Abigail Frazer, Michael Tanzer

Abigail Frazer, Michael Tanzer, Department of Orthopaedic Surgery, McGill University,Montreal H3G 1A4, QC, Canada

Abstract BACKGROUND As the average age of surgeons continues to rise, determining when a surgeon should retire is an important public safety concern.AIM To investigate strategies used to determine competency in the industrial workplace that could be transferrable in the assessment of aging surgeons and to identify existing competency assessments of practicing surgeons.METHODS We searched websites describing non-medical professions within the United States where cognitive and physical competency are necessary for public safety.The mandatory age and certification process, including cognitive and physical requirements, were reported for each profession. Methods for determining surgical competency currently in use, and those existing in the literature, were also identified.RESULTS Four non-medical professions requiring mental and physical aptitude that involve public safety and have mandatory testing and/or retirement were identified:Airline pilots, air traffic controllers, firefighters, and United States State Judges.Nine late career practitioner policies designed to evaluate the ageing physician,including surgeons, were described. Six of these policies included subjective performance testing, 4 using peer assessment and 2 using dexterity testing. Six objective testing methods for evaluation of surgeon technical skill were identified in the literature. All were validated for surgical trainees. Only Objective Structured Assessment of Technical Skills (OSATS) was capable of distinguishing between surgeons of different skill level and showing a relationship between skill level and post-operative outcomes.CONCLUSION A surgeon should not be forced to hang up his/her surgical cap at a predetermined age, but should be able to practice for as long as his/her surgical skills are objectively maintained at the appropriate level of competency. The strategy of using skill-based simulations in evaluating non-medical professionals can be similarly used as part of the assessment of the ageing surgeons’ surgical competency, showing who may require remediation or retirement.

Key Words: Aging surgeon; Competency; Surgical skill; Surgeon retirement

INTRODUCTION

The aging surgeon has remained a contentious patient safety issue, as the average age of surgeons continues to rise. The number of physicians exceeding the age of 65 has more than quadrupled in almost 40 years, and surgeons are no exception[1]. Currently,38% of surgeons working in Canada and over 46% of the surgeons in the United States are above the age of 55 and 16% of Canadian surgeons are over the age of 65[2-4]. When should an older surgeon stop operating? This becomes an important issue when we consider that the surgical profession is highly dependent on memory, sensory acuity,clinical decisiveness, technical skills and physical stamina; skills and abilities that may decrease with age.

Like all professionals, surgeons are fallible and vulnerable to the natural process of aging in which cognitive and physical skills experience a decline. The relationship between surgeon age and operative risk is controversial and uncertain, with some studies showing worse outcomes and some showing reasonable, or even better outcomes[3,5-7]. Even so, there are accounts of prominent older surgeons struggling with simple fine motor skills and clinical decision making; while various studies have demonstrated that senior surgeons have worse outcomes than their younger colleagues, suggesting surgeon age is an operative risk factor[2,8-12]. In the past two decades, more research has been dedicated to studying the aging surgeon and trying to find more effective ways to help surgeons experiencing age-related decline[8,13-15].

Although age has been identified as a possible occupation hazard in the surgical profession[9,10], other professions within the public sector have maintained a more proactive approach with their aging workforce. These strategies include enforcing strict certification and mandatory retirement. Currently, retaining certification in a surgical field is not as rigorous a process and retirement of surgeons remains largely at their discretion, relying on the assumption that they are fully capable of identifying their own cognitive and physical regression[1,2]. Both the American College of Surgeons(ACS) and American Medical Association (AMA) recognize the safety implications of the aging physician and surgeon; and have recommended practitioners aged 65 to 70 undergo voluntary physical examination and visual testing, in addition to peerreviewed performance evaluation for re-credentialing[1,2]. Programs have been developed to assess the competence of aging surgeons and guide them depending on their incapacities or capacities[16,17]. However, no standardized approach to address age-related deterioration in surgeons exists at this time.

In order to address this issue, we performed a scoping review of well-established and accepted policies of testing for competency of aging non-medical professionals from the industrial workplace. In particular we sought to identify strategies used to determine competency that could be transferrable in the assessment of aging surgeons.In addition, we reviewed the present testing of senior surgeons by hospitals to determine if the testing specifically addresses the skills, other than knowledge,required to maintain their competency to perform surgery.

MATERIALS AND METHODS

In order to identify mandatory testing of non-medical professions, where cognitive and physical competency are necessary for public safety, we conducted scoping review of the literature in PubMed, EMBASE, Google Scholar and Google using the terms mandatory retirement, mandatory retirement testing, retirement, mandatory retirement ages, surgeon retirement. The Google search engine was used to locate websites describing these professions within the United States. The mandatory age and certification process, including cognitive and physical requirements, were reported for each profession.

