Can J Anesth/J Can Anesth (2014) 61:781786

DOI 10.1007/s12630-014-0201-2

EDITORIALS

The aging anesthesiologist: Are we asking the right question?

Robert Byrick, MD

Received: 28 May 2014 / Accepted: 19 June 2014 / Published online: 23 July 2014
Canadian Anesthesiologists Society 2014

Kahneman,1 a Nobel laureate, recognized that we all have litigation in clinical practice, the unknown work
intuitive feelings and opinions about almost everything and it environment of the different groups, and the unknown
is our natural inclination to believe that we are rarely totally underlying mechanism for increased risk. He speculated
stumped. When a satisfactory answer to a complex that the increased risk among older anesthesiologists could
question is not readily available, a common intuitive have been related to easier fatigability, resulting in reduced
human response is to find a related question that is easier vigilance, longer response times, less continuing education,
to answer. In this issue of the Journal, Baxter et al.2 address or poorer communication skills. Eger4 commented that
an important topic that relates to the professionalism of another confounding factor may have been that the two
anesthesiologists in dealing with age-related decline in groups (i.e., older than 65 and younger than 65) were
clinical performance. The authors offer a proactive fundamentally different in their training and skill set right
strategy that hospital departments and practice groups from the outset of their professional careers. When dealing
should consider for managing this issue. They identify that with sensitive social and legal issues, we all agree that we
many anesthesiologists wish to continue in practice beyond must be careful not to draw possibly erroneous conclusions
age 65 and that the ability of physicians to self-assess has about individuals based on statistical analysis of groups.
been found to be inadequate to protect patient safety. We There are, however, other data that support Tesslers
have to ask whether this lack of ability to self-assess is conclusion that the age of anesthesiologists is a
limited to this age group (there is abundant evidence that this contributing factor to a decline in favourable outcomes in
shortcoming is not age-dependent) and whether the proposed clinical practice. For example, Campbell et al.5 reported
strategy would be expected to improve overall patient safety. that 52% of patient complaints to the General Medical
The rationale for undertaking Baxters review was partly Council in the United Kingdom (UK) involved
related to the findings by Tessler et al.3 that aging anesthesiologists qualified for more than 20 years,
anesthesiologists (i.e., older than 65 yr) have 1.5 times whereas only 39% of the cohort were over the age of 45.
the risk (after adjusting for exposure) of being found Baxter et al.2 have asked an important, yet complex,
responsible in litigation when compared with their younger question that requires serious analysis. We cannot, and
colleagues. Importantly, the degree of injury, as defined by should not, deny that there may be an unrecognized
the financial awards associated with the litigated cases, was problem pertaining to some anesthesiologists that is related
greater in patients of the older anesthesiologists. Tessler3 to an age-related decline in clinical abilities. Nevertheless,
acknowledged that his methodology, and hence his in order to develop a strategic approach to enhance patient
conclusions, had limitations due to the low frequency of safety, we need to identify the nature, extent, and
consequences of the problem as well as the solution.
The authors2 review physiologic changes that occur with
aging and speculate that the cause of the increased risk to
R. Byrick, MD (&)
patient safety may be perceptual limitations (e.g., hearing
Department of Anesthesia, St. Michaels Hospital, University of
Toronto, 30 Bond Street, Toronto, ON M5B 1W8, Canada or visual deficiencies) or cognitive decline, which would
e-mail: robert.byrick@utoronto.ca influence judgment and decision-making. They propose

