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May 2007

Guest Opinion
Hanging Up the Scalpel: Knowing When to Say “When”
By John C. Hagan III, MD

Not every physician is cut out, pardon the pun, to be a surgeon. The ideal surgical persona is a combination of intelligence, manual dexterity, self-confidence, good judgment and the stamina of a draft horse.

The two most difficult decisions I’ve had to make in my professional career have been: Do I want to do surgery? And 11,000-plus surgeries and 30 years later: Do I need to stop doing surgery? Along the way, others have assessed my development as an ophthalmic surgeon, my ongoing competency and my acquisition of skills to perform new types of surgery. But, ultimately, I am responsible for assessing my skill as a surgeon.

Every surgeon should evaluate their operative skills from the first day of their internship. For an estimated 10 percent of ophthalmology residents, attaining surgical competency is a real struggle. (In general surgery, the figure may be 20 percent.) This fact is important and germane as ophthalmology residency programs must now certify their graduates as surgically competent. When residents realize early on that they are not suited to the operating room and transfer to a medical specialty or become medical ophthalmologists, this ultimately benefits both the physician and the general public.

Once one’s residency/fellowship is completed, self-assessment becomes of paramount importance, as does unwavering commitment to lifelong scholarship and updating of surgical skills. Surgeons must constantly reassess their procedure-specific proficiency and be honest with themselves about when surgery is best done in subspecialty referral practices. Ethical surgeons must consider the patient’s best interests. One’s ego and diminished income must be disregarded in this assessment.

Throughout a surgeon’s career, there may be threats to maintaining surgical competency, some of which the surgeon, his or her family, fellow physicians and coworkers may not recognize or may ignore, or that surgeons may intentionally conspire to keep sub rosa. Sadly, abuse of drugs and alcohol are frequent causes of incompetence. A chaotic personal life or mental illness may be the culprit. Rarely mentioned, but common in my opinion, is unbridled avarice. Staff quality committees may identify surgeons with problems and, through a variety of rehabilitation pathways, correct the situation. Likewise, if an individual physician notices that a colleague is troubled, he or she should not cast a blind eye to the problem. Many state medical associations have excellent programs for helping impaired physicians, and this is frequently the best organization to contact about initiating a physician intervention and rehabilitation.

Illness and aging are eventualities that all surgeons must confront. General surgeons retire at an average age of 63, and disability is a factor in 14 percent of those cases.1 In fact, ophthalmic surgeons using operating microscopes have an increased incidence of musculoskeletal disorders as they age.

Over the past decade, I developed a burgeoning amalgam of afflictions, including osteoarthritis of the knees, hips and back, and tendonitis of hands and elbows. Performing surgery became excruciatingly painful. At age 59—while still a highly competent surgeon—I closed my surgical practice. I joined a top-quality ophthalmology group, refer my surgical patients and do medical ophthalmology. I have never regretted my surgery-ending decision.

1 Jonasson, O. and F. Kwakwa. Ann Surg 1996;224(4):574–582.