“What’s this I hear?” said the CA-1 resident earlier this year as we were setting up for our first morning case. “You’re going to retire?”

“Why yes,” I said. “That’s correct. In April.”

He shook his head. “No,” he said firmly. “I know you have another two years in you.”

That was very kind, and I appreciated it, as I did this text message from a senior resident: “If you try to leave before July, I’ll report you for resident abandonment.” It’s always better to leave while they still want you to stay, as opposed to lingering long past your sell-by date, right?

Even two years earlier, if anyone had told me I’d be ready to retire from clinical anesthesiology in spring 2022, I would have laughed at the idea. I always felt that the many sacrifices my parents made (and all the tax dollars the public spent) to give me an excellent education conferred an obligation to use it for good – to continue practicing medicine and caring for patients even after I became eligible for Medicare. Is that an antiquated concept? Maybe, but I believed in it nonetheless.

I also think it’s a shame that when an anesthesiologist leaves clinical practice all those years of practical bedside experience – all the tricks you can’t learn from the books – go to waste. There really isn’t a way in American anesthesiology practice for an emeritus anesthesiologist to contribute clinically once you’ve pushed that last syringe of propofol and you walk out of the operating room for good. You can see senior surgeons or internists making clinical rounds with a team to observe and impart some of their hard-earned wisdom, but there’s no comparable role for a senior anesthesiologist other than to come to Grand Rounds occasionally and pontificate.

Easing into retirement?

Some people advocate “easing into retirement” as a way of slowing down without leaving the profession completely. What does that mean? It could mean cutting back on clinical hours or working part-time. It could mean opting out of the long, difficult cases in the main OR, or going to work in an ambulatory surgical center. Those options appealed to me about as much as plunging a toilet.

What’s always been fun for me in anesthesiology – maybe “fun” is the wrong word – is dealing with the unusual cases that call for actual decision-making as opposed to following a protocol. I never minded managing a difficult airway or staying to finish a tough case when I felt it would be irresponsible to turn it over to a harried, overburdened call team. Vascular, bariatric, pancreatic, thoracic – I was happy with any of those case lists. To handle those cases well, in my opinion, you should do them all the time, not just occasionally.

Once in a while it wasn’t bad to have an easy morning with a plastic surgery free flap, but by lunchtime I longed to be elsewhere. Would I care to spend the day drawing up syringe after syringe of propofol in an outpatient center and rushing to turn over rooms in five minutes – no, thank you. I’m delighted that there are people who enjoy outpatient work, but I’m not one of them.

Yet in the autumn of 2021, a switch flipped and suddenly I knew I was ready to stop doing what I had been doing since the start of my CA-1 year in July 1984 – practicing clinical anesthesiology full time, day after day. It would be a full stop, not a gradual easing out.

What flipped that switch?

Naturally, more than one factor influenced the “full stop” decision.

Health system policies may be well-intentioned, but I refuse to spend time ever again on recurrent, mandatory “e-learnings” about sexual harassment or implicit bias. If that’s the price of employment, I respectfully decline. Life is short.

Physically, I knew I was tired. As the years creep by, all of us develop our share of physical woes. A lumbar compression fracture – sustained as I lifted the head of a 300-lb patient being turned to the lateral position – was a warning call. Anesthesiology, as I’ve noted in a previous ASA Monitor column, is more demanding physically than it should be, and that problem won’t disappear any time soon. Today’s clinical practice calls for stronger bones and more stamina than I have.

Did the pandemic have anything to do with it? Perhaps. It’s been a rough two years for all of us.

But I think the most important question weighing on my mind was how I could be sure to know if my cognitive ability started to slip, if my reaction time wasn’t as quick, if I started to lose my clinical edge.

“Conditions that undermine cognition may erode insight,” as neurologist Gayatri Devi, MD, MS, and colleagues noted in their 2021 article, “Cognitive Impairment in Aging Physicians.” Many of us have known colleagues who should have left clinical practice long before they actually did. I was determined not to be one of them.

During the last few months and especially the last weeks of my pre-retirement countdown, I remember thinking how dreadful it would be if a patient of mine suffered a bad outcome, and if I were forced to ask myself if it would have been the same in the hands of a younger colleague. Mercifully, that question never arose. When I took the last patient to the PACU, I felt a tremendous sense of thankfulness and relief.

But don’t you miss working?

