Hanging up the surgical cap: Assessing the competence of aging surgeons

Table 1 Surgeon certification compared to non-medical professions

Occupation	Mandatory retirement age (yr)	Certification based on cognitive and/or physical requirements
Surgeon[33]	None	Complete residency and board examination. Continuous self-learning or medical education (CME) for credit with periodic examination for certification. May have case list peer-reviewed and be evaluated by in-hospital staff. No physical exam or performance-based skills currently defined
Airline pilot[34,35]	65	Every 24 mo, complete flight review with instructor: Ground/flight training. Must demonstrate proficiency, competency, and sound judgement within approved standards during training. Medical certificate every 12 mo or every 6 mo if age > 40 yr
Air traffic controller[36-38]	56, 61 with exception	Apply at < 31 yr. Medical exam. Pass biographical assessment, pass the ATSA, and pass training course at FAA academy. The ATSA is designed to measure the cognitive, visuospatial reasoning, and psychomotor abilities of candidates. Must submit to yearly physical exam, and job performance twice a year, with periodic drug screenings. Certificate valid until surrendered, suspended, or revoked
Firefighter[39,40]	57	Complete CPAT. Complete annual medical exam and physical testing, depending on department discretion. Physical testing consists of exercises related to firefighting such as step tests, and leg lifts
United States State Judge[41,42]	70-75	Obtained law degree and passed Bar examination. State court often requires mandatory retirement for state court judges

ATSA: Air traffic controller specialists skills assessment battery; CPAT: Candidate Physical Ability Test; CME: Continuing medical education; FAA: Federal Aviation Administration.

Table 2 Late career practitioner policies adopted at health institutions

Program	Objectives	Candidates	Medical exam	Performance testing	Modification of privileges
Stanford Health Care[16,17]	To ensure high quality care for patients and protect them harm and identify health concerns of practitioners	74.5 years old and every 2 yr thereafter	Comprehensive history and physical examination including vision, hearing, neurological, and cognitive testing	Peer assessment by hospital staff of technical and procedural competencies, relative to Stanford expectations	Yes, if non-compliant or unsafe practice patterns
Aging Surgeon Program at Sinai Hospital, Baltimore, MD[43]	Designed to protect patients from unsafe surgeons and guard surgeons from arbitrary or unreliable methods of assessing competence or cognitive capacity. The program can identify potentially treatable or reversible disorders that, if properly treated, could restore or improve functional capacity	No mandatory age. Requested from surgeons, hospitals or licensing bodies of all surgical sub-specialties	Evaluation of general health, vision, hearing, neurocognition, visual-spatial and fine motor capability	None	No
Hartford Health Care[44]	To ensure patient safety and high-quality medical care	70 years old and above, and annually thereafter	Annual physical exam, vision, neurological testing and neuropsychological screening	OPPE. FPPE if needed, to identify patterns that may negatively impact quality and safety of care	Yes, discussion with department Chief ± Credentials Committee if deemed unable to safely exercise privileges
YNHH[21,45]	To protect patients from harm and safeguard fair physician assessment	70 years old and above	Ophthalmologic exam and 16 test neuropsychologic screening battery	None	Yes, MSRC suggestions based on screening results
Legacy Health, OR[46]	To assess physicians to ensure patient safety and physician wellness	70 years old and above, and every 2 yr thereafter	Physical capacity by occupational therapy and neuropsychological testing	Peer review assessment	Yes, determined by Credentials Committee, if health problems interfere with safe practice
Driscoll’s Children’s Hospital, Corpus Christi, TX[17]	To assure that patient safety and quality are adequately supported by carefully assessing the capabilities, competencies and health status of each practitioner	70 years old and above	Comprehensive examination addressing physical and mental capacity by a physician	Peer review assessment may be required. Must meet technical and procedural competencies	Yes, determined by Credentials committee, if practice unsafe or incompetent
University of Virginia Health System[17]	To assess each physician’s capacity to perform requested privileges	First assessment at age 70. Annual assessment after 75 years of age	Comprehensive examination addressing physical and mental capacity under the Physician Wellness Program	None	Yes, as determined by Department Chair
UC San Diego LCHS[47,48]	To detect any physical or mental health problems that may affect a physician’s ability to practice	70 years old and above. At request of hospital or medical group	History and physical exam. Cognitive and mental health screen	Dexterity tests for proceduralists/surgeons	No
Tahoe Forest Health System, CA[49]	To fairly and accurately evaluate physician performance and capabilities	70 years old and above. Required to partake in LCHS	See LCHS	See LCHS	Yes, after consultation with department Chair if adjustment is required

OPPE: Ongoing Professional Practice Evaluation; FPPE: Focused Professional Practice Evaluation; YNHH: Yale New Haven Hospital; MSRC: Medical Staff Review Committee; LCHS: Late Career Health Screening for Physicians and Healthcare Professionals.

