ACS Provides Guidance for Senior Surgeons Facing an Age-Old Question

When is it time for the senior surgeon to put down the scalpel?

While there isn’t a definitive answer to this question, the reality is that surgeons—just like everyone else—are susceptible to age-related decline in physical and cognitive skills. In fact, studies suggest notable variability in diminishing abilities between individual senior surgeons, with research supporting the assertion that decades of experience may compensate for moderate cognitive decline.

A considerable portion of the surgical workforce has grown considerably more gray within the last decade. More than 40% of US physicians will be 65 years or older within the next 10 years, according to the Federation of State Medical Boards Census of Actively Licensed Physicians in the US.^1-3 Unfortunately, there is a paucity of information on how to best assess a surgeon’s competency throughout his or her career while also maintaining patient safety and preserving physician dignity.

In an effort to address this gap, the ACS Board of Governors (BoG) Physician Competency and Health Workgroup published an article in the Journal of the American College of Surgeons (JACS), “Sustaining the Lifelong Competency of Surgeons: A Multimodality Empowerment Personal and Institutional Strategy,” which provides a literature review of recent studies examining the “neurocognitive function and the clinical competency of surgeons and recommendations for the implementation of ‘whole of career’ strategies to ensure the sustained competency of the surgical workforce.”¹

The JACS article informed some of the key guidelines featured in the newly released ACS Statement, “Sustaining the Lifelong Competency of Surgeons,” which is an updated version of “The Aging Surgeon” statement from 2015.

“The 2015 statement was a very conservative dip in the water,” said Todd K. Rosengart, MD, FACS, lead author of the JACS article and professor and DeBakey-Bard Chair of the Michael E. DeBakey Department of Surgery at Baylor College of Medicine in Houston, Texas. “It really advocated only for voluntary testing, and the results did not necessarily need to be shared. It was sort of a gentle introduction to the subject.”⁴

The JACS authors outlined guiding principles that helped drive the development of the new article and the ACS Statement, including the support of “comprehensive, multimodality clinical competency assessments, including neurocognitive testing and the early implementation of long-term transition planning for surgeons within a culture of safety, collaboration, and equity.”¹

The 2024 ACS Statement supports a “comprehensive, lifelong assessment program inclusive of all physicians” in order to “create a culture of safety, equity, and transparency in monitoring potential declines that could affect surgeon competency.”²

“The other big change in developing the updated ACS Statement was the focus on lifelong or career-long competency, which is a very different approach to this subject both by the College, and really to my knowledge, almost every other institution looking at the issue of surgeon competence,” explained Dr. Rosengart. “This really is a significant step forward from the 2015 statement.”

Being a physician is often at the core of a surgeon’s identity, and developing pathways that foster the maintenance of cognitive skills in an inclusive and nonjudgemental framework is essential to the maintenance of such competency.

“We need to empower our surgeons to be involved in their own assessments of competency throughout the entirety of their careers as opposed to focusing on the trigger of age,” said Adam M. Kopelan, MD, FACS, coauthor of the JACS article and Chair of the ACS BoG Physician Competency and Health Workgroup. “By doing so, we can help destigmatize the concerns of aging on performance,” said Dr. Kopelan, who also is chair of Surgery at Newark Beth Israel Medical Center and chief of general surgical services at RWJBarnabas Health Northern Region, both located in New Jersey.

Current Data on Assessing Surgeon Performance

The College does not support a mandatory retirement age, according to the ACS Statement, because “the onset and rate of age-related decline in clinical performance varies among individuals and suggests that “objective assessment of fitness should supplant consideration of a mandatory retirement age.”²

The JACS authors noted that while there isn’t a mandatory retirement age for US physicians, many other countries impose a mandatory retirement age (India: age 65; China and Russia: age 60 for males, 55 for females; Pakistan, Spain, British Columbia, and Australia: age 70).

The justification for whether or not an international governing body dictates a retirement age for its physicians may be a point for further debate, but one fact is consistently clear—studies show age-related cognitive decline can occur after the age of 60, which can affect the clinical competency of surgeons.¹

According to the JACS article, Korinek et al. and Turnbull et al. observed “significantly to severely impaired cognitive function in 16% and 23% of physicians referred for competency testing in their respective studies.” The article also cited a study by Boom-Saad et al. that found “senior surgeons (aged 61-75 years) were significantly outperformed overall on the Cambridge Neuropsychological Test Automated Battery by midcareer practicing surgeons (aged 45-60 years), who in turn were outperformed by medical students (aged 20-35 years).”

A review of 62 studies also cited in the JACS article outlined a correlation between increased age with “decreasing medical knowledge, lower adherence to evidence-based standards of care, and worse patient outcomes.”

