E47 Surgical Companion 1 – The Aging Surgeon

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Chad Ball  00:14

We’d like to welcome you to a new program we’re trying out at Cold Steel. We call it the surgical “Companion” series because it’s meant to be a more conversational format that outlines and discusses current media events, and recent publications in a novel interesting manner. Our standing members of the companion are Ameer Farooq, Kelly Vogt, Morad Hameed and myself with guest to come and go depending on the show. We’d love to stimulate respectful and thoughtful conversation and initiatives. And we’re really looking forward to developing it with you. We’d like to welcome the listeners to the first episode of the surgical Companion on Cold Steel. Again, the goal of our of our podcast in the “Companion” series is to have a frank conversation amongst friends from across the country from different backgrounds about various topics that are in fact topical. Today we have Morad Hameed, Kelly Vogt, Ameer Farooq and myself. And we’d like to generate a discussion and have a have a chat surrounding a manuscript that was published in the CMAJ in April, volume 192, Issue 15, entitled the “Relation between surgeon age and postoperative outcomes: a population-based cohort study.” We thought we’d just very briefly in two or three minutes walk through this paper, and then open up for will hopefully be an interesting and informative discussion. So the goal of the the author’s and I will say up front that, you know, buried in the middle of this author list is two very heavy hitting folks, one being Barbara Bass, who could arguably be called, you know, the US’s his most well known female surgeon, and Allan Detsky, who has been an internist in Toronto for many decades and is responsible for the Detsky perioperative risk index. So certainly some heavy hitters. And really their goal was to evaluate the the effective surgeon age on postoperative outcomes and patients undergoing what they determined to be or what they defined as common surgical procedures. So they picked 25 procedures, they used Ontario as their denominator, they looked at those procedures between 2007 and 2015. And they did really that, honestly, the the typical statistical analysis that you would expect, I don’t think there’s too much to be gleaned from it. But they looked at just over 1.1 million patients who were treated by a variety of surgeons, in fact, 3314 surgeons rate the surgeons themselves, their age range on them was 27 to 81 years. And they did model it as a continuous variable. However, a lot of their conclusions, as you’ll probably hear in the discussion come with really, by modal analysis, so older than 65 years of age on the surgeon side, or younger than 65 years of age. At the end of the day, I think they certainly presented as a surprising finding. When they looked up the dichotomous over 65 under 65, they found that those that were over 65, in other words, patients that had been operated on a surgeon of that age, had a 7% lower odds of adverse outcomes in the postoperative period. The paper goes on to discuss a number of things in the interpretation and discussion component of it. And although the paper is is not very old, as I mentioned, it was in April of this year, more recently, at the end of September CMAJ essentially republished a synopsis of it in their research synopsis section. And as a result, it’s sort of fired up, certainly in the in the West, and I would assume across the country a fair bit of discussion. And, you know, I think my impression is that a lot of senior surgeons were very proud of, rightly or wrongly, the the initial results but when they published the the synopsis, there was an editorial comment that I think got certainly some of the surgeons, senior surgeons that I’ve talked to a little bit worked up and maybe we’ll get into that. But I you know, I was curious more at what, what you sort of thought and how you how you frame this paper in general.

Morad Hameed  04:47

Yeah, thanks, Chad. It’s a great paper and a great topic to bring up, especially considering the workforce issues that that we encounter and the discipline. I think the paper probably raises a lot of questions, perhaps more than it than it answers. It is intriguing in a counterintuitive result that surgeons over the age of 65 have have less complications in it. Maybe I could turn it back to you guys to ask like, could it be, could this paper be affected a lot by selection bias? By a patient population? And how would we account for those kinds of things in in the interpretation of the results? Like is it a conversation starter? Or is this actually evidence?

