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/
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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
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https://pubmed.ncbi.nlm.nih.gov/31034982/
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https://www.journalacs.org/article/S1072-7515(11)00523-2/fulltext
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https://jamanetwork.com/journals/jamasurgery/fullarticle/2645308
