AANS Neurosurgeon
Dear Editor:
I read “Retirement and the Myth of Sisyphus” by Dr. Patrick Kelly and the companion piece by Dr. Deborah L. Benzil, published in AANS Neurosurgeon with great interest.
Dr. Kelly advises us that he retired when it was “time to check out while I’m at the top of my game.” He also wanted to enjoy his accumulated neurosurgical income and his houses around the world. Dr. Benzil has a more nuanced view. She recognizes that “there are neurosurgeons neither financially nor emotionally prepared to just walk away.” There are neurosurgeons, many or perhaps even the majority, who “live, breathe and eat neurosurgery.” For these people, what they do often defines who they think they are. Dr. Benzil also describes other neurosurgeons who “move beyond the traditional boundaries of neurosurgical practice in their professional worlds with additional degrees and skills apart from neurosurgery.”
Neither article comments on an increasingly urgent matter being debated in public health policy. Does the public (do patients) have a stake in the process of physician retirement? It is clear that the public, medical boards and hospitals do not want mentally or physically incompetent surgeons, of any age, operating on patients. It is also true that advancing age is often associated with increasing physical, cognitive or mental infirmities.
How should the medical profession “police” itself? Physicians are said to be poor evaluators of their own skills and performance. However, the individual doctor has a responsibility for self-evaluation. We may recruit others, e.g. our personal physician, other surrogates, to do this assessment. An infirmity-denying physician is a danger to both patients and himself.
Mandatory retirement at a given age is still a widespread practice for certain occupations in the United States, despite our Federal mandate against age discrimination. For example, airline pilots must retire at age 65 (raised from 60 only a few years ago). Many medical institutions still have mandatory retirement ages, especially for surgeons.
Wary of the legal thicket surrounding enforced retirement, some medical institutions have adopted policies for retirement based on a series of psychometric and physiological tests. Unfortunately, not one of these tests has been correlated in any meaningful way with practice performance.
Who, then, is to make this decision? Most neurosurgeons work in hospitals, medical schools or private practice groups in which a chief of service is delineated, placing the evaluation of practice competence on that individual, clearly an important responsibility. I personally lived through an uncomfortable period at the Neurological Institute of New York (Columbia University) when the Chairman of Neurosurgery had to ask for the retirement of a nationally known, prominent neurosurgeon. The important criterion here is that the chief of service evaluates the practice performance of the faculty or staff. When I was Chairman, I designated and legally authorized one of my faculty members (now a prominent program director) to evaluate my own performance, with the ability to suspend my privileges. Once I stepped down from the Chair, it became the responsibility of the current Chairman to evaluate my practice. The principle is that this decision rests in the hands of doctors, based on criteria encompassed by practice performance.
My perception of myself is that of an operating surgeon, performing lengthy, complex tumor removals. Neurosurgical training and its clinical practice condition us to have the physical stamina required for lengthy, complex, high-stakes surgery. I no longer possess this conditioning! Several years ago, I decided not to take on any surgery which required more than 90 minutes of OR time. When an operation required “extra innings,” I was painfully aware of the physical effort involved. Later, I decided that I should stop performing any surgery in my 80th year. Following my 79th birthday, in January 2016, I put this plan into place.
In June 2010, when elected president-elect of the AMA, I informed the Dean of the Medical School that I would resign my Chairmanship. Despite the Dean’s protests, I formally resigned. The recruitment process went forward, and in January 2012, a new Chair was appointed. I left the Chairmanship without regret or backward glance and have tried assiduously not to interfere with my successor. I do not regret my decision to leave the Chair at all.
In contrast, my determination to stop performing surgery left me with an entirely different feeling. I experienced a real sense of loss and a feeling of denial of who I was. Almost three months later, my decision still feeds self-anxiety. The other medically related components of my life, teaching, mentoring, writing and delivering speeches carry on. My patients nervously ask whether I will continue to see them, and of course I will. My institutional obligations are no less pressing now than before. There is much left to do!
Peter W. Carmel, MD, D. Med Sci
Director, Neurological Institute of New Jersey
Professor and Chairman Emeritus
Department of Neurological Surgery
Rutgers, The State University of New Jersey
President 2011-2012
American Medical Association
