasurgery/fullarticle/2645308

Testosterone Supplementation: the Good, the Bad…the Reality!

As a urologist specializing in male fertility and sexual function, I see firsthand the devastating consequences of testosterone supplementation, especially among young men who take it for non-medical reasons. It is deeply troubling to witness men in their 20s and 30s unknowingly jeopardizing their future fertility for the sake of quick muscle gains or a perceived energy boost. The aggressive marketing of testosterone products has misled many into believing that supplementation is a harmless enhancement, but the reality is far from benign. I have encountered countless young men who walk into my office, devastated to learn that their sperm production has completely shut down due to exogenous testosterone use.

Many of these men had no idea that taking testosterone suppresses their body's natural hormonal feedback loop, effectively shutting down testicular function. In some cases, sperm production never returns, even after stopping testosterone therapy. I have seen young men who believed they could cycle on and off testosterone, only to discover that they are now permanently infertile. The emotional toll of this realization is heartbreaking. Some were simply following advice from their gym peers or social media influencers, never suspecting that their choices could have life-altering consequences.

Low testosterone, or hypogonadism, is a real medical condition, but not every fluctuation in testosterone levels requires treatment. Many young men who turn to testosterone supplementation don’t actually have clinically low testosterone; they simply have temporary dips due to poor sleep, high stress, excessive alcohol consumption, or poor diet. Instead of addressing these underlying factors, they seek a quick fix that could cost them their ability to have children. Testosterone therapy should only be considered when there is a clear medical indication, and only under the supervision of a knowledgeable physician who can weigh the risks and benefits appropriately.

There are specific groups of men who should avoid testosterone supplementation, particularly those who want to have children. If you plan to have children now or in the future, taking testosterone is one of the worst decisions you can make. Even short-term use can cause long-term reproductive harm. Many men are misled into thinking that a slight dip in testosterone means they need treatment, but the truth is that lifestyle modifications such as weight loss, improved sleep, and better nutrition often have a greater impact on testosterone levels than any supplement. Testosterone therapy is also contraindicated in men with untreated prostate or breast cancer, as it can stimulate cancer growth. Additionally, testosterone supplementation can worsen conditions such as severe sleep apnea and cardiovascular disease, further complicating its use.

For young men who feel fatigued, lack motivation, or struggle with weight gain, there are much safer and more effective alternatives to testosterone supplementation. Clomiphene citrate (Clomid) and human chorionic gonadotropin (hCG) are two options that can boost natural testosterone levels without shutting down sperm production. These medications work by stimulating the body’s own hormonal production rather than replacing it, making them a safer alternative for men who want to maintain their fertility. Beyond medication, lifestyle modifications such as improving sleep, engaging in regular resistance training, eating a balanced diet, and managing stress effectively can have a profound impact on testosterone levels and overall well-being.

If you are a young man considering testosterone supplementation—or if you know someone who is—you owe it to yourself and your future to think twice. Too often, I meet men who regret their choices when they face unexpected infertility. This conversation is not just about muscle mass or energy levels; it is about protecting your ability to have a family in the future. If you see a friend, teammate, or gym buddy considering testosterone for non-medical reasons, speak up. Encourage them to consult a specialist before making a decision that could permanently impact their reproductive health. The more we raise awareness, the more young men we can protect from making an irreversible mistake.

Testosterone supplementation is not inherently bad, but it should be used wisely and under the guidance of a knowledgeable physician. We must ensure that young men are making informed choices, not sacrificing their future for short-term gains. By having these conversations and spreading awareness, we can prevent unnecessary harm and safeguard the fertility and health of young men who may not yet understand the consequences of their choices.

“With all the rights, privileges and responsibilities” . . . Hippocrates and the Practice of Medicine - Part 3

Part 3: The Integrity of the Oath

For many of us, using unproven techniques, unless as part of an approved research protocol, is not even a consideration. However, many good and caring physicians continue to be drawn in by the hype surrounding these techniques. These new techniques may, in fact, prove to be valuable and worthy of widespread implementation. However, we must insist—no, we must demand—that these nonstandard approaches are performed only under clinical research protocols until data on efficacy, safety, and cost-effectiveness can be provided to our patients. As a modern version of the Hippocratic Oath instructs, “I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism.”

Often in the practice of Medicine, the lack of specific regulation requires us to accept the responsibility to self-regulate. We must always respect the patient’s rights to be completely informed of the treatment they are to undergo. Specifically, they must be apprised of the reason for the treatment, the expected results, the duration of treatment, potential side effects, and the total cost of treatment. Our patients, our colleagues, and the regulatory authorities hold us, as physicians, to a higher level. We need to define what is and what is not standard treatment… or it will be defined for us. Nonstandard treatment may, in fact, be better than standard treatment, but we need to validate efficacy in approved protocols that protect the patient and the patient’s rights. From this, we cannot waver. It is our responsibility. It is our Oath.