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that the available evidence suggests a proactive safety from anesthetic complications may not be improved.
approach that could lead to a change in the default I would suggest that anesthetic safety is determined at any
position of continuing practice until a problem is age by the competence of the provider within the
recognized. They propose that the relevant departments environment in which he/she is practicing. The problem
and practice groups require their aging colleagues to of an aging workforce in anesthesiology is a systemic
undergo an annual review, including a demonstration of professional problem that requires a systemic professional
competence using simulation, to ensure their continued approach.
work in the hospital setting. Although this type of proactive Warner7 also considered the environment in which
approach may be intuitively appealing, the authors aging anesthesiologists work to be an important factor and
recognize that data are lacking to suggest that only older proposed a staged change in workload to reduce the impact
anesthesiologists have these deficiencies or that a of fatigue. This staged change included a reduction in night
simulation-based assessment would be an effective on-call shifts as well as a restriction in the scope of practice
screening tool specifically for aging anesthesiologists. and hours worked both intended as a means of providing
The authors also suggest that aging anesthesiologists an environment that fosters optimal patient care. Where are
may continue to practice due to a lack of retirement the data suggesting that the adverse events, which occur
savings. Interestingly, our professional society recognized specifically in aging anesthesiologists, take place
this issue many decades ago, and senior members of the disproportionately at night or after long shifts? Although,
profession initiated the Canadian Anaesthetists Mutual as already mentioned, this view is intuitively appealing.
Accumulating Fund6 to assist in providing financial Another feature of the operating room environment today
security. If financial considerations are the underlying is the increasing presence of anesthesia assistants acting as
cause for anesthesiologists to continue practicing, perhaps part of the anesthesia care team and providing important
inappropriately, our profession should once again examine support in managing difficult clinical problems. Optimiz-
pensions or further retirement strategies. ing the operating room environment may allow
Before adopting the strategy suggested by Baxter et al.,2 we anesthesiologists of all ages to provide safer patient care
should ask whether their proposal reflects the correct question without taking away the keys.7 If the fundamental
(i.e., a concern for overall patient safety) or whether it reflects problem is the inability of anesthesiologists to self-assess
an easier question (i.e., competence of aging anesthesiologists and match their competencies to patient care needs in the
working in hospitals), as Kahneman1 suggested was our environment in which they work, then addressing the
natural inclination. It should be emphasized that all studies environment and their self-assessment capabilities are key
show that the absolute number of adverse events (attributed to to improving safety for anesthesiologists of all ages.
anesthesiologists) that lead to complaints or litigation are Kahneman1 also analyzed decision-making in
greater in younger anesthesiologists, although the frequency is disciplines such as medicine. He pointed out that the
relatively higher in those older than 65. acquisition of expertise in complex tasks takes time
The suggested proactive strategy2 is a hospital-based because expertise in a domain is not a single skill, but
intervention that may help to reassure the public that rather a large collection of miniskills. He suggested that
patient safety is optimized in hospitals. Nevertheless, one the same professional may be highly expert in some tasks
predictable outcome is that aging anesthesiologists who in his/her domain, while remaining a novice in others. This
wish to continue in practice might elect to leave hospitals is the fundamental problem with using simulation-based
and practice in isolated out-of-hospital environments. assessments alone as a measure of global competence it
Out-of-hospital practice often lacks the safety of daily cannot assess the full range of miniskills required of a
collegial interactions that characterize group practice and practicing anesthesiologist and has never been validated to
supportive advice on patient care decisions. This do so. Warner7 asserts that many older physicians
environment may also limit opportunities for continuing compensate well for their lack of up to date
professional development. I would suggest that the practice knowledge with their experience. Kahneman1 concluded
environment for anesthesiologists of all ages is an that the likelihood for professionals to develop intuitive
important factor in the genesis of adverse events. This expertise, which characterizes experienced clinical
may have been another confounding variable in Tesslers decision-making, depends on the quality and speed of
study,3 as more elderly anesthesiologists may have been feedback in the clinical setting as well as on sufficient
working in isolated high-risk environments. Before opportunity to practice. He specifically mentioned that
assuming that the proposed strategy will enhance overall anesthesiologists benefit from feedback in clinical practice
patient safety, we should consider the potential societal because the effects of their actions are likely to be
impact. This may protect the hospitals (and practice immediately evident. He proposes that anesthesiologists
groups) from some medicolegal risk, but overall patient are in a better position than many other specialists to

