The Problem of the Aging Surgeon (2009) | Hacker News Reader

The Problem of the Aging Surgeon (2009)

ncbi.nlm.nih.gov

75 pointsJabavuAdams56 comments

I work in the medical device industry and one major dynamic that's improving surgical capabilities for aging surgeons is the increase in surgical robots.

I was in a lab testing a new product on the da Vinci Robot and one of the surgeons commented to me that "this robot will add another 10 years to my career" -- he was probably in his early 60's already! It will be very interesting to see how robotic technology changes surgical outcomes as robotic surgery becomes the standard of care.

Agree. Robotics hasn’t even really penetrated the market for treatment or diagnostics yet. There are many opportunities.

I'm really not sure it will any time soon.

I think robot enthusiasts sometimes underestimate what hands attached to a brain full of knowledge really are capable of.

There's a problem software developers have to solve if they really want robots to be a full replacement for a human physically performing a task and that's a way for the trained humans to communicate their knowledge to the robot. The problem with this is that most people really aren't great at communicating precisely. They have a hard time teaching each other and are often hopeless when it comes to giving precise and complete instructions for something to a robot. forget complex tasks like surgery even gardening and washing dishes is hard. Even something as simple as "grab the thing" is a pretty big project.

Maybe in the future as robots become more common speaking with the level of precision required will also become common (kind of like what happened to culture with the web and email.)

I think you are thinking of robotics in the sense of replacing surgeons or being an autonomous partner.

While OP is talking of robotics as an assitive tool to help a surgeon make finer or less invasive movements.

I'd really like to see robotic (light's out) pharmacies become a thing. Removing the extremely expensive Pharmacist from simply counting pills for things like repeats of common medications. This would surely reduce consumer costs with little/zero risk.

The idea of having a pharmacist is outdated and terribly expensive. Most countries dispense medications in blister packs. Why should anyone have to count pills in the first place? Give the patient a 7, 14, 30 or 90 count blister pack and done.

> add another 10 years to my career" -- he was probably in his early 60's already

I have absolutely no problem - even prefer - having a surgeon with 40+ yrs experience operating on me via a robot device that removes any tremors from old age. Their experience is what matters.

"In the end, the study group consisted of 291 patients (330 knees). Younger surgeon age was correlated with fewer complications"

There is a danger in such statistics in that for example older surgeons may have been assigned the more difficult cases.

You're right; it's probably a bell-shaped curve.

Simpson’s Paradox

https://www.lesswrong.com/posts/7FJRnxbRtT7Sbzizs/simpson-s-...

My father-in-law was an ophthalmic surgeon who "retired" in his 60's. In his case, he had a clear "line in the sand", where his fine motor control became reduced and he could no longer do the kind of delicate work his profession required.

This means other surgeons are also compromised but are "getting away with it" and also giving poorer results.

"Only wine and cheese improve with age". Fair warning, future fellow robotic workers..

More seriously, the issue of lack of formal training in emerging techniques (note the -40- year olds who have missed the latest hip surgery technique) has nothing to do with 'degraded cognitive abilities due to aging', and really should be discussed in context of a 'continuity of education and certification' regime. It is not an issue of age, rather the time it takes to produce skilled worker in a domain, and the frequency of significant breakthroughs/changes in that domain.

[edited]

This really disturbs me. Why wouldn't surgeons be constantly retrained on newer surgical techniques? Shouldn't this be standard procedure? Why should any patient have to suffer with the scars and complications from an old-style surgery instead of a newer less-invasive technique just because some surgeon hasn't bothered getting trained on the newer technique?

Instead of forcing them to retire, perhaps assign them to less demanding surgeries.

Or just much less surgeries, or only in support of newbies.

Fatigue and speed of execution seem central.

That's not how it works -- most surgeons aren't "assigned" surgeries. They run a practice, focused on a particular disease state, and perform surgeries on their patients to address health issues with respect to that disease state.

With that said, the kind of surgery being performed does have an impact on the body of the surgeon in terms of their posture.

It can work like that. Here in the UK, we increasingly rely on Surgical Care Practitioners - nurses who can independently perform a specific set of routine surgical procedures. Medicine stands to benefit greatly from the division of labour and economies of scale; a large surgical unit with a diverse range of skillsets can perform more surgeries with better outcomes at lower cost.

https://www.healthcareers.nhs.uk/explore-roles/medical-assoc...

You seem to be confusing the nature of the doctor-patient relationship (i.e., whether the patient contracts with the doctor or contracts with the hospital who employs a doctor) with the use of surgical assistants (generally a type of physician's assistant). Private practices routinely use PAs in the US to do less demanding procedures, just like the UK. Obviously, the nature of the doctor-patient relationship will influence the degree to which PAs are used -- patients generally want full surgeons, while 3rd party payers like the government want to save costs -- but that doesn't undermine zomg's correction of WalterBright's comment.

