Adaptive ageing surgeons

Surgery and the Aging Orthopaedic Surgeon

➤ Aging is associated with well-documented neurocognitive and psychomotor changes.➤ These changes can be expected to impact the skill with which orthopaedic surgeons continue to perform surgical procedures.➤ Currently, there is no standardized approach for assessing the changes in surgical skills and clinical judgment that may occur with aging.➤ Oversight by the U.S. Equal Employment Opportunity Commission, the impact of the Age Discrimination in Employment Act, and the current legal climate make it difficult to institute a mandatory assessment program.➤ The regularly scheduled credentialing process that occurs at each institution can be the most effective time to assess for these changes because it utilizes an established process that occurs at regularly scheduled intervals.➤ Each department of orthopaedic surgery and institution should determine an approach that can be utilized when there is concern that a surgeon's surgical skills have shown signs of deterioration.

The Aging Surgeon: Evidence and Experience

BACKGROUND

With doctors in short supply and a strong demand for surgeon services in all areas of the United States, urban and rural, there are pressures to remain in active practice for longer. Even with an older workforce, there are currently no requirements for when a surgeon must retire in the United States.

OBJECTIVES

The aim of this article was to highlight the importance of the aging surgeon to the medical community and to provide an evidence-based overview of age-related cognitive and physical issues that develop during the later stages of a surgeon's career.

METHODS

A search of the PubMed/MEDLINE database was performed for the phrase "aging surgeon." Inclusion criteria were applied to include only those articles related to surgeon age or retirement. Additional reports were handpicked from citations to substantiate claims with statistical evidence.

RESULTS

The aging surgeon contributes extensive experience to patient care, but is also prone to age-related changes in cognition, vision, movement, and stress as it relates to new techniques, surgical performance, and safety measures. Studies show that although surgeons are capable of operating well into their senior years, there is the potential of decline. Nevertheless, there are proven recommendations on how to prepare an older surgeon for retirement.

CONCLUSIONS

Age-related trends in cognitive and physical decline must be counterbalanced with wisdom gained through decades of surgical experience.

The Association Between Surgeon Age and Early Surgical Complications of Elective Total Hip Arthroplasty: Propensity-Matched Cohort Study (122,043 Patients)

BACKGROUND

The aim of this study was to examine the relationship between surgeon age and early surgical complications following primary total hip arthroplasty (THA), within a year, in Ontario, Canada.

METHODS

In a propensity-matched cohort, we defined consecutive adults who received their first primary THA for osteoarthritis (2002-2018). We obtained hospital discharge abstracts, patient's demographics and physician claims. Age of the primary surgeon was determined for each procedure and used as a continuous variable for spline analysis, and as a categorical variable for subsequent matching (young <45; middle-age 45-55; older >55). The primary outcome was early surgical complications (revision, dislocation, infection). Secondary analyses included high-volume vs low-volume surgeons (≤35 THA per year).

RESULTS

We identified 122,043 THA recipients, 298 surgeons with median age 49 years. Younger, middle-aged, and older surgeons performed 39%, 29%, and 32% THAs, respectively. Middle-aged surgeons had the lowest rate of complications. Younger surgeons had a higher risk of composite complications (odds ratio [OR] 1.25, 95% confidence interval [CI] 1.09-1.44, P = .002), revision (OR 1.28, 95% CI 1.07-1.54, P = .007), and infection (OR 1.39, 95% CI 1.12-1.71, P = .003). Older surgeons also had higher risk for composite complications (OR 1.18, 95% CI 1.03-1.36, P = .019), revision (OR 1.33, 95% CI 1.10-1.62, P = .004), and dislocation (OR 1.37, 95% CI 1.08-1.73, P = .009). However, when excluding low-volume surgeons, older high-volume surgeons had similar complications to middle-aged surgeons.

CONCLUSION

Younger surgeons (<45 years) had the highest recorded complications rate while the lowest rate was for surgeons aged 45-55. Volume rather than age was more important in determining rate of complications of older surgeons.

LEVEL OF EVIDENCE

IV.

