By Monica J. Smith

BOSTON—For many surgeons, winding down in the later part of their careers can be a challenging transition. At a session at last year’s Clinical Congress of the American College of Surgeons, key topics related to practice transition planning were discussed: tools and metrics to assess aging physicians, support (or lack thereof) for late-career surgeons, and what surgeons can do to help themselves and their peers maintain a presence in their surgical communities and beyond.

The session opened with an overview of the 2016 American College of Surgeons’ Statement on the Aging Surgeon by Steven C. Stain, MD, the chair of surgery at Lahey Hospital and Medical Center, in Burlington, Mass.

“This statement was approved in 2015, which makes me think it may be time for a new statement or policy, and I understand that process is underway. But it’s important to know where we’re starting from,” Dr. Stain said.

The statement consists of nine guidelines, many of which would be hard to argue with. The first, for example, recommends a wellness-promoting lifestyle. “We hear this from our residents all the time: Wellness is important, and we should try to have good health throughout our career,” he said.

But some points are a bit more contentious, such as the second guideline, in which the ACS does not support a mandatory retirement age, and the fourth, which recommends voluntary baseline physical exams and vision testing starting around age 65.

“A primary care doctor saying you’re OK is different from assessing your ability to assimilate clinical knowledge, make a decision, perform an operation and take care of a patient,” Dr. Stain said. “Should the college or your state or hospital have some sort of mandatory retirement or testing? I’m not sure the ACS is ready to advocate for required testing at a certain age.”

A paper written by members of the Society of Surgical Chairs notes that even with progressive transitioning efforts, some surgeons are unwilling to relinquish operating duties. This assertion is supported by the observation that physicians often have limited self-perception of their own cognitive decline, and that 45% of physicians with knowledge of impaired or incompetent peers do not report their concerns.

“In this draft article, the group of governors and other experts are planning, I believe, to recommend the introduction of mandatory cognitive and psychomotor competency of surgeons as part of ongoing professional practice evaluation,” Dr. Stain said.

Todd K. Rosengart, MD, the chair of surgery at Baylor Medical Center, in Houston, and lead author of the paper, “Sustaining the Lifelong Competency of Surgeons: A Multimodality Empowerment Personal and Institutional Strategy,” said the practice of surgery and medicine in general lag behind other industries in dealing with aging professionals. “There’s no organized way to look at what we should be doing as we age and our skill levels, interests and areas of meaningful contribution begin to change,” he said.

The paper, which will inform an update to the 2016 ACS guidelines, aims to address two main concerns: how to evaluate the competency of surgeons throughout the duration of their careers, and how to proactively prepare surgeons for the second half of their careers. (See “ACS Recommendations Address Aging Population of Surgeons,” General Surgery News 2024 Jun 20. generalsurgerynews.com/In-the-News/Article/06-24/Aging-Surgeons-Challenges-Competency/73976)

“We’ve found multifactorial impediments to making that a robust and supportive transition. That includes everything from planning—what do you do when operating is no longer appropriate? Are you financially settled?—to opening doors to fulfilling opportunities, whether administrative work, mentoring, teaching, community outreach,” Dr. Rosengart said.

Unfortunately, aside from a smattering of programs across the country, there is little in place today to help senior surgeons in their practice transition. “So really, this effort is trying to turn the page on this long-neglected need and opportunity,” he said.

Still, Dr. Rosengart said he found it confirmatory that transition planning for senior surgeons has been identified by the Society of Surgical Chairs as an important need. “Close to 90% of the chairs felt there was a gap that needs to be addressed. We hope the role of the ollege going forward will be one of education for its members and how we implement [transition planning] nationally.”

A Call for Better Assessment Tools and Metrics

Aging varies greatly from one individual to another, but some degree of physical or cognitive decline is inevitable. Physicians’ cognitive functioning tends to surpass that of nonphysicians, but surgeons’ self-perception of their own cognitive changes often do not line up with age-associated measures of change. In addition, as noted, a sizeable minority of surgeons are reluctant to report witnessing a peer who is struggling.

“This is why we need assessment,” said Celeste Hollands, MD, an associate professor of surgery at Texas Tech University Health Sciences Center, in Lubbock.

But of the available assessment tools, only one, the Objective Structural Assessment of Technical Skills, has been validated and correlated with outcomes, she said. “The other five are used after there has been a problem—a surgical audit, peer review, performance review, etc.—and that’s where the difficulty is. We don’t have a way to find the problem before you’re in trouble.”