I think it's more a question of ability than age. For surgeons in particular, it seems there needs to be a clear line drawn when it comes to factors like fine motor control or vision being compromised. Perhaps it's on the medical field to determine these diagnostics and actively regulate/test for them.

DeBakey performed his last surgery at age 90 [1], pioneered numerous procedures -- including one performed on himself at age 97 [2], and continued to practice medicine until his death at age 99. Remarkable person, but obviously an outlier. Just thought it would be interesting to bring him up in this thread.

[1] https://www.telegraph.co.uk/news/obituaries/2403698/Michael-...

[2] https://www.nytimes.com/2006/12/25/health/25surgeon.html

This is a very difficult problem. Aging is emotionally painful.

I think it is insane that in our societies (Western, I am not American) we prolong the age of retirement. I believe it should be 60, tops. And we should have culture that would celebrate moving to retirement, to make sure that people do not feel useless all of sudden.

But it is often hard for, especially really good, people to go into retirement, because you still have a (usually wrong) feeling that you can continue as if they were younger, and they see all the young hacks doing the same mistakes.. So if the society could support these people in giving up, I think it would be helpful for everybody.

As the Czech saying goes - stop at the best time. We should do that even if it is a small economic loss.

And spend the next 20-40 years hanging out?

Hopefully, over the next couple of decades more people reach a healthy 100.

https://www.smithsonianmag.com/smart-news/there-are-more-ame...

As we said to one of the old guys at work who didn't really want to be there anymore, didn't need the money and just hung around for the routine...

Join Rotary and volunteer or something. There are loads of things you can do that would make the world better.

...or you could pick a different/another career:

Writer, director, fund manager, ... Warren Buffet is still managing a lot of money at 88.

https://en.m.wikipedia.org/wiki/David_McCullough

https://en.m.wikipedia.org/wiki/Warren_Buffett

https://en.m.wikipedia.org/wiki/Carl_Icahn

https://en.m.wikipedia.org/wiki/Donald_Knuth

https://en.m.wikipedia.org/wiki/Woody_Allen

https://en.m.wikipedia.org/wiki/Martin_Scorsese

https://en.m.wikipedia.org/wiki/Bill_Belichick

Except all those people started their careers when they were much younger. How many people start a new career at retirement age and actually make it really successful?

> And spend the next 20-40 years hanging out?

I think this is a great point. I don't think it detracts from the post in question. But it highlights the observation that many do not seem to have anything meaningful to do outside work. Anecdotally, I've heard of people coming out of retirement because they were bored stiff. I'm wondering whether or not we should develop a broad range of interest and possibly hobbies/vocations that we could transition to in "retirement". Alternatively not retire altogether but transition to a different role more in line with our capabilities as we age.

Yes, that's what I was thinking. Just say, when you're 60, and you feel at the peak, now I am going to do something else as a hobby.

But again, this goes against our tradition where we celebrate "real work" and not doing something for fun or as a hobby.

That's exactly what the person you are replying to meant when they said:

"And we should have culture that would celebrate moving to retirement, to make sure that people do not feel useless all of sudden."

We need something other than just "hanging out".

Having other people “celebrate” your moving to retirement is a far cry from having meaningful purpose.

I am not suggesting that purpose is only found in work, only that getting others to pat you on the back for being retired doesn’t help much either.

By "celebrating", I meant counter the societal pressure to continue to perform.

Today, somebody retiring at the peak is considered an (economic) loss. Perhaps it shouldn't be.

I might be mistaken, but I think what the parent tries to say is taht while there is societal pressure to 'not be an economic loss', there's also something more personnal about not being able to cope with having nothing to do.

A non-negligible amount of retired people just sit at home, depressed, until death, out of a lack of better things to do.

Even celebrating their retirement would not make their day less grim.

I deliberately wasn't specific when I said "So if the society could support these people in giving up". Support can mean many things, for example support them having other hobbies (that do not contribute direct economic value, but rather only enjoyment).

Some people enjoy retirement. We have a retired army major attending our local python meetup without feel. He learns Python with great enthusiasm. He is now trying to understand cyber security. Having said that, that level of enthusiasm is a rare mindset and signs of indefatigable spirit.

Retiring at 60 would pose financial challenges for many people in the US.

Nearly 20% of 70-year-olds are working now. Source: https://www.bls.gov/emp/tables/civilian-labor-force-particip....

For many, this is an economic necessity. For well-heeled surgeons, it may be more of a choice -- the desire for extra financial cushion.

