Statement on Sustaining the Lifelong Competency of Surgeons

Read Sustaining the Lifelong Competency of Surgeons: A Multimodality Empowerment Personal and Institutional Strategy, which will be published in the August issue of the Journal of the American College of Surgeons.

A statement on “The Aging Surgeon” was initially developed by the American College of Surgeons (ACS) Board of Governors Physician Competency and Health Workgroup and was approved by the Board of Regents at its October 2015 meeting. The following update of this statement based upon the work of the Board of Governors Physician Competency and Health Workgroup in 2023 addressing specific issues focused on the supporting lifelong competency of surgeons was approved by the ACS Board of Regents in February 2024 during its meeting in Chicago, IL.

The average age of the practicing surgeon is rising along with that of the American population. More than 40% of physicians in the US will be 65 years or older within the next decade. For more than 100 years since its founding, the ACS has emphasized the importance of high-quality and safe surgical care. To address concerns that advanced age may influence competency and occupational performance, in 2016 the ACS published a statement on managing the competency and occupational performance of aging surgeons. Since then, increasing interest and research on surgeon competency has highlighted the need for more comprehensive guidance on how to best monitor and support the competency of the surgeon workforce. The following guidelines offer an evidence-based roadmap to support and ensure lifelong competency of the surgeon workforce.

• The ACS maintains that it is in the best interests of the surgeon to adhere to a lifestyle that promotes wellness. As such, the ACS stresses the importance of a lifelong approach to physical, mental, and emotional wellness for personal and professional well-being.
• Surgeons are not immune to age-related decline in physical and cognitive skills. Even so, the ACS does not support a mandatory retirement age because the onset and rate of age-related decline in clinical performance varies among individuals. Furthermore, a mandatory retirement age may have a deleterious impact on access to experienced surgical care, particularly in rural and underserved areas. Objective assessment of fitness should supplant consideration of a mandatory retirement age.
• Surgeons may not, on their own, recognize the deterioration of their physical and cognitive function and clinical skills with age. Colleagues and coworkers are an important resource for identifying the surgeon who displays initial signs of professional deterioration. Potential warning signs may include forgetfulness, unusual tardiness, evidence of poor clinical judgment, major changes in referral patterns, unexplained absences, confusion, change in personality, disruptiveness, drastic change in appearance, and unusually late and incoherent documentation.
• Although age-related deterioration varies from individual to individual, gradual decline in overall health, physical dexterity, and cognition generally increases after the age of 60. A comprehensive, lifelong assessment program inclusive of all physicians will help create a culture of safety, equity, and transparency in monitoring these potential declines that could affect surgeon competency. Routine, lifelong competency screening will better enable baseline comparisons against future age-related declines and empower aging surgeons to preemptively adapt and change practice patterns if early onset deficits are detected.
• 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. In addition, the surgeon’s quality and outcomes of patient care are the ultimate measures of ongoing competence and safety for surgeons of all ages.
• The ACS accordingly recommends implementation of a comprehensive, whole-of-career testing strategy for all surgeons and surgical trainees, regardless of age and experience level. An age-based trigger for such competency testing should be avoided to minimize bias and stigma and to ensure the focus remains on quality of patient care and clinical competency. A holistic evaluation including quantitative and qualitative clinical performance metrics, physical and mental assessments, and standardized evaluations of neurocognitive function should be administered to all such individuals.
• As a part of one’s professional obligation, the ACS also encourages and supports voluntary self-disclosure of any concerning and validated findings of impaired performance and limitation of activities appropriate to such declines.
• Implementation of whole-of-career competency testing should be performed routinely as part of Ongoing Professional Practice Evaluations (OPPE) that is required of all hospitals subject to third party credentialing. Such evaluations must include physician and ideally surgeon evaluators.
• Neurocognitive assessment tools, such as the MicroCog^TM: Assessment of Cognitive Functioning Windows® Edition 2004, The St. Louis University Mental Status (SLUMS) Examination, Montreal Cognitive Assessment (MoCA Test), Cambridge Neuropsychological Test Automated Battery (CANTAB), and The Halstead-Reitan Neuropsychological Test Battery (HRNB) could be considered as a possible component of OPPE but would require further validation and correlation with surgical performance and patient outcomes.
• If a potential clinical competency issue is identified through the OPPE, self-reporting and/or peer review processes, 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. In these cases, once the initial potential issue has been addressed, more detailed and frequent reviews, such as Focused Professional Practice Evaluation (FPPE), may be indicated.
• Occasionally, the surgeon will need to be referred to a comprehensive evaluation program. These examinations currently are being conducted at a number of specialized centers where an expanded battery of tests for neurocognitive function can be conducted. The hospital or medical staff should bear the costs of such testing, not the surgeon. 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 as part of an overall evaluation as described earlier in this statement.
• Further research is required to develop accurate and reliable screening tests to help identify surgeons who are potentially experiencing age-related decline in cognition and surgical skills.
• Career-long competency assessment should be paired with long-term career transition planning to not only normalize age-related declines in competency but also to foster a culture of support throughout all stages of career development.
• Senior surgeons can play a vital role in their hospitals and communities, and their knowledge and years of experience can be valuable resources. Transition planning should enable opportunities for willing and able surgeons as they relinquish their operative clinical roles for their engagement in teaching, surgical assisting, research, administration, and peer review, and most importantly, mentoring and coaching junior surgeons, advanced practice practitioners, nurses, trainees, and other staff members.
• Decisions regarding hospital and operating room privileges should be made by medical staff credentialing and executive committees only after careful evaluation of all evidence available. Possible interventions include remediation, restricting scope of practice, or retirement/withdrawal from clinical duties. Medical staff bylaws and due process must be followed. Strict confidentiality is essential. As always, the best interests of the patient remain the first priority, while at the same time the confidentiality, dignity, and contributions of the surgeon must be respected.
• All hospitals and facilities that deliver surgical care are encouraged to develop policies as appropriate for their institution in compliance with state and federal regulations. It also is expected that there will be local variations that cannot be covered or predicted with this statement.
• Implementation of competency assessment and transition planning strategies will require support from key stakeholders, adequate financial capacity, and infrastructure capability at a departmental and institutional level. As such, successful integration of career-long competency testing as part of standard evaluation practices will require a unified and sustained effort over time.

Bibliography

1. American College of Surgeons. Statement on the Aging Surgeon. 2016.
2. Rosengart TK; Chen JH; Gantt NL; et al. Sustaining the Lifelong Competency of Surgeons: A Multimodality Empowerment Personal and Institutional Strategy. J Am Coll Surg:10.1097/XCS.0000000000001066, April 09, 2024. | DOI: 10.1097/XCS.0000000000001066