Table 3 Existing methods for determining surgical competency

Method	Basic structure	Assessment	Procedure examples	Validated1 for
				Practicing surgeons	Surgical trainees
Licensing bodies assessments
State Medical Boards[50-52]	Mandatory to practice. Required to demonstrate competency through CME. However, states individually may evaluate professional conduct when a physician fails to provide appropriate quality of care	Must regularly participate in CME activities and may require board certification. May have competency evaluation by independent evaluator or approved assessment program if signs of dyscompetence	-	Unclear	-
ABMS[18,19]	Voluntary certification to show knowledge of standards of practice. Rigorous process of evaluation every 10 yr with MOC	MOC consists of 4-part assessment: Licensure/professional standing, participation in CME programs, cognitive expertise through examination, and documentation of quality of care and/or audits or peer review	-	Unclear	-
Provincial Licensing Bodies in Canada[53-55]	Mandatory to practice. Required to demonstrate competency through CME. Provincial licencing bodies identify those with deficiencies in competence, requiring peer review	Must regularly participate in CME activities. If evidence of dyscompetence, rigorous individualized assessment of the surgeon’s practice is performed, with emphasis on quality of care	-	Unclear	-
Fellows of the RCPSC[56,57]	Voluntary certification to show commitment to competent practice. Evaluation and successful completion of MOC program every 5 yr	Must participate in CPD activities. MOC based on 3 section framework: Group learning, self-learning, and assessment	-	Unclear	-
Non-licensing bodies assessments
OSATS[58-61]	Multi-station and timed with bench and live model simulations or surgical procedures. Peer evaluated with rating scale	Checklist and global rating scale by expert examiner to evaluate technical skill. Does not assess decision making or concrete surgical aspects	Laparoscopic Gastric Bypass Saphenofemoral dissection. Meniscectomy transtibial or anteromedial femoral tunnel	Yes	Yes
C-SATS[26,31]	Video recorded surgical performance and evaluated with validated with rating scale	Crowds of anonymous and independent reviewers, including those nonmedically trained, evaluate surgical skill with validated performance tools such as OSATS	Urinary bladder closure. Robotic surgery skills	No	Yes
O-SCORE[27,62]	Surgical procedure peer evaluated with rating scale	Surgical experts rate performance with 9 item tool and scaling system to assess competence to perform procedure independently	Open reduction internal fixation of hip, wrist, or ankle. Arthroplasty (total hip or hemi). Knee arthroscopy	No	Yes
GOALS[63,64]	Laparoscopic procedure peer evaluated with rating scale	Surgical experts evaluate performance with 5-point rating scale of 5 items unique to laparoscopy	Laparoscopic cholecystectomy	No	Yes
GEARS[65,66]	Robotic procedures peer evaluated with rating scale	Surgical experts evaluate performance with 5-point rating scale of 6 items unique to robotic surgery	Inanimate simulators–continuous suturing. Prostatectomy	No	Yes
Direct Objective Metric Measures[67,68]	Skill/surgical procedure measured with concrete aspects	Measurement of stiffness and failure load for each repair construct, with comparison to expected rehabilitation loads	Tibial plafond fracture reduction. Distal radius fracture reduction	No	Yes

¹To note: Methods to determine surgical competency are deemed valid for (1) Experienced surgeons; or (2) Residents/trainees if the assessment (continuing medical education, maintenance of certification or rated technical skill) correlated with experience level and/or with patient outcomes. Validity was shown for specific procedures within specific subspecialties. For example, experienced bariatric surgeons who had higher rated technical skill in laparoscopic gastric bypass surgery had patients with fewer post-op complications[46]. Generalized validity has yet to be shown in literature with regards to the technical skill assessments, although validity was typically demonstrated across several procedures. ABMS: American Board of Medical Specialties; CME: Continuing medical education; MOC: Maintenance of certification; RCPSC: Royal College of Physicians and Surgeons of Canada; CPD: Continuing professional development; OSATS: Objective structured assessment of technical skill; C-SATS: Crowdsourced assessment of technical skills; O-SCORE: Ottawa Surgical Competency Operative Room Evaluation; GOALS: Global operative assessment of laparoscopic skills; GEAR: Global evaluative assessment of robotic skills.