Do I miss my job? Six months later, I can honestly say that the answer is no. I don’t have to set an alarm unless I’m heading to the airport. I’m still writing and serving on editorial boards. I’m going to the gym more often. I see more of my grandchildren. I’m honored to be chairing the California Society of Anesthesiologists’ January meeting in Maui. (Don’t miss it! We have a fantastic lineup of speakers!)

And to the apparent surprise of many of my friends, I’m back in school – I’ve started a master’s degree program in theological studies, reading so many wonderful books that I’ve never before had time or energy to read. Truthfully, I feel as though I’ve been let out of jail.

Many of us, though, want to keep working clinically longer than I did for a multitude of reasons. Interestingly, in the United States anesthesiologists historically have tended to work far longer than they do in the United Kingdom. A 2021 article in BJA Education reports that in the UK, only 17.2% of anesthesiologists work clinically beyond the age of 55, whereas in the US 40% continue working. (Those numbers are based on pre-pandemic survey data; they may be lower today in both countries.)

I would be the last to suggest that there should be a mandatory cut-off age for American clinical anesthesiologists the way there is for airline pilots, at 65. In an excellent editorial, “Cognitive Screening in Aging Physicians,” psychiatrist Lawrence Whalley, MD, argues that no system is foolproof for detecting mild cognitive impairment, and that coercion to undergo neurocognitive testing at any specific age is unwarranted. “Repositories of knowledge (crystallized intelligence) are well preserved and can increase with age,” he believes.

Given the current demand for anesthesiology services, it makes sense to consider how we can do a better job of keeping older anesthesiologists in the workforce, of creating new roles for them, without jeopardizing either their own physical health or the safety of patients. Many of us still have much to teach and contribute. A number of retired anesthesiologists volunteered to help staff ICUs in New York City at the worst of the COVID-19 pandemic, doubtless saving many lives in the process.

In Dr. Whalley’s words, “Although public safety must remain a priority, fellow physicians share a collegial responsibility to care for and support older physicians who wish to continue in practice. This can never be overlooked and should be embedded in future health care systems.” I hope that’s a concept we all can embrace.

This article appeared first in the ASA Monitor issue of December, 2022

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References

1. Devi G, Gitelman DR, Press D, Daffner KR. Cognitive Impairment in Aging Physicians: Current Challenges and Possible Solutions. Neurol Clin Pract. 2021 Apr;11(2):167-174. doi: 10.1212/CPJ.0000000000000829. PMID: 33842070; PMCID: PMC8032410.

2. Garfield JM, Garfield FB. The ageing anesthetist: lessons from the North American experience. BJA Educ. 2021 Jan;21(1):20-25. doi: 10.1016/j.bjae.2020.08.007. Epub 2020 Nov 5. PMID: 33456970; PMCID: PMC7807987.

3. Whalley LJ. Cognitive Screening in Aging Physicians: Faith in Numbers. Neurol Clin Pract. 2021 Apr;11(2):89-90. doi: 10.1212/CPJ.0000000000000833. PMID: 33842058; PMCID: PMC8032417.

Author’s Note: This is the text of the Leffingwell Honorary Lecture delivered at the annual meeting of the California Society of Anesthesiologists on April 9, 2022. Slides are available on request.

It is truly an honor to be here, and I want to thank Dr. Ronald Pearl and the California Society of Anesthesiologists for your kind invitation to speak.  I was quite surprised to receive it.  I’m neither a department chair nor an eminent researcher.  I find the concept of being a “thought leader” or an “influencer” frankly horrifying. Physicians aren’t sheep, and we don’t need to be led to think.

What I am is a well-trained writer. I owe that to my college professors and my editors at the Wall Street Journal, who were pitiless with their red pencils and equally quick to point out poor writing, or sloppy thinking, or both.

Since I never wanted to become a department chair, or a politician, or ASA President, I haven’t hesitated to say what I think about the sad state of healthcare – or really, anything else. I mean, if no one disagrees with you, have you said anything worth hearing?

Alexandr Solzenitsyn was right: “Truth seldom is pleasant; it is almost invariably bitter.” You may not agree with some or any of the ideas I’m going to talk about today, but if that’s the case, I hope you’ll be inspired to come up with better ones! I’m going to zero in on some of the hard truths about our profession and offer some thoughts about what we can and perhaps should do going forward.

