Age-associated differences in cognitive performance of physicians and control participants as assessed by total score on MicroCog testing. Adapted with permission from Powell and Whitla.10
Data represent results of the 2018 online survey of all members of the Society of Surgical Chairs (n = 80 respondents). A, Definition of the senior, aging surgeon. B. Importance of strategies used by chairs to transition the aging surgeon beyond an operating role (combined percentage of strategies respondent chairs rated as high or moderate [Table 1]). C, Prevalence of established institutional policies for transitioning senior surgeons. D, Anticipated referral destinations for surgeon fitness evaluations.
eTable. Examples of Mandatory Retirement in Other U.S. Occupations
Customize your JAMA Network experience by selecting one or more topics from the list below.
Identify all potential conflicts of interest that might be relevant to your comment.
Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.
Err on the side of full disclosure.
If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.
Not all submitted comments are published. Please see our commenting policy for details.
Rosengart TK, Doherty G, Higgins R, Kibbe MR, Mosenthal AC. Transition Planning for the Senior Surgeon: Guidance and Recommendations From the Society of Surgical Chairs. JAMA Surg. Published online May 15, 2019154(7):647–653. doi:10.1001/jamasurg.2019.1159
Aging is well documented to be associated with declines in cognitive function and psychomotor performance, but only limited guidance is currently available from medical professional societies or regulatory agencies on how to translate these observations into the appropriate monitoring of physician performance.
The Society of Surgical Chairs conducted a panel discussion at its 2017 annual meeting and a subsequent survey of its membership in 2018 to develop recommendations for the transitioning of the senior surgeon.
Conclusions and Relevance
Recommendations include mandatory cognitive and psychomotor testing of surgeons by at least age 65 years, potentially as a component of ongoing professional practice evaluation; career transition discussions with surgeons beginning early in their careers; respectful consideration of the potential financial needs, long-standing work commitments, and work-life concerns of retiring surgeons; and creation of teaching, mentoring or coaching, and/or administrative opportunities for senior surgeons in modified clinical or nonclinical roles. Ideally, these initiatives will catalyze a thoughtful and comprehensive new vista in supporting an aging workforce while ensuring the safety of patients, the efficient management of health care organizations, and the avoidance of unnecessary depletions to a sufficiently sized cadre of physicians with case-specific competencies.
Aging is well documented to be associated with declines in cognitive function and psychomotor performance, but only limited guidance is currently available from medical professional societies or regulatory agencies on how to translate these observations into the appropriate monitoring of physician performance.1-4 This contrasts with the many other industries in which mandatory or contingent age-based restrictions exist for the maintenance of privileges, especially if the failing performance of operators may endanger human lives.5
The challenge of ongoing physician performance certification and credentialing is likely to become increasingly important as the mean physician age increases. Specifically, the number of US physicians older than 65 years increased from 50 000 to more than 240 000 from 1975 to 2013.6-9 There are 12 000 aging or senior surgeons (those older than 70 years) practicing in the United States, who make up approximately 10% of the surgeon work force. An additional 50 000 surgeons who are 55 to 69 years of age will soon enter senior status.8
Monitoring of aging surgeons who engage in patient care, which requires a complex interplay of cognitive and psychomotor functions, will thus pose a growing challenge to ensuring patient safety. It is well established, however, that the association of aging with cognition and clinical performance varies considerably among individuals and physicians typically function at higher levels of cognitive skill than nonphysicians do.1,3,5,10-13 These considerations reflect the near absence of obligatory physician retirement ages in the United States, which may be considered discriminatory and can unnecessarily exclude the practice of appropriately functioning senior surgeons.14
Some have advocated mandatory cognitive skills testing and long-term planning as important ways to instead address the transitioning of the senior surgeon.5,9,12,13 Ad hoc approaches to the senior surgeon with demonstrable deterioration in clinical skills can otherwise lead to deferred patient safety and inconsistent, inequitable surgical staff management. Such nonuniform interactions can damage professional relationships, raise concerns regarding potential retribution, or even lead to age-discrimination lawsuits.14
Given the dearth of established national protocols or institutional guidance, decision making on the management and certification of aging physicians typically falls to departmental leadership. Accordingly, the Society of Surgical Chairs (SSC), whose membership of 185 department of surgery chairs represents approximately 70% of the nearly 270 academic departments of surgery in the United States, conducted a panel discussion in 2017 and a survey of its membership in 2018 to develop insights into optimizing the management of the aging surgeon. This article was formulated from these initiatives to provide guidance and recommendations in the transition of aging surgeons.
