While the expertise and skills of aging surgeons are invaluable, it is crucial to recognize and address the potential risks associated with age-related cognitive and physical decline. Programs like the Aging Surgeon Program serve as essential tools to ensure that surgeons can continue to practice safely and effectively, thereby protecting patient well-being and maintaining high standards of care. This proactive approach benefits not only the surgeons themselves but also their patients, healthcare institutions, and the broader medical community.
This transcript has been edited for clarity and length.
Mike Sacopulos: My guest today is Mark Katlic, MD, MMM, FACS. Dr. Katlic is the chair emeritus of surgery for LifeBridge Health System in Baltimore. He helped create the Aging Surgeon Program.
Mark Katlic, welcome to SoundPractice.
Mark Katlic: Thank you. Happy to be here.
Sacopulos: Before we delve into the Aging Surgeon Program, could you please tell me about your career path as a physician?
Katlic: I went to Washington and Jefferson College in western Pennsylvania, a small liberal arts college, then Johns Hopkins School of Medicine in Baltimore, and the Massachusetts General Hospital for residencies and surgery and cardiothoracic surgery. For many years, I practiced in private practice, general surgery, and general thoracic surgery in Northeastern Pennsylvania. Then I became more of an academic and joined the Geisinger Health System, then subsequently joined LifeBridge Health System in Baltimore. I joined as their chief of surgery 13 years ago.
Sacopulos: In preparing to speak with you today, I looked at some material, and I must admit, I was surprised by some of the studies linking age of a surgeon to higher rates of patient mortality. Would you describe the problem of aging surgeons for us?
Katlic: Well, first, this is not a huge problem in terms of numbers of surgeons. However, there are many surgeons still practicing in their 70s, and a few even in their 80s. And so, even though it’s not an enormous number of surgeons, it is a problem that most chiefs of surgery, hospital presidents, or chief medical officers will encounter during their careers, because it does happen.
We can’t deny biology. There are deteriorations in both physical and cognitive functions with increasing age — that’s just the reality. And surgeons are human, so it happens to them also. The problem is, people like to be surgeons. They like operating, and generally, cases go well. One receives a lot of gratification from doing good work in the operating room, and patients are typically very grateful.
At the same time, surgeons have spent so much time training to be surgeons, and the lifestyle is so intense that many have not developed hobbies or interests outside the hospital. And so, there’s great incentive to continue operating and less incentive to leave the OR – do something else or retire.
And that’s where the problem comes in. Surgeons are not particularly self-aware. They like what they’re doing and therefore they continue to do it. But some tiny percentage of those surgeons will have problems and will put patients at risk, and their hospitals at risk for liability, and themselves at risk for liability.
The American College of Surgeons has a category called Senior Surgeons. They are surgeons over 70 who are still practicing. They don’t have to pay dues. There are some 11,000 surgeons in that category, but we know that not every surgeon in the country belongs to the American College of Surgeons. So, if one sort of extrapolates, there could be 20,000, 30,000, even more surgeons over 70 still practicing. If even a few percent of those surgeons are cognitively impaired in any way or have unrecognized medical problems, then that’s where the problem lies. So, it’s not an enormous number, but the consequences are high, even if it’s a few.
Sacopulos: There’s a lack of surgeons in many specialties of medicine and in geographic areas in the country, or at least not enough surgeons to meet demand. Does this fact encourage some surgeons to practice too long?
Katlic: I think that’s absolutely true, and also is an argument for why there should not be a mandatory retirement age. We do need good older surgeons. As you pointed out, there are counties in the United States that have zero to one general surgeon, and sometimes that’s an older general surgeon. So, as a resource to society, we need those folks, and that’s a strong argument against mandatory retirement age.
One other argument against mandatory retirement age is that the variability among individuals actually increases with increasing age. If we test a number of 40-year-olds or even 50-year-olds, we don’t really find major differences. But as we reach 70- and 80-year-olds, the variability among individuals increases. Some are still very, very good, but some are getting bad. Therefore, to pick a mandatory retirement age would be unscientific, it would be unfair, and you would take away those surgeons that are necessary for some places in America.
Sacopulos: Could you describe how the Aging Surgeon Program works?
Katlic: I sat down with members of various specialties, including hospital lawyers and physical therapists and ophthalmologists and physical and occupational therapy folks. It took us about a year and I charged those folks with coming up with a practical evaluation in their area of expertise. Then we put this all together into a two-day comprehensive evaluation.
