When Are Surgeons Too Old to Operate?

GOLDEN YEARS Forcing older surgeons into retirement could be discriminatory and might take many competent physicians out of practice.

Octogenarian Richard Rothman, MD, PhD, founder of the renowned Rothman Institute in Philadelphia, Pa., is still performing hip and knee replacements and has shown no signs of slowing down with the scalpel. But what if Dr. Rothman were no longer allowed to operate simply because he was considered too old?

That's the dilemma addressed in a recent report published in JAMA Surgery, which calls for non-punitive evaluations of physicians' cognitive and physical skills as they age in order to support those who continue to deliver great care based on their decades of experience and to protect patients from those who are unable to practice safely.

The report notes that nearly one-fourth of practicing physicians were at least 65 years and older in 2015. The report also says the average person's cognitive ability declines by more than 20% between 40 and 75 years of age. However, mental capacity and physical skill vary among aging individuals, so age-based evaluations are needed in health care, similar to what's used to test the competency of workers in other fields, such as commercial aviation.

The testing itself would not be discriminatory if applied to all physicians at a certain age threshold, according to E. Patchen Dellinger, MD, a 73-year-old general surgeon and co-author of the report. He says any action that followed based on the results of the testing would not be discriminatory, because it would be based on the assessment of competence.

"We recommend that healthcare institutions, through their medical staff offices, consider mandatory testing of physicians as they age, as several leading institutions are already doing," says Dr. Dellinger.

By starting at a time when most physicians are fully competent and before they are "old," facilities can avoid the stigma of age discrimination, points out Dr. Dellinger. He adds, "There are going to be trade-offs with any age thresholds that are set — start too early and do lots of testing that turns out to be unnecessary, start too late and miss some physicians whose competence has declined — but we can't let this difficulty keep us from moving forward."

Daniel Cook

Surgeons Remove More Gastric Bands Than They Implant

BAND AID The number of laparoscopic adjustable gastric band surgeries has dwindled in recent years, while other forms of bariatric surgery have grown in popularity.

Bariatric surgeons are now taking out or adjusting more of a once popular surgical weight-loss device than they're putting in. Researchers suggest the reversal of fortune may be due to the emergence of other surgical weight-loss alternatives that promise more dramatic results.

Laparoscopic adjustable gastric banding received FDA approval as a treatment for morbid obesity in 2001. It seems to have since fallen out of favor, say the authors of a new study published in the Journal of the American College of Surgeons. The annual number of implantation procedures began decreasing steadily after 2010, and surgeons have been performing more device explantations than implantations since 2013.

The researchers studied 28,202 patients who underwent laparoscopic adjustable gastric band implantation at academic medical centers from 2007 through 2015. In the same time period, 12,157 patients underwent explantation.

Laparoscopic adjustable gastric banding is one of the least invasive operations available for treating obesity. It requires just a few small cuts to the abdomen to place the inflatable belt around a portion of the stomach, which, in turn, reduces the amount of food the stomach can hold. Explantation or revision is a different story, as the procedure to remove or adjust the gastric band can lead to a longer hospital stay, a greater number of serious complications and a higher likelihood of being admitted to the ICU, the study finds.

The study does not explain why the bands were removed, so it's tough to determine if the removals stemmed from complications or patient desires for a different surgical weight-loss option. Some have suggested the decline may be to due to the rise to prominence of other surgical weight-loss procedures, such as the laparoscopic sleeve gastrectomy.

The sleeve gastrectomy accounted for more than half of all surgical weight-loss procedures performed in the United States in 2015, according to the American Society for Metabolic and Bariatric Surgery, up from just 17.8% in 2011. Comparatively, laparoscopic adjustable gastric banding accounted for just 5.7% of bariatric procedures in 2015, down from 35.4% in 2011.

Other forms of bariatric surgery have been in the headlines of late. Earlier this month, the U.S. Food & Drug Administration issued a second safety warning to healthcare providers in the aftermath of 5 patient deaths that occurred soon after the patients were implanted with liquid-filled intragastric balloons.