Association of Cataract Surgical Outcomes With Late Surgeon Career Stages: A Population-Based Cohort Study

Importance

Evidence suggests that the quality of some aspects of care provided by physicians may decrease during their late career stage. However, to our knowledge, data regarding the association of advancing surgeon career phase with cataract surgical outcomes have been lacking.

Objective

To investigate whether an increase in cataract surgical adverse events occurs during later surgeon career stages.

Design, Setting, and Participants

This population-based study of 499 650 cataract operations performed in Ontario, Canada, between January 1, 2009, and December 31, 2013, investigated the association between late surgeon career stage and the risk of surgical adverse events. Linked health care databases were used to study cataract surgical complications while controlling for patient-, surgeon-, and institution-level covariates. All ophthalmologists who performed cataract surgery in Ontario within the study period were included in the analysis.

Exposures

Isolated cataract surgery performed by surgeons at early, mid, and late career stages.

Main Outcomes and Measures

Four serious adverse events were evaluated: dropped lens fragments, posterior capsule rupture, suspected endophthalmitis, and retinal detachment.

Results

Of 416 502 participants, 244 670 (58.7%) were women, 90 429 (21.7%) were age 66 to 70 years, 111 530 (26.8%) were age 71 to 75 years, 90 809 (21.8%) were age 76 to 80 years, and 123 734 (29.7%) were 81 years or older. Late-career surgeons performed 143 108 of 499 650 cataract operations (28.6%) during the study period. Late surgeon career stage was not associated with an increased overall risk of surgical adverse events (odds ratio [OR] vs midcareer, 1.06; 95% CI, 0.85-1.32). In a sensitivity analysis with surgeon volume removed from the model, late career stage was still not associated with overall adverse surgical events (OR, 1.10; 95% CI, 0.88-1.38). Among individual complications, late surgeon career stage was associated with an increased risk of dropped lens fragment (OR, 2.30; 95% CI, 1.50-3.54) and suspected endophthalmitis (OR, 1.41; 95% CI, 1.01-1.98). These corresponded with small absolute risk differences of 0.11% (95% CI, 0.085%-0.130%) and 0.045% (95% CI, 0.028%-0.063%) for dropped lens fragment and suspected endophthalmitis, respectively.

Conclusions and Relevance

These findings suggest that later-career surgeons are performing a substantial proportion of cataract operations with overall low surgical adverse event rates. Future studies might extend evaluations to the frequency of secondary surgical interventions as additional measures of surgical care quality.

Evaluation of physician volumetric accuracy during hyaluronic acid gel injections: An observational, proof-of-concept study

BACKGROUND

Findings indicate that standard injection techniques for hyaluronic acid (HA) soft tissue fillers result in considerable variations in the applied boluses. Furthermore, despite the knowledge that the varying biophysical properties of HA fillers (eg, G', cohesivity, viscoelasticity) can affect their ease of injection, the impact of device attributes on an injector's volumetric accuracy is currently unknown.

OBJECTIVES

(a) Evaluate the ability of aesthetic physicians to accurately inject a specific amount of HA filler; (b) investigate the effect of physician experience on injection accuracy; and (c) investigate the impact of different HA gel properties on an injector's performance.

METHODS

Thirteen physicians with aesthetic experience were recruited. Subjects were blindfolded and asked to deposit 0.2 cc of four HA fillers under two conditions: (a) onto a scale and (b) into a porcine membrane. The amount of gel deposited/injected was then measured. An accurate injection was defined as 0.2 cc ± 15%.

RESULTS

Subjects were rarely able to dispense accurate amounts of injectate (42/208 injections or 20.19%) and often underestimated their injection quantities. Variations in the accuracy distributions between groups were observed. An injector's experience, the conditions under which injections were performed and the product choice were all variables found to affect the accuracy distributions.

CONCLUSIONS

The findings of this study provide evidence that the use of visual and/or audible stimuli is necessary for dispensing accurate volumes. This has clinical implications for treatment efficacy and patient satisfaction during free hand injections. To ensure more accurate and reproducible results, the investigators propose a possible modification to the standard injection technique.

