Overall, investigators found that surgeons within this 15-year age range had a lower risk for postoperative complications during thyroidectomies when compared with both their less and more experienced counterparts.

“The take-home message of the study is that surgeons can’t necessarily expect to maintain their top performance without trying to improve every day,” said lead study investigator Antoine Duclos, MD, assistant professor of public health in the Department of Medical Information, Health Evaluation and Clinical Research at Lyon Academic Hospital in France. “Surgeons should want to assist in tracking their own outcomes over time to see whether they are performing well and how they can get better.”

Previous studies have shown that surgeons generally reach their peak performance between the ages of 30 and 50 years and that physicians in practice for more years tend to possess less factual knowledge and are less likely to adhere to guidelines. In 2006, researchers looked respectively at mortality in approximately 461,000 patients undergoing one of eight surgical procedures between 1998 and 1999 and found that for pancreatectomy (adjusted odds ratio [OR], 1.67), coronary artery bypass grafting (OR, 1.17) and carotid endarterectomy, surgeons older than age 60 years, particularly those with low procedure volumes, had higher operative mortality rates than their younger counterparts (Ann Surg 2006;244:353-362). For the other five procedures, however, surgeon age was not an important predictor of patient mortality.

Although the results showed a tenuous relationship between age and postoperative risk, the study helped spawn a discussion about the possible drop in surgical performance over time. “Is there a decline in fine motor skills, worse judgment with advancing age, less of a grip on how to use new technology?” asked Amir A. Ghaferi, MD, MS, research fellow with the Michigan Surgical Collaborative for Outcomes Research and Evaluation group, in the Department of Surgery, University of Michigan Health Systems, Ann Arbor, who was not involved in the study. “I don’t think anyone really knows why a surgeon’s performance may decline after a certain age. You can speculate until you’re blue in the face, but it’s hard to say anything definitively.”

To help clarify whether years of surgical experience are associated with postoperative outcomes, Dr. Duclos and his colleagues prospectively collected outcomes data on 3,574 thyroid procedures completed by 28 surgeons between April 1, 2008 and Dec. 31, 2009, at high-volume referral centers in five academic hospitals in France. The team used thyroid surgery as a benchmark because it is a highly reproducible and well-defined procedure that has not changed substantially in many years. The two major complications of thyroid surgery measured—recurrent laryngeal nerve palsy or hypoparathyroidism—were evaluated once 48 hours after surgery and again six months postsurgery. The researchers also recorded all patient demographics as well as surgeons’ background and professional experience, adjusting surgical performance by the type and complexity of cases treated.

The investigators discovered that surgeons with five to 20 years of experience, those between the ages of 35 and 50 years, had the lowest risk for permanent complications after thyroid surgery. And it was surgeons in practice for 20 years or longer, not inexperienced surgeons, who had the greater increased risk for permanent complications after thyroid surgery. According to a multivariate analysis, 20 years or more of practice was associated with increased probability of both recurrent laryngeal nerve palsy (OR, 3.06; P=0.04) and hypoparathyroidism (OR, 7.56;P=0.01). The researchers, however, did not identify a volume threshold or a particular time of day associated with an increased risk for complication.
Dr. Duclos and his co-authors pointed to several possible explanations for why surgeon performance can decline over time, including mental fatigue from repeating detailed procedures over many hours, reduced stress with age or habits that might lead to poor compliance and increased complication rates as new techniques are introduced. Additionally, many veteran surgeons spend more time on academic and administrative duties than their younger colleagues, which could affect their attention in the operating room.

“Despite these findings, surgeon age is still a pretty weak predictor of outcomes, and the study is not predictive on the individual level,” said Dr. Ghaferi.

Dr. Duclos added that the results certainly cannot be generalized. “We don’t know if this trend holds for other surgeries, in other countries at other hospitals,” said Dr. Duclos.

To make sure surgeons continue to execute their surgical duties at a high level, Dr. Duclos suggested that the individual performance of surgeons should be tracked over time, not by benchmarking, but by receiving feedback on their outcomes every month or every quarter and by continuing to train in new techniques in order to keep sharp. “This way, if at some point a surgeon starts to perform poorly, he or she can work on figuring out the problem, sharpening techniques or changing tactics,” Dr. Duclos said.
Dr. Ghaferi agreed that surgeons may need coaching throughout their careers. “We need tactics that we can implement throughout a surgeon's career, even when we reach our pinnacle, to make sure we are up-to-date with the latest techniques.”