This article intentionally excludes the consideration of other potential causes of deficient or deteriorating clinical skills (eg, substance abuse) as too broad in scope. We likewise do not address other cohorts, such as early-career surgeons, who may paradoxically not have had adequate career longevity to support the development of appropriate clinical expertise and cognitive or technical competencies.15,16 Conversely, at least some of the considerations relevant to the aging surgeon may also pertain to these or other (eg, nonsurgeon) groups, but these groups are also not considered.
Declines in cognitive and psychomotor performance of up to 20% may occur between the ages of 40 years and 75 years, with substantial evidence of such decline generally appearing by the age of 60 to 65 years (Figure 1).1,10,15,17-21 The rate and timing of these changes are however quite variable, especially in older populations.1,10,15,17-21 The limited number of studies available assessing age-associated declines in the cognitive performance of physicians generally correlate these to that of nonphysicians (Figure 1), although physicians demonstrate a higher level of cognitive function than their lay counterparts; these disparities increase with age.1,3,10,15,17-21
Korinek et al12 used MicroCog, a commercially available 60-minute neuropsychological testing battery specifically designed for physicians, to assess physician cognitive function. They found that 65 of 279 physicians (23.3%) referred for competency testing demonstrated greater than a 1 SD of decline in cognitive function compared with a matched physician control group.12 Turnbull et al22 similarly showed that 31 of 45 physicians (69%) referred for competency testing demonstrated significant neurocognitive dysfunction, of whom 7 (16%) had severe impairment.
Quiz Ref IDBeyond physicians referred for competency testing, Boom-Saad et al3 found that senior surgeons (aged 61-75 years) were significantly outperformed by midcareer practicing surgeons (aged 45-60 years), who in turn were outperformed by medical students (aged 20-35 years) on the Cambridge Neuropsychological Test Automated Battery (CANTAB), a more extensive neuropsychological testing battery than MicroCog. Drag et al20 likewise reported that only 38% of practicing surgeons older than 70 years and only 55% of practicing surgeons older than 60 years performed within the range of surgeons aged 45 to 59 years on CANTAB analysis.
Importantly, these changes in cognitive and psychomotor performance do not to appear to merely be testing artifacts without clinical correlate.4,11,23,24 A review of 62 studies associated age with decreasing medical knowledge, lower adherence to evidence-based standards of care, and worse patient outcomes.4 Older surgeons have also been shown to be less likely to incorporate new treatment modalities and guidelines into their practices and to be subject to increased licensing actions.25-28 McAuley et al23 likewise reported significant age-associated increases in clinical practice deficiencies, from 24 physicians (9%) younger than 49 years to 22 physicians (35%) older than 75 years in a peer assessment of Canadian physicians.
Quiz Ref IDOther studies also point to a decline in clinical outcomes as a function of operator age, including those for coronary bypass, carotid endarterectomy, and hernia repair.3,29-31 Conversely, age-associated declines in clinical outcomes have also been associated with declining case volume and have been discounted by others who highlight nonanalytical clinical and cognitive competencies and experience compensating for potential cognitive deficits.15,21,32,33 Tsugawa et al,34 for example, in a study of 900 000 Medicare beneficiaries, found that patients who had surgery performed by older surgeons (≥60 years) had modestly lower mortality rates than patients operated on by younger surgeons, especially with surgeons who reported a higher volume of procedures and patients with nonelective cases.
In this context, in a survey of nearly 1000 surgeons, more than half of whom were older than 55 years, 58% stated that they had no immediate plans of retiring and that the primary factor in determining their retirement will be their own perception of declining skill level.18 While 32% of respondents 55 years and older in this survey did report self-perceived changes in memory recall and name recognition, it has also been shown that the association between a surgeon’s self-perception of cognitive change does not correlate with objective, age-associated measures of change.17,18,20 Thus, the self-imposed plans of surgeons to transition from active clinical practice seems to be an ill-founded solution to the issue of age-associated functional impairments in surgeons.
Prior to the 1980s, mandatory retirement at a certain age existed for many professions in the United States, including medicine. In 1986, however, Congress abolished mandatory retirement by amending the Age Discrimination in Employment Act, recognizing that retirement should not be required based on chronologic age alone.
