More than just taking the keys away ….

I wasn’t sure whether or not to be offended when James Eisenach, M.D., Editor-in-Chief of this journal, asked me to write an editorial on a very simple but provocative article, “Association Between Anesthesiologist Age and Litigation,” by Tessler et al. in this volume of ANESTHESIOLOGY. The article raises important questions about aging anesthesiologists and potentially declining clinical performance. Was our editor asking because I have expertise in aging and physician performance? Obviously not, because as a part-time administrator who has oversight of physicians, I, like others, struggle mightily when confronted with decisions on when older colleagues should step away from clinical practice. Was he asking because I am getting older and personally am experiencing declining performance? Potentially, because as an anesthesiologist practicing in a residency-training environment, I can attest that it is difficult to stay even with our residents, fellows, and younger faculty in current medical knowledge and clinical practices that have changed dramatically since I finished training three decades ago. Regardless, I agreed to participate because I think the invitation came to me precisely because I’m not an expert on this topic – and it’s a topic that many of us will address administratively and all of us will consider or confront as we near the ends of our careers. Tessler et al. have taken a very unique situation in Canada and put it to good use. First, most anesthesiologists in Canada are assigned cases based on department policies (e.g., specialty expertise) and are not selected by surgeon or patient preferences or requests. Second, the authors had complete billing data during a 10-yr period from January 1993 through December 2002 for all physician-patient interactions performed by anesthesiologists in three provinces of their country. These three provinces, British Columbia, Ontario, and Quebec, include approximately 80% of all Canadian anesthesiologists. Third, the Canadian Medical Protective Association handles all litigation for virtually all Canadian anesthesiologists, has a system to ascribe responsibility for adverse events leading to litigation, and also tracks all complaints filed against anesthesiologists with the licensing colleges in each province. These factors provide a treasure trove of consistently defined and collected data. The authors found that anesthesiologists older than 50 years of age, and particularly those 65 and older, had a higher frequency of litigation filed against them and a greater severity of injury defined by cost associated with litigated cases than did their younger colleagues. Augmenting these findings, they also reported that billing data suggest that anesthesiologists 65 and older cared for fewer patients on average and that these patients underwent procedures of lower complexity than those provided care by younger anesthesiologists. In essence, anesthesiologists older than 65 provided care for patients undergoing lower complexity procedures but as a group had a higher frequency of litigated claims against them (1.94 ratio) and a higher average cost per litigated case (3.04 ratio) compared with anesthesiologists 50 years of age or younger. What do these findings mean to us in practice? Do they imply that there may be an age, as with commercial pilots in most countries, when anesthesiologists should no longer provide acute (e.g., intraoperative) care? If these findings are replicated and confirmed in other countries or populations, how would we apply them in our practices, rules, and regulations? Most importantly, why do older anesthesiologists have these problems at a higher frequency than younger colImage: ©istockphoto.com.