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develop useful intuitive skills, specifically as a result of the intraoperative monitors for all patients without definitive
feedback inherent in their work. This assumes that they evidence of effectiveness, yet their use by all
take advantage of these opportunities for feedback or anesthesiologists, independent of age, was intuitively the
practice in a simulated environment. The value of right thing to do. The current Guidelines10 specifically
simulation for anesthesiologists of all ages may not be address Administrative and Educational Policies in
only in practicing technical and non-technical skills or in several areas, such as continuing competence for nurses
managing unpredictable rare clinical crises in a controlled caring for patients having neuraxial anesthesia. It is unclear
environment. A largely unrecognized benefit of simulation why these same Guidelines could not address minimum
is affording the clinical anesthesiologist the opportunity to standards for the maintenance of competence for all
practice self-reflection and to receive objective feedback on anesthesiologists. If the problem is a failure of
performance from peers. If the rationale for the adoption of anesthesiologists to self-assess their ability to make
a proactive strategy to address the problems of aging decisions effectively in their work environment (at any
anesthesiologists is their lack of ability to self-assess these age), then as a profession, we should build a meaningful
skills, then arguably, this is the problem that should be system to assess competence.
addressed. Kahneman1 stressed that professionals in many
areas of practice have not learned to identify the situations
and the tasks in which their intuition will betray them, and Lanesthesiologiste vieillissant:
these unrecognized limits of professional skill help to
explain why experts (of all ages) are often overconfident.
posons-nous la bonne question?
We must be careful not to deny that problems related to
aging exist in the anesthesia workforce but we must Kahneman,1 un laureat du prix Nobel, a reconnu que nous
understand and develop strategies to address the precise avions tous des avis personnels et des intuitions sur a` peu
nature and extent of the problem. Tessler3 was correct pre`s tout et que notre inclination naturelle nous pousse a`
more work is needed. It is somewhat ironic that our croire que nous restons rarement totalement bouche bee.
specialty in Canada is moving toward competence-based Quand une reponse satisfaisante a` une question complexe
assessment of residents,8 yet Baxter et al.2 focus on an age- nest pas facilement disponible, une reponse intuitive
based (time-based) model for continuing professional humaine courante consiste a` trouver une autre question
competence. The idea may be intuitively appealing, but apparentee a` laquelle il est plus facile de repondre. Dans ce
is it the answer to the correct question with respect to numero du Journal, Baxter et coll.2 abordent un sujet
patient safety? In a similar situation, the appropriate important qui a trait au professionnalisme des
relationship between surgical resident work hours and anesthesiologistes et du declin de leurs performances
adverse events was intuitively assumed, and shifts were cliniques lie a` lage. Les auteurs proposent une strategie
reduced in the name of patient safety. Nevertheless, recent proactive que les departements hospitaliers et les
reviews of this experience have documented that the groupes de professionnels devraient prendre en compte
expected improvement in patient outcomes has not been pour gerer ce proble`me. Ils identifient le fait que de
confirmed in fact, outcomes may be worse!9 This simply nombreux anesthesiologistes souhaitent continuer a` exercer
emphasizes that we need to be aware of unexpected au-dela` de lage de 65 ans et que laptitude des medecins a`
consequences of decisions based on assumptions that we sautoevaluer sest averee inadequate pour proteger la
believe are true but may be founded on unknown securite des patients. Nous devons nous demander si cette
preconceived notions. incapacite a` sautoevaluer est limitee a` ce groupe dage (il
Another option to consider as a proactive approach to y a dabondantes donnees probantes montrant que cette
the problem would be to ensure that all anesthesiologists lacune nest pas dependante de lage) et si on peut attendre
have purposeful periodic assessments of their patient de la strategie proposee quelle ameliore la securite globale
outcomes throughout their career not as a means to des patients.
retain hospital privileges, but as a professional Le fondement de la synthe`se entreprise par Baxter etait
responsibility and a guideline to practice. This would not partiellement en rapport avec les constatations de Tessler et
entail a single simulation-based high-risk assessment at age coll.3 pour qui les anesthesiologistes vieillissants
65, but rather, a meaningful peer assessment with self- (cest-a`-dire ages de plus de 65 ans) avaient un risque 1,5
reflection and peer feedback to optimize patient safety at fois plus eleve (apre`s ajustement pour lexposition) detre
all ages. The Canadian Anesthesiologists Society (CAS) consideres responsables dans des contentieux, par rapport a`
was among the first to implement national Guidelines to the leurs colle`gues plus jeunes. Il est important de noter que le
Practice of Anesthesia10 to improve patient safety. The degre des torts, definis par les dedommagements financiers
CAS adopted oximetry and capnography as routine associes aux cas litigieux, etait plus eleve pour les patients

