Los Angeles, California, USA: Because surgery has a long learning curve, patients do slightly better when the surgeon is more experienced than operations done by younger colleagues, according to a new study.
The researchers also found there was no difference in the quality of surgical care between male and female surgeons (BMJ 2018;361:k1343).
“Our finding that younger surgeons have higher mortality suggests that more oversight and supervision early in surgeons’ post-residency career may be helpful,” said Yusuke Tsugawa, MD, PhD, an assistant professor of medicine at the David Geffen School of Medicine at UCLA, in Los Angeles, and the lead author of the study.
“These findings provide evidence of a long ‘learning curve’ in surgical practice that has a potentially meaningful effect on patients’ outcomes,” he said. “The accumulation of skills and knowledge from experience may lead to better surgical performance.”
The U.S. observational study of 892,187 Medicare fee-for-service patients aged 65 to 99 years who were treated by 45,826 surgeons with a median age of 50 years for 20 major nonelective operations between 2011 and 2014 found that the risk-adjusted operative mortality rates were 6.6% for surgeons younger than 40; 6.5% for surgeons between 40 and 49; 6.4% for surgeons between 50 and 59; and 6.3% for surgeons aged 60 years or older (P=0.001).
The study found no evidence that risk-adjusted operative mortality differed between patients treated by female versus male surgeons, Dr. Tsugawa said.
The adjusted mortality for female surgeons was 6.3%, compared with 6.5% for male surgeons. “We found that patients’ mortality declined with surgeons’ age for both male and female surgeons, except for female surgeons aged 60 or older, with female surgeons in their 50s having the lowest operative mortality,” he said.
The study defined operative mortality rate as “death during hospital admission or within 30 days of the operative procedure, after adjustment for patients and the characteristics of surgeons and hospitals.”
“The lower mortality by the older surgeons in Dr. Tsugawa’s study represents a statistical difference but not a difference that would be important to patients, namely, 6.3% mortality versus 6.5%,” said Mark R. Katlic, MD, MMM, FACS, the chair of the Department of Surgery and surgeon-in-chief at LifeBridge Health System, in Baltimore, who was not associated with the study.
“Nevertheless, their study did show that older surgeons did not demonstrate higher mortality,” Dr. Katlic said. “Even this conclusion must be tempered by the observation that their ‘older’ surgeons were not really very old. We are not concerned about older surgeons as a group, as the vast majority are excellent, but rather those few individual surgeons who manifest cognitive or physical problems. There is variability among individuals, and that variability actually increases with increasing age.”
Dr. Katlic, the director of the Sinai Center for Geriatric Surgery and director of the Aging Surgeon Program at LifeBridge, argued against a mandatory retirement age for surgeons (Ann Surg 2014;260:199-201) and instead argued “for an objective evaluation of functional age.”
This assessment would weigh the value of an experienced surgeon, the dignity of a committed practitioner with patient safety. In his paper, Dr. Katlic recommended the Aging Surgeon Program, a comprehensive, multidisciplinary, objective and confidential evaluation.
“Most of the great differences among surgeons will not appear until we assess a group of surgeons in their 70s and 80s. This would be impractical, as there are not large enough numbers of those surgeons to perform the type of study that [Dr.] Tsugawa did. Hence, hospitals should have late-career practitioner policies to screen all physicians above a certain age, such as 75 years,” Dr. Katlic said.