You’d think surgeons would be the first to know when to hang up their scalpel, but alas, they’re as stubborn as a rusted bolt. When should a surgeon put down the knife and stop pretending they’re not going blind? It’s a question of cognitive decline, ego, and knowing when to pass the baton—or in this case, the scalpel.

Unlike our colleagues in internal medicine, surgeons wield sharp objects, making the temporal relationship between their actions and patient outcomes hard to miss. As a result, there has been significant academic soul-searching about when a surgeon should retire.

While wine and some cheeses improve with age, the same cannot be said for humans, especially in the years leading up to retirement.

“Knowledge and experience remain for a long time. First to go is strength, then eyesight, then dexterity, and finally cognition. Knowledge, experience, and reputation can compensate for a long time.”

While the exact ordering of these events varies, physical limitations often appear first. Because they are gradual, these limitations may go unnoticed by both the surgeon and their team for long periods. After all, everyone has a “bad day.” Knowledge and experience, the wisdom of age, and the halo of our more halcyon years codified as reputation increasingly misinform our current abilities. To some extent, there are aids for declining physical ability; you can sit and operate, but you needn’t stand all the time. There are multiple “prosthetics” to improve one’s eyesight. But cognitive decline is a different beast.

Cognitive testing has been in the news a lot lately. Surgeons’ scores on the MicroCog, a computerized test of cognition, clearly decline with age. However,

“There has not been any showing that a good score on the MicroCog correlates with good performance of surgery or that a low score on the MicroCog correlates with incompetency or lack of skill.”

As fiduciaries, we are both legally and ethically required to act in the best interest of our patients. This obligation includes stepping aside when physical or mental aging limits our abilities. But we often ignore those early warnings. A study of neurosurgeons suggests we fail to put the scalpel down because of a resistance to change, a fear of death, and a lack of self-esteem. The habits and rituals that have defined our practice for decades are hard to let go of, especially when no new path seems viable. (Internists can work part-time or do locums; there are no part-time surgeons.) While I take issue with the phrasing of a “fear of death,” I will readily attest to the discomfort of finding myself on the opposite side of the desk in a physician’s office. I still struggle with this eight years after leaving clinical medicine.

Lack of self-esteem seems contrary to the highly confident surgical personality stereotype. But for those of us in the trade, you are, at best, only one or two bad outcomes away from losing your self-respect. Moreover, for many surgeons, providing surgical care is a calling. When one “stops doing surgery, he or she runs the risk of no longer valuing him or herself.”

Perhaps no better literary description of the loss of self-esteem exists than in Arthur Miller’s Death of a Salesman. I wanted to share two salient quotes:

“You can’t eat the orange and throw the peel away—a man is not a piece of fruit!”
– Willy Loman

“I don’t say he’s a great man. Willy Loman never made a lot of money. His name was never in the paper. He’s not the finest character that ever lived. But he’s a human being, and a terrible thing is happening to him. So attention must be paid. He’s not to be allowed to fall in his grave like an old dog. Attention, attention must finally be paid to such a person.”
– Linda Loman, Willy’s wife

Today, on the national and global stage, we watch the act of putting the scalpel down. Unlike Willy, whose name was never in the paper, we are witnessing “a terrible thing,” made more difficult and heart-wrenching by the millions looking on. While the decision facing the president is partly political, onlookers and pundits viewing the situation solely through a political lens are like those who hope to protect themselves by whistling past a graveyard. John Donne said it best:

“… never send to know for whom the bell tolls; it tolls for thee.”

Charles Dinerstein is a surgeon.