Now I’ve never for a moment regretted becoming a doctor. I wanted to be a doctor since I was a kid and read a book my father gave me, published in 1960, called “All About Great Medical Discoveries.”  It had a horrifying and yet fascinating chapter about how terrible surgery was before anesthesia was invented, and how anesthesia made modern surgery possible.

In the 40 years – yes, 40 years — since I graduated from medical school, I’ve never regretted going into anesthesiology. It’s a wonderful field. We have the honor of being with patients and safeguarding them through some of the most critical moments in their lives.

There are amazing young people entering our field, I’m happy to say, so from that point of view, the future is promising.  In this year’s match, I believe there was only ONE unfilled position. But there are storms and riptides threatening our profession, and that is why we need – urgently – to rethink, redesign, and reimagine the practice of anesthesiology.

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Today’s noteworthy definitions, not new but often ignored:

1. Unintended consequences: The principle stating that an intervention in a complex system tends to create unanticipated and often undesirable outcomes.

2. Good intentions: The paving stones of the road to hell.

In anesthesiology, these precepts should be kept firmly in mind in our attempts to improve “quality”. Anyone who speaks out against measures that are taken under the banner of improving “quality of care” or “patient safety” risks coming across as reckless, heartless, or both. Yet the pursuit of “quality” in healthcare has a track record of implementing changes and policies that haven’t been subjected to any rigorous scientific study, in effect “prioritizing action over evidence.”

Quantitative neuromuscular monitoring

In anesthesiology, we love our gadgets. We especially like gadgets that generate numerical values we can track. It’s no wonder that quantitative nerve stimulators measuring thumb movement via acceleromyography are gaining in popularity. They give us a ratio of neuromuscular recovery that we can document and trumpet as evidence of high-quality care, blessed by the Anesthesia Patient Safety Foundation (APSF) in its most recent recommendations for patient monitoring.

A recent review article in Anesthesiology concluded that “the use of quantitative monitoring may reduce the risk of hypoxemic events and episodes of airway obstruction in the PACU, decrease the need for postoperative reintubation, and attenuate the incidence of postoperative pulmonary complications.”

Note the use of hedging verbs such as “may” and “attenuate”. The authors, Drs. Murphy and Brull, are not claiming that the use of quantitative nerve stimulators should be considered an absolute standard of care or a guarantee of improved outcomes. That’s because they are scientists and understand the hazards of confusing association with causation.

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I found myself on the wrong side of the ether screen earlier this year, having surgery on my left hand to release Dupuytren’s contracture, a genetic gift from my father and (maybe) generations of our Viking forebears.

Wondering how long it will take to heal – and when I’ll get some (any?) grip strength back in my hand – leads to reflection on the combination of brain and brawn necessary in the clinical practice of anesthesiology, something we don’t think much about when we’re young and fit.

Obviously, our clinical work demands intelligence. But we should ask this question: does it need to be as physically arduous as it currently is?

Would we reduce burnout, and keep clinical anesthesiologists in the workforce longer, if we devoted some of our collective brain power to making our workplaces less physically punishing and more ergonomically friendly? This is not an idle question to ask, considering that 55 percent of anesthesiologists (more than 23,000) in active practice are age 55 or older, according to AAMC data.

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My patient and his wife didn’t understand that an anesthesiologist is a physician, despite his having been cared for by anesthesiologists during past procedures. They thought only CRNAs give anesthesia. What are we doing so wrong with our messaging, and how can we fix it?

One recent afternoon in the GI endoscopy suite (not my favorite place to work, but that’s a topic for another day), I walked up to the bedside of my next patient and introduced myself as I always do.

“Hi,” I said, holding up my name badge for the patient and his wife to see. “I’m Dr. Sibert.  I’m with the anesthesiology department and I’ll be looking after you today.”

The patient was an otherwise healthy man in his mid-30s, having his fifth endoscopy this year for a chronic though serious problem. My questions were few and he understood very well what was about to happen.

The consent process concluded, I asked if the couple had any other questions. The wife did.

“You’re a doctor when you’re not giving anesthesia?” she asked.

Wait. What?

 I’m seldom speechless, but this question took me by surprise. “Why yes,” I said, unsure how to respond.

“You’re a doctor, and you give anesthesia,” the patient’s wife said, making sure she heard correctly.  “Usually we’ve had CRNAs.”

“Yes,” I said. “I’m a doctor, and I give anesthesia all the time. I’m actually an MD who specializes in anesthesiology.”

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