Age of Surgeons May Raise Ethical Concerns over Memory Lapses

Clinical Scenario

Archibald Fitch, MD, is a senior, highly respected, experienced, and innovative head and neck surgeon at your medical center. Tall and lean, with a full head of white hair and a robust disposition, he has a commanding presence. He was the first otolaryngologist in your community to practice the full scope of head and neck oncologic and reconstructive surgery, adding a number of innovations of his own to the field, including several textbooks and a host of journal publications. Beyond those credentials, he is considered a compassionate and meticulous surgeon with keen judgment and discernment, serving as a role model to many in the community and beyond.

Dr. Fitch, now in his mid-70s, has continued to practice head and neck surgery and is always willing to give formal or informal counsel when consulted regarding a colleague’s patient. His general health appears good, and he is an avid golfer and tennis player. His attendance at committee meetings and participation in medical center affairs is consistent and admirable. He is very active in several national charities of his passion.

Because of his prominence in the medical community, as well as his experience and expertise, there are often observers in his operating rooms, including yourself. On a recent occasion, you stopped by Dr. Fitch’s operating room to observe a few minutes of him performing bilateral modified neck dissections. You were close enough to hear this verbal exchange between Dr. Fitch and the scrub technician:

Dr. Fitch: “Sandra, may I have … uh… you know, that long instrument with the blunt tips that you cut tissue with … it’s a pair of scissors, I just can’t think of its name, right now. But you know what it is.”

Sandra: “Dr. Fitch, are you thinking of the Metzenbaum scissors?”

Dr. Fitch: “Of course, Sandra, thank you. How could I forget that old friend?”

A few minutes later, the same scenario was played out with an automatic clip applier and a Penrose drain. At other times, you noted that Dr. Fitch preferred to find an instrument himself on the instrument tray rather than ask for it. His technical performance of the procedures was flawless, however, and the blood loss was minimal. You were impressed, as usual.

Verification

These brief memory lapses concern you, and you feel you should verify your observations with other colleagues—discreetly. Over coffee in your office, you describe your observations to two fellow otolaryngologists whose opinions—and discretion—you trust. Both colleagues did remember recent incidences when they were either observing or assisting Dr. Fitch and he experienced such memory lapses, but these involved names of medications and names of personnel. Neither had observed any breach of technique or of patient safety.

As chief of otolaryngology-head and neck surgery at the medical center, a position previously held for many years by Dr. Fitch, along with his tenure as chief of the medical staff, you feel a professional obligation to monitor the capabilities of every otolaryngologist in the department. You have, in the past, dealt with issues such as disruptive behavior and other unprofessional activities. In this particular situation, your concerns involve a highly regarded senior surgeon who continues to practice within the standards of technical capability, but with a possible early deterioration of memory.

Again, in confidence, you request a separate meeting with Dr. Fitch’s regular anesthesiologist and his circulating nurse. Both are initially wary of where you might be headed with this line of inquiry, but after you assure them that you are interested only in the welfare of both Dr. Fitch and his patients, they do acknowledge having observed an increasing frequency of memory lapses, although he compensates cleverly using his sense of humor and warm personality. As a model of professional propriety and decorum, Dr. Fitch simply does not get flustered or act inappropriately in the healthcare setting.

You review Dr. Fitch’s medical staff privileges and the letters of recommendation and support for their renewal; there is no evidence of concern being passed on by those endorsing his continued staff privileges. There are no documented complaints about his behavior or interactions with colleagues, staff, or patients. In short, he is what everyone feels he is—a consummate professional. In more than 40 years of surgical practice, he has had no medical liability suits, and there have been no complaints filed with the state medical board.

You feel very conflicted about raising this issue with Dr. Fitch—on one hand, he shows no deterioration of dexterity and motor skills, and his clinical judgment appears intact. On the other hand, your observations and those of others raise the concern that subtle cognitive deterioration might be present that could worsen over an unknown period of time. This surgeon has devoted his professional career to excellence and innovation in patient care, medical education, and community service and, at age 75, continues his dedication to clinical work. You are aware that, over the past several years, there has been increasing national discussion regarding the issue of the “aging surgeon,” a topic previously side-stepped in many regards with respect to a surgeon’s prerogative to decide when is the proper time to retire.

Is it time to initiate this discussion at your medical center, and should you be the one to initiate it? What should you do?

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