By Bruce Campbell, MD
Published in Doximity on August 8, 2022
View the original essay here.
Featured in Op-Med, a collection of original articles contributed by Doximity members.
Your close friend, Caleb, knows you work in a hospital, so he tells you a story: His healthy 35-year-old sister Melissa has thyroid cancer. She had surgery this week to remove her thyroid and nearby lymph nodes. That evening, she developed a large blood clot and had to go back to the OR. In the morning, her fingertips tingled and they gave her calcium and vitamin D. At breakfast, she choked trying to swallow and they determined that one of her vocal folds is paralyzed. After lunch, her neck was swollen and there was chyle under the skin. She may need to go back to the OR again.
You say that his poor sister has had pretty much every complication of this surgery. Caleb says he asked the doctor, “Can you say why this happened to her? Was there some mistake? How much experience do you have doing thyroidectomies?” The doctor says complications happen, and it was just bad luck. For now, Melissa is a mess, but the doctor says she will get better as time goes on.
Caleb wants to know what you think. “Oh, and by the way,” he says, “I looked up the surgeon’s age.”
So, what do you tell Caleb? Does your answer change if the surgeon is 33 years old? What if the surgeon is 73 years old?
There are relevant data on both sides of the “young vs. old” debate. If the surgeon is young, they might be more current, both in the relevant literature and surgical techniques. If there is some newfangled way to solve a surgical puzzle, they likely have encountered it and played with the technology.
For some procedures — particularly those that are evolving over time — younger surgeons have the advantage. A 2005 study of laparoscopic inguinal hernia repair outcomes published in the Annals of Surgery showed that inexperienced, “older surgeons” (here, defined as older than 45) had significantly higher rates of recurrence against inexperienced “younger” surgeons. These findings parallel other quantitative studies that document gradual declines in quality-of-care delivery as physicians age.
However, procedures performed by younger surgeons can also be associated with higher complication rates. A 2020 CMAJ paper demonstrated that the incidence of death, surgical complications, and 30-day readmission rates dropped 5% for each subsequent decade of surgeon age. Similarly, a 2018 BMJ paper found that older surgeons had lower mortality rates after operations on a cohort of almost 900,000 Medicare patients. The BMJ study also found that the patients had the best outcomes when their surgery was performed by woman surgeons in their 50s.
Why might younger surgeons have more perioperative complications? Given their relative youth, they might not have encountered all the clinical “zebras” and might be less circumspect about their own limitations. Being fresh out of training, they could be more rigidly fixed in their fidelity to the ways their mentors insisted things be done. As a result, they might rush headlong into fraught clinical situations or miss things that will become obvious later in their careers.
Older surgeons, to their credit, have accumulated a breadth of clinical experiences over the years and are less likely to get trapped in no-win surgical situations. They might be more comfortable going “off script,” if needed. On the other hand, older surgeons might be too cautious, and avoid procedures that could carry low, but still real, opportunities for success. Depending on their own health and stamina, they might be less likely to take on complex procedures.
To help me understand what others think, I asked more than a hundred of my social media contacts to chime in on the younger versus older surgeon dilemma. In general, given equal credentials and characteristics between a hypothetical young and old surgeon, almost half refused to make any recommendation. Of the rest, two-thirds recommended Melissa see the older surgeon based almost entirely on the sense that they would have more experience and would be better equipped to deal with complications. Those who preferred the younger surgeon cited their recent training, up-to-date knowledge, and better reflexes. When complications occur, my friends agreed that “stuff happens,” and that the problems were unlikely related to the surgeon’s age. When asked to assign a range when surgeons are in the “prime of their careers,” the majority put the sweet spot between 45 and 60.
“Young vs. old” expertise is relevant both inside and outside of medicine. Think back to your own journey from being a complete novice to mastering a hobby, profession, or body of knowledge. My own sense of being an expert has fluctuated over the decades. I found my development of expertise as a surgeon to be iterative, complicated, and variable.
My view of whatever proficiency I possessed also evolved. I completed my head and neck surgical oncology fellowship when I was 32 and am now 67. Over the years, I accompanied patients through surgical complications and, although my suffering never compared to theirs, I ached for them. When I was younger, I blamed postoperative problems on the cancer, the condition of the tissues, the patient’s nutrition, and a host of other “not my fault” factors. Now that I am older, I wonder if many of the problems were the direct result of my own failures and shortcomings.
On the flipside, surgeons, like everyone, are prone to age-related decline and experience deteriorating sensory functions, a loss of habitual and controlled analytic memory, and decreased visual-spatial abilities. A surgeon’s declining function and absence of insight is a very dangerous combination, indeed.
So, what to tell Caleb and Melissa? Well, first of all, her surgeon is correct. Each of Melissa’s complications is a challenge, yet each might resolve. But, what about the choice of a surgeon? That’s more difficult for me. Young surgeons bring fresh vitality, along with evidence-based, cutting-edge perspectives to the conversation. At the same time, older surgeons bring a wealth of experience and insight. As Mark Twain noted, “Good judgement is the result of experience and experience the result of bad judgement.” There are some moments that must be experienced to be deeply understood.
So, here’s another way to look at the dilemma. Benjamin Franklin cautioned his contemporaries to “beware of both the young doctor and the old barber.” We surgeons trace our roots to the barber surgeons of Franklin’s time, so he was warning his readers that young doctors are unsafe since they have yet to hone their skills, while old barbers are dangerous since they don’t maintain the sharpness of either their razors or their techniques. His aphorism still rings true.
From my own personal experience, I know many surgeons who are wonderful, wise, and talented. Still, I might tell Caleb and Melissa that, although the surgeon’s age isn’t that critical, they should avoid those whose insight has yet to develop, those in whom it has started to evaporate, and especially those in whom it never appeared in the first place.
Illustration by April Brust of Doximity