Kelly Vogt  05:36

I love that question, conversation starter or evidence. I think, you know, you go back to the concept that all observational studies in some way, shape or form are hypothesis generating, I think that this raises tremendously interesting questions, and I agree with you more than it does provide us answers. I think you hit the nail on the head with your comments about the struggle we have. This paper comes with a tremendous volume of data. And that’s the power of an administrative data source or linkage of administrative data sources at a population level. It would be next to impossible to do that without using administrative data, or at least tremendously expensive. But downside to that, though, is that you lose granularity at the patient level. And you lose granularity at the provider level even more so. At least using these types of databases. So there’s I when I read this paper, I was left with so many questions about who were the patients that they were operating on? And what who are these surgeons that continued to be operating well into, I think, I mean, they cut it off at 80. But there were, there were quite a few surgeons who are operating into their 70s. How are they different than the surgeons who weren’t operating into their 70s? Literally, there’s one of my big questions.

Chad Ball  06:59

Yeah, it’s so interesting. You know, the the other thing that was unclear to me, and maybe I missed it, despite a couple of read throughs. But, you know, the 25 procedures, it was an interesting selection to I mean, they had cardiothoracic surgery in there, didn’t have liver surgery, for example. So there was some some bigger, I would argue, maybe less common surgical procedures put in there as well. And then, of course, the dichotomy between emergency and elective cases. You know, we all know that doing a four day in terribly scarred 2 am gallbladder looks very different than, you know, the cost on pancreatitis, you know, three months out in the young, 20 year old gal. You’re right, you’ll lose a lot of granularity. But it’s it’s an interesting, interesting set of conclusions, isn’t it?

Ameer Farooq  07:48

There’s a huge selection bias here, that the actual number of patients that were operated on by those over 65 was only 6% of the total number of operations. So it actually represents a very small number of the total number of operations being done in Ontario. I mean, having said that, they did do, they did look at not just, you know, the dichotomous variables, but also, you know, by 10-year intervals, and they also found that there seem to be better outcomes. And their, their graphs are actually quite remarkable. Like, you can see these beautiful curves, like someone, you know, just drew them when they’re had like, it’s actually kind of amazing. But, I mean, the key thing is that you just can’t control for the complexity of these cases. And, you know, maybe there is something to the idea that older surgeons are better able to figure out who needs an operation, and maybe maybe older surgeons become a bit more selective and are just not as willing to offer operations that maybe they would do otherwise. Again, I mean, this is more hypothesis generating than actual evidence, as you’ve all said. One of the things that I always think about when we do these kinds of studies is to what and right, so, there we you know, Ahmer Karimuddin, one of the colorectal surgeons and I recently had a letter to the editor or a comment published in Annals about a study done by again some heavy hitters in the US, Justin Dimick, Ashish Jha about the outcomes of international medical graduates and, and their surgical outcomes. And basically that they found that there was no difference for IMGs versus US graduates. But then, you know, our comment was basically that, to what end are we doing these studies? Right? So, I guess one, even if, let’s say you accepted there, the conclusions of this study at face value, how would that change what we do now? I mean, they talk about in their discussion about not mandating age cutoffs or forced retirements for surgeons, but I don’t think as far as I’m aware, that’s actually a policy anywhere. So I also have to ask the question how this would actually change our policy and what we would do differently. Even if the conclusions of the study, were things that we all accepted.

Chad Ball  10:26

I think you have two great points there. You know, Ameer, the first one was, was something that I’d thought deeply about as well. And we know at least in certainly in big in the big case world, and I assume that it extends, you know, clearly beyond HPB surgery into places like cardiothoracic surgery, for example, that as surgeons get older, they do get more conservative, they do not push as hard. And there’s lots of psychological reasons for that. And, and experiences is a big one, you know, as a as a broad monitor. But, you know, the reality is, you probably want a mix of different age groups within the 4 6 8 person teams that do these really complex operations. So I think the patient selection is going to be a huge part of this that of course, there’s no way to address I’m curious Morad from, from your point of view, as a section or a division head, in relation to Ameer’s second comment, how do you frame this in terms of maybe UBC as a as a retirement policy or a transition policy? Or just just in general is does it have any application to how you think and how you run your group?

