“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.

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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Remember the dark days of the pandemic in March and April, when the true risk of caring for COVID patients started to become clear?  Remember when you could be censured by a nursing supervisor or administrator for wearing a mask in public areas lest you frighten patients or visitors?

Right around then, a third-year resident at UCLA decided to wear a mask wherever he went in the hospital, as testing wasn’t readily available yet for patients, and visitors still had full access. Someone with a clipboard stopped him and said he couldn’t wear a mask in the hallways. The resident politely responded that yes, he could. Why? Because his union representative said so. The discussion ended there.

The resident enjoyed backup that his attendings lacked because all UCLA residents are members of the Committee on Interns and Residents/SEIU, a local of the Service Employees International Union (SEIU). This union represents more than 17,000 trainees in six states and the District of Columbia.

As CMS threatens further pay cuts for anesthesiology services and other third-party payers are likely to follow suit, many attending anesthesiologists are asking:  Why can’t we form a union? Alternatively, why can’t the ASA function like a union and negotiate on our behalf?

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When you tell anyone in healthcare that “sedation” to the point of coma is given in dentists’ and oral surgeons’ offices every day, without a separate anesthesia professional present to give the medications and monitor the patient, the response often is disbelief.

“But they can’t do that,” I’ve been told more than once.

Yes, they can. Physicians are NOT allowed to do a procedure and provide sedation or general anesthesia at the same time – whether it’s surgery or a GI endoscopy. But dental practice grew up under a completely different regulatory and legal structure, with state dental boards that are separate from medical boards.

In many states, dentists can give oral “conscious” sedation with nitrous oxide after taking a weekend course, aided only by a dental assistant with a high school diploma and no medical or nursing background. Deaths have occurred when they gave repeated sedative doses to the point that patients stopped breathing either during or after their procedures.

Oral surgeons receive a few months of education in anesthesia during the course of their residency training. They are legally able to give moderate sedation, deep sedation or general anesthesia in their offices to patients of any age, without any other qualified anesthesia professional or a registered nurse present. This is known as the “single operator-anesthetist” model, which the oral surgeons passionately defend, as it enables them to bill for anesthesia and sedation as well as oral surgery services.

Typically, oral surgeons and dentists alike argue that they are giving only sedation – as opposed to general anesthesia – if there is no breathing tube in place, regardless of whether the patient is drowsy, lightly asleep, or comatose.

The death of Caleb Sears

Against this backdrop of minimal regulation and infrequent office inspections, a healthy six-year-old child named Caleb Sears presented in 2015 for extraction of an embedded tooth. Caleb received a combination of powerful medications – including ketamine, midazolam, propofol, and fentanyl – from his oral surgeon in northern California, and stopped breathing. The oral surgeon failed to ventilate or intubate Caleb, breaking several of his front teeth in the process, and Caleb didn’t survive.

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The real surprise – to me, at least – came more than halfway through Dr. Atul Gawande’s keynote address at the opening session of the American Society of Anesthesiologists’ annual meeting in Boston.

Much of his talk on October 21 celebrated the virtues of checklists and teamwork, topics that have turned into best-selling books for the well-known surgeon and professor of public health. “We are trained, hired, and rewarded to be cowboys, but it’s pit crews we need,” he said.

Then Dr. Gawande posed this question to the packed room: “What are the outcomes that matter?”

He answered his own question somberly. “The most unsafe operation is the operation that shouldn’t be done,” Dr. Gawande said. “Does the operation serve the patient’s goals or not?”

“We’ve all been there,” he continued. “Taking people to the operating room and wondering what we’re doing.”

Those are comments I’ve heard from anesthesiologists many times before, but I never thought I’d hear them from a surgeon.

Flogging the dead

For any of us who practice anesthesiology in a major hospital – doing cardiac, thoracic, or liver cases, for instance – there are days when all our efforts are spent on behalf of a patient whose health is unsalvageable. “Flogging the dead” is a phrase sometimes used to describe prolonged and futile care in the operating room or ICU.

Sometimes aggressive interventions are driven by a family that wants “everything” done, because in their innocence the family members have no idea how terrible and dehumanizing the process of postponing death can be.

In other circumstances, however, the decision of whether to do surgery is driven by the mission and the financial motivation of the health system to provide care. If care doesn’t occur, if the surgery isn’t done, no one gets paid.

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