Notably, data contradicting the association of surgeon age with patient outcomes also were highlighted in the article. “Together, these findings suggest that surgeon experience may, at least in some cases, have a ‘protective’ effect against declining psychomotor and cognitive performance,” said Dr. Kopelan.

For example, Wallis and colleagues examined a retrospective cohort analysis of 1.1 million patients in Ontario, Canada, undergoing 25 common elective and emergent surgical procedures and found that surgeon advancing age was associated with 5% relative decreased odds of a composite of death, readmission, and complications with every 10 years of surgeon experience and a 7% reduction with surgeons over age 65.

Tsugawa and colleagues showed modestly lower mortality in 900,000 Medicare beneficiaries performed by surgeons older than 60 years of age compared to those performed by younger surgeons. And Clark and colleagues found that survival in a population of 950 lung transplant patients in the UK had a higher 30-day posttransplant survival rate sustained at 5 years posttransplant for those patients whose surgeons were older than 48 years.

“Some of these studies show that older surgeons can perform better in terms of outcomes because they've learned through years of experience about how to avoid trouble, how to navigate complex cases or the like,” explained Dr. Rosengart.

Tools for Identifying Declining Capacity

A survey administered to 995 surgeons at ACS Clinical Congress meetings from 2001 to 2006 examined subjective changes in cognitive abilities, caseload, engagement with new technology, and retirement-related decisions. Of those surveyed, only 32% (55 years and older) reported self-perceived alterations in memory recall and name recognition, which according to the JACS article, is “inconsistent with corresponding objective, age-associated measures of such changes.”^1,5-7

The 2024 ACS Statement corroborates the survey findings and suggests that “surgeons may not, on their own, recognize deterioration of their physical and cognitive function and clinical skills with age.”

“A significant number of physicians surveyed at the ACS annual meetings were not aware of their own cognitive decline, nor were many peers comfortable, understandably, calling them out and saying, ‘I’m concerned about my colleague,’” said Dr. Rosengart. “In the current culture, there’s more than a bit of discomfort in discussing the issue of a surgeon’s competency. The ability to create a framework where we normalize taking care of ourselves and each other in a nonpejorative way is very important.”

Potential warning signs of age-related decline may include forgetfulness, unusual tardiness, evidence of poor clinical judgment, major changes in referral patterns, unexplained absences, confusion, change in personality, disruptiveness, drastic change in appearance, and unusually late and incoherent documentation.

“A very important part of both the ACS Statement and the JACS article is that they both address the question of: “Who is going to lead this effort? Is it going to be the American College of Surgeons, the American Board of Surgery, or other state or national entities? If not us, though, if we abdicate this responsibility, is it going to be the federal government mandating what we do?” posited Dr. Rosengart, who encouraged surgeons to take the leadership role in developing competency assessments and associated policy.

The ACS recommends the implementation of a “comprehensive, whole-of-career testing strategy for all surgeons and surgical trainees regardless of age and experience level.” It is suggested that this approach be performed routinely as part of the Ongoing Professional Practice Evaluation (OPPE) that is required of all hospitals subject to third-party credentialing. The ACS Statement and the JACS article also support the use of neurocognitive assessments tools, which could be considered a potential component of OPPE.

“Importantly, maintaining this responsibility at the local, institutional level with guidance from national entities such as state medical boards, the American College of Surgeons, or the American Board of Surgery could create universal recommendations that could be integrated into local assessments of relevant capabilities,” observed Dr. Rosengart.

The authors of the JACS article highlighted specific neurocognitive tests that are available for widespread use, such as the MicroCog test, a computerized neuropsychiatric screening tool that assesses attention and mental control, memory, reasoning, calculation, spatial processing, and reaction time. Other tests described in the article and the ACS Statement include the St. Louis University Mental Status Examination, Montreal Cognitive Assessment, Cambridge Neuropsychological Test Automated Battery, and the Halstead-Reitan Neuropsychological Test Battery.

“Measuring surgeon competency is a multidimensional assessment of the physical and intellectual ability to assess and treat patients who have a variety of diseases,” explained Dr. Kopelan. “There are no singular measures (with exceptions) that we are aware of that can render a surgeon ‘competent’ or ‘incompetent.’ Additionally, competence of a surgeon may vary among a variety of diseases. Developing a set of tools to trigger when a more formal assessment of competency must be made will be challenging especially given the variability of measurements and the subjective biases of these evaluations.”