Morad Hameed  11:42

You know, I think the comments that that you and Kelly and Ameer made are are actually influencing me in real time right now. I think we could talk so much about what happens to us as we age, is our knowledge grow, does our mental acuity stay the same? Does our stamina change? Does it fall off sharply after we reach 65? Fact that people are getting healthier and fitter, does that mean that we we our growth continues on, you know, beyond how it used to be? So these are all fascinating things that we could talk about all day, but Chad, what you said about teams, and you know, you know, I love talking about diversity of teams. But it’s, it’s so it’s such an interesting idea that it maybe if we’re older, our judgment may be improved, maybe we get a little conservative or maybe risk averse. Who knows? Maybe that’s true. If it is true, maybe that’s a good influence to have in team based care, like a diversity of perspectives on on a case. You know, like when we discuss cases in our morning report complex ACS cases. It’s great to have perspectives in the room about would you operate or would you not? Would you be aggressive or would you not, and I think that the approaches are more personal than related to age. And to me, I think, maybe study like this highlights that that we all have valuable perspectives, and that, that everybody brings something different to the table. And everybody’s has a different sort of path. So like Kelly said, it raises a bewildering number of questions. And maybe one point could be that it’s just not easy to, to assess what what skills are intangible things somebody brings to a conversation about patient care.

Chad Ball  13:36

Yes, it’s totally true. You know, Kelly in in London, you have lots of great senior voices. You know, Ken Leslie comes to mind immediately, but there’s certainly many, many others. Vivian and and a whole host of folks. How do you think they would see this? And how do they influence sort of groupthink in London, for example?

Kelly Vogt  14:00

Yeah, I think it’s so interesting. So we actually discussed this paper in our journal club, right after it came out. And Ken Leslie’s voice is probably the loudest one at the table. And he raised the point that I was just gonna actually tie to what Morad had to say, which is, maybe what this paper shows us is that surgeons are smart about when they stop operating. Because what we we see in this paper is there’s there’s attrition, right? We lose surgeons as they choose to retire and they’re not captured in this data. So maybe what we’re seeing is, as surgeons get older as they get smarter, not only about what pays what patients are choosing what cases they’re doing, the decisions that they’re making, but also maybe they get smarter about when their time has come and they should no longer be operating. I think that was a really interesting point that came out in our discussions and certainly what I know Ken took away at least in part from the paper.

Chad Ball  14:57

Yeah, that’s that’s really interesting. You know, we Ameer and I were lucky to interview Henry Pitt, who is a very senior surgeon in the US, as you guys know, and he is one of the sharpest minds I can I can think of and, you know, not to not to pump the tires on on the Cold Steel interviews. But, you know, in the in the next couple of weeks, we’re going to interview Rick Buckley, who’s one of it has been one of Canada’s preeminent orthopedic trauma surgeons for a long time. And, and he has a passion about essentially progressive retirement and when, when it’s time and how, you know, it’s time and how not to hang on too long. But, you know, I don’t know what you guys think. It’s great, Kelly, when when folks have that insight, but I imagine Morad it’s probably pretty difficult to deal with the small percentage of folks maybe who don’t do, and who are, who are not meeting the trends of benefit that this paper would show us and maybe are struggling, how do you deal with those folks? Or how do you address that scenario?

Morad Hameed  16:00

I think like Kelly said and like Ken said it is amazingly true that surgeons are smart about the pace of their work, and when, when and how to cut back. And occasionally people don’t have that insight. And in that case, I think it’s very important to have, like a culture that supports open communication, and where people feel secure to, to talk to each other about sensitive issues, and also in the background, to to create a surgical culture that that measures that measures performance Well, from a patient perspective, provider perspective, we’re where I think we haven’t quite reached the point where we’re measuring outcomes, and performance in in granular enough detail, to influence these conversations, like even the best QI programs probably can’t really distinguish surgeon performance that well, or account for variability in case mix. But I think we do have to measure and try to adjust for complexity and, and be transparent about reporting performance. So I think maybe a combination of having a culture that supports surgeons and gets the best out of them and makes them realize their full potential, but also that measures performance and holds us accountable for for the critical work that we do. And that that sort of honors that commitment that we have to our patient population.