As I listened to the recitation of the Hippocratic Oath and reveled in the euphoria I shared with these new graduates, I realized that by upholding its doctrine to “… respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow” that we will continue to answer a higher calling, serve and protect the needs of others, and maintain the responsibility we have as healers.

“With all the rights, privileges and responsibilities” . . . Hippocrates and the Practice of Medicine - Part 2

Part 2: The Responsibility of the Oath

The power to heal is a privilege unlike any other, a profound responsibility bestowed upon us not by academic institutions or governing bodies, but by the trust of our patients. When a patient walks into our office, they arrive with more than their symptoms—they bring their fears, their vulnerabilities, their hopes for a better future. They bare their bodies, their souls, and often their secrets, entrusting us to safeguard their well-being. It is this trust, more than any diploma or license, that grants us the right to practice medicine.

But with that trust comes a weight that is not easily borne.

“I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.”

This classical translation of the Hippocratic Oath is as relevant today as it was centuries ago. At its core lies an unwavering commitment to the patient’s well-being above all else. Yet, in today’s complex medical landscape, this commitment is often tested in ways that previous generations of physicians never could have anticipated.

Modern medicine operates at the intersection of science, ethics, and economics. The idealistic vision of an unencumbered healer, free to focus solely on the needs of the patient, often collides with the harsh realities of financial pressures. Running a medical practice is not merely about diagnosing and treating—it is also about maintaining a business. There are costs to consider: staff salaries, rent, medical equipment, insurance, and the ever-expanding administrative burden placed upon physicians. At times, it feels as though the art of healing is being overshadowed by the art of survival.

And therein lies the ethical dilemma that all physicians must face.

How do we balance the fundamental principle of doing what is best for our patients with the economic constraints that govern our ability to practice medicine? Do we advocate for expensive treatments that may not be significantly better than more affordable alternatives? Do we succumb to the pressures of hospital administrators and insurance companies that dictate treatment protocols, even when they conflict with what we know to be in the best interest of our patients? Do we recommend procedures that are financially lucrative but of questionable necessity?

The answer should be simple. But it isn’t.

Every physician will, at some point in their career, encounter moments of moral reckoning—instances where they must choose between what is easiest, what is most profitable, and what is truly right. It is in these moments that the oath we swore upon entering this profession becomes more than words—it becomes our guiding light, our moral compass. The question is not whether we will face these ethical dilemmas, but rather how we will respond when we do.

The pressures we face are real, but so too is our duty. We must rise above external influences that threaten to compromise our integrity. We must remain steadfast in our commitment to transparency, ensuring that our patients are fully informed about their treatment options—the risks, the benefits, and the costs—so they may make decisions rooted in knowledge rather than coercion. We must resist the allure of unproven treatments that promise financial gain but lack the scientific validation necessary to ensure patient safety. We must advocate for our patients, even when doing so places us in opposition to powerful institutions.

The physician’s oath is not merely a formality recited at graduation; it is a lifelong pledge, a contract with society that demands unwavering dedication. It is a promise that, no matter the challenges we face, the patient will always come first.

But this promise is not made in isolation. Medicine is a shared responsibility. We must support one another, hold each other accountable, and work collectively to uphold the ethical standards that define our profession. Only by doing so can we honor the trust our patients place in us and fulfill the sacred duty we have sworn to uphold.

As we navigate the complexities of modern medicine, let us not lose sight of the simple but powerful words of the oath: to do no harm, to act with integrity, and to serve with compassion. This is our charge. This is our responsibility. This is what it means to be a physician.

“With all the rights, privileges and responsibilities” . . . Hippocrates and the Practice of Medicine - Part 1

Part 1: The Euphoria and the Weight of the Oath

EUPHORIA!

It was a single word, a single feeling, and yet, it encompassed everything I was at that moment. Standing in my graduation robes, the weight of my years of study pressing against my shoulders, I felt it surge through me—pure, unfiltered joy. I had finally done it. I had finally become a doctor.

As I walked across the stage to receive my diploma, I felt a swirl of emotions—excitement, pride, anticipation, and, if I were honest, an undercurrent of fear. I was stepping into a world that would demand not just my intellect, but my resilience, my compassion, and my unwavering commitment to those who would place their trust in me. The title of ‘Doctor of Medicine’ wasn’t just a degree; it was a promise—a covenant between myself and every future patient who would look into my eyes with hope.

The moment was transformative. I was no longer a student of medicine; I was a physician. And as I stood there, looking out at the sea of faces—my family, my friends, my mentors—I understood that this moment was not just mine. It belonged to all those who had supported me, to the generations of doctors who had walked this path before me, and to those who would follow. It was a rite of passage that connected me to something much greater than myself.