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What’s New in the Patient Safety World

May 2020

The Aging Surgeon Paradox

 

 

Many studies have demonstrated more adverse patient outcomes when treated by aging physicians, leading to calls for careful evaluation of the older physician in credentialing and privileging programs in healthcare organizations.

 

But for surgeons, there is a paradox, at least from a statistical perspective. Tsugawa and colleeagues (Tsugawa  2018) found that patients treated by older surgeons actually had lower mortality than patients treated by younger surgeons. There was no evidence that operative mortality differed between male and female surgeons. And, for eye surgeons performing cataract surgery, Campbell et al. (Campbell 2019) found that “late career” surgeons did not have more complications that eye surgeons earlier in their careers. That finding held up even when surgical volume was factored in.

 

Now another study from Ontario, Canada (Satkunasivam 2020) found that increasing surgeon age was associated with decreasing rates of postoperative death, readmission and complications. And the association was in a nearly linear fashion. These findings persisted after accounting for patient-, procedure-, surgeon- and hospital-level factors. A 10-year increase in surgeon age was associated with a 5% relative decreased odds of the composite outcome. Patients receiving treatment from surgeons who were older than 65 years of age had a 7% lower odds of adverse outcomes.

 

A strength of this study was that it included a variety of surgical specialties and both

elective and emergent procedures, and the single-payer health care system in Ontario for surgical procedures ensured capture of virtually all procedures and identification of readmissions or complications after surgery that occurred anywhere in the province.

 

The authors discuss possible reasons for this finding. One is that those older surgeons may be a highly select group. Surgeons with lesser skills or impaired cognitive abilities may have already ceased operating. On the other hand, it may well be that the longstanding experience of this group of surgeons has allowed them to better select patients who will have better outcomes. Older surgeons did have higher volumes so the volume/outcome phenomenon might play a role. We might speculate that perhaps older surgeons might avoid new technologies or new procedures, like robotic surgeries, that have a learning curve. But the Canadian study excluded robotic surgeries.

 

Their findings definitely suggest that use of mandatory retirement ages for surgeons would be counterproductive. Many geographic areas, particularly rural ones, are already experiencing shortages of surgeons, both in surgical subspecialties and especially in general surgery.

 

Nevertheless, programs like the Yale New Haven program we discussed in our February 2020 What's New in the Patient Safety World column “The Older Physician: A Practical Approach?” are still likely to be of benefit in determining which older surgeons are likely to practice with high quality.

 

In our May 28, 2019 Patient Safety Tip of the Week “The Older Physician” we again noted that age, per se, cannot be the sole factor considered in decisions about the status of aging physicians. Katlic et al (Katlic 2019) note that “establishing a mandatory retirement age for surgeons would be a straightforward solution but would be illegal, inappropriate, and unfair because of the variability in function among older individuals of a given age”. They note that some hospitals have adopted a Late Career Practitioner Policy in their medical staff bylaws. These hospitals may require physicians and advanced practice clinicians older than 70 years who apply for recredentialing to undergo physical examination, eye examination, and cognitive screening. Katlic and Coleman previously described the elements of a formal Aging Surgeon Program (Katlic 2014). In both articles they described this as a more comprehensive option for surgeons identified either through screening or performance issues identified by medical staff. Their program is a 2-day, multidisciplinary, objective, and confidential evaluation of a surgeon's physical and cognitive function. It includes physical, neurologic, and ophthalmologic examinations, neuropsychological and physical/occupational therapy testing. A confidential report is then sent to the hospital medical staff that requested the evaluation. Based on the objective information provided in the report, the hospital medical staff may consider options such as continuing full privileges; no privileges; no operating privileges; operating privileges if assisted by another surgeon (routine vs only complex cases); assistant privileges only; focused review of cases (all vs certain number); or decreased work hours (eg, no on-call duties). Katlic et al do discuss surgical simulator testing but note that its validity for privileging issues has not yet been determined. (They also note that surgical simulator testing can be resource intensive, for both equipment and human time, and would need to be specialty specific.)

 

They note that there is great variability in the cognitive decline that takes place with aging, but also that clinical experience may offset declines in cognitive performance. As such, mandating retirement at a specific age would undoubtedly remove some competent surgeons from the workforce. But they also note that physicians’ self-awareness of cognitive decline often does not coincide with objective performance measures.

 

In our July 7, 2015 Patient Safety Tip of the Week “Medical Staff Risk Issues  we noted the AMA had voted to approve a report saying it is time to have a system for assessing the competence of older physicians but there was considerable sentiment expressed that screening physicians at a certain age “is inappropriate and smacks of ageism” (Frellick 2015). The AMA had not yet developed criteria or processes for such assessments. Subsequently, guiding principles for assessing the competency of senior/late career physicians were proposed by the AMA’s Council on Medical Education, but these were not adopted and the report was back to the Council on Medical Education (Firth 2018).

