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On being 60
Nancy Redfern
Consultant Anaesthetist
Honorary Membership Secretary AAGBI [email protected]
The Ageing Anaesthetist
Baby Boom (1945-1962)
• Optimistic, ambitious permissive, rebellious
• Value - youth, personal success, wealth
• Workaholics work is part of your identity
and as patients?
Richard Marks Learn@AAGBI WSM 2014
Generation Y (1982 – 2002)
• Co-operation, communication, conformity, perfection
• Don’t stay long in bad jobs
• Want to get job done & have fun
• Relationship with employers – expect to be trained, have positive bosses and encouragement
• Like a consensus view
• Want good working atmosphere & family friendly
• Sense of civic responsibility
• Location of job important
• Independent, resourceful entrepreneurial
• Alienated & misunderstood
• Don’t have same levels of allegiance
• Will go abroad, change jobs
Richard Marks Learn@AAGBI WSM 2014
Generation X (1963-1981)
Attitude to Work
Cognitive function declines
• processing speed slower (dealing with incoming information quickly and efficiently)
• working memory less agile (short-term memory and maintenance of new information)
• episodic memory encoding declines (formation of new memories of specific events or episodes)
Tiredness makes this worse
Vigilance becomes more variable
Premature diagnostic closure
Age related physical illnesses
– Normal declining function e.g. eyesight & hearing
– Impact of common health problems e.g. musculoskeletal, DM, hypertension, surgery
Redfern 2014
Age-related changes in performance
Ageing & Sight
• accommodation (focusing power), contrast sensitivity, and visual acuity all decline with age
• Drug labels and monitor displays are easier to read if they are high contrast and if they have larger print.
• legibility of different font styles - sans serif fonts, (Arial, Calibri) easier to read than Serif fonts, (Times New Roman)
Redfern 2014
If older people continue to work
• Increased number of workers with a chronic disease
• Will need effective interventions to improve participation of people with a chronic disease
• Wholescale change in the way society views health and work
• Workplaces that promote health and wellbeing
• Ensure that everybody with the potential to work has the support they need to do so
To enable people to work longer needs
Evidence from clinical practice
• Canadian study: rate of successful claims against anaesthetists aged > 65 yrs 1.5 times anaesthetists < 51 yrs, led to more severe injuries, despite the older anaesthetists’ being involved in fewer complex cases
Tessler et al Anesthesiology 2012; 116: 674-9
• Increased risk of permanent complications from thyroidectomy performed by less experienced surgeons & by those in practice for > 20 yrs. Suggested surgeons aged 35-50 provided the safest care
Dudos et al BMJ 2011: 343 :d8041
• Similar evidence for carotid artery surgery, cardiac surgery, parathyroidectomy, laparoscopic hernia
Redfern 2014
Age (yr) Practice activities
60-64
• no further on-call duties (to avoid interrupted sleep, stress of
higher case acuity, limited help available to deal with crises)
• recommend annual simulation CPD to practice and assess
crisis management
65-69 • no further high-intensity/high-acuity cases (defined for the
individual, with no exceptions unless in a life-or-limb crisis)
> 70
• retirement from operating room clinical practice
• if desired, replace with non-operating room activities such as
pre-assessment clinic, admin, research, mentoring, education
Structured pre-retirement “winding down” of clinical activities - example
Baxter AD , Boet S, Reid D and Skidmore G The aging anesthesiologist: a narrative review and suggested strategiesCan JAnesth. 2014
On being 60
Nancy Redfern
Consultant Anaesthetist
Honorary Membership Secretary AAGBI [email protected]
Cognitive function declines with age
• semantic memory (knowledge) & routinised behaviours show little change - just as quick to respond and draw on previous experience when not tired
Over 60 -
• processing speed slower (dealing with incoming information quickly and efficiently)
• working memory less agile (short-term memory and maintenance of new information)
• episodic memory encoding declines (formation of new memories of specific events or episodes)
Redfern & Gallagher Anaesthesia 2014
Expert performance
4 types of process
• Reading the situation
