Editor’s note: The following is the third in a series of excerpts from Being Well and Staying Competent: Challenges for the Surgeon, a guidebook issued in 2013 by the ACS Board of Governors’ Committee on Physician Competency and Health. The complete document is posted on the American College of Surgeons members-only portal at www.efacs.org.
Unlike some other professions, surgery has no mandated or commonly accepted retirement age. In recent decades, surgeon age as a marker of performance has been the subject of much debate and some scholarly research.1-5 Questions commonly raised include:
- How does the aging process affect surgical skills and judgment?
- Do the changes associated with aging occur uniformly in all surgeons?
- Is self-evaluation of skills and judgment reliable?
- Is objective assessment of surgical skills and judgment feasible or practical?
- What options are available for the surgeon who is considering a change of practice?
Age is just a number
According to data from the American Medical Association, many surgeons continue to practice beyond the “standard” retirement age of 65.6 As the baby boomer generation reaches retirement age, it is anticipated that an increasing number of these surgeons will continue to practice as well. Nonetheless, the number of trained general surgeons relative to a growing and increasingly aging population is on the decline, and a mandatory retirement age for surgeons would likely exacerbate this shortage.7-10
Surveys of surgeons indicate there is no consensus in favor of a mandated retirement age nor widespread agreement on when a surgeon should retire, ultimately leaving the decision to the individual.11 A high sense of value and satisfaction experienced during active clinical practice is cited as the most common reason surgeons continue to practice.12 On a less positive note, inadequate retirement planning, both due to financial concerns and a lack of nonsurgical interests to replace clinical practice, may contribute to a prolonged surgical career.13-14
The Age Discrimination in Employment Act of 1967 (ADEA) protects individuals who are 40 years of age or older from employment discrimination. In direct contrast to the ADEA, numerous professionals are subject to mandatory retirement age—most notably air traffic controllers, airline pilots, Federal Bureau of Investigation agents, and other federal law enforcement officers. Professions with a mandatory retirement age seem to support the viewpoint that performance is inversely proportional to age, causing some to advocate a “one size fits all” compulsory retirement age for surgeons—regardless of performance status and without empiric data to support this position.1
More nuanced observations, however, suggest that the relationship between age and performance may be more complex.15 Stamina, cognition, and fine-motor skills decrease with age, but not uniformly across populations, and some learned tasks and physical memory are remarkably preserved over time.4 In neuropsychological testing, decreases in cognitive processing efficiency as well as skills related to attention span, reaction time, and visual learning occur with age, as well as a decline in memory, particularly recall. Specific cognitive testing of surgeons, however, showed that the decline in reaction time was less than that of comparison groups and most practicing surgeons older than age 60 performed comparably to younger colleagues in all areas of cognitive testing.14
Age may be inversely related to clinical performance in primary care, but for most procedures, surgeon age is a poor predictor of operative risk.1,16-17 Nonetheless, for some complex procedures (pancreatectomy, coronary artery bypass graft, carotid endarterectomy, and so on), surgeons older than 60 years of age with low procedure volumes relative to younger surgeons have slightly higher mortality rates than their younger cohort.1 Aging surgeons who gradually decrease the volume of these procedures may experience a counterproductive deterioration in the skill sets necessary for safe conduct suggesting that an “all or none” approach to complex procedures is better to maintain skills and a safe practice.1
Unfortunately, self-assessment of performance is often inaccurate. In a study of 359 surgeons, subjective perception of cognitive changes did not correlate well with objective assessments.18 Other studies have supported the finding that physicians are unable to accurately self-assess performance and knowledge, with those surgeons receiving the weakest external assessment also proving to be least effective at self-assessment.19 From a credentialing standpoint, ongoing professional practice evaluations and focused professional practice evaluations are designed to respond to aberrations in performance, frequently after an occurrence when colleagues or hospital administrators are moved to limit or terminate the surgeon’s practice. Hence, these assessments are of little help for planning purposes.
Patients, colleagues, payors, hospital administrators, plaintiffs’ attorneys, and physicians all have a stake in this issue, which calls for an urgent response from the surgical community. The profession must be able to assure patients that their surgeons are trained to deliver safe care. The profession must also be able to prove that it has developed thoughtful, proactive, logical policies or risk the imposition of external regulation.
Available data support the claim that age alone is an inadequate criterion for determining when an individual should retire. The authors recommend an individualized approach for credentialing bodies to apply focused psychomotor assessments of practicing surgeons at defined intervals—analogous to those required to maintain a driver’s license at an advanced age—as a requisite for ongoing practice.15 Suggested ages for beginning this type of testing range from 62 to 75, with 65 years old appearing to be a more common threshold.