Google Scholar and the Google search engines were used to search for current policies, at health institutions in the United States, that are being used to evaluate older physicians and surgeons with regard to their ability to provide safe and highquality care. The search queries used were: Late career practitioner policy, late career practitioner, assessing late career practitioners, aging physician policy, and aging surgeon policy. These policies were described based on their objectives, candidates,examination procedures, and modification of privileges.

Methods for determining surgical competency currently in use or practice as well as those existing in the literature were identified. Licensing bodies and subspecialist certification boards were described, along with their use of Continuing Medical Education (CME) and Maintenance of Certification (MOC) as a means of assessment.These agencies were selected as they are invested in ensuring the clinical competency of practicing physicians for the welfare of the general public[18,19]. The published literature was reviewed for objective assessments of surgical technical skills that were shown to be valid and reliable, as well as predictive of surgeon competency and improved patient outcomes for surgeons. Studies were identified through a search of databases, including PubMed, EMBASE, and Google Scholar. Search queries were developed from the following keywords: Technical skill, surgery, assessment, surgical training, surgical skill. Objective assessment tools identified in the database search were described if studies evaluating these tools were written in English, evaluated participants performing surgical tasks, and analyzed the validity and reliability of the objective assessment. Review articles found were used to identify studies assessing the reliability and validity of the objective assessment tools. Virtual reality simulators were excluded as assessment tools as they are often used primarily to determine the validity and reliability of the performance tools in mock surgical procedures, rather than for assessment of surgical skills. All search queries were completed by May 20,2020.

RESULTS

Non-medical professionals

Four non-medical professions requiring mental and physical aptitude that involve public safety and have mandatory testing and/or retirement were identified: Airline pilots, air traffic controllers, firefighters, and United States State Judges (Table 1). The nature of their work is such that any condition which compromises their competency,such as knowledge; cognition; illness or physical stamina; can put many members of the public at risk. As a result, these professions have mandatory retirement at specific ages, as well as strict recertification and licensing programs. A mandatory retirement age, which is different for each occupation, is enforced in all 4 professions. An annual medical exam is required for 3 of these professions; a skills refresher course and assessment in two of the professions; and a physical ability test in one to maintain the professional’s ability to continue working. These skill assessments, knowledge or physical, are designed to reflect the competency and proficiency standards of their profession. They entail simulated situations one may expect to encounter as part of their profession.

Table 1 Surgeon certification compared to non-medical professions

Late career practitioner policies

There are currently no mandatory retirement criteria for all surgeons in North America. We identified 9 late career practitioner policies designed to evaluate the ageing physician, including surgeons. One of the policies, the Aging Surgeon Program at Sinai Hospital, specifically targets the aging surgeons, but is identical to the Hospital’s evaluation of medical doctors, and has no specific testing of surgical skills(Table 2). All nine of these policies vary according to their trigger for assessment, the assessments being utilized (medical exam and performance testing), and their influence on hospital privilege modification. Eight of the policies use age to identify physicians that require cognitive and physical testing, starting typically at the age of 70 years, with repeated testing required every 1 or 2 years. All 9 physician monitoring programs have a medical exam component, focusing on general health, cognition,vision, and hearing testing, although the evaluation process does vary from program to program. Performance testing is part of the evaluation in 6 of the health systems and is done by peer assessment in 4, and only done by dexterity testing in 2. In the peer review assessment, two policies address the technical and procedural competencies required by surgeons to safely and effectively perform surgery. The evaluation of these technical competencies is subjective in nature, where candidates are rated on scale from “significant concern” to “outstanding” clinical competence. Observed performance or behavior that influenced the peer assessment must be commented if labeled “significant concern” or “minor concern”. The results of the testing could be used to modify the physician’s privileges in 7 of the 9 health systems identified.

Competency assessments in the workplace

Licensing bodies and certification boards in the United States and Canada use CME and MOC as assessment methods to ensure continued clinical competency in the surgical workplace of board-certified surgeons (Table 3). However, these competency evaluations only address knowledge and do not take into account surgical skills, and to some degree judgment. State and provincial licensing bodies can initiate a competency evaluation by independent evaluator if a surgeon has been identified to the licensing body as performing below the accepted level of competency. Within the hospital setting, the surgeon-in-chief is primarily responsible to the community for the safety of the operating room and the competence of surgeons on the staff.

