In the fall of 2015, Dr. Herbert Dardik, chief of the vascular surgery department at Englewood Hospital and the New Jersey Medical Center, nodded in the operating room.
Note that Dr. Dardik, then 80, did not perform the operation. He had himself undergone a minor medical procedure a few days earlier. He had told his patient that another surgeon would take care of his carotid endarterectomy, in which plaque was removed from the carotid artery to improve blood flow.
But when she at least asked Dr. Dardik to be present during the operation, he agreed to sit down. "I was really an accessory," he recalled. "It was so boring, I didzed off a bit," and an alarmed anesthetist nurse reported the incident to the administrators.
A few days later, the chief of anesthesiology and the hospital's chief doctor were in Dr. Dardik's office, praising his surgical skills while asking him to reduce his workload.
"I got so upset that I got up and opened the door and said," Get out, "said Dr. Dardik. "Who knows better what I can do but myself?"
He also resisted the suggestion of being tested at Sinai Hospital in Baltimore, who had set up a two-day program to assess whether older surgeons could continue to practice safely.
Shortly after, Dr. Dardik was on a plane when his captain, who looked older, came aboard. (Federal regulations prescribe a retirement age of 65 for commercial pilots.)
"I hope this guy is always good," recalls Dr. Dardik. At one point, "it hit me like a hammer – that's what others think when they look at me."
A few weeks later, he became the first physician evaluated by the senior surgeon program at Sinai Hospital.
Like the rest of the population, the physician labor force has become much more gray in recent years. According to the American Medical Association, nearly a quarter of practicing physicians were 65 or older in 2015. In 2017, more than 122,000 physicians in this age group took care of patients.
Health researchers and analysts are debating what needs to be done, if any, against this wave of aging practitioners. "We know that human faculties decrease with age," said Dr. Mark Katlic, a thoracic surgeon behind the Sinai Hospital program.
The decline in vision, hearing and cognition can affect any health professional (or any human being). But Dr. Katlic has expressed a particular concern for surgeons, who must maintain exceptional vision, manual dexterity, speed of reaction and endurance.
After the age of 70, "can you catch a tiny blood vessel with forceps and not catch anything else?" He asked. "Or use very small instruments for sutures?" Some operations, he said, last six or seven hours or more.
The studies did not provide clear answers to these questions. Cognition and other abilities decrease with age – but the variability among individuals increases.
At age 75, "there are great and talented doctors, and those who need to stop," said Dr. E. Patchen Dellinger, senior author of a review on aging physicians published in JAMA Surgery.
The question of whether the results of older surgeons is worse than that of younger surgeons also remains questionable, as decades of experience and judgment can offset modest physical or cognitive declines.
A large study of Medicare patients found that surgeons over the age of 60 had higher mortality rates for several types of operations, including coronary bypass, but not for other procedures. And the differences were small, especially among doctors who performed little surgery.
Last year, on the other hand, researchers who looked at the records of nearly 900,000 Medicare patients reported that surgeries performed by older surgeons resulted in lower mortality than younger physicians.
"It's probably a small percentage of 70-year-old surgeons who have problems, maybe 5 or 10 percent," said Dr. Katlic. "But these are the ones we want to identify."
This proved to be discouraging. "The public believes that we regulate ourselves as a profession," he added. "We do not do it, at least not very well."
For example, in a statement published in 2016 by the American College of Surgeons, older surgeons were subjected to physical, visual and neurocognitive tests, but on a completely voluntary basis, with no obligation to disclose the results.
Becoming a surgeon is difficult, it's a grueling marathon. But staying is not very demanding, say the experts. The recertification of usual hospitals tends to be superficial. Peers often fail to report disturbing behavior, especially since experienced physicians can be powerful and respected characters.
Research also indicates that older surgeons do a poor job of judging their own skills. "We're sort of a fraternity of highly regarded professionals," said Dr. Dellinger. "And we consider ourselves highly."
Doctors are against the idea of slowing down or moving away, added Dr. Glen Gabbard, a psychiatrist at Baylor College of Medicine, specializing in the psychological assessment of physicians.
"Being a doctor is at the heart of who they are," he said. "It's become something they can not give up. They can not imagine retiring. "Who will take care of my patients?"
A mandatory retirement age could solve such problems. But it could also violate the laws of discrimination, put away perfectly competent doctors and leave rural communities even more underserved.
Counsel argues that mandatory testing at a later age is a better approach, a way to distinguish the most experienced experienced professionals from those who should retire, reduce their responsibilities or transition to teaching, and other roles.
Some hospitals have already adopted this tactic, including the University of Virginia Health System, the Temple University Hospital and the UPMC in Pittsburgh.
End-of-career practitioners' policies, as they are often called, come into effect at age 70 and generally cover not only physicians but also nurse practitioners, medical assistants and other professionals.
The Society of Surgical Chairs, which represents leaders of academic medical centers, could strengthen these efforts in the coming months when it will publish a new white paper entitled "Transitioning the Senior Surgeon". The president of the company, Todd Rosengart, expects the report to spark broader discussions.
But for the moment, the number of institutions taking formal age-related measures remains minimal. In its fifth year, the Sinai Hospital Evaluation Program screened eight surgeons aged 55 to 81 years old.
As the first researcher, Dr. Dardik found the test difficult, but it worked well. The program report indicated that it could continue to function.
When the evaluation team talked about his performance, "most people said," If I needed a short surgical procedure, such as a carotid endarterectomy, I would do it do, "recalls Dr. Katlic. However, they could opt for someone from a younger age.
Back in Englewood, however, Dr. Dardik began to experience an intensification of back pain. Worried about distractions in the O.R., he voluntarily stopped performing surgery in 2016.
Now 83, he still comes to the hospital every day of the week, but he went on to research, teach and mentor.
"You think you are invincible," he reflects. "But time is running out and I have become a supporter of evaluation."
He could not, however, convince his colleagues to adopt an end-of-career program. "We were looking at it," he said. "I thought we were getting there. Then he collapsed discreetly. "