The American College of Surgeons has published a Statement on the Aging Surgeon that offers guidelines on how to address surgeons’ cognitive and physical decline. The Statement includes warning signs and testing information.
- Surgeons can be referred for extensive testing if needed.
- One hospital is testing all practitioners age 75 and older before credentialing and recredentialing.
The first sign of trouble happened when the surgeon was 78. He performed surgery on a woman who subsequently developed a pulmonary embolism. The nurses made urgent calls, but he didn’t respond. The woman died.
The hospital reported the doctor to the state medical board. However, the surgeon continued to operate for four years. Finally the hospital board sent him for a competency assessment at the University of California, San Diego. The surgeon’s neuropsychological exam was “very abnormal,” according to the director of the physician assessment program there, quoted in The New York Times. According to the director, the surgeon had visual-spatial abnormalities, his fine motor skills were impaired, he couldn’t retain information, and his verbal IQ was significantly lower than they expected. However, he thought he was fine, and no one else knew about his cognitive deficits. Once this information was known, the surgeon was asked to surrender his medical license. (To access the article, go to http://nyti.ms/1TjvnAY.)
It’s an issue that isn’t going away. About one-third of all practicing surgeons are older than 55, according to the American College of Surgeons. Hospitals and surgery centers have been slow to address this issue for many reasons, including pushback from the medical staff. However, this year the College released a highly controversial Statement on the Aging Surgeon.
When the College was trying to develop a policy on this topic, surgeons became very angry and had a visceral response, almost “like we’re trying to take away people’s guns,” says Roger Perry, MD, FACS, former chair of the Physician Competency and Health Workgroup at the American College of Surgeons, who took the lead on the aging surgeon statement.
Physician in general, and surgeons in particular, feel that they are losing control, he says. They face multiple mandates for training in areas ranging from bloodborne pathogens to sexual harassment, he says. “We didn’t want to come up with something viewed as another mandate that would be onerous,” Perry said.
Everyone agreed that the College should not give a firm age at which surgeons should no longer be able to operate. “Everyone agreed, but beyond that, it was extremely controversial,” Perry says.
Best Way to Address It?
It’s common knowledge that everyone, including physicians, has deteriorating neurocognitive function and skills as they get older, but there is significant variability from person to person, Perry says.
“Firm and hard and fast rules were very difficult, especially due to the paucity of data,” he says. “Any policy like this generates a tremendous amount of controversy.”
However, leaders at some healthcare facilities are taking a position. In April, Sinai Hospital in Baltimore passed a policy that every practitioner, including nurse practitioners, physicians, and nurse anesthetists, who turns 75 must have three tests to continue practicing: a general physical exam, an eye exam, and a brief neurocognitive exam that tests one’s thinking ability and memory. The hospital pays for any testing not covered by insurance. They also must have these three tests conducted at recredentialing, which is every two years at Sinai.
Only a handful of hospitals in the country have such a policy, says Mark R. Katlic, MD, MMM, FACS, chairman of the Department of Surgery and surgeon-in-chief at Sinai Hospital and director of the Sinai Center for Geriatric Surgery, also in Baltimore. The policy was passed unanimously by the hospital’s Credential Committee, Medical Executive Committee, and Board of Directors.
“We just arbitrarily picked age 75, because I felt it would be less controversial, and everyone would agree that’s reasonable,” Katlic says. “The hospital has an obligation to make sure all doctors are capable of performing what they’ve been given credentials to do. The ASC would too.”
The testing scores go to the Credentials Committee and the chief of that person’s department to determine whether the practitioner can continue with full privileges. With this type of testing, if a provider’s results are far below what is considered “normal” for the general public, those results should raise some questions, Katlic says.
Have a Policy
Every hospital and surgery center should have a policy on aging practitioners, Katlic says.
“That way, you’re doing your duty to make sure everyone who practices in your facility is competent,” he says. “I’m not a lawyer, but I would think having a policy on the books would be helpful if there were a problem, because it would show that the ASC was taking this seriously. My fear is that if we don’t do it, the federal government might impose a mandatory retirement age … .”
When looking for guidelines to develop a policy, healthcare facilities can use the College’s Statement on the Aging Surgeon, which includes the following points:
- Surgeons might not recognize that their clinical skills and physical and cognitive function are declining. Peers can help identify surgeons who show deterioration.
- Warning signs 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.
- At age 65 or 70, surgeons should have confidential baseline physical exams and visual testing by their personal physicians. This step should be voluntary, according to the College.
- After that baseline exam, regular re-evaluation at intervals is advised. “Surgeons are encouraged to also voluntarily assess their neurocognitive function using confidential online tools,” the College says. “As a part of one’s professional obligation, voluntary self-disclosure of any concerning and validated findings is encouraged, and limitation of activities may be appropriate.”
Perry recommends a Dementia Risk Assessment developed by Jason Brandt, PhD, director of the division of medical psychology at Johns Hopkins Medicine. “It is free and available at www.alzcast.org,” he says.
- Peers must be able to share concerns about a surgeon’s performance and any decline related to age without fearing retribution. “In addition, the surgeon’s quality and outcomes of patient care is the ultimate measure of ongoing competence and safety for surgeons of all ages.” For that reason, the College recommends that recredentialing include peer review, with evaluation of a surgeon’s professional practice on an ongoing basis. “If a potential issue is identified, 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,” the College says. The surgeon might need more reviews that are more detailed, such as focused professional practice evaluation.
- Some surgeons will need a referral to a comprehensive evaluation program. There are several specialized centers where surgeons can have tests to measure their neurocognitive function. The facility or medical staff should pay for this testing, not the surgeon, the College says. “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 ...,” the College says. (For details on such a program, see story included in this issue.)
- Once the medical staff or facility leaders have evaluated all evidence, then a decision should be made regarding privileges. Confidentiality must be maintained, and the staff and leaders should follow medical staff bylaws and due process, the College says. “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,” it says.
- If surgeons who are leaving their clinical roles are interested, and their abilities permit them, they should be given opportunities to contribute through teaching, surgical assisting, conducting research, or being in administration.
All facilities that deliver surgical care are encouraged to develop policies that comply with government regulations. (The Statement also lists items that should be included in a comprehensive neuropsychological assessment. To see the statement, go to http://bit.ly/22dDHpl.)
“The statement is purposely designed to be general and provide guidelines, understanding that each institution has its own challenges and situations which may be different from another institution,” Perry says. “We tried to be pretty broad and give a lot of flexibility.”