The end-of-history illusion and the aging surgeon

For the aging surgeon who trained in the 1970s and 1980s, retirement can be a daunting prospect. The enemy of this phase of one’s life is the personal battle against regret—rumination about the past and apprehension about the future. For example, the realization that 30 years of experience in skill and judgment cannot be transferred into a “surgical cloud” from which others can access, learn, and improve seems regrettable. Looking back on one’s career and then projecting that experience onto the future of current trainees can make the near-retirement surgeon grumpy, resentful, and, worse yet, cynical. A landmark paper published in Science may explain some of the psychic entropy that seems to permeate the near-retirement surgical mind.¹

This article attempts to explain why—when surgeons look back on their careers—things always seem to have been better “back then” and why the future of surgery they imagine is one in which there is loss of autonomy, dependence on technology, and dissolution of the physician-patient relationship in an endless vision of gloom.

Understanding the forces that shape our thinking and feelings as we age in our career is an important teachable moment that can help us gracefully move aside and let the next generation do it their own way. In this author’s opinion, the best is yet to come in the practice of surgery and its golden age has yet to be realized.

Overwhelming regulatory burdens

For near-retirement surgeons, it seems impossible to escape the flurry of e-mails mandating unending compliance training, the compulsory use of the electronic health record (EHR),² and the threatening influx of expertly trained subspecialized surgeons³ and robots lining the operating room corridors as if they are decorative ornaments.⁴ The sheer mental strain of all this incoming noise can shift one’s inner psyche into a state of annoyance, resentfulness, and, worst of all, cynicism. The realization that this noise can no longer be avoided in the operating theater, once the surgeon’s inner sanctum, is even more unnerving.⁵ Accepting that one’s technical mastery of the 45-minute open right hemicolectomy through a 5 cm incision is slowly being replaced by a three-hour robotic procedure whose carbon footprint includes the mass disposal of endless plastic drapes and instruments—considered by some as a hate crime against the earth—can shift one’s personality from happy to grumpy.^6,7

The near-retirement surgeon may irrationally long for the 100-plus hour resident workweek, the days of three-hour rounding sessions while writing illegibly in charts, starting an elective operation at 10:00 pm for no particular reason, and so on. To this aging mind, it seems patently clear that the halcyon days of yesteryear were better than the present, and the future is riddled with training modules, mandated compliance webinars, and the gradual loss of cases to interventional radiologists, cardiologists, gastroenterologists, and finger-twiddling robo-surgeons.

Many near-retirement surgeons say they would do it all again, even with little monetary reward; others, however, state that they would never do it again and that they are glad to be at the end of their careers.^8,9 As members of a profession that values introspection, it is important to understand the thinking among those of us who embrace technology and feel optimistic about the future generations of surgeons we are training, and why we would recommend this journey to anyone interested in a surgical career. Equally important, however, is to understand why there is bitterness among those surgeons who feel things were better in the past, that the golden age of surgery is behind us, and that the surgeons we are training today will never rise to the caliber of those who trained in the past.

Science tells us that much of this problem lies in the fact that humans have a fundamental misconception of the power of time. A type of oblique thinking in this regard has been described as the “end of history illusion.”¹ The illusion is that the now is as good as it will ever get and nothing in the future could ever be better. When we look back in time, we forget that we were younger, more curious, and that every experience was new and exciting. The future always seemed bright back then because we were advancing in our careers and rapidly changing for the better.

However, now facing retirement, what we see are the challenges of aging, the cognitive burden of learning new techniques, and perhaps that our skills and experiences have become less relevant to many of the new advances in the field. At later phases of adulthood, we perceive that we have hit the peak of our personal growth, and have no ability to grow or mature in the future.¹ Furthermore, despite having changed significantly in goals and personality over the last 10 years, we cannot imagine changing over the coming 10 years. As a result, we predict that we will think and act in the future as we do now.

Perhaps we fall prey to the end-of-history illusion phenomenon because it is easy to romanticize the past and more difficult to imagine a future in which our judgment, skill, and experience cannot simply be time-stamped, signed, and uploaded to the cloud to preserve our legacy. This phenomenon might be especially relevant as surgeons approach retirement and ponder their risk for mental and physical deterioration.¹⁰ This latter aspect makes this end-of-history illusion particularly interesting for the near-retirement surgeon. Gilbert, a pioneer in this field, speculates that the phenomenon occurs because we actually realize we cannot predict how we or our circumstances will change.¹ Also, our dissatisfaction with our current state of being—in this case our declining, outdated, and unneeded skills—may play into our dissatisfaction as we age. Gilbert also speculates that the phenomenon may be a function of how humans perceive time in general.¹

Were the good old days really that good?

One thing that has remained constant over the last 30 years is that, in all aspects of patient care and career choice, surgical trainees aspire to excellence. Throughout the profession’s history, trainees have understood the challenges and demands of a surgical residency and have embraced the personal sacrifice and discipline it takes to persevere. Yet in looking back, rounding on a service of 40 or more patients, calculating antibiotic doses, hand-writing the composition and concentration of nutritional formulations, personally drawing blood and starting intravenous fluids, going down to radiology to scout for films, hunting down lab values across separate areas to obtain both microbiology and central lab data—all while going in and out of the operating room to assist—seems untenable, unachievable, and even unsafe.

Some argue this was the best environment in which to develop discipline, resilience, and expertise. While I and many others will attest that we enjoyed every minute of our residencies, in retrospect it is difficult to reconcile that this environment is one that is ideal for learning and providing care to surgical patients. Furthermore, the number and ways in which trainees’ lives were disaffected by this approach remains undocumented.

Surgeons view this era of training in one of two ways. Some romanticize training in the 1970s and 1980s, remembering themselves as disciplined soldiers learning, operating all night, and saving lives. Others recall this era as dismissive both of its actual efficacy as a learning and training tool and of its collateral damage on the individual. Of course, our mentors, like our parents, did what they thought was best for us. Yet the inattention to sleep, destroyed personal relationships, and deteriorated physical and mental health often were ignored. Imagining that era of training as better than the present era may be a function of a distorted perception that it was your residency training that made you the surgeon you are today. This way of thinking ignores the advances in anesthesia that have occurred; how your family and personal experiences have changed you; the improved devices and instrumentation that are readily available; access to video materials; laparoscopy; tumor boards; immediate cellphone access to colleagues; the EHR; and, of course, your accumulated experience.

Automobile and air travel are safer today than ever, and so is surgery. Is this because training in the ’70s and ’80s was better? Are today’s recent surgical trainees less qualified when they finish their training than we were? Is the future going to be riddled with surgeons who are overloaded with administrative work, technically inferior, and more focused on their own well-being than that of their patients? Are we at the watershed moment where things are as good as they will ever be, and younger trainees are not being trained properly? Is this perception making the future look bleak?

Fear of obsolescence and irrelevancy

As a senior medical student, I often worked up patients admitted for “acute viral syndrome.” Many of these patients were young, with minimal symptoms that today would not qualify for a hospital admission. Workups included many unnecessary tests and admissions that lasted five days or longer. Similar scenarios back then were observed that involved marginally indicated operations. Physicians who trained in the 1960s−1980s commonly complain of “loss of autonomy.”11 The idea that an operation needs preauthorization from an insurance carrier is frustrating. Often ignored in these heated discussions, however, is that both the indications and costs for the same operations vary widely across hospitals, surgeons, and states. In general, surgeons do not want to be told what to do. The aphorism “not always right, but never in doubt” spills into their sense of loss of autonomy.

Yet at the same time, tumor boards, morbidity and mortality conferences, tracking of the indications and complications of operations by quality officers, and “superspecialization” have led to the development of massive databases that provide us with guidelines, core values, and even web-based regulations that govern the indications for surgery. Surgeons may abhor being told what to do, but the data that is being generated on complications, costs, indications, and so forth are defining, in real time, best practices. Cooperative resource sharing projects run by surgeon-scientists with expertise in data analysis are erasing the confirmation bias that exists when one practices surgery solely based on one’s own experience. Science and technology are helping us avoid the trap of “memory error” as identified by those in the field of end-of-history illusion scholarship. Hard data are being generated that allow science to state the obvious—complex operations performed by multidisciplinary teams in major medical centers organized and led by board-certified subspecialists have better, more efficient, safer, and more cost-effective outcomes. The irony of all of this “outcome science” is loss of autonomy at the individual practitioner level. Yet is this really bad? And for whom is it bad? At the individual practitioner level, it might feel that nothing will be the same, our bond with the patient will be lost, and our practices are doomed to be run by machines and administrators. For the aging surgeon facing retirement, it may seem difficult to see the future of surgery as bright given this changing landscape.

The goal has always been to be better and safer

The future has never been more exciting. Today, we are training the best and brightest minds and hands that surgery has ever seen.

To get a sense of the magnitude of information and knowledge that is incorporated into a surgical resident’s brain by the time he or she enters training, we only need to realize that the science and math we learned in college and medical school is now being taught in high school. For those of you with college students studying to be physicians, opening their college molecular biology textbooks will reveal a mind-blowing degree of molecular detail that must be learned very quickly.

The accumulated knowledge between 1960 and 2020 is enormous and yet must be incorporated into the brain of the pre-med student to be competitive for medical school. Today in the U.S., this education often involves a “gap year” in which students prepare for standardized tests while performing research or obtaining an advanced degree. Yet despite this recognition, many argue that the best and the brightest are no longer applying to medical school, despite medical school admissions data indicating otherwise. Competition to obtain a surgical residency is similarly structured. That students do basic research while in medical school, that many take a year off for research to be competitive for residency, sheds little doubt that their level of preparedness is unprecedented.

The onslaught of robotic surgery, its evolving telementoring capabilities, online educational video libraries, communication technology, endoscopic-enabled surgery, and biologic drugs are, in the aggregate, radically changing the field of surgery. At light speed, today’s trainees can attend clinic, complete and close all their EHR encounters in real time, rapidly learn robotic surgery, understand the nuances of surgical anatomy with online visualization tools—all while arranging for a ride home in an Uber and with plenty of time to make dinner reservations online.

While the workload is different than it was in the ’70s and ’80s, it certainly is not less. Much is accomplished in a work day with plenty of time to prepare a first-rate presentation for a morbidity and mortality conference complete with video clips and an insightful review of the literature. Although technology has enabled this generation to accomplish all these things and work-hour restrictions have given them personal time not afforded to their predecessors, let us remember that they have had to master an unprecedented degree of technology, to amass far more knowledge, and that they use their personal time to stay mentally and physically well. At least to this observer, today’s trainees exercise more, smoke less, have healthier diets, and practice mindfulness to a much greater degree than previous trainees. As an example, today’s trainees no longer aspire to perform endocrine, vascular, and trauma surgery in their practice, but rather to work in trusted teams and environments where they can perform five to seven procedures for which they have been properly trained and can achieve technical mastery.

Their quest for excellence remains unwavering. The difference is that automated enhanced recovery programs, patient expectations from satisfaction surveys, and regulatory oversight impose heightened awareness of their individual outcomes from which they can measure room for growth. The emergence of rigorous scholarship in outcome sciences and advances in surgical biology now guide their practice.

Relinquishing nutritional orders to a well-trained pharmacist, pain management to subspecialized anesthesiologists, and drug kinetics and antibiotic dosing to pharmaco-therapists is no longer perceived as loss of autonomy, but rather an opportunity to concentrate on the indications and technical execution of operations within their subspecialty. They do not fear emerging technology in surgery; they embrace it and are creating it. For trainees today, experience becomes less of a commodity when experience can be digitized into a training platform and when information is now an open book on the Internet. For trainees today, their goals are technical mastery, deep insight into the indications and mechanisms by which operations are effective, and leveraging technology to make surgery safer and more available to all.

In view of this discussion, it is interesting to speculate why teaching hospitals invariably rank highest in virtually every ranking survey.¹² It also is interesting to realize that private hospitals are modeling university hospitals by forming regionalized centers of excellence run by board-certified subspecialists. While these high-ranking, university-based teaching hospitals continue to publish credible scholarship demonstrating that high-volume surgeons performing complex surgery in high-volume centers have better outcomes,¹³ regionalization of care, its costs, and its inconveniences continue to be discussed, feared, and rendered implausible by some.

The implications of the end-of-history illusion can help us to understand why we chose surgery in the first place and to be positive about the future of our specialty. As we age, it is natural to think that at each point in time, we are at the peak of our performance and nothing can possibly improve for us. It also is natural that as we age, many of us carry the illusion that our history has come to an end. We invariably underestimate how much we will change at pretty much every point in our lives. The problem for late-career surgeons is perhaps, as Gilbert speculates, “the ease of remembering versus the difficulty of imagining.”¹ For the near-retirement surgeon, it is difficult to imagine a world in which physicians lack the autonomy to make decisions using our best judgment and rely more heavily on the judgment of learning machines. Similarly, it is difficult to imagine a world in which we are not fully and continuously engaged with our patients from the initial consultation, to the surgical procedure through the window of risk of a complication, to the long-term recurrence of disease such as cancer. We fear the current rate of change in residency education and surgical practice and that technology and hand-offs will erode the trust and bond between physicians and patients. We cannot imagine that our accumulated encyclopedic knowledge of disease can be trumped by online search engines, machine learning, and some 20-year-old with a smartphone.

Danish philosopher Søren Kierkegaard said, “Life can only be understood backwards; but it must be lived forwards.”¹⁴ The problem is, our memories often are inaccurate and our anxiety about living forward, especially as we face retirement, distorts our thinking.

It is important for surgeons of my generation to understand that we and our current trainees have enjoyed all of the advances made by those that came before us. Neither we, nor our forebearers, ever imagined a robotic pancreatico-duodenectomy could be performed in four hours, with the patient discharged in four days and eating regular food. Perhaps it is “the ease of remembering” the joys of learning how to master an open pancreatico-duodenectomy that we mourn and that impedes our ability to recognize that today’s trainees, in many ways, are actually better off than we were.

Understanding the implications of end-of-history illusion science can help us realize that not only have our contributions been significant because we learned, trained, and shared our experience, but also that this generation of surgeons is doing the same, albeit with new tools and in a slightly different way. As I age, I am confident that the teams and systems that current trainees are developing and using will make the takeoff and landing of an operation as smooth and safe as air travel is today. As I may need their services sooner than I might expect, I remain positive that I will be in good hands.

Acknowledgment

The author would like to thank Daniel Gilbert, PhD, Harvard Medical School, Boston, MA, for his technical advice with this article.

References

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