Last month, Senator John McCain underwent what his staff described as a minimally-invasive craniotomy, in order to remove a 5-cm hematoma from above his left eye. The operation is said to have been uncomplicated.
However, a couple of days after the procedure, the media began to speculate that McCain was unlikely to return to work as quickly as previously intimated, and might require a week or 2 of convalescence before returning to Capitol Hill – this was a week or so before he announced that he’d been diagnosed with a glioblastoma. In response, the Senate leadership reiterated that voting on a bill to decimate the Affordable Care Act would not begin in McCain’s absence1. And just like that, McCain’s post-operative course has become a matter of national concern.
McCain is 80 years old; the lede here is probably the serendipitous delay of potentially ruinous legislation. However, buried not too far below is the media’s asymptotic approach to the idea that, if a routine physical can put him on the bench for weeks and consequently throw sand in the gears of maybe the most important legislative process of the Congressional term, then perhaps McCain has become too old to serve as a senator.
American surgeons — like Supreme Court justices, but unlike pilots and air traffic controllers — are not subject to a mandatory retirement age. In an intuitive sense, the potential issues raised by this lack of regulation are obvious. For one thing, a surgeon who’s rounding the bend into, say, his ninth decade, probably started his residency right around the Kennedy assassination.
Back then, residencies were a bit shorter and fellowships were less common, but that’s not really the issue. It’s more that so much has changed since then; the state of the art has made several 180-degree turns during his career. For a general surgeon graduating in the 60’s, laparoscopy was about as common — and, for that matter, plausible — as flying cars; to stay on the cutting edge, the surgeon has had to unlearn and relearn entire bodies of knowledge.
Even more salient is the omnipresent specter of age-associated physical and cognitive decline. Fine motor skills, visual acuity, and reaction time all, to varying extents, inevitably decline with age.2,3 Measures of cognitive capability — which encompasses capacities as diverse as verbal memory, numeric recall, mental calculations and visuospatial facility, among many others — have also been shown to inexorably diminish with age; doctors who, of note, perform better and suffer milder declines than non-doctors lose an average of 25% of their starting performance by age 75.4 Physical decline usually starts creeping in late during the third decade; cognitive decline is typically staved off until late in the fifth. However, in all arenas, Father Time remains undefeated.
But performing surgery isn’t the same thing as playing specially-designed computer games in some anodyne laboratory. And there’s no evidence showing that elderly surgeons produce worse outcomes than younger ones; our fears are stoked principally by our intuition and a handful of admittedly terrifying anecdotes of older surgeons falling asleep at the operating table or being too confused to get back to their offices after operating. On the contrary, we know that experience has real value in the operating room. The logic is airtight: older surgeons have seen more cases and so are more adept at diagnosing and managing both rare and common problems.
It follows that a surgeon’s performance for much of her career is defined by the interplay between her experience — thus knowledge — and the decline of her cognitive and physical skills. Athletes exist on much the same spectrum — there’s a limited window of time during which both physical ability and knowledge of the game are sufficient to achieve optimal results. Peak performance, also known as the beginning of inevitable lifelong decline, is usually in an athlete’s early 30s; surgeons often don’t reach that nirvana until their 50s. In either case, though, decline will eventually set in; it happens to everyone.