Chad Ball  17:39

So that’s so well said. I mean, I have a particular question for you, you know, I, I just reviewed a manuscript that talked about focusing on different types of contributions from senior and or retiring surgeons, to the surgical profession. And mostly what they were talking about was the ability of senior surgeons to educate and and they looked at some performance and educational metrics, and, you know, they were absolutely superb. And, and you could argue, maybe they’re less busy, or maybe they’re more experienced, whatever the rationale was, you know, that this their student body, their targets, absolutely love them. And, you know, to, to a greater or lesser extent, I think you and I both got a flavor of that with Jeff Blair, in, in the last interview from from last week. You know, there’s somebody that’s retired and still has a massive passion to teach in is, by all accounts is superb at it what, what’s your sense of that?

Ameer Farooq  18:39

I can tell you that I call my dad and my grandfather, who were both surgeons all the time. And you know, despite the fact that supposedly, I’m all up to date on the evidence, and I just studied for my Royal College exam and supposed to be all whip-smart and know what to do about everything. I find their advice, invaluable. And some of the best teachers that I even had in medical school in terms of our anatomy teaching, and all those kinds of things were retired surgeon so I, there’s no question that we under utilize the expertise of senior colleagues and there’s such a, there’s such a powerful resource. And it’s just a pleasure to if you ever get the chance to have them, assist you. It’s such an amazing experience to have. And so, you know, I keep trying to tell my grandfather who, you know, hasn’t been involved as much with the undergraduate medical education in Edmonton to then, you know, come back and teach them anatomy and all those things because, you know, I benefit from him all the time.

Chad Ball  19:42

You know, it’s, it’s interesting, I had the privilege of being a visiting professor at Memorial Sloan Kettering and I happen to hit the day that Leslie Blumgart, obviously, the famous liver surgeon was there and he’s there on that given day every single week, doing that didactic hour to two hours of teaching and the amount of wisdom that I picked up, you know, in that hour and a half say was unparalleled, almost ever, it was remarkable. I’m curious, in Vancouver or London or anywhere that you guys know of, do either of you have a program whether this is more formalized or more structured? Or is it just sort of here and there, whenever possible.

Kelly Vogt  20:25

So in London, I would say it’s really a part of our culture, that this is happening. But there is not a formal structure, at least in general surgery. Some of the other programs in London do have sort of retired surgeons routinely assisting and I think that’s spectacular. But within our general surgery division, it does happen very organically, that our most senior surgeons are often the ones you know, you’re running into a little bit of trouble or cases difficult that you just call them in, and they’re there because of the collegiality and because of the opportunities that exist. And you know, the smart junior surgeon is the one who pick up the phone and make that phone call similar to what Ameer was talking about. But an answer to your specific question, nothing formal,

Morad Hameed  21:09

And nothing formal here in Vancouver, either Chad, but this conversation makes me realize that there’s totally should be.

Chad Ball  21:19

Yeah, that’s true you wonder if if we shouldn’t be utilizing this amazing resource more and more frequently? Certainly more than we are. I’m just curious. I’ll ask you guys one more question. And then, and then maybe I’ll zip it for a bit. But, you know, I’m curious what you thought in particular about the editors comment in the synopsis, that was just republished in September, and maybe for the for the listeners, I’ll just take 60 seconds here and read it. The editor says the findings of the study may seem counterintuitive, particularly the finding that surgeons of older age, older than the standard retirement of 65 years, were less likely to have adverse postoperative outcomes than those who operated were operated on by surgeons younger than 65 years of age. He says, however, we shouldn’t forget that surgery is a team activity, better outcomes may reflect the mutual support and performance of a great team possibly refined over the years of working together, rather than the skills of a single individual within it. What How do you guys take that that comment? And again, I preface it by saying I know that there was some people that were a little bit upset about it. Certainly I I mean, I don’t know if you guys are maybe more lucky in London and Vancouver than in Calgary. But we rarely have sort of the same team, like, like a Mayo Clinic would operating with a surgeon over years, per se. I don’t know. What do you guys think?

Kelly Vogt  22:50

I agree with you. I mean, I think that would be absolutely the exception and not the rule. From a team perspective. I my when I read that sort of editorial comment, I wondered if it was a bit of a nod to some of the shortcomings that we’ve identified with this study, and not necessarily shortcomings. But some of the areas that have made us question sort of what exactly the findings are showing us, as opposed to being, you know, negative against the older surgeons. I wonder if that was sort of where it came from when I first read it.

