Assessing performance in ageing surgeons: systematic review

The number of physicians exceeding the age of 55 years has increased dramatically over the past 40 years, with close to 40 per cent of surgeons in Canada and the USA being above that age1. Surgeons are not immune to physical and cognitive decline that accompanies human ageing. An older surgeon’s accumulated knowledge and experience may not be sufficient to mitigate the inevitable changes in cognition and physical function that occur with age2. Although patient mortality outcomes show conflicting results between older and younger surgeons3, some studies have highlighted that senior surgeons have worse outcomes for some procedures than their junior colleagues, leading to the concept of surgeon age as an operative risk factor4. At the heart of the issue of ageing surgeons is balancing the need to protect patients from impaired surgeons while ensuring that competent surgeons are not discriminated against. In this delicate and often highly emotive matter, there is little guidance for surgeons, their colleagues, employers, and regulators as it is unclear how age-related decline in learning, attention, reaction time, and dexterity correlate with surgical outcomes5. Determining a defensible age cut-off for surgeons is, therefore, both practically and ethically problematic. Compounding the issue is an overall paucity of robust longitudinal data examining ageing and surgical performance. Although programmes have been developed to assess the competence of ageing surgeons at individual institutions6, no standardized approach to addressing age-related decline in function exists, and validated tools for assessing the performance of ageing doctors are lacking7. A systematic review of the literature (Supplementary material and Table S1) was performed to September 2022 to investigate current means of assessing ageing surgeons’ performance, and to develop standardized guidelines. Of 1173 studies identified, 21 performance assessment programmes were included in this review (Table S2 and Fig. S1). Nineteen programmes were based in the USA, one in Canada, and one in Australia. The majority of the programs (14 of 21) were implemented at individual medical centres, five were recommendations of medical boards or organizations representing surgeons in a particular jurisdiction, and two were driven by a College of Surgeons (College of Physicians and Surgeons of Ontario and American College of Surgeons). The majority of programmes (13 of 21) began during the past decade, and two were implemented in 2011 and 2012. The median age at which these programmes were introduced was 70 (range 65–72) years. The frequency of reassessment varied between 1 and 5 years, the most common being 2 yearly. Only four programmes specifically targeted surgeons; the rest were aimed at the general physician population, which included surgeons. The components of each performance assessment programme are summarized in Table S3. In four of 21 programmes, the assessment was conducted or recommended by an independent organization. Three programmes had peer assessment as one aspect of the evaluation. Six had history-taking as part of the overall assessment, although the components asked were not elucidated. Physical and cognitive/neuropsychological assessment were much more prevalent, being an integral part of 18 and 17 of 21 programmes respectively. Components of the physical examination varied, and included combinations of vision and hearing testing, and neurological and fine motor testing. Likewise, a variety of cognitive and neuropsychological testing tools were used across different programmes. Six of 21 programmes assessed the clinical performance of ageing physicians, often by analysing the medical records of their patients, and morbidity and mortality data. Only three programmes looked at the record-keeping ability of physicians by assessing patient notes. No programme incorporated simulation testing to assess clinical skills and surgical dexterity. Some programmes incorporated triggers that could prompt performance assessment, irrespective of physician age (Table S4). These included sentinel events of concern, failure of routine and specific professional practice evaluations, worrisome malpractice history in the context of a new complaint, or an investigation at the discretion of the chief of surgery or hospital executive. Eight of 21 programmes described possible modification of practice privileges as a consequence of the performance assessment. Functional age may be a more valid measure of competence than chronological age8. Considering the potential impact of a surgeon’s ability on patient outcomes, and lack of a universal, evidence-based retirement policy, there is an argument for implementation of performance assessment programmes in older surgeons that are tailored to individual practitioners. Yet, as identified by the present study, the programmes in place across various institutions show considerable variation in method of assessment of surgical performance, which limits their utility. First, nearly all programmes identified here are based in individual institutions in the USA and may not be generalizable across other healthcare environments, especially in resource-poor settings where senior surgeons may be the only experienced surgeons available. Second, none of the programmes have been validated independently as improving surgical outcomes. Third, the frequency of reassessment and age at which assessment first began were arbitrary, as reflected in the variation between programmes. Without good evidence to support age-based revocation of privileges or mandatory screening, any age cut-off will be challenging to defend. What are necessary are more longitudinal data examining the performance of surgeons over the course of their careers, clarification of the merits of carrying a full caseload across the length of surgical life, and validated functional and cognitive tests that can discriminate between poor performers and competent surgeons at any age. Fourth, none of the programmes employed simulation testing as a means of assessing performance. Given the increasing use of virtual reality models and simulation in medicine9 and other industries where public safety is paramount, this seems an obvious way to assess surgical competency. Fifth, non-technical skills did not seem to be the focus of any of the performance assessment programmes despite the growing recognition of their importance in surgery. Sixth, a minority of programmes used certain triggers, such as discretion of department chairs or hospital leadership, to refer older practitioners into performance assessment programmes. Although the leadership team and peers should be able to express concerns about patient safety stemming from a surgeon’s behaviour, there must be checks built into the referral pathway to ensure protection of surgeons from vexatious complaints that could cause unnecessary anxiety and loss of productivity. Similarly, peer assessment can be subject to various biases that must be taken into account. Although an independent organization seems to be an obvious solution to the problem, it places further financial burden on healthcare systems and may not be available in all jurisdictions. Studies investigating physical and cognitive decline with age are often confounded by marked individual variation in the rate and extent of this decline10,11. In light of this, a three-tiered framework for ensuring performance and supporting safe career transitions was proposed by Sherwood and Bismark12. This consisted of self-reflection and open-mindedness about personal and professional transition, support from employers and professional colleagues to identify risks early, followed by closer assessment and remediation, rehabilitation, or adjustment of work demands, and intervention of a regulator in the small number of instances where the surgeon had poor insight into their performance12. Recertification programmes assessing the performance of older surgeons in an objective and independent manner may be an important adjunct to help guide decisions to alter clinical practice, transition to academic and mentoring roles, or retire. These data have revealed the heterogeneous nature of performance assessment programmes and practices currently in place that lack a strong evidence base. Future prospective, controlled studies using individual-level data on duration of procedures, duration of hospital stay, and postoperative complication rates are needed to address the surgeons’ outcomes accurately13. Longitudinal data are also required to see whether performance assessments can be used to individualize the age of retirement for surgeons and thereby maintain patient safety. The authors have no funding to declare. The authors acknowledge R. Mayberry and G. Jones, librarians at South and East Metropolitan Health Services, for assistance with the search strategy. Saiuj Bhat (Data curation, Formal analysis, Investigation, Methodology, Visualization, Writing—original draft, Writing—review & editing), Benjamin Chia (Data curation, Writing—review & editing), Wendy Babidge (Conceptualization, Methodology, Project administration, Supervision, Writing—review & editing), and Guy Maddern (Conceptualization, Methodology, Project administration, Supervision, Writing—review & editing). The authors declare no conflict of interest. Supplementary material is available at BJS online. All data are provided in the Supplementary material.