So, a surgeon will come to Baltimore, have a nice little breakfast and talk to me, then they’ll have a physical exam, a neurology exam, and a whole afternoon of neurocognitive evaluation. These are typical neurocognitive tests that are done on individuals with so-called high executive functioning — typically, professionals.
And then they’ll leave the hospital, have dinner on their own, come back the next day for more neurocognitive testing, some physical and occupational therapy testing, which tests hand-eye coordination, fine motor skills, balance, all of which are important for surgeons — not necessarily for, say, psychiatrists, but important for surgeons. Then they have a comprehensive eye exam and a brief hearing screen, too.
After they leave, our individual departments send comprehensive reports and we meet as a group, typically on a Friday and prepare an executive summary. All of that is sent as an encrypted PDF document to whomever contracted for the evaluation — typically, a hospital president or chief of surgery. On occasion surgeons come in on their own, because they want to know about their capabilities. Those are the basics of the program.
Sacopulos: What are the typical costs associated with a surgeon being evaluated through the program?
Katlic: It costs $10,000. That’s actually less than when we started. We’ve found that by holding the evaluations in certain so-called unregulated space in Maryland, it’s a little less expensive. And we don’t make any money on this, by the way. That’s simply what it costs for all this comprehensive two-day evaluation. We require that money upfront, we put it into an escrow account, and then the various departments that evaluate the surgeon draw from that account at Sinai Hospital.
Sacopulos: What about confidentiality? If a surgeon chooses to ignore or minimize the results of his or her evaluation, assuming that they’re the ones that ordered the evaluation or started the process as opposed to a hospital, are the results reportable?
Katlic: We hold confidentiality with great respect. We send the encrypted report only to the person who contracted for the evaluation — basically who paid for the evaluation — and to no one else short of a court order. Now, we did recently receive a court order from a physician who had been, I think, relieved of certain privileges at his hospital, and he did not contract for the evaluation himself. So he did not have the results of his evaluation. The hospital would not provide him results of the evaluation, which had been sent to the hospital, but his lawyers were able to obtain a court order that required us to relinquish the document to them, which we did. But failing that, we will only send the document to whomever contracted for it.
We do get permission upfront from the individual who allows us, if we find findings that we believe are dangerous to the individual, to notify his or her family member or personal physician. But we will not report it to a State Board of Medicine, for example, short of a court order.
Sacopulos: Is the testing yield only binary results? I mean, either the surgeon is competent to operate or not. It seems possible that a surgeon may be completely competent to perform some minor or lesser procedures but not other procedures. Am I wrong?
Katlic: You’re not wrong; it is not a binary report. There’s a lot of quantitative information in the individual evaluations, but the executive summary tends to be more qualitative, a summary of the results. And you’re absolutely right. There could be findings that would allow a surgeon to do some things but not others.
For example, in some physical therapy and occupational therapy evaluations of the surgeon’s hand functions, the evaluator will sometimes determine that the function deteriorated under certain conditions of stress or after a long period of performing the test.
Similarly, some of the neurocognitive tests may have findings that say cognition was not within normal limits when attention was divided, when there were noisy conditions, or when there were distracted conditions. So, yes, there may be findings in the report that would still allow a surgeon to do something, but maybe not everything.
Those types of decisions, however, are left to whoever contracted for the evaluation. We are not going to make credentialing decisions or even credentialing recommendations or privileging recommendations, I should say. We might occasionally make a soft recommendation.
We have also found ways to improve a surgeon’s function. One older orthopedic surgeon had been sent to us because he fell asleep during cases and did not perform well during long cases. We determined that he simply was not managing his diabetes well, and he was likely having hypoglycemic episodes during these operations.
Many surgeons don’t see their doctor very often and don’t take care of themselves very well. And so, with proper diabetes management, he’s still operating. This was years ago; he’s still operating and apparently doing fine.
There may be conditions whereby a surgeon can be taken off the call schedule or his or her schedule limited to allow that surgeon to get more rest at night. There may be conditions whereby that surgeon can still see patients in a clinic but not do major cases, or has to have another surgeon as an assistant, for example. There are all sorts of options, but we will not say, “This surgeon can continue or should not continue.”
Sacopulos: What age do you believe surgeons should start being evaluated for age-related competency?
Katlic: That’s a very good question, and it actually leads me into the type of policy we have at all of our three hospitals within our LifeBridge Health System in Baltimore. There’s a policy called a Late Career Practitioner Policy, and this applies to everybody on the medical staff, not just surgeons. We set that age at 75; other hospital systems, although very few have these policies, have set it at 70 or 72 or 75.