Furthermore, of the nine surgeon assessment programs in the United States, only two—one at the University of California, San Diego and the other in Baltimore—are open to all and have no impact on privileges. UCSD’s program and the Tahoe Forest Health System, in California, are the only two to formally assess technical skills.

The flaws in the status quo are clear. “Assessments must be validated. We must balance safety and liability issues with respecting surgeons and their value to society. We need an individualized approach, and we have no best practice guidelines on dealing with poor performance,” Dr. Hollands said. “I think this is a call to action that we need to be in charge of developing what these metrics are going to look like, what we’re going to do with them and how we’re going to assess ourselves.”

A Snapshot of Today’s Older Surgeons

Investigating the topic of senior surgeon transition planning, Roy Phitayakorn, MD, and his colleagues developed a needs assessment and surveyed ACS members 60 years and older, capturing feedback from 2,904 respondents. Overall, 43% of the surgeons were fully retired, 23% worked part-time and 43% were still working full-time (Global Surg Educ 2023 Apr 24. doi.org/10.1007/s44186-023-00125-5).

Among the retired surgeons, 63% retired before or after their targeted retirement age. Many of those who retired early cited workplace environment as a driving factor. Those who retired late were concerned about their financial portfolio.

“Only 20% had a desire to pursue other activities, including spending time with family and friends, which I think is a little sad,” said Dr. Phitayakorn, an associate professor of surgery at Harvard Medical School, in Boston.

An overwhelming majority of respondents-whether retired, or working part-time or full-time-indicated they would have liked more education on financial planning as well as some resources on career change and how to transition away from active clinical surgery.

“Asked what types of professional activities would interest them in retirement, a constant theme was teaching and training the next generation of surgeons: mentorship, mission work, coaching, mentoring faculty. This group of surgeons really wants to be involved and included,” Dr. Phitayakorn said.

When should this transitioning start? Dr. Phitayakorn said: “59% thought five to 10 years in advance; so if you’re thinking of retiring at 65, this should start in your 50s.”

Respondents also indicated that their preferred resources would be printed materials and seminars, but that it would be especially helpful to talk through the process with someone who’s been there—in essence, a transition mentor.

Thoughts From a Senior Surgeon

Julie A. Freischlag, MD, remembers the first time she became aware of her own mortality, at age 55, when her son had reached his mid-teens.

“Mothers don’t really think we’re going to die when our children are little. But all of a sudden, I realized, I’m not going to live forever. He’s 15; he can probably handle it now. And just like you’re not going to live forever, you also can’t be a surgeon forever.”

One major reason for this is patient safety. Just before hopping off an extensive Twitter (now called X) session about rib resections, Dr. Freischlag, whose practice focuses on thoracic outlet syndrome, posed the question: Would you let you take your rib out? “I think that’s the question we need to ask ourselves: would you let you do whatever you plan today, if it was you or your loved one.”

She asked audience members to remember the senior surgeons they knew from medical school. There were those with power and authority, who brilliantly taught technique, diagnosis, how to get out of trouble when things fall apart, how to form a pact with a patient.

“But you also remember some who needed a little extra help, who were told to do smaller cases, told that the fellow needed to scrub with them. Perhaps there are some in your practice now who should have retired,” Dr. Freischlag said.

She recalled feeling quite irritated a few years ago when surgeons over age 60 didn’t have to take call anymore. “But it’s right-you shouldn’t.”

So, what should you do? Plan ahead for what you will do when you’re no longer practicing surgery. “I’m planning when I’m going to stop doing rib resections, which I love doing. This is hard, but I’ve already made my plan. It’s next year,” said Dr. Freischlag, who authored the editorial “Planning for Retiring From Operating: ‘Will You Still Need Me, Will You Still Feed Me, When I’m 64,’” five years ago, when she was 64 (JAMA Surg 2019;154[7]:653-654).

To continue being productive, senior surgeons can step into teaching, mentoring and administrative roles, but they need to be able to take a step down in salary. “Get a handle on your financial health. We make a lot more money than most people in this country, so put it somewhere,” she advised.

Also important: Find people to talk to. “Join other teams—at the hospital, in your city—so you’ll have creative people to talk to. You’ll find it not just in the hospital with residents, but also in the community. Mentoring is my passion, so that’s where I’ll spend my time,” Dr. Freischlag said.

“We’re all going to deteriorate; we’re all going to need to give up practicing surgery; but it doesn’t mean you need to give up your passion for other things that you do,” she pointed out.