However, when a surgeon or hospital system decides to measure surgical performance and potential declining capacity, one factor is consistent across all practice settings—one size does not fit all. Notably, evidence of decline on any of these tests can also signal an opportunity for individualized training, which in at least some cases, has been shown to reverse or at least slow neurocognitive declines and potentially extend a surgeon’s service as an active operator.

“What we’re proposing is not that a cognitive test would be the one and only standard, the be-all and end-all of approving competency,” Dr. Rosengart said. “These assessments would be part of a mosaic of cognitive testing, including clinical performance, peer review, and so on, that would be potentially different at each institution. And what we're going to do, hopefully, is create guidelines and a framework for institutions to decide for themselves what that competency testing and approval should look like.”

A primary goal of the Physician Competency and Health Workgroup is to support the College in educating the surgical community about the issues faced by some senior surgeons. “We’re not attempting to take on the role of monitoring the community, but rather, we want to provide support, encourage, and help each other,” said Dr. Rosengart. “We’re certainly not seeking to single out older surgeons. We are simply asking ‘Why wouldn’t you want to focus on a surgeon’s competency throughout their entire career?’”

Career-Long Transition Planning

Senior surgeons may be hesitant to think about the next phase of their careers, particularly if they are considering a transition to nonsurgical roles. Surgeons sometimes experience a perceived obligation to maintain clinical activity due to their dedication to patient care and/or perceptions that the next generation does not share their level of commitment or capability, according to the JACS article.

It is advisable to pair careerlong competency assessments with long-term transition planning so that surgeons are prepared should testing and other factors indicate a transition away from standard clinical practice.

“Up until now, surgeons have not had that awareness of, yes, this will come to an end, and you need to be prepared,” Dr. Rosengart said. “What we envision both in the statement and article is early career considerations of ‘What am I going to do when I can't, or decide not to, go to the operating room?’”

Individually tailored transition strategies should provide flexibility for surgeons looking to move away from the clinical workforce or retire altogether. For example, a transition plan could include a first step of moving from the primary surgeon role to privileges as a first-assistant or consultant role.

“A senior surgeon can continue to contribute in many diverse ways,” said Dr. Rosengart. “An individual could serve as a wonderful first assistant to a more junior surgeon who could benefit from that surgeon’s skills and experience. Another surgeon, however, might decide they are ready to leave the operating room with the goal of helping the hospital institution in other ways. Think about all of the needs we have for talented and experienced physicians to support our institutions in quality improvement, research, education—or through mentoring or coaching, or community outreach.”

For some surgeons, it might be hard to imagine a day when they will be ready to take off their scrubs and contribute to patient care in different but meaningful ways.

“I think too often surgeons think ‘The day I leave the operating room is the day my life as I know it has ended,’” said Dr. Rosengart. “That's something that can be frightening; we want to change that next chapter into something that physicians and surgeons will welcome as a new opportunity.”

Tony Peregrin is the Managing Editor of Special Projects in the ACS Division of Integrated Communications in Chicago, IL.

References

1. Rosengart TK, Chen JH, Gantt NL, Angelos P, et al. Sustaining the lifelong competency of surgeons: A multimodality empowerment personal and institutional strategy. J Am Coll Surg. April 9, 2024. Available at: https://journals.lww.com/journalacs/citation/9900/sustaining_lifelong_competency_of_surgeons_.939.aspx. Accessed April 26, 2024.
2. American College of Surgeons. ACS Statement on Sustaining the Lifelong Competency of Surgeons. April 9, 2024. Available at: https://www.facs.org/about-acs/statements/sustaining-the-lifelong-competency-of-surgeons/. Accessed April 26, 2024.
3. Young A, Chaudhry H, Pei X, Arnhart K, Dugan M, Simons K. FSMB Census of Licensed Physicians in the United States, 2020. J Med Regul. 2021;107:5764.
4. American College of Surgeons. ACS Statement on the Aging Surgeon. 2015. Available at: https://www.facs.org/about-acs/statements/aging-surgeon/. Accessed March 19, 2024.
5. Bieliauskas LA, Langenecker S, Graver C, Lee JH, O’Neill J, Greenfield LJ. Cognitive Changes and Retirement among Senior Surgeons (CCRASS): Results from the CCRASS Study. J Am Coll Surg. 2008;207(1):69-78.
6. Lee JH, Drag LL, Bieliauskas LA, et al. Results from the Cognitive Changes and Retirement among Senior Surgeons Self-Report Survey. J Am Coll Surg. 2009;209(5):668-671.
7. Drag LL, Bieliauskas LA, Langenecker SA, Greenfield LJ. Cognitive Functioning, Retirement Status, and Age: Results from the Cognitive Changes and Retirement among Senior Surgeons Study. J Am Coll Surg. 2010;211(3):303-307.