Morad Hameed  23:23

Chad from my sampling, yeah, I, I think I think that’s exactly it, that that might have exactly been their intent. You know, I I’m actually my thoughts about team, teamwork and surgery are still evolving, like, I do care a lot about the team. And I can’t think of a single day that I don’t benefit from the expertise of my team, that my team doesn’t save me that a colleague doesn’t come in and make an important point that that changes to the tide of the case. Whether it’s in the in the operating room, or or in the ICU, or in the trauma bay, the team matters a lot. But also, we know that the technical, active operating matters a lot as well. And we sometimes forget with a big team based approach to to performance improvement, we forget that the central act of surgical care is in the operating room. And so I think that these are both complimentary forces, I think and then there is some equilibrium between, you know, team based effort and individual performance. And so, who knows, I think, I think that that the resilience of the team and the adaptability of the team, probably is is result result of great outcomes for surgeons end up probably does buffer complications a little bit, but I think the active technical active operating does definitely impact outcome.

Kelly Vogt  25:03

What do you think Chad? You have been asking all the questions.

Chad Ball  25:07

Yeah, you know, I don’t know, Kelly to be to be fair with you my, I mean, my overriding take home message, as tangential as it may seem to this manuscript is that, you know, I would support what Morad said, which is that, you know, a team is so critically important. And I, I, my, if I’m honest about it, when I, when I think of these concepts, I think back to a paper that was lucky enough to essentially coordinate that looked at some very well known high volume, pancreas surgeons that together had done over 10,000 Whipples. And I sort of asked them in the, in the, in the central, the central tenant of it was, how do you prevent bleeding? Technically, what are the things that you think about before, during and after basically? And then number one answer, across all of these extremely well known surgeons from all over the world was the same, and they didn’t talk to each other at all, it was, operate with your partners, operate with them a lot, and call them often. And I thought, wow, like, that’s an unbelievable comment. And I think, as I think we’ve all sort of insinuated, that’s really probably what this is about. It’s about mixing up age as more at says, diversity in your teams, obviously, beyond age ages is one one factor clearly. But we need that mixture of personalities and age and gender and race and experience and diversity and training. You know, we don’t all we should not be hiring the the fellows that we train, we want them to go to all these different places. And that that heterogeneity, I think, is what keeps us all at a trouble. I don’t know. What do you guys think that I mean, that that’s my take home from it? For sure.

Morad Hameed  27:07

You know, isn’t it interesting that we’re going from talking about standardizing everything in surgery and making it like a factory in terms of reducing variation to saying that variation in perspective, and in training is actually a key element of performance and resilience. It’s, it’s, I think it’s an interesting, very interesting evolution that kind of recognizes how complex this surgical systems are.

Kelly Vogt  27:35

But it’s what makes them adaptable. And I think, you know, as much as we try to aim for homogeneity in processes, and ideally, homogeneity in outcome, you have to recognize that what we do is a heterogeneous thing. You can’t predict what’s going to happen. And so you need the backups. And I couldn’t agree more about the team aspect in that regard.

Chad Ball  27:57

Ameer, I think you get the final comment.

Ameer Farooq  28:00

It just highlights from me all the things that make surgery a fantastic career. It’s there’s, there’s so many different aspects of it that we just have to pay attention to. From how we perform technically, you know, we know all the work that has been done to show how technical skills really do correlate with outcomes. And I’ll just say one thing, what that editorial comment, I mean, I don’t think it’s counterintuitive for anyone who’s ever stepped in the operating room worked in the operating room. It is definitely not counterintuitive that older surgeons would have good outcomes. So it’s not just about your steadiness of your hands. It’s all of the other things that you bring to the table. But yeah, I think I think there’s so much that we can do to improve ourselves technically, individually and as a system, and I think we just need to keep on thinking about ways that we can do that. You’ve been listening to Cold steel, the official podcast of the Canadian Journal of Surgery. If you’ve liked what you’ve been listening to, please leave us a review on iTunes. We’d love to hear your comments and feedback. So feel free to email us at podcast.cjs@gmail.com or connect with us on Twitter @CanJSurg. Thanks again.