The Aging Neurosurgeon: When Is Enough, Enough? Attitudes Toward Ceasing Practice and Testing in Late Career

A Scoping Review of Professionalism in Neurosurgery

BACKGROUND AND OBJECTIVES

The Accreditation Council for Graduate Medical Education's Milestones provides a foundation for professionalism in residency training. Specific professionalism concepts from neurosurgery could augment and expand milestones for the specialty. We reviewed the current literature and identified professionalism concepts within the context of neurosurgical practice and training.

METHODS

We used a scoping review methodology to search PubMed/MEDLINE and Scopus and identify English-language articles with the search terms "professionalism" and "neurosurgery." We excluded articles that were not in English, not relevant to professionalism within neurosurgery, or could not be accessed. Non-peer-reviewed and qualitative publications, such as commentaries, were included in the review.

RESULTS

A total of 193 articles were included in the review. We identified 6 professionalism themes among these results: professional identity (n = 53), burnout and wellness (n = 51), professional development (n = 34), ethics and conflicts of interest (n = 27), diversity and gender (n = 19), and misconduct (n = 9).

CONCLUSION

These 6 concepts illustrate concerns that neurosurgeons have concerning professionalism. Diversity and gender, professional identity, and misconduct are not specifically addressed in the Accreditation Council for Graduate Medical Education's Milestones. This review could be used to aid the development of organizational policy statements on professionalism.

Doctors' attitudes to maintenance of professional competence: A scoping review

CONTEXT

Recent decades have seen the international implementation of programmes aimed at assuring the continuing competence of doctors. Maintenance of Professional Competence (MPC) programmes aim to encourage doctors' lifelong learning and ensure high-quality, safe patient care; however, programme requirements can be perceived as bureaucratic and irrelevant to practice, leading to disengagement. Doctors' attitudes and beliefs about MPC are critical to translating regulatory requirements into committed and effective lifelong learning. We aimed to summarise knowledge about doctors' attitudes to MPC to inform the development of MPC programmes and identify under-researched areas.

METHODS

We undertook a scoping review following Arksey and O'Malley, including sources of evidence about doctors' attitudes to MPC in the United States, the United Kingdom, Canada, Australia, New Zealand and Ireland, and using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) as a guide.

RESULTS

One hundred and twenty-five sources of evidence were included in the review. One hundred and two were peer-reviewed publications, and 23 were reports. Most were from the United Kingdom or the United States and used quantitative or mixed methods. There was agreement across jurisdictions that MPC is a good idea in theory but doubt that it achieves its objectives in practice. Attitudes to the processes of MPC, and their impact on learning and practice were mixed. The lack of connection between MPC and practice was a recurrent theme. Barriers to participation were lack of time and resources, complexity of the requirements and a lack of flexibility in addressing doctors' personal and professional circumstances.

CONCLUSIONS

Overall, the picture that emerged is that doctors are supportive of the concept of MPC but have mixed views on its processes. We highlight implications for research and practice arising from these findings.

The Aging Surgeon: Evidence and Experience

BACKGROUND

With doctors in short supply and a strong demand for surgeon services in all areas of the United States, urban and rural, there are pressures to remain in active practice for longer. Even with an older workforce, there are currently no requirements for when a surgeon must retire in the United States.

OBJECTIVES

The aim of this article was to highlight the importance of the aging surgeon to the medical community and to provide an evidence-based overview of age-related cognitive and physical issues that develop during the later stages of a surgeon's career.

METHODS

A search of the PubMed/MEDLINE database was performed for the phrase "aging surgeon." Inclusion criteria were applied to include only those articles related to surgeon age or retirement. Additional reports were handpicked from citations to substantiate claims with statistical evidence.

RESULTS

The aging surgeon contributes extensive experience to patient care, but is also prone to age-related changes in cognition, vision, movement, and stress as it relates to new techniques, surgical performance, and safety measures. Studies show that although surgeons are capable of operating well into their senior years, there is the potential of decline. Nevertheless, there are proven recommendations on how to prepare an older surgeon for retirement.

CONCLUSIONS

Age-related trends in cognitive and physical decline must be counterbalanced with wisdom gained through decades of surgical experience.

A Consensus Study: Generational Differences in Neurosurgeons' Perception of Retirement and Practice Limits

BACKGROUND

Concerns about the changing demographics in the United States and the aging of the neurosurgical workforce exist. Both the importance and inherent risk of surgical responsibilities suggest that thought be given to whether workloads should change later in surgeons' careers. We sought to assess current neurosurgeons' expectations concerning their late-stage careers.

METHODS

A survey was sent to 3317 U.S. board-certified neurosurgeons. It was designed to assess surgeons' perceptions of call and operative responsibilities in the later stages of their careers. Statistical analyses were completed in R version 3.6.1, with an alpha set to 0.05.

RESULTS

Six-hundred and fifty-nine neurosurgeons completed the questionnaire. Seventy-seven percent believed that the call burden should decrease later in practice, and 66% planned to decrease their own call burden later in their career. The most common age range for planned retirement was 65 to 69 years (36%), followed by 70+ years (33%). Most (67%) believed that there should not be a mandatory age to stop operating. More recent year of residency completion was negatively associated with the belief that call burden should decrease at older age groups and positively associated with support for a mandatory age to stop operating as well as an earlier retirement age.

CONCLUSIONS

This study suggests that neurosurgeons have differing views on how workloads should change later in their careers. Younger neurosurgeons support an earlier decrease in workload or even a policy-mandated stop to operating after a certain age. These results may give insight into future trends and turnover in neurosurgery and provide a valuable tool to help practices anticipate workforce changes.

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

BACKGROUND

As the average age of surgeons continues to rise, determining when a surgeon should retire is an important public safety concern.

AIM

To investigate strategies used to determine competency in the industrial workplace that could be transferrable in the assessment of aging surgeons and to identify existing competency assessments of practicing surgeons.

METHODS

We searched websites describing non-medical professions within the United States where cognitive and physical competency are necessary for public safety. The mandatory age and certification process, including cognitive and physical requirements, were reported for each profession. Methods for determining surgical competency currently in use, and those existing in the literature, were also identified.

RESULTS

Four non-medical professions requiring mental and physical aptitude that involve public safety and have mandatory testing and/or retirement were identified: Airline pilots, air traffic controllers, firefighters, and United States State Judges. Nine late career practitioner policies designed to evaluate the ageing physician, including surgeons, were described. Six of these policies included subjective performance testing, 4 using peer assessment and 2 using dexterity testing. Six objective testing methods for evaluation of surgeon technical skill were identified in the literature. All were validated for surgical trainees. Only Objective Structured Assessment of Technical Skills (OSATS) was capable of distinguishing between surgeons of different skill level and showing a relationship between skill level and post-operative outcomes.

CONCLUSION

A surgeon should not be forced to hang up his/her surgical cap at a predetermined age, but should be able to practice for as long as his/her surgical skills are objectively maintained at the appropriate level of competency. The strategy of using skill-based simulations in evaluating non-medical professionals can be similarly used as part of the assessment of the ageing surgeons' surgical competency, showing who may require remediation or retirement.