1. THE OLDER SURGEON AAOS ETHICS COMMITTEE Stuart A. Green, MD 1

2. Objectives Recognize early signs of age-related diminished mental capacity Consider types of responses that are necessary and appropriate when observing symptoms of diminished capacity in a colleague Contemplate the influence competing economic and political forces have on ethical actions 2

3. Case Finally, in your last year of residency, you get to scrub with the legendary Dr. R. Truman Cole. Although now semiretired, he’s still admired and respected by all. Hemera/Thinkstock “ Where are you from, young man?” he asks in the surgeon’s lounge. “ Buffalo, New York,” you reply. “ Ah,” he says, “we honeymooned at the Falls.” 3

4. He then regales you with a not-so-funny story of how he accidentally dropped his father’s beloved Leica III-C camera into the Niagara River while leaning over the railing of The Maid of the Mist. iStockphoto/Thinkstock The circulating nurse pops her head in and asks about positioning the patient. 4

5. “Sandbag under right hip; foam wedge behind right knee,” he briskly replies. At the scrub sink, Dr. Cole turns to you and asks: “Where are you from, young man?” “Buffalo, New York, sir,” you answer. He thereupon repeats his entire honeymoon story, word-for- word. 5

6. What are the ethical issues? What are the practical issues? What are the medicolegal issues? What would you do? 6

7. Anesthetized on the OR table is Morgan Thompson, the NFL’s leading wide receiver. Morgan had been advised by several prominent orthopaedic surgeons that his recent injury Hemera/Thinkstock could be career-ending, although, perhaps with extensive rehabilitation, he might benefit from the “Cole Procedure.” That’s why he chose Dr. Cole to do his surgery! 7

8. What would you do now? 8

9. Three dozen members of the national sports media are sitting in the hospital’s auditorium, awaiting a post-op report from Dr. Cole. iStockphoto/Thinkstock The hospital’s administrator recently said, “This case will put us on the map.” 9

10. Are there more issues at work with this case? Do you intervene? 10

11. SUMMARY  Performing surgery is similar to driving a car An automatic activity with occasional need for rapid, definitive action Both cognitive and motor skills are necessary  State requirements for older drivers vary More frequent vision tests in several states On-road driving tests in a few states 11

12.  There are no uniform policies or guidelines regarding when a physician or surgeon is too old to perform his or her professional activities.  From the AAOS Code of Medical Ethics and Professionalism for Orthopaedic Surgeons, II.E: 12

13. “Orthopaedic surgeons should promote their own physical and mental well being by maintaining healthy lifestyles. They should be attuned to evolving mental or physical impairment, both in themselves and in their colleagues, and take or encourage necessary measures to ensure patient safety. These measures might include medical intervention, professional counseling, or, in situations where reasonable offers of assistance are declined, reporting the impairment to appropriate authorities.” 13

14. References American Academy of Orthopaedic Surgeons: Code of Medical Ethics and Professionalism for Orthopaedic Surgeons, II. E. Adopted 1988, revised 2011. http://www/aaos.org/about/papers/ethics/code.asp American Academy of Orthopaedic Surgeons: Standards of Professionalism on Providing Musculoskeletal Care to Patients, Mandatory Standard 12. Adopted April 2005, amended April 2008. http://www3.aaos.org/member/profcomp/provmuscserv.pdf Council on Ethical and Judicial Affairs: Code of Medical Ethics, Opinions 9.0305-9.031. Chicago, IL, American Medical Association, ed 2010-2011. Choudhry N, Fletcher R, Soumerai S: Systematic Review: The Relationship between Clinical Experience and Quality of Health Care. Ann Intern Med, 2005 (4); 142: 260-273. 14

15. De Raedt R, and Ponjaert-Kristoffersen I: Short Cognitive/Neuropsychological Test Battery for First- Tier Fitness-To-Drive Assessment of Older Adults. Clinical Neuropsychol, 2001;15:3. Leopold S, Morgan H, Kadel N, Gardner G, Schaad D, Wolf F: Impact of Educational Intervention on Confidence and Competence in the Performance of a Simple Surgical Task. J Bone Joint Surg Am, 2005; 87 (5):1031-1037. Moorthy K, Munz Y, Sarker S, and Darzi A: Objective assessment of technical skills in surgery. BMJ 2003, 327. Ranawat C, Rothman R: A surgeon‘s transition: When to retire from surgical practice. J Bone Joint Surg Am, 2010; 92 (8):e7 1-3. Ritter M, Austrom M, Zhou H, Hendrie H: Retirement from Orthopaedic Surgery. J Bone Joint Surg Am, 1999; 81 (3):414-8. 15