Retirement plans and perspectives among general surgeons: a qualitative assessment

Background

General surgeons’ retirement plans have wide-ranging personal, professional and system-level effects. We explored the drivers of and barriers to surgeon retirement to identify opportunities to support career-long retirement planning.

Methods

We conducted a qualitative study from May to October 2016 using semi-structured telephone interviews (mean duration 29 min) with general surgeons in Ontario. We used a purposive sampling strategy to recruit surgeons at 3 career stages (no plans to retire within next 5 yr, had slowed down practice or planned to slowdown within 5 yr, and no longer operating as primary surgeon). We analyzed the data using established techniques of thematic analysis.

Results

We interviewed 22 general surgeons. Their retirement status ranged from fully retired to no plans to retire. Preservation of reputation and quality care, commitment and succession planning, and retirement planning were dominant themes. Mid-career and senior surgeons’ plans were made later in their careers and were driven by desires to preserve reputations and surgical identity. Younger surgeons’ (≤ 50 yr) early retirement was driven by lifestyle choices and work environment. Logistical barriers and financial insecurity led to retirement delay.

Conclusion

Surgeons begin to plan for retirement both early and late in their careers. Most surgeons wish to establish retirement plans that allow for the gradual reduction of surgical patient care and the creation of job opportunities for younger colleagues balanced by a continued contribution to the profession. Opportunities to support surgeons at all career stages in their retirement planning require further exploration.

Occupational Determinants of Successful Aging in Older Physicians

OBJECTIVES

Demographic, physical and psychological associations of successful aging (SA) have been evaluated, but occupational factors have not. Nor has SA been evaluated in a specific occupational group. The aims of this study were to examine the occupational associations of SA in older physicians, and to explore the concept of occupational SA.

METHODS

Physicians aged 55+ years completed self-ratings of occupational and personal SA on a 10-point visual analogue scale (VAS; 1 being "least successful" and 10 "most successful"). Associations between occupational and personal SA (defined as 8-10 on the VAS), respectively, and demographic and practice characteristics; health; social and financial resources; cognitive, emotional and motivational resources; work centrality; and anxiety about aging were examined.

RESULTS

Rates of occupational SA (69.2%; 95% CI: 66.3-72.0) were significantly higher than personal SA (63.1%; 95% CI: 60.1-66.0) in the sample of 1,048 physicians. Occupational and personal SA were strongly positively correlated (r = 0.73, N = 1,041, p < 0.001). Personal SA was predicted by demographic (older age, female, international medical graduate, urban practice), physical (better self-rated health), psychological (less depression, better cognitive, emotional and motivational resources, and greater anxiety about aging), and occupational (higher work centrality, fewer practice adaptations and not intending to retire) factors.

CONCLUSIONS

Occupational factors are central to physicians' self-conceptualization of SA. That greater work centrality, fewer work adaptations and less retirement planning were associated with personal SA suggests older physicians' sense of "success" is intertwined with continuing practice. There is a need for educating physicians to adapt to aging and retirement.

Aging women and men in the medical profession: The effect of gender and marital status on successful aging and retirement intent in Australian doctors

Despite increasing interest from the medical profession in aging and retirement, we know little about effects of gender, marital status, and cohort on aging within the profession. We surveyed 1,048 Australian doctors from "younger" (55-64) and "older" (65-89) cohorts, investigating gender and marital effects on perceptions of successful aging, career, and retirement intent. Women intend to retire earlier. Younger cohort and married women more frequently viewed their career as a calling, while women in general, and single women more frequently, endorsed personal successful aging more than men. Broader understanding of the different experiences of aging for men and women doctors is needed.

A systematic review of physician retirement planning

BACKGROUND

Physician retirement planning and timing have important implications for patients, hospitals, and healthcare systems. Unplanned early or late physician retirement can have dire consequences in terms of both patient safety and human resource allocations. This systematic review examined existing evidence on the timing and process of retirement of physicians. Four questions were addressed: (1) When do physicians retire? (2) Why do some physicians retire early? (3) Why do some physicians delay their retirement? (4) What strategies facilitate physician retention and/or retirement planning?