 

The American College of Surgeons did issue a Statement on the Aging Surgeon in 2016 (ACS 2016). While it was not in favor of a mandatory retirement age, it recommended that, starting at age 65 to 70, surgeons undergo voluntary and confidential baseline physical examination and visual testing by their personal physician for overall health assessment and regular interval reevaluation thereafter for those without identifiable issues on the index examination. It also encouraged surgeons to also voluntarily assess their neurocognitive function using confidential online tools. It also noted that voluntary self-disclosure of any concerning and validated findings is encouraged as part of a surgeon’s obligations. It also noted that colleagues and staff must be able to bring forward and freely express legitimate concerns about a surgeon’s performance and apparent age-related decline to group practice, departmental and medical staff, or hospital leadership without fear of retribution. It stressed the importance of peer-reviewed methods, including ongoing professional practice evaluation, as part of recredentialing and, if a potential issue is identified, additional methods of evaluation may include chart reviews, peer review of clinical decision making, 360-degree reviews and patient feedback, observation or video review of operating room cases, and proctoring.

 

It acknowledged that there will be occasions were a surgeon will need to be referred to a comprehensive evaluation program, conducted at a number of specialized centers where a battery of tests for neurocognitive function can be conducted in the form of a neuropsychological assessment (the costs of which should be borne by the hospital or medical staff, not the surgeon). But it emphasized that these results cannot be used in isolation to determine continuation or withholding of hospital and surgical privilege but should be incorporated as an additional piece of information.

 

Recommendations such as those from the Society of Surgical Chairs (Rosengart 2019). and Stanford Health Care’s Late Career Practitioner Policy (Weinacker 2018) are a good starting point. The concept of beginning the discussion with your clinicians long before they are “aging” needs to be ingrained in your programs. Resources such as the Aging Surgeon Program at Sinai Hospital/LifeBridge Health (developed by Katlic and others) may be very helpful to you once have reached an age where their skills and cognitive functions may start to wane. And the Yale New Haven program (Cooney 2020) that we discussed in our February 2020 What's New in the Patient Safety World column “The Older Physician: A Practical Approach?” offers a way to provide an objective assessment in a respectful manner.

 

 

Our prior columns dealing with the issue of the aging physician:

 

 

 

References:

 

 

Tsugawa Y, Jena AB, Newhouse RL, et al. Age and sex of surgeons and mortality of older surgical patients: observational study. BMJ 2018; 361 Published 25 April 2018

https://www.bmj.com/content/361/bmj.k1343

 

 

Campbell RJ, el-Defrawy SR, Gill SS, et all Association of Cataract Surgical Outcomes With Late Surgeon Career StagesA Population-Based Cohort Study. JAMA Ophthalmol 2019; 137(1): 58-64

https://jamanetwork.com/journals/jamaophthalmology/article-abstract/2706484

 

 

Satkunasivam R, Klaassen Z, Ravi B, et al. Relation between surgeon age and postoperative outcomes: a population-based cohort study. CMAJ 2020; 192 (15):  E385-E392

https://www.cmaj.ca/content/192/15/E385

 

 

Katlic MR, Coleman J, Russell MM. Assessing the Performance of Aging Surgeons. JAMA 2019; 321(5): 449-450

https://jamanetwork.com/journals/jama/article-abstract/2721291

 

 

Katlic MR, Coleman J. The aging surgeon. Ann Surg 2014; 260(2): 199-201.

https://journals.lww.com/annalsofsurgery/fulltext/2014/08000/The_Aging_Surgeon.1.aspx

 

 

Frellick M. Screen Aging Physicians for Competency, Report Asks. Medscape Medical News June 15, 2015

http://www.medscape.com/viewarticle/846497

 

 

Firth S.How Can Competency be Measured in Older Docs? AMA council guidance for testing fails to win over delegates. MedPage Today 2018; November 14, 2018

https://www.medpagetoday.com/meetingcoverage/ama/76334

 

 

ACS (American College of Surgeons). Statement on the Aging Surgeon. January 1, 2016

https://www.facs.org/about-acs/statements/80-aging-surgeon

 

 

Rosengart TK, Doherty G, Higgins R, et al. Transition Planning for the Senior Surgeon. Guidance and Recommendations From the Society of Surgical Chairs. JAMA Surg 2019; Published online May 15, 2019

https://jamanetwork.com/journals/jamasurgery/fullarticle/2733041

 

 

Weinacker A. Staffing: How Do You Deal With Aging Surgeons? Outpatient Surgery Magazine 2018; XIX(6): June 2018

http://www.outpatientsurgery.net/surgical-facility-administration/surgery-business/staffing-how-do-you-deal-with-aging-surgeons--06-18

 

 

LifeBridge Health. Aging Surgeon Program

http://www.agingsurgeonprogram.com/AgingSurgeon/AgingSurgeon.aspx

 

 

Cooney L, Balcezak T. Cognitive Testing of Older Clinicians Prior to Recredentialing. JAMA 2020; 323(2): 179-180

https://jamanetwork.com/journals/jama/article-abstract/2758602

 

 

 

 

 

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