Senior surgeons in active practice (2018)

To provide general guidance and advice to surgeons in their last ten years of practice.

The formation of a Senior Surgeons Section reflects RACS’ engagement in addressing workforce challenges and in supporting fellows as they transition into the latter stages of their surgical career. Ultimately this will involve considerations associated with ageing and the withdrawal from active clinical practice.

RACS supports the following principles:

Ageing

The RACS Code of Conduct states A surgeon will be aware of the effects of ageing and ensure that these are managed to prevent any harm to patients and/or consider reduced scope of practice or retirement where this may be necessary. Reduced scope of practice may be a sensible step towards retirement. Some surgeons will take a planned, timely approach to retirement in other ways. Quality and safety of patient care remains paramount. Dialogue with local colleagues may help decision making. Ageing involves a decline in cognition especially in the capacity to process information and reason which is critical to analysing and solving novel or complex problems. The process of cognitive decline begins in middle adult years. There is little literature on how this process affects competence and surgical skill with advancing age, as experience may compensate. Cumulative information acquired throughout life, including professional expertise and wisdom tends to remain stable. On the other hand older physicians and surgeons become increasingly efficient in diagnostic skill involving pattern recognition, countered by age-related decline in analytic reasoning skills. Many factors other than age may contribute to continuing competent surgical performance including;

• Surgeon factors such as engagement in continuing self-directed education and deliberate maintenance of expertise
• Patient factors including the complexity of the problem and acuity of illness
• Practice factors including time pressure, support from colleagues, and staffing

Senior surgeons working within a group situation are often well-supported and undertake work appropriate to their skills, with their experience complementing the skills provided by younger colleagues. The sole practitioner working in private practice or providing short-term locums may lack this support and could be vulnerable to working at a declining level of functioning.

Health checks

The 2016 RACS Workforce Census indicates that approximately one third of respondents have not seen a general practitioner (GP) in the last two years, one third regularly see a GP and the remaining third as needed. All surgeons should attend an annual health check. If illness that could impact practice has been identified (e.g. hypertension, diabetes, etc), further medical advice should be sought and action taken to ensure that the treated illness will not compromise the surgeon’s performance. Ageing surgeons in operative practice should also consider an annual ophthalmic assessment, including checking refraction, visual acuity, intraocular pressure and fundoscopy. Senior surgeons should be aware that impairment risk increases with age.

RACS also recognises the increasing focus on the importance of good mental health. According to the Beyond Blue National Mental Health Survey of Doctors and Medical Students (2013), the rate of high psychological distress was significantly greater in doctors in comparison to the general population and other professionals. All surgeons should seek support for depression, anxiety, addictions, stress and other mental health concerns from suitable professionals.

Continuing professional development (CPD)

All active fellows are required to participate in CPD regardless of age or hours worked. The program offers a variety of practice options that reflect the transition of surgeons throughout the different phases of their career. The RACS CPD program includes a category on performance assessment. Senior surgeons, particularly those in operative practice, should consider undergoing such a review at least every three years. Participation in performance review can act as a means of providing reassurance to the surgeon, colleagues and their patients. Local peer reviewed audit and morbidity/mortality meetings will help. These processes assist identification of any problems at an early stage allowing remediation or adjusted scope-of- practice, thus minimising the risk of poor patient outcomes. All surgeons can also opt to participate in a structured practice visit as a method of performance review, such as the New Zealand Orthopaedic Association (NZOA) program or through other peer groups.

All surgeons should participate in CPD related to their specific scope of practice or profile. There is also considerable value in department or hospital time-based credentialing and annual performance appraisals. If this is well structured and completed regularly it should alert ageing surgeons to any decline in performance and result in appropriate reorganisation of their work. Service credentialing should be completed every five years (or less) and performance appraisals annually.

The senior surgeon as a locum

Senior surgeons often provide locum cover, particularly in regional and rural areas. Fellows working as locums are often able to participate in the normal peer reviewed audit that takes place in their hospitals. If locum surgeons cannot meet this requirement, they should submit their de-identified MALT audit data to the Locum Evaluation and Peer Review Committee (LEPRC) for review. The LEPRC will only review the logbooks of locums who perform a minimum of the equivalent of 10 weeks full time work. Ageing surgeons working as locums may be placed in situations where they have less support than that available in their regular workplace. Consequently there may be some risks inherent in undertaking this form of work late in one’s career.

Support for senior surgeons

RACS has a number of publications and conducts seminars through the year to support senior surgeons, particularly in relation to financial, legal and social factors affecting them as they plan for retirement from practice. The RACS Building Towards Retirement program as well as the Surgical Career Transitions: a guide to opportunities and challenges, are intended to assist younger fellows, mid-career and senior surgeons navigating these career transitions. Both are available from the RACS website www.surgeons.org.

Confidential counselling and support services are available through the RACS Support Program which is run independently from RACS through Converge International. Fellows may access up to four sessions per year for counselling, coaching and support for workplace, emotional and personal issues.

Withdrawal from active practice

The withdrawal from active clinical practice may result in the surgeon losing his or her role as a surgeon” and may have significant impacts for remuneration and income. Withdrawal from practice can also have significant emotional and psychological effects. Whilst there are no definite rules as to when to consider withdrawing from practice there are a number of alternatives that the individual may consider. These considerations may vary based on each surgeon’s circumstances, health and practice profile. Alternative strategies that may be considered include; reducing scope of practice, taking up alternative roles related to medicine/surgery and being cognisant of personal health.

Clinical competence and the aging surgeon. Stuart A. Green, MD. AAOS Now September 2008

Medical Board of Australia - Good Medical Practice: A Code of Conduct for Doctors in Australia (includes information regarding personal performance, risk management, doctor’s health and steps to close a medical practice)

Medical Council of New Zealand - Good Medical Practice

Medical Board of Australia – Guidelines for Mandatory Notifications

Age, performance and revalidation – Report (on RACS website)

Retention of doctors in their “third age”: A Report for Health Workforce New Zealand, Sue Ineson, Karo Consultants Ltd May 2011

Royal Australasian College of Surgeons - Code of Conduct

The Aging Physician With Cognitive Impairment: Approaches to Oversight, Prevention, and Remediation. Sheila M. LoboPrabhu, M.D., Victor A. Molinari, Ph.D., ABPP, Joseph D. Hamilton, M.D., James W. Lomax, M.D. Am J Geriatr Psychiatry 17:6, June 2009 p445-54

The aging surgeon: How old is too old? Charles D. Hummer III, MD. AAOS Now May 2007

RACS Workforce Census Reports (on RACS website)

RACS Activities Reports (on RACS website)

National Mental Health Survey of Doctors and Medical Students (2013) Beyond Blue

Surgical Locums Position Paper (on RACS website)

Building Towards Retirement (on RACS website)

Surgical Career Transitions: a guide to opportunities and challenges (on RACS website)