Exceptions to the Age Discrimination in Employment Act most typically exist for professions, such as air-traffic controllers or active-duty soldiers, that are considered perilous or have high demands on physical and mental skill, reflecting the importance of balancing individual practitioners’ rights with those of their customers or clients (eTable in the Supplement).9,14 Likewise, retirement safeguards exist even in fields with less immediate risks to human safety, such as Foreign Service officers and state judiciary officers.5,9
Quiz Ref IDIn comparison with these results for other occupations, however, Boom-Saad et al3 demonstrated that surgeons and medical students perform better than normative control participants on CANTAB studies, and others have demonstrated that surgeons’ abilities may decline less rapidly than other physicians’ do.1,10,17,35 Thus, whatever the standards of other fields, these may be inappropriate for the evaluation of medical professionals such as surgeons, who may possess a higher margin against risk-provoking impairment.3
There are currently no reported age-associated mandatory institutional retirement requirements for US surgeons, their having largely been removed following the passage of the Age Discrimination Act of 1967. In comparison, while some countries do maintain such requirements (for example, India, Japan, China, Ireland, and Finland set retirement ages between 60 and 68 years), others do not (eg, Canada, Germany, Australia, and the United Kingdom).13,35
Considerable evidence suggests that hospitals and other institutions providing for patient care have considerable latitude to test health care practitioners for age-associated and other competencies in the context of patient safety.14 A few US health care institutions do accordingly require age-based screening for cognitive, visual-spatial, and physical impairment of practicing surgeons (typically between the ages of 70 and 75 years), although these standards have frequently been tempered or eliminated after concerns raised by physicians.36 The Canadian College of Physicians and Surgeons likewise mandates age-based peer review of physicians, set by specific provinces at between 60 and 75 years of age. There are approximately 10 programs in the United States that can provide comprehensive cognitive and psychomotor testing and/or treatment of potential performance issues for surgeons identified through screening programs.
Both the American Medical Association (AMA) and the American College of Surgeons (ACS) have attempted to address the issue of age-associated physician impairment in recent years through workshops on the topic and public statements.6,7 Each organization has principally relied on voluntary action by physicians to address this issue and primarily recommended institutional consideration of these issues on a local basis and through state and national licensing and specialty boards.6,7 Importantly, however, the AMA Council on Medical Education in its 2015 report “Competency and the Aging Physician” took a significant step away from the AMA’s previous admonition against “use of written cognitive examinations of medical knowledge”6(p14) in recommending the rescinding of this policy. The AMA Council on Medical Education also recommended that “physicians must develop guidelines/standards for monitoring and assessing both their own and their colleagues’ competency,”6(p12) noting that physician self-assessment and self-reporting “is not always reliable.”6(p15)
The ACS Board of Governors’ Physician Competency and Health Workgroup in 2016 likewise recommended peer review assessments, medical record reviews, and 360ο evaluations to assist in assessing the competency of aging surgeons, noting that “gradual decline in overall health, physical dexterity, and cognition generally occurs after the age of 65.”7 While the ACS statement accordingly recommended that “starting at age 65 to 70, surgeons undergo voluntary and confidential baseline physical examination and visual testing by their personal physician,”7 they recommended only that surgeons voluntarily assess their neurocognitive function using confidential online tools.
The SSC surveyed its membership in 2018 to develop data on current practices for a document titled “Management of the Senior, Aging Surgeon.” This survey was anonymous and exempt from institutional review board approval. This online survey achieved a response rate of 60% (80 respondents of all contacted, active members). Notably, 75 respondents (94%) were supportive of an SSC white paper on this topic, with 24 respondents (30%) viewing the issue as “very significant” and an additional 46 (57%) viewing it as “somewhat significant.”
Quiz Ref IDOf 47 SSC respondents that defined an age for an aging surgeon, 25 (53%) selected 65 years of age and 14 (30%) selected 70 years of age, while none believed that surgeons younger than 60 years were defined as an aging surgeon (Figure 2A). These results are consistent with the 2013 report from the Coalition for Physician Enhancement Conference, with 72% of their respondents recommending screening beginning at ages 65 to 70 years.37
Thirty-three respondents (41%) in the SSC survey reported that they encountered issues associated with clinical, technical, or cognitive skills of so-defined aging surgeons at least occasionally. In comparison, 17 respondents (23%) reported that they received questions associated with senior or aging surgeons’ maintenance of privileges at least occasionally.
Regarding their strategies for addressing the transitioning of senior surgeons, respondents indicated that these most commonly involved transitioning to retirement or into other nonclinical roles (Table 1). Approximately 60 SSC respondents (75%) ascribed nearly equal (high or moderate) importance to mentoring or coaching, role transition, objective performance assessment, and peer review in transitioning senior surgeons, compared with only 18 respondents (23%) who regarded mandatory retirement as at least moderately important (Figure 2B). Interestingly, however, chairs were far more likely to support the importance of these measures than use them (Table 1). Furthermore, no more than 20 respondents (25%) were able to identify any one policy in place at their institution to help resolve cognitive competency issues or destination to refer surgeons for fitness evaluations (Figure 2C and D).
