A view from the coffee room…grandparent effect in surgery

I read with great interest Post reproductive female killer whales reduce socially inflicted injuries in their male offspring in Current Biology.¹ I was intrigued to learn that in only a few animal species apart from humans, females experience menopause, and live past it. Currently, only humans and toothed whales; killer whales and short-finned pilot whale females live, as it is called, a post reproductive life.² To be brutally honest, I had not contemplated about the menopause in other animal species nor in humans. But now that I think if it, I have never heard of post-menopausal ants or menopausal lionesses. Another term linked to this is the grandmother effect, that basically means that older female kins can take care of the younger.³ Is this beneficial or not, results are contradicting?³ We should not focus on gender; thus I suggest that we talk about the grandparent effect in surgery.

Surgical departments consist typically of surgeons of different ages. Every individual brings their experience, vision and  insight to benefit the community. It has long been the case that the views of senior surgeons are listened to and respected more than those of newcomers. Thus, as they get older, surgeons expect their opinions to be automatically respected more. Of note, I strongly disagree.

Our profession is highly physical, and we use a lot of neurocognitive skills. Physical decline together with chronological ageing is a fact. We acknowledge this in our patients, but not with ourselves. Hearing, vision, dexterity, strength and reaction time usually tend to deteriorate with aging,^4,5 although I must note that this is highly individual. Likewise, age-related neurocognitive changes such as processing speed, problem solving and adaptive thinking, and critical and analytical reasoning usually decline.^5,6 Together these natural ageing-related phenomena pose a risk both to the surgeon and the patient.  Add to this that, in general, doctors take poor care of their physical and mental health and do not consult physicians,⁷ other than themselves. So, it is clear that older surgeons may be a serious risk factor for poor outcome.

The paradox in ageing surgeons is greater experience with worse clinical performance.⁸ What about the experience, you may now ask, that is important, right? Times they are a changing, and unfortunately, old doctors do not follow new treatment strategies and are more prone to use inappropriate medicines and treatments in their practice.⁸

When I read the whale menopause article and got the idea for this article, I must confess, I had not gone exhaustively through literature. After having done that, I am saddened. But characteristically to myself, I decided to write this to the end. We all know fellow surgeons who don’t want to give up. Their life – especially among older generations – is determined through work and work performance. There are too many sad examples of old surgeons that end up being the object of pity and sudden silence when they enter the room. I tried to find published articles with the prompt  “what old surgeons can teach to young” but nothing. It seems that we as a profession are obsessed with technical skills and do not care about non-technical skills.

What are non-technical skills in surgery? By The Royal College of Surgeons of Edinburgh they are situational awareness, decision making, communication, teamwork and leadership.^9,10 I personally feel that these skills are equally important to technical skills, and it is about time we started to acknowledge them! Well, of course one can organize formal teaching for non-technical skills in surgery including reading before teaching, PowerPoints, lectures and a lot of recitation, but I am not sure if this is a good way to teach non-technical skills in surgery. The thing is we encounter situations during working and, at least in the beginning of our careers, we get puzzled – a lot and often. Therefore, having someone trusty and experienced (= old) to talk to almost immediately would be the best solution. People skills do not change, and it is likely that an experienced colleague will have been in the similar situation. Thus, you could defuse the situation with an experienced colleague.

Schenarts & Cemaj⁸ and Kirk¹¹ suggested  retired surgeons should teach but clinical teaching.⁸ Rather anatomy, history, patient examination or basic surgical skills.¹¹ At first glance this seems great. However, if one has prided themselves as clinicians for their whole career, not being allowed to teach what you love most and are good at must be devastating. 

I embrace age variety among surgical teams and think that we can learn from each other – but different things. Getting back to the grandparent effect – providing maintenance and support for younger colleagues is an important role, and the benefit of networking with an older surgeon will benefit the entire department. This is what I think now, get back to me in 15 years to see if I think differently.