Our policy says that at age 75, you must have a physical exam, an eye exam, and a two-hour neurocognitive screening evaluation by a PhD neuropsychologist of our choosing. The practitioner must do it every time they come up for re-privileging when they’re over 75. That’s every two years at our hospital. We just chose 75. Completely arbitrary, because it was old enough not be controversial, but not too old.
By the way, some members of our medical staff leadership think we should start a little sooner. We’ve been doing this for six or seven years, and although there is controversy on this topic with many hospitals, and many hospitals don’t have strict policies, it has worked very well at our hospitals.
Now, I’m actually an advocate for groups in surgery to have similar evaluations for surgery, basically to go ahead and police ourselves before someone else does it. If our American Board of Surgery had a similar requirement when one comes up for recertification, what’s called maintenance of certification in surgery — and that’s every two years, by the way — that you had to send in a neurocognitive evaluation when you apply for maintenance of certification, then surgeons would be evaluated. I think the public could sleep a little better.
It came up in our recent presidential election that maybe high-impact professions should undergo some form of evaluation. And I think you can make a strong case for that. I don’t believe any board of medicine or surgery has such a requirement now. I understand it would be very controversial, but I will continue to encourage surgical organizations to think about that. That’s a long-winded answer to your question. So, whether you pick age 70, 72, 75, something in that range seems appropriate.
Sacopulos: Is there a concern with false positives from the evaluation process?
Katlic: All the tests that we do have been validated within the neuropsychology literature and have been used for years for occupational therapy evaluations and neurocognitive evaluations of professionals. Similarly, the physical therapy and occupational therapy tests have been done for years and they’re standard hand therapy evaluations, standard physical therapy evaluations of reaction time and coordination and balance and fine motor skills. So, the chances of a false positive are extremely low. One could also point out that you would want your surgeon to be at least as good as the general public in cognition and physical function.
Sacopulos: That seems hard to argue with. Do you know any professional liability insurers that require older surgeons to be evaluated?
Katlic: I’m not aware of a single one.
Sacopulos: You would think that they would have a natural interest in knowing the abilities of those they insure.
Katlic: I think you’re absolutely right. It probably would be a forward-thinking insurer who instituted that requirement. Now, it could be the case, but I’m not aware of any insurer having that requirement.
Sacopulos: Since you’ve helped with the inception of this program, has there been anything that’s really surprised you about how the program has gone?
Katlic: I’ve been a little surprised that we haven’t had more surgeons come through our program. We’ve had perhaps two dozen, maybe as many as 30, over the years that we’ve been doing the program, which is, I think, almost 10 years. So, we’re not seeing huge numbers of surgeons.
We’ve had tremendous interest, and I’ve received inquiries from every state in the United States and many foreign countries. For anybody who doesn’t have a mandatory retirement age, this is an issue. So, there’s been a great deal of interest in the topic. And I’ve actually been invited to speak overseas. I’ve been to Korea, Amsterdam, and England, and had other interest in our program.
I also know that many surgeons have voluntarily retired or retired from the operating room when so-called “threatened” with our program. In other words, rather than be forced to come through our program, they have voluntarily stepped down or changed what they do. And that’s just anecdotal, but I’ve heard that that’s happened. So, I think that the existence of the program has affected more people than just the relatively few surgeons who have come through our program.
Sacopulos: It seems to me that cognitive problems are not always the result of aging. Would your program accept someone who is maybe younger than the average age, but there are questions of cognition?
Katlic: Yes, we would. We have tried to exclude people with drug dependency issues; however, we have evaluated two or three surgeons returning from major illness or major surgery, and their hospital simply wanted to be certain that they were good. One had had a major transplant, and another had brain surgery. And both did fine, actually, but their hospitals wanted to ensure they were safe.
In a way, I think our program also provides the hospitals with some feeling of security that they’ve gone the extra mile to ensure the safety of these surgeons, just in case something should happen.
Sacopulos: Well, I think this program makes all the sense in the world, and there should be lots of interest in it. As our time together draws to a close, can you tell me how people interested in the Aging Surgeon Program can learn more?
Katlic: Well, I think if you type in Aging Surgeon Program in any search engine, the program will come up.
There’s a fairly simple website. We have a coordinator who is an experienced nurse practitioner, and her phone number is on the website. Anybody can also look me up on a search engine and the program will come up, or my contact information will come up.
Sacopulos: This is certainly a great service that you offer to your colleagues and to the general public indirectly, so thank you. Thank you very much for that. My guest has been Dr. Katlic. Thank you so much for being on SoundPractice.