Based on these SSC survey findings and the 2017 panel discussion on this subject, as well as other writings in the field, we propose several recommendations to assist department of surgery chairs and their institutions in addressing issues associated with the senior, aging surgeon (Table 2). These recommendations are formulated to facilitate a well-planned and gradual transition of the senior surgeon to nonclinical roles in the face of declining operative and clinical skills, which is preferable and more manageable than an abrupt and seemingly unforeseen and disrespectful forced retirement of the senior surgeon. Central to these recommendations is the need to respect the professional commitment and intentions of senior surgeons while prioritizing patient safety, as specifically noted in the 2016 ACS Statement on the Aging Surgeon.7
As outlined in the University of Toronto Department of Surgery guidelines,13 which have been adopted by other Canadian departments, transition planning can begin early in a surgeon’s career and should include progressive evaluation, discussion, and career planning as part of the regular reappointment process, mirroring already prevalent mentorship programs. At the University of Toronto, this approach includes faculty signing a letter on appointment regarding these goals and expectations. Such transcareer conversations can create a culture of positive discourse that consistently telegraphs planned structural changes around a surgeon’s late-career transitions out of active clinical practice.
Quiz Ref IDTransitioning efforts must take into consideration 3 common reasons why senior physicians may wish to defer retirement: lack of outside interests, financial needs, and a perceived obligation to maintain clinical activity because of dedication to patient care and/or perceptions that the next generation does not share their own level of commitment or capability.1,38,39 More specifically, it is important to consider that older-generation physicians and surgeons may have been encouraged over the course of their career to embrace a perception of work-life balance that favors career as a primary focus and priority.1 Commitment to their work may have led such physicians to a paucity of interests or hobbies outside of medicine and thus no foundation on which to transition from a more active, time-demanding clinical practice. Many physicians have likewise reported that they have had no time to focus on financial planning and thus do not have the financial resources to retire while maintaining their lifestyle.1,3
Transitioning strategies should accordingly provide the senior surgeon with ongoing meaningful engagement with their department or institution while providing enough financial support in a defined role to help with financial transitioning to retirement.40-42 In some cases, this transition may be facilitated by a switch from primary surgeon privileging to privileges in a consultant or first-assistant role for some interval. Compensation for nonclinical roles can play an important part in this process, but it is not a substitute for support and tutorials on appropriate personal financial management beginning in early career. Discussions about transition, ideally held in a private setting, potentially with a trusted administrative confidant or confidante, should be supportive of the senior surgeon’s ongoing, important contributions to his or her field and department but clearly delineate a change from the surgeon’s clinically active and/or primary surgeon status.38,39
Nonoperative roles for senior surgeons can include administration and peer review, research, education, community and/or philanthropic outreach and development, and perhaps most importantly, mentoring or coaching of junior surgeons, advanced practice practitioners and nurses, trainees, and other staff members. Some of these activities might be more readily supported in academic institutions, as has recently been modeled by the Johns Hopkins Senior Faculty Transition Program and Emeritus Faculty Academy.41,42 At least some other needs, such as peer review and staff training, can also be readily found in community hospitals.
Mentorship and coaching creates a real opportunity for experienced senior surgeons to pass along important professional lessons and invaluable insights that may be difficult to glean from reading or episodic clinical experiences, such as those into surgical planning, decision making, and error detection, while creating a role for the senior surgeon as an important colleague in the department culture.20,40,43 Consistent with this premise, 37 respondents (47%) in the SSC survey rated mentoring or coaching as a highly important transitioning strategy for senior surgeons, making this the transitioning strategy most frequently ascribed high importance in the survey (Table 1). While the limited diversity of today’s senior surgeons might impede their ability to more effectively mentor a more diverse junior faculty, it is unlikely to undermine their otherwise important potential contributions and will recede with the maturing of more junior faculty.
