Contribution of senior surgeons

All participants emphasised the value of older surgeons, including the contribution of those who have reduced or ceased operating. Of note was the frequent mention of older surgeons as ‘wise counsel’ whose advice may include when not to operate. While the emphasis was on the wisdom and judgement of senior surgeons, some participants also noted the breadth and depth of some older surgeons’ procedural skills.

Impact of ageing

Participants frequently (34/52) perceived that age can influence performance. Examples given included declining eyesight, hearing, fine motor skills and co-ordination. Some participants noted that older surgeons may cope less well with fatigue, and that a decline in non-technical skills—such as communication and cognitive flexibility—could also place patients at risk.

Our capacity to operate under stress, our capacity to be physically as active as we get older, our capacity to make quick decisions… all slowly deteriorate. (hospital CMO)

Participants emphasised that age-related problems can occur in any specialty, with serious consequences for patients. Examples included misdiagnoses and out-of-date prescribing practices among older doctors in non-surgical specialties. One hospital CMO explained:

We need to not forget if you’re a physician or a psychiatrist, and you make a grave error in medication prescription or not preventing a suicide, that is also a huge impact. (hospital CMO, non-surgeon)

However, they acknowledged that signs of ageing might be more obvious in surgery due to the procedurally driven, high-technology, time-critical nature of the specialty, with adverse outcomes often more immediately visible than among non-surgical specialties.

You could see a tremor in the surgeon and be concerned, but you may not see the rigidity of thinking in a physician. (regulator, general practitioner)

Over a quarter of interview participants (13/48) could recall a specific case where they perceived that patient safety was put at risk because of age-related changes in a surgeon’s performance. Others said they ‘knew of a case’ where age was a contributing factor to a poor outcome.

Timing of retirement

Participants perceived that personal fulfilment from work, lack of outside interests, financial pressures and poor retirement planning all contribute to delayed transitions to retirement. Several commented on the strong sense of identity that many surgeons find in their work:

For a lot of surgeons, their work is their life and they won’t stop because they can’t see what to do when they hang the scalpel up. (surgeon, head of unit)

There was a sense that some surgeons were so devoted to their careers that they “didn’t develop hobbies, they perhaps didn’t invest in personal relationships” (surgeon). The most commonly mentioned financial pressures to keep working were the costs of divorce(s), re-partnering, poor retirement planning and losses on investments. As one employer noted:

Financial is a big one. They’ve been screwed over by someone with the bad investments, they’ve had the second or third or fourth marriages and they’ve got family to keep up. (hospital CMO)

Participants from the UK explained that National Health Service pension arrangements currently disincentivise working past the age of 60 years, although this may change with future policy changes.31

Merits of age-based testing

When discussing the Medical Board of Australia’s introduction of health and performance checks at age 70, more than half of the participants (22/36) drew an analogy with the airline industry which mandates performance testing and retirement for older pilots. Others referred to age-based requirements for drivers, judges, firefighters and air traffic controllers.

Some participants felt that surgeons would perceive the introduction of age-based testing as an affront to their autonomy and status, resulting in ‘push-back’. These sentiments were tempered with a view that many surgeons would see the positive role of assessment in affirming their competence.

Most surgeons who think about it, rather than react to it, are going to say “‘that is reasonable, we’d have to do it to maintain a licence to drive’… so surgeons must be under the same scrutiny for public safety”. (professional college executive, surgeon)

Participants were divided in their support for additional assessment of older surgeons. Around half of Australian participants (19/40) supported additional assessment:

I was very heartened when I saw that AHPRA (the Australian Health Practitioner Regulation Agency) was talking about bringing in cognitive testing at the age of 70. I think that’s a very sensible idea. (hospital CMO)

Some saw a leadership opportunity for the surgical profession, with surgeons already ahead of other specialities in data collection, clinical audit and reflective practice.

I think surgeons would support it because surgeons have led the way with Morbidity and Mortality meetings. Surgeons have led the way with peer review. (hospital CMO)

However, experts perceived that the ‘devil was in the detail’, with reservations expressed regarding (1) the evidence base for the threshold of age 70, (2) the lack of detail as to what the testing would involve and (3) how the results of testing would impact on the practitioner.

It’s a good principle. It’s a question of how you do it and who does it. (professional college executive, surgeon)

Some of these reservations may reflect the fact that, at the time of interviews, the Medical Board of Australia had yet to confirm a detailed implementation plan.

Assessment of performance

Participants had different views on the age at which assessment for age-related deficits should begin, with suggested thresholds ranging from 55 to 75 years. Some participants favoured a whole-of-career approach, with similar triage, testing and responses for all surgeons. They argued this would avoid age discrimination and reinforce standards across surgical careers, with better opportunities for early remediation.

Others preferred a more targeted approach for older surgeons. Both groups—those who favoured a whole-of-career approach and those who saw merit in age-based assessment—stressed the need for a staged approach where an initial assessment would be followed by more detailed evaluation and remediation or restrictions as appropriate.

Participants from all four countries spoke about the lack of validated tools for assessing surgical performance. The most commonly mentioned approaches were multisource feedback, direct observation of procedural skills, data analysis to identify outliers or changes over time, self-evaluation and cognitive assessment. Each approach was noted to have strengths and limitations (online supplementary appendix D). A common challenge was that variation in performance among surgeons made it hard to objectively assess early signs of deterioration.

