The ageing surgeon

Whereas surgeons may be perceived by some of their colleagues as arrogant, self-centred and totally lacking in humility and insight, much has been achieved by the Royal Australasian College of Surgeons (RACS) in recent years to influence surgeons’ behaviour through a number of strategies related to the nine core competencies that guide surgeons in their lifelong journey.1 Towards the end of that journey, surgeons have passed the peak of their operating abilities,2 face a lower volume of cases with potentially more complications,3 and move into the transitional period of their career, progressing from an operating surgeon to . . . what?

In an article in this issue of the Journal, Skowronski and Peisah4 have analysed the plight of the ageing intensivist and offer a range of solutions relevant to all medical practitioners, including surgeons.

The RACS has developed strategies that provide some of those solutions. Their code of conduct advises surgeons to be aware of the ageing process, to refrain from practice if impaired by a physical disability and, on retirement, to ensure a smooth handover of patients under their care.5 The RACS also facilitates the Senior Surgeons Group6 — a group that developed from a 2004 RACS workshop, “Winding down from surgical practice”, which targeted retiring surgeons. The group’s objective is to support senior surgeons aged over 65 years (in 2050, this is expected to be about 25% of surgeons). The Executive Committee has produced a draft position statement that provides clear guidelines to ageing surgeons, with a focus on continuing professional development (CPD) (Mr Robert Rae, Chair, Executive Committee, Senior Surgeons Group, personal communication, March 2012). The recommendations cover:

• health management, including an annual report from a general practitioner covering any pre-existing chronic conditions and stating whether these will impair the surgeon’s performance, a mandatory ophthalmic examination to exclude such things as glaucoma and macular degeneration, and a hearing test;

• performance review, including a practice visit that would replace the need for a CPD and logbook analysis, and CPD modifications for surgeons who are only educators, or who practise only as a locum or a surgical assistant.

The profile of the senior surgeon and whether they have a public hospital appointment or practice only in the private sector would also influence their CPD requirements. Private sector requirements are particularly difficult to manage and may include mandatory practice visits.

The draft position statement does not address the potential for objective assessment of competency, which trainees in the Australian Surgical Education and Training (SET) program must undergo. Based on research by Drag and colleagues,7 the American College of Surgeons suggests the need for formal measurements of objective cognitive functioning to help surgeons make decisions about retirement. Indeed, a surgeon-specific profile of cognitive assessments similar to that developed by Trunkey and Botney,8 who made the obvious comparison with airline pilots, could become a mandatory component of the health assessment of ageing surgeons in Australia.

The RACS publication Surgical competence and performance — a guide to aid the assessment and development of surgeons,9 developed by the Professional Development and Standards Board, is an extremely valuable tool that applies to surgeons of any age. It can be used for self-assessment, performance appraisal of colleagues and 360-degree assessment (anonymous feedback from multiple sources).

Some solutions for tackling retention strategies and workplace adaptation processes involve planning a phased withdrawal from operating by reducing the volume and complexity of surgical procedures, no longer participating in the on-call roster, and considering roles in teaching, administration and medicolegal work.10 The caring and sharing philosophy applicable to burnout11 can be translated to the ageing surgeon’s situation — caring for oneself and one’s colleagues and sharing the workload by working in group practice, developing a succession plan, empowering younger colleagues and handing over the administrative tasks.

The new breed of surgeons will take the ageing process in their stride. They are products of the SET competency-based program in which six of the nine core competencies are non-technical skills, including collaboration and health advocacy. They will use robust guidelines, workshops and assessment processes, including evaluation of cognitive function, allowing a smooth transition to life outside operative surgery and into retirement. Their colleagues will be impressed with their humility and insight and their adaptivity to cultural change. Let’s look forward to the realisation of this dream!