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des anesthesiologistes plus ages. Tessler3 a reconnu que sa travail dans le cadre hospitalier. Meme si ce type de
methodologie (et donc ses conclusions) avait des limites demarche proactive peut etre intuitivement attrayante, les
dues a` la faible frequence des litiges en pratique clinique, a` auteurs reconnaissent que lon manque de donnees pour
lenvironnement de travail inconnu des differents groupes suggerer que seulement les anesthesiologistes les plus ages
et a` la meconnaissance du mecanisme sous-jacent a` ont ces types de deficits ou quune evaluation basee sur la
laugmentation du risque. Il a specule que le risque simulation pourrait etre un outil efficace de depistage
augmente chez les anesthesiologistes plus ages pourrait envers specifiquement les anesthesiologistes les plus ages.
avoir ete lie a` une plus grande fatigabilite, entranant une Les auteurs sugge`rent egalement que les
baisse de la vigilance, des temps de reponse allonges, une anesthesiologistes vieillissants puissent continuer a`
formation continue moins intense ou de moins bonnes pratiquer en raison dun manque depargne pour leur
pratiques de communications. Dans un commentaire, Eger4 retraite. Il est interessant de noter que notre societe
a remarque quun autre facteur confondant pourrait avoir professionnelle a identifie ce proble`me il y a deja`
ete que les deux groupes (cest-a`-dire les plus de 65 ans et plusieurs decennies et que les membres anciens de la
les moins de 65 ans) etaient fondamentalement differents profession ont cree le CAMAF ou Canadian Anaesthetists
en termes de formation et densembles de competences Mutual Accumulating Fund6 pour contribuer a` fournir une
depuis le debut meme de leur carrie`re professionnelle. securite financie`re. Si les considerations financie`res sont la
Lorsque lon traite de questions sociales et legales cause sous-jacente de la poursuite de lactivite clinique des
delicates, nous sommes tous daccord pour dire que lon anesthesiologistes, de facon peut-etre inappropriee, notre
ne doit pas tirer des conclusions possiblement erronees sur profession devrait de nouveau examiner les pensions ou de
des individus a` partir de lanalyse statistique de groupes. nouvelles strategies de retraite.
Il y a, toutefois, dautres donnees en faveur des Avant dadopter la strategie suggeree par Baxter et
conclusions de Tessler selon lesquelles lage des coll.,2 nous devons demander si leur reponse est le reflet de
anesthesiologistes est un facteur contributif a` la la bonne question (cest-a`-dire une preoccupation pour la
diminution des resultats favorables en pratique clinique. securite globale des patients) ou sils ignorent que leur
Campbell et coll.,5 par exemple ont rapporte que 52 % des reponse attire lattention sur une question plus facile
plaintes de patients enregistrees au Royaume-Uni par le (cest-a`-dire la competence des anesthesiologistes
General Medical Council impliquaient des vieillissants travaillant dans les hopitaux) puisque
anesthesiologistes qualifies depuis plus de 20 ans alors Kahneman1 a suggere que cela etait notre tendance
que seulement 39 % de la cohorte etaient ages de plus de naturelle. Il faut insister sur le fait que toutes les etudes
45 ans. Baxter et coll.2 ont pose une question importante et montrent que le nombre absolu devenements secondaires
neanmoins complexe qui requiert quon lanalyse (attribues aux anesthesiologistes) qui aboutissent a` des
serieusement. Nous ne pouvons pas, et ne devrions pas, plaintes ou des contentieux est plus eleve pour les
nier quil puisse y avoir un proble`me non reconnu ayant anesthesiologistes plus jeunes, bien que leur frequence
trait a` certains anesthesiologistes, qui soit une baisse des soit relativement plus importante chez les specialistes ages
habiletes cliniques liee a` lage. Neanmoins, pour elaborer de plus de 65 ans.
une demarche strategique destinee a` ameliorer la securite La strategie proactive2 suggeree est une intervention
des patients, il nous faut identifier la nature, letendue et les basee a` lhopital qui peut aider a` rassurer le public en
consequences du proble`me ainsi que sa solution. montrant que la securite des patients est optimisee dans les
Les auteurs2 passent en revue les changements hopitaux. Cependant, une evolution previsible est que les
physiologiques survenant avec le vieillissement et anesthesiologistes vieillissants qui souhaitent continuer a`
speculent que la cause de laugmentation du risque pour pratiquer puissent choisir de quitter les hopitaux et de
la securite du patient pourrait etre des limites de pratiquer dans des environnements isoles hors hopital .
perceptions (par exemple, des deficits auditifs ou visuels) Un exercice hors hopital est souvent depourvu de la
ou un declin cognitif qui pourrait influencer le jugement et securite que sont les interactions collegiales quotidiennes
la prise de decision. Ils proposent que les donnees qui caracterisent la pratique de groupe et les conseils et
probantes disponibles sugge`rent une demarche soutiens concernant les decisions de soins aux patients. Cet
proactive qui pourrait conduire a` un changement dans environnement peut aussi limiter les occasions de
la position par defaut qui consiste a` continuer dexercer developpement professionnel continu. Je sugge`rerais que
jusqua` ce quun proble`me soit reconnu . Ils proposent lenvironnement de pratique des anesthesiologistes de tous
que les departements et groupes de pratique concernes ages est un facteur important dans la gene`se des
demandent a` leurs colle`gues vieillissants de subir un bilan eve`nements indesirables. Cela pourrait etre une autre
annuel, y compris une demonstration de competence a` variable confondante de letude de Tessler,3 car des
laide de simulation, pour assurer la poursuite de leur anesthesiologistes ages peuvent avoir travaille dans des

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environnements isoles a` haut risque. Avant de proposer que comme mesure de la competence globale: elles ne peuvent
la strategie proposee ameliore la securite globale des pas evaluer leventail complet des mini-habiletes que
patients, nous devons considerer son possible impact sur la doit posseder un anesthesiologiste praticien et elles nont
societe. Cela pourrait proteger les hopitaux (et les groupes jamais ete validees pour cela. Warner7 soutient que de
de pratique) dun certain risque medico-legal, mais la nombreux medecins plus ages compensent bien leur
securite globale des patients par rapport a` des manque de connaissances mises a` jour grace a` leur
complications de lanesthesie pourrait ne pas etre experience. Kahneman1 a conclu que la probabilite que des
amelioree. Je sugge`rerais que la securite anesthesique professionnels developpent une expertise intuitive, qui
puisse etre determinee a` tout age par la competence du caracterise une prise de decision clinique basee sur
fournisseur au sein de lenvironnement dans lequel il ou lexperience, depend de la qualite et de la vitesse du
elle exerce. Le proble`me dun effectif vieillissant en retour dinformation dans le cadre clinique et aussi de la
anesthesiologie est un proble`me professionnel systemique possibilite davoir une activite suffisante. Il a indique de
qui necessite une demarche professionnelle systemique. facon specifique que les anesthesiologistes beneficiaient du
Warner7 a egalement considere que lenvironnement retour dinformation en pratique clinique parce que les
dans lequel travaillent les anesthesiologistes vieillissants effets de leurs actions avaient toutes les chances detre
est un important facteur et a propose une modification par immediatement visibles. Selon lui, les anesthesiologistes
etapes de la charge de travail pour reduire limpact de la sont mieux places que de nombreux autres specialistes pour
fatigue. Ce changement par etapes incluait une reduction developper des habiletes intuitives utiles, plus
des gardes de nuit ainsi quune limitation dactivite pour particulie`rement du fait du retour dinformation inherent
certains domaines et du nombre dheures travaillees, ces a` leur travail. Cela suppose quils puissent tirer parti de ces
deux mesures etant destinees a` creer un environnement occasions de retour dinformation ou pratiquer dans un
favorisant des soins optimaux aux patients. Ou` sont les environnement simule. La simulation pour les
donnees suggerant que les eve`nements indesirables, lies anesthesiologistes de tous ages peut ne pas avoir
specifiquement aux anesthesiologistes vieillissants, uniquement de la valeur pour sexercer a` des habiletes
surviennent de facon disproportionnee la nuit ou apre`s de techniques et non techniques ou a` la gestion des crises
longues gardes? Meme si, comme cela a deja` ete cliniques rares et imprevisibles dans un environnement
mentionne, cette idee parat intuitivement attrayante. Une controle. Un avantage largement meconnu de la simulation
autre caracteristique de lenvironnement dune salle est de donner aux anesthesiologistes cliniciens la
doperation moderne est la presence croissante possibilite de reflechir sur leur propre pratique et de
dassistants danesthesie agissant comme membres de recevoir un retour dinformation sur leurs performances de
lequipe de soins anesthesiques et apportant un soutien la part de leurs colle`gues. Si la justification de ladoption
important pour la gestion des proble`mes cliniques dune strategie proactive pour repondre aux proble`mes
difficiles. Loptimisation de lenvironnement de la salle poses par les anesthesiologistes vieillissants est leur
doperation peut permettre a` des anesthesiologistes de tous manque de capacite a` autoevaluer ces habiletes, alors
ages de fournir aux patients des soins plus securitaires sans cest sans doute ce proble`me-la` quil faut resoudre.
avoir a` confisquer les cles .7 Si le proble`me Kahneman1 a insiste sur le fait que, dans de nombreux
fondamental est lincapacite des anesthesiologistes a` domaines de lexercice du metier, les professionnels nont
sautoevaluer et a` faire correspondre leurs competences pas appris a` identifier les situations et les taches dans
avec les besoins des soins des patients dans lesquelles leur intuition pourrait les trahir et ces limites
lenvironnement dans lequel ils travaillent, cest alors non identifiees de lhabilete professionnelle permet en
lenvironnement et leurs capacites dauto-evaluation qui partie dexpliquer pourquoi des experts (de tous ages) sont
sont les cles permettant dameliorer la securite pour les souvent trop confiants dans leurs capacites.
anesthesiologistes de tous ages. Nous devons faire attention a` ne pas nier quil existe des
Kahneman1 a egalement analyse la prise de decision proble`mes lies au vieillissement dans leffectif des
dans des disciplines telles que la medecine. Il a fait anesthesiologistes, mais nous devons comprendre et
remarquer que lacquisition dune expertise dans des taches elaborer des strategies pour repondre a` la nature precise
complexes prend du temps parce que lexpertise dans un et a` letendue du proble`me. Tessler3 avait raison: il faut
domaine ne repose pas sur une seule habilete, mais plutot poursuivre les recherches. Dune certaine facon, il est
sur une grande serie de mini-habiletes . Il a suggere que le ironique quau Canada notre specialite se dirige vers une
meme professionnel peut etre un grand expert de certaines evaluation des residents basee sur les competences8 alors
taches dans son domaine et rester novice dans dautres. que Baxter et coll.2 sinteressent a` un mode`le base sur lage
Cest la` lun des proble`mes fondamentaux souleves par (base sur le temps) pour ce qui concerne le maintien de la
lutilisation devaluations basees sur de la simulation seule competence professionnelle. Lidee pourrait paratre