It probably depends on where you start off with your technical ability as to how long it takes you to fall below the unacceptable line. (surgeon)

Several participants emphasised the need for holistic assessment as safe surgery includes not just operating well, but having a supportive team, choosing the right treatment, optimising preoperative care, communicating well and managing complications.

There’s no point at being excellent at doing the wrong operation. (surgeon, professional college executive)

Finally, participants urged those involved in the governance or regulation of older surgeons to avoid assessments that were “onerous tick box exercises… without improving quality” (surgeon).

Addressing concerns

Participants identified three options for addressing performance concerns: remediate, restrict or retire. Several participants noted that some age-related changes may be remediable, as in the case of a surgeon who needed new glasses:

(I was) certainly aware of a colleague whose eyesight went off, who didn’t see something on the cervix, a very competent individual, and I spoke to the secretary afterwards who just said, ‘Oh, I told him he’d need new glasses’. (surgeon, professional college executive)

The second option was to restrict a surgeon’s scope of practice. Examples included reducing surgical caseload or complexity, ceasing on-call, not working in solo practice, assisting rather than being primary operator and moving towards a non-procedural practice. Change of scope was generally seen as a pragmatic, non-punitive response. As one surgeon explained:

There are operations I do now which I have no desire to be doing in 10 years’ time. Does that mean I still won’t be performing at a decent level in 10 years’ time? No, I’d hope I am. (surgeon, unit head)

Participants identified four barriers to changing scopes of practice. First, the impact on rosters and colleagues could be significant. Second, particularly in private practice, there might be significant financial disincentives to moving into non-operating roles. Third, reduced exposure to complex acute surgery could lead to atrophy of skills. Some participants cautioned that even seemingly simple surgery can quickly become complex, requiring agile problem-solving. Finally, participants emphasised that teaching or non-consulting roles should not be seen as a safe haven for impaired practitioners, as sound judgement and up-to-date skills are just as important in these roles as in the operating theatre.

The third option was to encourage or, if necessary, compel retirement. As part of this process, participants noted the importance of understanding organisational and personal barriers to retirement. For some surgeons, a shortage of highly specialised skills in their geographical area may make it more difficult to retire. For others, the barriers might be more personal:

“The fear of boredom, fear of retirement, fear of their self, their definition of themselves”. (hospital CMO, non-surgeon)

Roles and responsibilities

Participants voiced concern that having multiple entities involved in surgical governance could lead to poorly co-ordinated responses to deteriorating performance by an older surgeon. This had two adverse consequences—some impaired older surgeons fell through the cracks with no-one willing to address their performance leaving patients at risk; others faced action on multiple fronts leading to distress and worsening of health conditions. There was widespread support for a more co-ordinated and collaborative approach to assuring performance and supporting safe career transitions among older surgeons. Roles and responsibilities of different organisations, as viewed by participants, are set out in table 2.

Individual surgeons: Participants agreed that, ideally, surgeons themselves should be making decisions around career transitions with self-awareness and concern for patient safety. Overall, participants had a high degree of confidence that most surgeons were managing these transitions well. However, participants also recognised that due to personality traits or health impairments, not all ageing surgeons had the insight to know when to cease operating.

Employers: Participants identified two key roles for employers in relation to ageing surgeons: (1) appraising performance through annual performance reviews and credentialing activities, and (2) managing performance proactively through career planning and reactively in response to concerns. Participants emphasised that effective performance appraisal and management is a skill needing to be taught rather than assumed. Private hospitals were generally perceived as having less mature clinical governance frameworks, greater financial interests in allowing ageing surgeons to keep working and less influence over the conduct of surgeons than public hospitals. A contrasting view was expressed by some participants from private hospitals who saw their systems as on par with public hospitals. A few participants from regulatory backgrounds expressed concern that some employers failed to intervene with older surgeons in time to prevent escalation to the point where regulatory intervention was needed.

Regulators: Participants recognised that the primary role of regulators, such as the Medical Board of Australia, is protection of public safety. Regulators were seen as playing a vital role in protecting patient safety when employers ‘run out of solutions’ for a surgeon who is recalcitrant or lacks insight. The most common criticisms of regulatory boards were that (1) their “timeliness and responsiveness are not great”, (2) the process could have a negative impact on the health of a struggling older surgeon, and (3) boards appeared to pay greater heed to unethical conduct than impaired competence, even though deficits in performance may pose a greater risk to patient safety.

MDOs: Participants widely acknowledged the increasingly pro-active role that MDOs are taking to reduce claims through risk identification and targeted education, in addition to their usual role of legal advice and representation. MDO participants did not support differential premiums for individual older surgeons based on claims history (profession-specific differential premiums exist already), although limiting or withdrawing their cover for certain procedures was a possible response.

Professional colleges: Participants, both from within and external to professional colleges, supported a strong role for the professional colleges in developing specialty-specific policy, promoting validated assessment tools and offering guidance to ageing surgeons. Some surgeons noted that the Royal Australasian College of Surgeons already offered resources on career transitions12 32 and had an active senior surgeons group.