Bill Donahue

What Happens When Patients Remind Docs and Nurses to Wash Their Hands?

HANDS OFF? Patients were given light-hearted, cartoon-styled paddles to use to remind clinicians to clean their hands. Attending physicians were split, with half saying they didn't want to be reminded by patients.

Should you encourage visitors to hold up signs that remind physicians about hand hygiene? A recent study in the American Journal of Infection Control suggests that patients generally like the idea, and parents of pediatric patients like it even more. Physicians, however, appear less enthusiastic.

The J.W. Ruby Memorial Hospital in Morgantown, W.Va., instituted several initiatives in 2015 to improve its hand hygiene compliance rate, including a "patient empowerment tool" (PET) that consisted of 5 laminated cartoon drawings, each attached to a tongue depressor and each containing a phrase, such as "Did you wash your hands?" or "Please wash your hands. Thank you!" The hospital asked each patient or family to use the "PET" to remind providers.

The researchers correctly hypothesized that parents of young children would be especially willing to do so. Asked whether they felt comfortable using the signs, 77% of parents said yes to reminding physicians, and 81.4% said yes to reminding nurses. For adult patients, the numbers were slightly lower — 64.8% for physicians and 71.2% for nurses.

But only 49% of attending physicians felt that patients should be asked to remind physicians to wash their hands (65.5% of residents thought it was a good idea). Among those who didn't like the idea, 37.8% said hand hygiene reminders weren't the patient's responsibility, 16.2% said it was embarrassing for the doctor and 13.5% felt it would negatively affect the patient-physician relationship. Physicians also said they'd prefer to have patients use words, rather than signs, to get the message across.

The hospital, meanwhile, which also began using posters and direct observations to boost hand hygiene, improved its compliance rate from 48% in 2015 to 75% in 2016.

Jim Burger

InstaPoll: Do You Turn Over Your ORs in 15 Minutes?

The unwritten but universally accepted industry standard for OR turnover time is 15 minutes. Tell us in this week's InstaPoll how often you achieve a 15-minute turnover time.

Even though some states require IV access for any patient entering an OR regardless of the type of anesthesia provided, more than one-third (37%) of the 373 respondents to last week's InstaPoll only start IVs on patients receiving sedation. An OR manager has a warning for facilities that don't start IVs for local cases. "Once a patient refused an IV for the removal of a small lesion on the left lower lid and wanted only local," she says. "This patient ended up passing out — low heart rate and blood pressure — and we were scrambling to gain IV access. Since that incident, anyone having a procedure in the OR must have IV access."

Do you require IV access for any patient entering an OR?

  • yes 63%
  • no 37%

Dan O'Connor

News & Notes

  • Win a free stay at ORX If you've ever wanted to do Vegas in style, now's your chance. Register for OR Excellence (Oct. 11 to 13 at the Red Rock Casino Resort and Spa) by Aug. 31, and you'll be entered into a drawing for great prizes, including spa gift certificates, room upgrades and the grand prize: a complimentary 3-night stay in a Red Rock Signature Suite for ORX. Plus, you'll take advantage of the $100 early-bird price discount and secure your room in the heart of the conference action.
  • Buffalo VA issues infection risk notice to patients The Buffalo Veterans Affairs Medical Center is notifying 526 patients that the use of an improperly cleaned endoscope may have put them at risk of infection. Medical center officials saying a hospital employee may not have followed manufacturer's instructions for reprocessing. "Notification does not mean veterans were infected," medical center officials said in a brief statement in which they characterized the risk of infection as "very low." The VA will offer screening to the patients at no charge.
  • Post-op antibiotics don't help after colorectal surgery A study in the journal Diseases of the Colon & Rectum suggests that antibiotic administration after colorectal surgery provides no benefit. Researchers at the Mayo Clinic in Rochester, Minn., found a 5.7% infection rate among 493 patients who were given post-op antibiotics (in 2012 and 2013), and a 5.3% infection rate among 472 patients who were not (in 2014 and 2015 after a policy change).