METHODS

English-language studies were searched in electronic databases MEDLINE, Web of Science, Scopus, CINAHL, AgeLine, Embase, HealthSTAR, ASSA, and PsycINFO, from inception up to and including March 2016. Included studies were peer-reviewed primary journal articles with quantitative and/or qualitative analyses of physicians' plans for, and opinions about, retirement. Three reviewers independently assessed each study for methodological quality using the Newcastle-Ottawa Scale for quantitative studies and Critical Appraisal Tool for qualitative studies, and a fourth reviewer resolved inconsistencies.

RESULTS

In all, 65 studies were included and analyzed, of which the majority were cross-sectional in design. Qualitative studies were found to be methodologically strong, with credible results deemed relevant to practice. The majority of quantitative studies had adequate sample representativeness, had justified and satisfactory sample size, used appropriate statistical tests, and collected primary data by self-reported survey methods. Physicians commonly reported retiring between 60 and 69 years of age. Excessive workload and burnout were frequently cited reasons for early retirement. Ongoing financial obligations delayed retirement, while strategies to mitigate career dissatisfaction, workplace frustration, and workload pressure supported continuing practice.

CONCLUSIONS

Knowledge of when physicians plan to retire and how they can transition out of practice has been shown to aid succession planning. Healthcare organizations might consider promoting retirement mentorship programs, resource toolkits, education sessions, and guidance around financial planning for physicians throughout their careers, as well as creating post-retirement opportunities that maintain institutional ties through teaching, mentoring, and peer support.

A snapshot survey of perceptions of healthcare professionals on ageing surgeons

OBJECTIVE

The aim of this research was to understand healthcare professionals' perception of the continued practice of ageing surgeons in Singapore.

METHODOLOGY

A quantitative method was chosen for this research to determine healthcare professionals' perception of the practice of ageing surgeons. Ethical approval was obtained from the local ethical review board. A cross-sectional method using a population survey was performed among healthcare professionals in two tertiary institutions and the study was confined to stakeholders in practices of ageing surgeons. The population sampled was limited to nurses in the theatre, anaesthetists, surgeons and geriatricians (physicians). An online questionnaire was designed for the survey that took into consideration the various conceptual frameworks of ageing surgeons' practice that was obtained from a literature review.

RESULTS

There were 104 respondents of a population of 350 sampled (theatre nurses, anaesthetists, physicians and surgeons) giving a respondent rate of 30%. The mean age of the participants was 39.7; 72% were doctors (surgeons 34%, physicians 20% and anaesthetists 18%) and 28% nurses. Only 35% agreed with the statement that older surgeons face deterioration in cognitive faculties and 29% remained neutral. A similar trend was seen with the perception that older surgeons face a decline in memory. However, 44% agreed with the statement that older surgeons face a decline in visuospatial ability and another 40% agreed that they had a decline in psychomotor skills and reaction time. Fifty per cent agreed with the statement that they face deterioration in physical abilities. Sixty-three per cent did not think that older surgeons face a decline in reasoning and judgement. Forty-eight per cent believed that older surgeons' vast fund of knowledge and experience could compensate for physical and cognitive changes. Only 13% agreed with the statement that older surgeons have higher surgical mortality. Forty-five per cent agreed that the retirement age should be 65 while 22% believed it should be over 65. Forty-four per cent agreed that a regular multidisciplinary, objective and comprehensive evaluation of an older surgeon's physical and cognitive function would help to identify and treat reversible problems which when corrected would aid in restoring the surgeon's function. Seventy-four per cent felt that it was the responsibility of all stakeholders to decide or report on when an ageing surgeon is unsafe to continue practicing. Fifty-five per cent disagreed with a mandatory retirement age for surgeons.

CONCLUSIONS

This study showed that, in Singapore, stakeholders agreed there are changes in physical and cognitive abilities of ageing surgeons but they thought that these can be overcome with selective strategies to optimise their role in the workforce. They also disagreed on a mandatory retirement age.

The aging psychiatrist: lessons from our colleagues in surgery and anaesthesia

OBJECTIVES

The Royal Australasian College of Surgeons (RACS) has been innovative in developing core competencies, which provide a framework for assessing performance and a 'Code of Conduct', for the lifelong journey of all surgeons. The older surgeon may face significant challenges, having passed their peak, with a lower volume of cases, and potentially increased complications. They also face the challenges of retiring from active clinical practice with its logistical and psychological dilemmas. The RACS has, therefore, put in place several initiatives to deal with these dilemmas.