Making a lot of money does not mean you have a lot of money. There are quite a few people who pull down huge salaries, spend it all, and live paycheck to paycheck.

Arguably, it is the best option if you have enough security through insurance; put all your extra cash into some kind of investment.

> Retiring at 60 would pose financial challenges for many people in the US.

Which is frankly insane too. It's not like the wealthiest nation on Earth couldn't support these people.

USA is the 10th wealthiest nation per capita.

Have you actually run the numbers? We could support an earlier retirement age but it would require a major reduction in living standards and higher taxes for everyone else. There's nothing insane about opposing that.

Too much defence spending perhaps?

This is a complicated can of worms...

In the past, it was certainly possible to have high living standards economies and relatively low retirement age. I don't think, even if you take longer age into account, that people are such a big spenders that it would be impossible to replicate today.

There is a theory that lot of (especially service and high-pay) jobs are actually bullshit, and detract rather than add social value. So if people retire these jobs sooner, living standards might actually increase for everybody.

Financial is the least of it. There is a spike of people who die right after they retire - they never learned how to fill their free time. Keeping busy and having friends is one of the keys to live a long life. A job provides both of those for you.

> Keeping busy and having friends is one of the keys to live a long life.

source?

It's pretty well documented and both the popular and academic literature I believe. A quick search at found http://longevity.stanford.edu/social-engagement/ to start.

> you still have a (usually wrong) feeling that you can continue as if they were younger, and they see all the young hacks doing the same mistakes.. So if the society could support these people in giving up, I think it would be helpful for everybody.

I think many retiring people in this situation would be okay with having a period of companionship where they would work together with a younger professional until they feel they are able to work on their own, and then retire. It used to be a common practice in the past.

But it would be less economical (from a short-sighted point of view) as two persons would have to be paid (even if not a full pay maybe) for the work of just one for some period, and of course there is no obvious way to prevent all kinds of loopholes and bad incentives, so it's just easier to do it like we do now, a local minimum caused by individual-centric policies.

I think phased retirement is the best approach. We see this in academia all the time and also at NASA. There’s a period of time over several years where people start doing part time work, then even after retirement they’re often brought in for consulting. At NASA in particular, it’s been 50 years since Apollo and NASA is trying to go back to the Moon and these old folk have tons of irreplaceable insight. Invaluable, really, and in my opinion their limited lifespan adds (or ought to add) a significant sense of urgency to NASA’s current efforts.

Also reminds me of https://en.wikipedia.org/wiki/Senior_status

The data I’ve looked at is surprisingly unclear on whether or not people enjoy retirement versus working. For empowered workers in meaning filled fields, such as surgeons, I could easily see retirement being unsatisfying versus working.

Also it makes no sense for society for people to "go out at their best," even if that can be well predicted. If a person is great at 40, even better at 55, and back to great at 70 we shouldn't care they were better 15 years ago, just that they are great today.

Off topic, but every time I see the domain in parentheses on links from pubmed, it shows up as nih.gov. I know that the NIH/NLM runs pubmed, but I feel like I get misled thinking that this is an official NIH publication before I click on the link.

The important thing is that the NIH domain hosts the PubMed website, not that the NIH runs PubMed from an administrative standpoint. The domain in parentheses tells you the URL domain for the link, nothing more, and shouldn't be interpreted as endorsement. It would be infeasible for HN to automatically determine who the authoring/endorsing institution is.

I know, I guess my brain has been trained to think of it as an endorsement even though I can infer that it likely isn't.

Discussion point: Uni is not the only way to be educated about something. In fact, I have found industry experience to be more effective learning

You didn't read the article did you? This is not about experience, it's about getting old enough that you've got lapses in attention no longer are fully aware of what you're doing. It's about being good at A, but times change, and since you're good at A, you're assumed to be good at B too, but you are not. It's about systems evolving around highly esteemed people, that make detecting life-threatening situations hard or impossible.

A large portion of the article mentions specifically that students who graduate uni more recently are educated in more modern surgical techniques .. but the premise assumes the surgeon basically doesn’t learn on the job which I’m not sure is a strong argument

"You didn't read the article did you?"

Firstly, don't be an ass.

Secondly, the article mentioned many factors, including specifically "quantity of education, remoteness of education", which are arguably are not an issue if an old dog keeps learning new tricks.

"When contemplating the effect of age on surgeons, quantity of education, remoteness of education, and obsolescence of the content of the education are all at least theoretical concerns."

"Please don't comment on whether someone read an article. "Did you even read the article? It mentions that" can be shortened to "The article mentions that.""

https://news.ycombinator.com/newsguidelines.html

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