“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.

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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If you think about scope-of-practice creep at all, you may think immediately of the advocacy efforts so many physicians have made to preserve physician-led care and discourage independent practice by nurse anesthetists or physician assistants.

You may not have paid as much attention to the current momentum to grant independent practice to nurse practitioners, or NPs, nationwide.

In addition to the District of Columbia, 28 states allow NPs full practice authority to treat and prescribe without formal oversight. Half of these states grant NPs full practice authority as soon as they gain their licenses; the other half allow it after the NP practices with physician oversight for a period of time.

My home state, California, is one of the states that has always required physician oversight. Last fall, however, Governor Newsom signed a bill, Assembly Bill 890, that will allow NPs to practice independently after they have completed a three-year transition period, practicing under physician supervision.

That was when I started to worry.

Preop assessments that make us laugh or cry

No doubt everyone who practices anesthesiology or surgery has encountered preoperative medical assessments, H & Ps, or “clearance” notes that have been so far off the mark they’re laughable. I’m not just talking about the three-word “cleared for surgery” note scrawled on a prescription pad. I recall in particular:

A consultation at a VA hospital that “cleared” my cirrhotic patient with massive ascites and coagulopathy for his inguinal hernia repair under spinal anesthesia but not general.

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Every death related to anesthesia is a tragedy; even more so when a minor procedure such as a colonoscopy leads to a completely unexpected death. Everyone knows that open heart surgery carries a mortality risk, but few of us walk into the hospital for a colonoscopy thinking that death is a plausible outcome.

We know so few facts at this point about what happened on January 21 at Beaumont Royal Oak Hospital in Michigan. The patient who died, sources say, was a 51-year-old man who walked into the hospital for a routine colonoscopy. He was obese, with a BMI of 39, and suffered from obstructive sleep apnea, a common problem, where people snore heavily and their breathing may obstruct intermittently while they’re sleeping. Author Charles Dickens described a portly gentleman’s sleep apnea perfectly in The Pickwick Papers:

“His head was sunk upon his bosom, and perpetual snoring, with a partial choke occasionally, were the only audible indications of the great man’s presence.”

Sleep apnea is a risk factor for anesthesia complications, especially airway obstruction, but every anesthesiologist is taught how to recognize and manage it. With the obesity epidemic in America today, sleep apnea is part of daily reality in anesthesiology practice.

According to recent reports in Deadline Detroit by journalist Eric Starkman, who has reported extensively on problems at Beaumont Health, the patient was intubated by a nurse anesthetist who ordinarily worked at another Beaumont Hospital. At the end of the procedure, the nurse anesthetist removed the breathing tube, and the patient began to “thrash around”. It isn’t clear from reports if he was trying unsuccessfully to breathe or wasn’t breathing at all. The nurse anesthetist called for help from an anesthesiologist, and an emergency back-up team was summoned, but the patient went into cardiac arrest and couldn’t be resuscitated.

How could this happen?

We’re not likely to learn further details any time soon, as NorthStar Anesthesia has refused to comment. NorthStar took over the contract for anesthesiology services at Beaumont in 2020, leading to the resignation of a number of experienced anesthesiologists and nurse anesthetists who had worked there for years. Prominent surgeons, specialists, and nurses also resigned, according to reports, concerned that extreme cost-cutting measures would compromise patient care. Senior cardiologists wrote a letter in September, according to Deadline Detroit, expressing “serious concerns that NorthStar will not be able to provide the quality of cardiac anesthesia services that we have received for several decades.”

“We oppose the concept that any Beaumont physicians can be considered replaceable commodities, or that corporate leadership can assume that we would blindly accept another group of physicians to care for our patients with life-threatening cardiac conditions,” the cardiologists’ letter stated.

In the context of this upheaval at Beaumont, we can ask these questions.

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I live and work in Los Angeles, one of the plastic surgery capitals of the world. Quite a few of my patients have “had a little work done” — the blandly euphemistic term you’ll hear for plastic surgery makeovers of all kinds. That’s fine. Plastic surgeons have children to feed too.

The problem is this: many of my patients want to convince everyone that their “look” is entirely natural. They don’t want to admit that they’ve had a tummy tuck, an eyelid lift, or breast implants. One patient tried to tell me that the perfectly matched scars behind her ears were the result of a car accident, not a face lift. In front of family members, patients will even deny having dentures. That’s understandable, but unwise from a medical point of view.

The fact is that plastic surgery has implications for future medical care. Your anesthesiologist needs to know about it, and your surgeon does too. It may be cosmetic, but it’s still a bigger deal than getting your eyebrows waxed.

Here’s why we need to know the cosmetic secrets our patients may NOT want to tell us.

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