• Making decisions
• Overt activity
• Metacognition
3 modes of cognition
• intuitative
• analytic
• deliberative
Automatic routines punctuated by rapid intuitative decisions based on tacit understanding of the situation Involves
Eraut
Using deliberative thinking
‘A mixture of analysis, intuition and reflection’
Used by skilled professionals when
• outcomes are particularly critical
• uncertain about outcomes/need to incorporate differing interests/ need to consult other people
• managing messy, fuzzy, unique and context related problems
• a new situation - no previous experience
• feel uneasy with initial choice of action
• misinterpret a situation and events do not develop as expected
• guidance from theory is only partially helpful
Eraut
Decision-making using deliberative thinking
Making a good decision using deliberative thinking
depends on • the correct analysis of the problem
• considering the full range of potential actions
• assessing their risks and benefits
• finding the best fit between the situation and the options (including getting more information before reaching a decision)
• relies on self-awareness and open honest enquiry • processing speed slower, working memory &
episodic memory less agile
Eraut
Cognitive function declines with age
Over 60 –
slower at recognising & managing new situations
more variable & declining vigilance
• problem if the older anaesthetist
– does not notice situation is changing,
– misinterprets events,
– has no previous experience upon which to draw
Redfern & Gallagher Anaesthesia 2014
Ageing anaesthetists - tiredness • tiredness affects older doctors’ performance & mood
• quality of sleep worsens with age; sleep becomes shorter
• reduced capacity to adapt to shift work with increasing age
• cognitive performance of older shift workers more impaired during night work but may be less aware of their degree of impairment than younger shift workers
Normal pension age - 66 by 2020 - 68 by 2046
Redfern & Gallagher Anaesthesia 2014
Age related physical health problems
• chronic conditions
musculoskeletal problems, diabetes, hypertension
• Hearing - beeps, alarms, conversation
• acute illess e.g. ischaemic heart disease / cancer
• Return to work after illness/surgery very tiring at any age
• Many people feel less confident
Redfern 2014
Ageing & Sight
• accommodation (focusing power), contrast sensitivity, and visual acuity all decline with age
• Cataracts, glaucoma, Age Related Macular Degeneration more common
• Drug labels and monitor displays are easier to read if they are high contrast and if they have larger print.
• legibility of different font styles - sans serif fonts, (Arial, Calibri) easier to read than Serif fonts, (Times
New Roman)
Redfern & Gallagher Anaesthesia 2014
Age related physical health problems
• chronic conditions
musculoskeletal problems, diabetes, hypertension
• Hearing - beeps, alarms, conversation
• acute illess e.g. ischaemic heart disease / cancer
• Return to work after illness/surgery very tiring at any age
• Many people feel less confident
Redfern 2014
Age related changes in organ function
• Hearing - beeps, alarms, conversation
• Vision
• Stamina is less
• Physiological reserve is less
• circadian rhythm disruption & inability to adapt to changes in the sleep-wake cycle
• chronic conditions
musculoskeletal problems, diabetes, hypertension
• Self perception of poor health is the main reason for leaving work
Redfern 2014
Age related physical health problems
• Return to work after illness/surgery is tiring
• Many people feel less confident Departments more likely to retain staff if they offer sensibly paced return to work plan good support from colleagues gradual increase in responsibilities realistic future job planning regular review so anaesthetist can reassess capability and stamina appreciate effect on performance of chronic condition /long term treatment on performance
Redfern & Gallagher Anaesthesia 2014
How might this affect departments?
• Older anaesthetists
– less good at night work
– need colleagues on hand in case of difficulties
– Good at pattern recognition
– ? Education, Standing up to external pressure
• Younger anaesthetists also tired – young families
• Good job planning & good access to a consultant Occupational Physician with an interest in doctors’ health
• 7 day service
• Recruitment
• 24 hour consultant presence
• Peri-operative physicians
Redfern 2014