To the Editor:
The excellent article by Tessler et al. 1and the accompanying editorial by Warner2offer an intriguing glimpse into one of many challenges confronting older anesthesiologists.3However, this study paints in broad strokes the issue of medico-legal experience that might obscure important details. The risk of suboptimal clinical outcomes and resulting litigation can be minimized if all clinicians, including older ones, limit their practice to exclude those procedures that they rarely perform. As demonstrated in a report on surgical mortality subsequent to various complex surgical procedures, older surgeons’ age was not an independent predictor of surgical risk, provided that the surgeon maintained a high volume in those specific procedures.4On the other hand, bad outcomes occurred most frequently among older surgeons who maintained low volumes in those same procedures.
The study by Tessler et al. 1failed to identify this potential confounding variable among their study subjects. Although the authors’ analysis did account for overall clinical volume, the small numbers precluded further stratification to identify which of those bad outcomes occurred when older anesthesiologists were working outside their “comfort zone”– regardless of whether or not these were intrinsically complex cases or straightforward cases in unfamiliar patient populations (i.e. , pediatrics, bariatrics, obstretics, and so forth). The study of surgical mortality (previously cited) suggests that bad outcomes among older anesthesiologists could be minimized by stricter attention to case assignment. To extend Warner’s analogy, maybe we should design ignition keys that restrict a senior citizen’s access to a 4-cylinder pickup truck on a snowy winter evening as well as a 16-cylinder high-performance sports car on a sunny afternoon.
As suggested by the authors, these findings should inspire additional studies to examine what is a growing source of concern as our specialty continues to age.
, Yale University School of Medicine, New Haven, Connecticut. jonathan.katz@yale.edu