Considering the fact that personal health care issues may contribute to the decline of cognitive and technical skills, periodic medical evaluation is an essential part of the assessment. Whereas the individual surgeon may fail to recognize or may deny diminishing skills, peer evaluation by direct observation also is important. Case review may be insufficient to evaluate subtle changes in decision making or waning technical abilities. It is also essential that these appraisals be applied equally and be carried out in a confidential manner that maintains the dignity of the surgeon. For example, Stanford University Medical Center, CA, recently endorsed a policy requiring medical staff ages 75 and older to have a “physical examination, cognitive screening and peer assessment of…clinical performance” every two years. “If the findings…point to potential concerns for patient safety, the service chief and the credentials committee will, on a confidential basis, consider the results and recommend further evaluation as necessary.”20
Transitioning away from practice
The authors recommend that hospitals and departments of surgery explore ways to take advantage of the aggregate expertise of their senior practitioners by allowing them to continue, if appropriate, performing adequate numbers of less complex procedures without impinging on the productivity and satisfaction of their younger colleagues.4 The cumulative wisdom and clinical experience of the senior surgeon is an invaluable asset that should be honored and maintained.
For the surgeon who would like to continue to be engaged in surgical practice, assisting in operations, focusing on an office-based or an academic practice, staffing clinics, and rounding on clinical services are activities that offer the opportunity to stay involved with reduced work hours and flexible scheduling. Another vital role for the senior surgeon is mentoring junior colleagues, ranging from offering informal advice to developing a departmentally defined relationship. The experienced surgeon’s knowledge is also valuable for the teaching of surgical topics and anatomy to both residents and medical students. Additional opportunities for the surgeon who is reducing clinical practice time include administrative and quality/performance improvement activities, such as establishing and implementing American College of Surgeon National Surgical Quality Improvement Programs or cancer programs in their institutions.
The authors further recommend that surgeons seek professional guidance at the start of and throughout clinical practice to plan financially for retirement. Recent economic downturns have adversely affected retirement planning for many individuals, making careful preparation all the more important. Although many surgeons do pay close attention to the financial aspects of retirement, some of them give less consideration to planning for meaningful activities to pursue once the decision to retire is made. Development of (and perhaps some trial and error participation in) activities before full-time retirement from practice is important. For most surgeons, it is unrealistic to anticipate personal fulfillment in an abrupt transition from a busy surgical practice to a few hours of sports activities a week. In the maintenance of well-being throughout one’s professional life, meaningful endeavors and relationships are essential.
- Waljee JF, Greenfield LJ, Dimick JB, Birkmeyer JD. Surgeon age and operative mortality in the United States. Ann Surg. 2006;244(3):353-362.
- Birkmeyer JD, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL. Surgeon volume and operative mortality in the United States. New Engl J Med. 2003;349(22):2117-2127.
- O’Neill L, Lanska DJ, Hartz A. Surgeon characteristics associated with mortality and morbidity following carotid endarterectomy. Neurology. 2000;55(6):773-781.
- Blasier RB. The problem of the aging surgeon: When surgeon age becomes a surgical risk factor. Clin Orthop Relat Res. 2009;467(2):402-411.
- Waljee JF, Greenfield LJ. Aging and surgeon performance. Adv Surg. 2007;41:189-198.
- Smart DR. Physician Characteristics and Distribution in the U.S. Chicago, IL: American Medical Association; 2006.
- Sheldon GF, Ricketts TC, Charles A, King J, Fraher EP, Meyer A. The global health workforce shortage: Role of surgeons and other providers. Adv Surg. 2008;42:63-85.
- Jonasson O, Kwakwa F. Retirement age and the workforce in general surgery. Ann Surg. 1996;224:574-582.
- Cofer JB, Burns RP. The developing crisis in the national general surgery workforce. J Am Coll Surg. 2008;206(5):790-797.
- Lynge DC, Larson EH, Thompson MJ, Rosenblatt RA, Hart LG. A longitudinal analysis of the general surgery workforce in the United States, 1981–2005. Arch Surg. 2008;143(4):345-350.
- Greenfield LJ, Proctor MC. Attitudes toward retirement. A survey of the American Surgical Association. Ann Surg. 1994;220(3):382-390.
- Luce EA. The aging surgeon. Plast Reconstr Surg. 2011;127(3):1376-1383.
- Virshup B, Coombs RH. Physicians’ adjustment to retirement. West J Med. 1993;158(2):142-144.
- Drag LL, Bieliauskaus 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(3);211:303-307.
- Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: The relationship between clinical experience and quality of health care. Ann Intern Med. 2005;142(4):260-273.
- Stolley PD, Becker MH, Lasagna L, McEvilla JD, Sloane LM. The relationship between physician characteristics and prescribing appropriateness. Med Care. 1972;10:17-28.
- Rhee SO. Factors determining the quality of physician performance in patient care. Med Care. 1976;14(9):733-750.
- Bieliauskaus LA, Langenecker SA, Graver C, Jin Lee H, 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):69-79.
- Davis DA, Mazmanian PE, Fordis M, Van Harrison R, Thorpe KE, Perrier L. Accuracy of physician self-assessment compared with observed measures of competence: A systematic review. JAMA. 2006;296(9):1094-1102.
- Sanford J. New policy to require evaluations for late-career practitioners. Inside Stanford Medicine. July 16, 2012. Available at: http://med.stanford.edu/ism/2012/july/evaluate-0716.html. Accessed February 12, 2014.