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attrayante, mais est-ce la reponse a` la bonne question pour a` auto-evaluer leur capacite a` prendre efficacement des
ce qui concerne la securite des patients? Dans une situation decisions dans leur environnement de travail (quel que soit
semblable, la relation appropriee entre les heures de travail leur age), alors, en tant que profession, nous devons batir un
chirurgical des residents et les eve`nements indesirables a syste`me adequat pour evaluer les competences.
ete supposee de facon intuitive et les gardes ont ete reduites
au nom de la securite des patients. Neanmoins, des Acknowledgements The author thanks Dr. David Mazer and Dr.
David McKnight for their thoughtful comments on the manuscript. As
analyses recentes de cette experience ont montre que a disclosure of potential bias and conflict of interest, the author is
lamelioration attendue des resultats pour les patients ne compelled to acknowledge that, although he may perceive that he is
sest pas confirmee: en fait, les resultats pourraient etre mid-career, his colleagues continue to remind him that he is a senior
moins bons!9 Cela souligne simplement le fait que nous member of the Department.
devons avoir conscience des consequences inattendues de Conflicts of interest None declared.
decisions basees sur des hypothe`ses que nous pensons
vraies, mais qui sont fondees sur des notions preconcues Conflits dinterets Aucun declare.
inconnues.
Une autre option a` envisager comme demarche
proactive face au proble`me serait de sassurer que tous
les anesthesiologistes aient des evaluations regulie`res References
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