CONCLUSIONS

The Senior Surgeons' Group, which conducts annual 'Building Towards Retirement' workshops, has been the driving force behind these initiatives. The group has a regular program in the RACS Annual Scientific Congress, including the multidisciplinary session 'The ageing specialist - challenges for regulators: hypothetical' which took place in 2014, and some of its members are part of a multidisciplinary team with an approach to adapting to ageing that encourages self-reflection and self-monitoring. It has also influenced the RACS Council to change the continuing professional development (CPD) regulations to include requirements for ageing surgeons regards health maintenance, peer reviews, and modified requirements to satisfy CPD completion. The RACS offers a variety of other opportunities for the ageing surgeon to remain active in college activities.

Physician health and wellbeing provide challenges to patient safety and outcome quality across the careerspan

OBJECTIVE

Age correlated changes in mental and physical capacity have contributed to increasing concerns about older physicians' clinical competence. This paper explores the relationship between age and health in a clinical population referred for fitness for duty evaluations.

METHODS

Fifty cases from an evaluation center performing fitness for duty evaluations were randomly selected. Cases were reviewed for referral reason, demographic information, diagnosis, and recommendations.

RESULTS

Age ranged from 28-70 (median age of 51, mode of 45).Eighty-eight percent of cases had a diagnosed medical condition with potential cognitive sequellae.

CONCLUSION

While the literature supports performance concerns in aging practitioners, health independent of age, appears to be an important contributing factor. A screening process considering biopsychosocial reserve and professional load while applicable to older clinicians would optimally be implemented for physicians across their careerspan.

Successful ageing for psychiatrists

OBJECTIVE

This paper aims to explore the concept and determinants of successful ageing as they apply to psychiatrists as a group, and as they can be applied specifically to individuals.

CONCLUSIONS

Successful ageing is a heterogeneous, inclusive concept that is subjectively defined. No longer constrained by the notion of "super-ageing", successful ageing can still be achieved in the face of physical and/or mental illness. Accordingly, it remains within the reach of most of us. It can, and should be, person-specific and individually defined, specific to one's bio-psycho-social and occupational circumstances, and importantly, reserves. Successful professional ageing is predicated upon insight into signature strengths, with selection of realistic goal setting and substitution of new goals, given the dynamic nature of these constructs as we age. Other essential elements are generativity and self-care. Given that insight is key, taking a regular stock or inventory of our reserves across bio-psycho-social domains might be helpful. Importantly, for successful ageing, this needs to be suitably matched to the professional task and load. This lends itself to a renewable personal ageing plan, which should be systemically adopted with routine expectations of self-care and professional responsibility.

When should surgeons retire?

BACKGROUND

Retirement policies for surgeons differ worldwide. A range of normal human functional abilities decline as part of the ageing process. As life expectancy and their population increases, the performance ability of ageing surgeons is now a growing concern in relation to patient care. The aim was to explore the effects of ageing on surgeons' performance, and to identify current practical methods for transitioning surgeons out of practice at the appropriate time and age.

METHODS

A narrative review was performed in MEDLINE using the terms 'ageing' and 'surgeon'. Additional articles were hand-picked. Modified PRISMA guidelines informed the selection of articles for inclusion. Articles were included only if they explored age-related changes in brain biology and the effect of ageing on surgeons' performance.

RESULTS

The literature search yielded 1811 articles; of these, 36 articles were included in the final review. Wide variation in ability was observed across ageing individuals (both surgical and lay). Considerable variation in the effects of the surgeon's age on patient mortality and postoperative complications was noted. A lack of neuroimaging research exploring the ageing of surgeons' brains specifically, and lack of real markers available for measuring surgical performance, both hinder further investigation. Standard retirement policies in accordance with age-related surgical ability are lacking in most countries around the world.

CONCLUSION

Competence should be assessed at an individual level, focusing on functional ability over chronological age; this should inform retirement policies for surgeons.