Several tools using surgical simulation or direct observation are currently being used on practicing surgeons to evaluate performance and technical skills needed for a surgical specialist (Table 3). Six of these tools reliably and accurately detect different level of technical skills among study participants, consisting of surgical trainees,fellows, and staff. All of these methods were validated for surgical trainees. Objective Structured Assessment of Technical Skills (OSATS) is the only method capable of distinguishing between surgeons of different skill level and showing a relationshipbetween skill level and post-operative outcomes.

Table 2 Late career practitioner policies adopted at health institutions

Surgical procedures and/or skills are evaluated by an expert, or non-medically trained reviewers with regards to Crowd-Sourced Assessment of Technical Skills (CSATS), using a paper-based tool in six of the object assessments, blinded to the postgraduate year of the participant. The objective assessments were designed for common surgical procedures extending over multiple specialties, including laparoscopic cholecys-tectomy, open reduction and internal fixation (hip, wrist, or ankle),arthroplasty, and robotic prostatectomy. Global Operative Assessment of Laparoscopic Skills (GOALS) and Global Evaluative Assessment of Robotic Skills (GEARS),however, target laparoscopic and robotic surgery only. The last tool, Direct Objective Metric Measures, uses measurable metrics to determine skill level instead of technique.Direct Objective Metric Measures investigate the stiffness and failure load of the final surgical product, which are critical within the orthopaedic field.

Table 3 Existing methods for determining surgical competency

DISCUSSION

For almost all of history, people worked until they died. Retirement is a recent phenomenon, starting during the Great Depression when governments, unions, and employers, desperate to make room in the workforce for young workers institutionalized retirement programs as we know them today, complete with social security and pension plans. Initially, the designated retirement age of 65 was longer than the life expectancy, but as life expectancy has increased, retirement age in certain professions has become more arbitrary. Surgeons may continue to work longer than other professionals because of their satisfaction and gratification in treating patients, because their work connects the surgeon to an identity or for financial reasons. Surgeon’s retirement age remains a contentious issue and presently there is no mandatory retirement age for surgeons. Furthermore, we could not find any universal, wellestablished and accepted policies of testing for competency of aging surgeons.

Although a review of 65 studies of physicians’ retirement planning found that most physicians retire between ages 60 and 69 years, some surgeons delay retirement because of financial insecurity, lack of other interests or fear of change in their personal lives and identity[20]. Despite the well-recognized decline of cognitive and physical skills with ageing, most surgeons only require verification of their CME to maintain their medical license to practice, in the absence of skill-based simulations that regulate non-medical professionals. Airline pilots, air traffic controllers, firefighters,and United States State Judges were found to have thorough medical examinations and skill assessments during their practice. Regardless of inherent ability, they are further subjected to mandatory retirement ages. Although the United States Age Discrimination and Employment Act of 1967 protects individuals at or above the age of 40 from mandatory retirement ages, employers have established a legitimate agebased criterion referred to as a bona fide occupational qualification (BFOQ), allowing them to justify an age-based BFOQ for certain professions.

Despite age being a variable process, the potential association within the surgical profession between increasing age and poorer operative outcomes has been reported in some studies[9-12]. The mandatory late career practitioner policies identified in this study begin to address the competency of the surgical workforce, through cognitive and physical testing. Performance testing consisted of peer-review assessment and varied across the different health institutions. In the absence of standardized technical skill assessments and continued legal challenges[21], age may not be the most reliable and objective performance indicator.

Surgeons, like other medical specialties, need to regularly engage in activities that keep them up to date with standards of care. However, the requirements to be certified or licensed are highly dependent on the standards developed by individual states,provinces or specialty boards. Furthermore, the validity of CME and MOC, defined as the ability to distinguish expertise level and effects on patient outcomes, was noted as unclear based on available literature. CME, such as didactic educational meetings,were shown to have only a small effect on clinical practice and patient outcomes[22,23].Completion of MOC is not associated with differences in complication rates in specific surgical subspecialties[24]. In fact, surveyed surgeons were in favor of improving MOC with additional testing such as cognitive assessments or review of cases for older surgeons, in place of a mandatory retirement age[25]. Meeting CME or MOC requirements alone does not guarantee a successful surgical practice, despite being used to certify surgeon competency.

Similar to the testing of pilots and air traffic controllers, there are surgical simulators designed to provide an objective assessment of surgical technical skills. Although these simulators have been used primarily for surgical residents to gauge their level of training, surgical simulators can equally be used to evaluate practicing surgeons by their peers or recognized experts[26,27]. These simulators may then be used to assess surgical competency among, not only older surgeons, but all surgeons as part of their medical education, showing who may require remediation or retirement. However,one of the most significant limitations in the use of simulation for assessing competence for aging surgeons–namely the ability to evaluate the most important skill that dictates surgical expertise and competence: Intra-operative cognitive skills. To date, very few if any surgical simulations have demonstrated the ability to assess advanced mental processes such as decision-making and judgment; and pattern recognition. These cognitive behaviors (or “thinking skills”) are some of the most important aptitudes that dictate performance in the operating room and better methodologies are required to measure them[28]. In addition, the use of simulators would need to be specialty specific and the specialty societies have not yet built these programs.

While this study demonstrated that current competency assessment methods for older surgeons require improvement, the study was limited by various factors. This study is a scoping review, thereby providing an overview of an important topic,without describing every possible assessment tool. Information regarding non-medical specialties was constrained to predefined professions, weakening the comparative analysis between these professions and surgeons. Other non-medical professions were not investigated, although the ones presented are commonly known. The number of late practitioner policies identified was also small, as they needed to be accessible online. It is clear that other policies exist, some of which have been referenced to online, such as Sharp Rees-Stealy Medical Group, Intermountain Healthcare in Utah,Scripps Health network in San Diego, Arkansas Children’s Hospital, Cooper University Hospital, University of Pittsburgh Medical Center, and Virtua Health[29,30].However, their policies are not explicitly described so that it is unclear whether or not these policies address older surgeon competence in a similar manner to the policies discussed in this study, or in a manner separate from cognitive testing or peerassessment. As well, there are likely other late practitioner policies that exist but are not present online. In addition, the non-licensing body surgical simulators have been studied across different procedures within different specialties, but the generalizability remains in question. For example, Crowd Sourced Assessment of Technical skills (CSAT) was shown to be valid for robotic skills amongst urology residents but whether it is valid in orthopaedics or other specialties is not known[26,31]. And given that these surgical simulators have largely been validated for distinguishing skill among surgical residents, more studies need to evaluate the validity and reliability of these simulators for staff surgeons before even considering implementation. In addition, even when there is a valid technique for objective assessment of competence in the execution of particular operations by surgeons, such as the assessment of intraoperative videos,there has been low utilization due to its labor-intensive nature involving human factors (cognitive engineering) expertise[32].

CONCLUSION

Surgery is a profession that requires good surgical judgment, as well as manual dexterity and physical skills for performing an operation. Age alone is not an indication of surgical competence, so testing of these attributes is necessary to ensure that the ageing surgeon remains competent. This requires regular periodic review of the surgeon’s outcomes and skills to ensure that the ageing surgeon has the competency to meet the standards of the profession. The strategy of using skill-based simulations in evaluating non-medical professionals can be similarly used as part of the assessment of the aging surgeons’ surgical competency. While more studies investigating the validity of these simulators is needed, future implementation of these simulators may ensure all aging surgeons maintain an appropriate professional standard for patient safety. A surgeon should not be forced to hang up his/her surgical cap at a predetermined age, but should be able to practice for as long as his/her surgical skills are objectively maintained at the appropriate level of competency. For those aging surgeons with a diminishing skillset, there other potential options to integrate these surgeons into important aspects of surgical care such as assisting younger surgeons for more complex cases, teaching and training the next generation of surgeons, coaching surgeons in practice, being involved in qualityimprovement and leadership roles.

ARTICLE HIGHLIGHTS

Research background

The aging surgeon has remained a contentious patient safety issue, as the average age of surgeons continues to rise.

Research motivation

When should an older surgeon stop operating? This becomes an important issue when we consider that the surgical profession is highly dependent on memory, sensory acuity, clinical decisiveness, technical skills and physical stamina; skills and abilities that may decrease with age.

Research objectives

The aim of this scoping review study was to investigate strategies used to determine competency in the industrial workplace that could be transferrable in the assessment of aging surgeons and to identify existing competency.

Research methods

Scoping review.

Research results

Surgeon’s retirement age remains a contentious issue and presently there is no mandatory retirement age for surgeons. Furthermore, we could not find any universal,well-established and accepted policies of testing for competency of aging surgeons.

Research conclusions

A surgeon should not be forced to hang up his/her surgical cap at a predetermined age, but should be able to practice for as long as his/her surgical skills are objectively maintained at the appropriate level of competency.

Research perspectives

More studies need to evaluate the validity and reliability of these simulators for staff surgeons before even considering implementation.