Even with progressive transitioning efforts, some senior surgeons may not be willing to relinquish their operative duties when indicated. This premise is supported by the observations that physicians possess limited self-perception of cognitive deterioration and that 45% of physicians with direct knowledge of impaired or incompetent peers fail to report these concerns.6,17,18,20,44 Unplanned or even precipitous chair engagement with senior surgeons regarding career transitioning, potentially initiated by adverse clinical or professional events, thus may be expected. Department chairs may face primary obligations to address a potential risk to patient safety in the setting of limited institutional infrastructure and interest, as highlighted in the SSC survey (Figure 2C and D). Such unsupported, ad hoc interactions may be construed by the transitioning surgeon to be unfounded, arbitrary, or even discriminatory.
We accordingly recommend the introduction of mandatory cognitive and psychomotor competency testing of surgeons, potentially paired or incorporated into ongoing professional practice evaluation, as a final component of the portfolio of measures designed to optimize transitioning of the senior surgeon. Such testing is well supported by the precedents of standard hospital recredentialing as well as national board and professional society recertification processes. Notably, 53 SSC survey respondents (67%) thought a mandatory fitness assessment would be moderately or highly helpful in evaluating the physical and cognitive skills of surgeons, consistent with the recommendations of others.17,33
Given recognition by the ACS that cognitive decline generally occurs after age 65 years and additional evidence of cognitive decline beginning at even younger ages (Figure 1),7,10 we recommend that mandatory cognitive and psychomotor competency testing of surgeons begin by at least 65 years of age (Table 2). Testing at ages even earlier than age 65 years would provide a baseline for comparison for potential future changes in individual performance; establish a culture of transparent, evidence-based clinical performance assessment and self-awareness; and provide an opportunity for cognitive skills training, medical treatment, and/or healthy lifestyles counseling that have been suggested to arrest or improve declines in cognitive skills.1 Testing could be performed as a standard component of the hospital recertification process, similar to the testing of airplane pilots.5,10,18
Suggestions for the composition of such cognitive and psychomotor performance testing include MicroCog, the St Louis Mental Status Examination, or the Montreal Cognitive Assessment, which are all relatively simple to administer but could be outsourced as well.5,12,45 An alternative is the 7-subtest assessment based on the Halstead-Reitan Neuropsychological Test Battery, recommended by the ACS.7 Detection of declines in cognitive testing could trigger referrals to more specialized testing centers. Referrals might also be triggered by sentinel events, failures of ongoing or focused professional practice reviews, or discretionary concerns of hospital or department leadership.9
Ultimately, given that the effects of cognitive decline on clinical competencies may be counterbalanced by a practitioner’s careerlong clinical experience and accrued clinical judgement, final determinations of privileging status would likely fall to medical staff credentialing and executive committees, who could weigh these factors against the acuity of cases for which privileges are requested and the extent to which additional counterbalancing resources (eg, teaching rounds, didactic sessions, resident support) might be available at academic vs community medical centers.32-34,46
Undoubtedly, chairs of surgery and other departments working with colleagues and hospital leadership, such as chief medical officers and/or chief quality officers, will need to play leading roles in assessing the competency of aging surgeons and enacting a new culture for transitioning senior physicians. National board certification organizations (eg, the American Board of Surgery) could also incorporate cognitive and psychomotor competency into their recertification processes to aid in this process. The recommendations of the SSC are for health care organizations to engage in orderly long-term planning and discussions with senior surgeons for their transitioning into meaningful nonclinical roles and for chairs to advocate at their local institutions and with their national societies for mandatory cognitive and psychomotor testing beginning by at least 65 years of age. Ideally, these initiatives will catalyze a thoughtful and comprehensive new vista in supporting an aging workforce while ensuring the safety of patients, the efficient management of our health care organizations, and the avoidance of unnecessary depletions to a sufficiently sized cadre of physicians with case-specific competencies.
Accepted for Publication: February 26, 2019.
Published Online: May 15, 2019. doi:10.1001/jamasurg.2019.1159
Correction: This article was corrected on June 12, 2019, to fix a sentence in the Results section. The sentence “Furthermore, 20 respondents (25%) identified a single policy in place at their institution to help resolve cognitive competency issues…” should have said “Furthermore, no more than 20 respondents (25%) were able to identify any one policy in place at their institution to help resolve cognitive competency issues….” The error has been corrected.
Corresponding Author: Todd K. Rosengart, MD, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, 1 Baylor Plaza, MS 390, Houston, TX 77030 (firstname.lastname@example.org).
Conflict of Interest Disclosures: None reported.
Disclaimer: Dr Kibbe is the Editor of JAMA Surgery, but she was not involved in any of the decisions regarding review of the manuscript or its acceptance.
Additional Information: Representatives of the Society of Surgical Chairs reviewed and approved these recommendations.
Create a personal account or sign in to: