In this episode, Lillian Erdahl, MD, FACS is joined by Todd Rosengart, MD, FACS, from the Baylor College of Medicine. They discuss Dr Rosengart’s recent article, “Sustaining Lifelong Competency of Surgeons: Multimodality Empowerment Personal and Institutional Strategy,” which focuses on maintaining and ensuring the competency of an aging surgeon workforce. The study provides evidence-based guiding principles as part of a comprehensive “whole of career” strategy that can be adopted at a personal, institutional, and national level.
Disclosure Information: Drs Erdahl and Rosengart have nothing to disclose.
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(00:03):
You are listening to The Operative Word,
a podcast brought to you by the Journalof the American College of Surgeons.
I'm Dr Lillian Erdahl,and throughout this series, Dr Tom
Varghese and I will speak with recently
published authors about the motivationbehind their latest research
and the clinical implicationsit has for the practicing surgeon.
The opinions expressed in this podcastare those of the participants,
(00:26):
and not necessarilythat of the American College of Surgeons.
Hello, and welcome to the Operative Word,
a podcast of the Journalof the American College of Surgeons.
I'm Lillian Erdahl, and todayI'm joined by Dr Todd Rosengart,
who is the chair of the Baylor Collegeof Medicine Department of Surgery
and also serves as a governorfor the American College of Surgeons.
(00:49):
Welcome, Dr Rosengart. Glad to be here.
Thank you.
We're here to talk
about your paper, SustainingLifelong Competency of Surgeons:
Multi-Modality Empowerment,Personal and Institutional Strategies.
And first, I'll just ask you, do you haveany disclosures that we need to share?
I do not.
Okay, great.
Well,I, as I told you, when we set this up,
(01:12):
I'm so excited to talk about this work.
It's important for our workforce,our surgeons,
and it's important for our patients,which is the reason that we're all here,
is really to serve our patientsand ensuring that we're doing that while
also considering the health and well-being
and the career longevity of surgeonsis really exciting to me.
(01:33):
And I love that word empowerment, as well,both on the individual
and the professional levelfor all of our profession.
So tell me a little bitabout the background of how this work came
about for you.
Yeah, this actually startedthrough my personal experience
as a chair of surgery,and I really came to see
(01:54):
fairly quickly that there really isno comprehensive, well,
well thought through mechanismto evaluating and supporting,
the competency of surgeonsthrough their career.
And as,
as many of us know, that sometimescomes, comes to a head
when we're dealing with someonewho is at end of career and
there's not much of a mechanism in place,at least currently,
(02:17):
to properly evaluateand support, that clinician of any sort.
And especially, surgeons,so around 2018, 2019,
the society of surgical chairstook this on, in an exploratory way.
And we found that, the vastmajority of chairs felt likewise.
And our initial paper came out that,there was no mechanism.
(02:40):
This was a significant problem.
And it was an opportunity, potentially,for the American College of Surgeons
to help develop a strategy
for dealing with the lifelong competencyof surgeons, in particular.
So, the Society of Surgical Chairs,
came out with a paper on the topic.
and when I became a member of the boardof governors, and joined the task force
(03:04):
on physician competency with the supportof my colleague Adam Kopelan.
We took this on,
and we developed a verycomprehensive review of the literature
of the state, state of the art,and then recommendations, which the
as you know, the American Collegeof Surgeons eventually adapted.
As their statement on this issue,
to really chart a path forward.
(03:26):
So, yeah. I'm sorry.
Go ahead. Oh, no. You're fine.
I was just going to ask, you know, it's,there's so many,
pieces to just the background,you know, who is monitoring the competence
of the physician and particularlythe surgeon and, who owns it, right.
How is it regulated?
So can you talk a little bit about,you know, what things maybe do exist
(03:48):
on the institutionalor the national level for monitoring this?
Yeah.
And so of course everyone is interestedat some level in making
sure that surgeons are competentand overviewed
to make sure they're competent,that largely resides, our investigation
showed, at the level of medical staffsof hospital medical staff
(04:10):
committees, and a processthat's called ongoing
professional performanceevaluations or OPPEs,
however
that, really, once you get belowthe surface
that is a fairly informaland not well described process.
it typically includesreview of a physician
(04:33):
or a surgeon's clinical record,but in no, no specific ways.
And the one thing that is not part of thatin almost all circumstances
is any evaluations of a physicianor surgeons’
cognitive or psychomotor capabilities.
This work originally beganin, dealing with senior surgeons.
(04:53):
The evidence, of course, across the boardclearly shows that all of us get older,
not surprisingly our cognitive and ourpsychomotor function begins to decline.
Interestingly, physicians and surgeonsin particular, that decline tends
to be less, abrupt and dramaticas the lay population.
But it occurs nevertheless.
(05:14):
And at least some of the datain the literature clearly shows
that that can be correlatedwith declines in clinical performance.
Now, interestingly,
that's not always the case.
In many surgeons,because of their experience, judgment
that is developed over the years,actually retain, and in some cases
exceed the performanceof younger surgeons.
(05:36):
but that's not always the case.
And interestingly, many surgeonsand physicians are either unaware
or unwilling or uncomfortabledeclaring that they've noticed a change.
So all of that really comes together
to suggestthat we needed to create a structure,
not only for senior surgeons,but really surgeons
throughout their careerto support and maintain their competency.
(05:59):
Yeah.
The old adage, “physician, heal thyself”sort of comes to mind when you say that.
And, I think the culturethat's mentioned as well of,
you know, sort of being toughand being able to function,
you know, after no sleep and after,you know, days and weeks and,
and maybe months on call in, in certaincircumstances, really has to change.
(06:24):
It's not just the individual physician.
So I appreciate a strategy aroundproviding the access
to have your competencyand your physical and,
you know, cognitive health assessed,
as opposed to kind of waitingfor an individual
to identify that they're struggling,
especially when they may feelthat people are depending on them.
(06:45):
I mean,I think that so much of the experience,
of, burnout is that people don't feelthat there is an option
to work less or to ask for help.
so making it, you know,routine, makes a lot of sense to me.
Yeah.
And the other thing to that point,the other thing that we learned
as we went through the literatureis, often again, not a surprise.
(07:07):
Physicians and surgeons really definethemselves by their clinical work.
And surgeons
in particular, think of their mindset,and I've experienced this myself.
Or if I'm not in the operating roomdoing what I was trained to do,
then by definition,I am no longer contributing.
Yeah. What is my value?
What is my value? That's exactly right.
(07:27):
And of course, one of the major emphasesof, what will hopefully be an ongoing,
development effort, supportedby the American College of Surgeons
is began at an early pointto educate surgeons about the opp...and
prepare surgeons for the opportunitiesthat are outside the operating room.
Of course,senior surgeons are surgeons, surgeons
who bring a lot of experience, have lotsto contribute, outside the operating
(07:52):
leading hospitals, leading their programs,being mentors and teachers.
and it's important that we helpdevelop those things, early on
so that when the time doescome, surgeons are prepared for that.
Interestingly,one thing that we learned is, for example,
airline pilots, commercial, FAA airlinepilots know that they actually have
(08:15):
a mandatory retirement, around 65.
And they very early in their careerbegin to start thinking about, well,
what am I going to do afterI have faced this mandatory retirement?
We, of course, in surgery
don't have a mandatory retirementand we are not at all advocating for that.
In fact, just the opposite, becausesome of the things that we talked about,
(08:36):
however, we do have to startthinking about what do you do,
when that time does come,if you're interested in doing so?
And I like the idea of, you know,equitable practices, we're looking
not just at age and that number, buthow is someone performing and functioning.
And I think also if we can identify someof these trends, just like any other work,
(08:58):
we can empower peopleto look at their own practice.
One of the things that came up on the dataon aging surgeons is that there may be
a decrease inherentin adherence to evidence-based standards
of care, particularly over the age of 50.
And I think that makes sense to mepersonally.
You're a little bit farther awayfrom maybe your training.
And also, you know, we all get maybea little more set in our ways as we age.
(09:24):
And I think being aware of that tendencymay help people
to look for ways to stay up to dateand for feedback on their practice.
Yeah, absolutely.
And again, it's fascinatingthat there are surgeons who,
and the variability and changes in
cognitive functionactually increases as you get older.
(09:45):
There's a broad spectrum.
So, there are some who do maintainand there clearly are some who don't.
That number,of course, is relatively small. The,
the surgeons who actually do significantlyfall off, their performance curve.
It's probably somewhere around 10% or so.
But of course, that's in absolute terms,that's a significant number.
(10:07):
And even if it were just a handful,I think as a profession, it's important.
You know, we are very
gratified to get the supportof our colleagues in this effort.
As a profession, we think we should bethe ones who are both monitoring this
and assuring our our patient populationthat that we do have this in hand and are
(10:28):
making sure that we are providing themwith the best possible care.
Well,and the other thing that came to my mind
was how we inform health systemsand how we think about practices.
If we have this limited resource,
this finite resource of surgeonsor workforce availability,
what are we doing to ensure that surgeonsare functioning at the top of their
(10:53):
license and utilizing the health system
to really maximize the use of surgeons
during their peak,during the time when they can do the work,
that's traditionally thought of andbefore they transition to something else.
Are there mechanisms such as
using more advanced practiceproviders, you know, looking at,
(11:18):
partnering with our colleaguesin other specialties,
how can we ensure that with an agingand perhaps,
a challenged resource in termsof being able to meet all of the needs
of the surgical population,how do we maximize the use of surgeons?
Yeah.
Well, first of all,
you touch on a very important point,which is, preserving our workforce.
(11:40):
And as you, you know,the surgical workforce is limited.
There are many, many countiesin the United States that have inadequate
numbers of surgeons available,and that is just going to get worse.
The physician shortfall,as you know, is going to be
in the tens of thousandsover the next decade or so.
So we don't want to be, either,arbitrary or,
(12:03):
or capricious about inappropriately
suggesting that a surgeon is not capableof continuing to contribute.
And that's one reason why we think that
the individual hospitaland the individual medical staff OPPE
is probably a very good placeto start in terms of creating this,
(12:23):
competency support and evaluation system,
so that it one rule does not fit all.
And the needs of one hospital
in a certain part of the countrymay be different than elsewhere.
that said, we think that there area lot of mechanisms
that that can continue to provide supportto surgeons.
It includes things, as you suggest,that of, greater APP involvement,
(12:47):
changing roles, perhaps being a firstassistant vs a primary surgeon
or again, start taking on activitiesthat are still clinical
but may not be doing the highest risk,highest complexity cases,
that one might have done when they were,you know, 20 or 30 years younger.
And again, I think most surgeons,make that adjustment.
(13:09):
But not all do.
And again, that that's part of whatwe're trying to tackle in this initiative.
You talked about some programs out
there, such as the Aging Surgeon program.
What are some of the modelsthat you think can help us
as we develop this more robust practiceacross the country?
Yeah.
(13:29):
Thanks for asking that question.
There are a number of programs out there.
because of course, thishas not been a highly focused, identity
or area for improvement.
They aren't there are not that manynor as many as I think there could be.
Hopefully this initiative will help growthose competency and wellness programs.
And I think they come in two forms,which are interesting.
(13:52):
One is evaluation.
And that could be, fairly simplistic,especially in a, in a screening manner.
But they can get very, sophisticatedand even multi-day evaluations.
Currently, there are also mechanisms.
And this is growing as we understandmore about,
neurocognitive health,
(14:13):
where you can train yourself to actually,at least retain
or slow the deterioration,but in some cases is evidence
that you can actually improveyour cognitive and psychomotor function.
I will tell you personally,
as I've gotten older and gotten much morefocused on my own health,
physical fitness and focusing on
(14:34):
how do I support my brain activity,and I think many of us do that.
But, as we learnmore about how to do that,
I think that this is not just about
avoiding the inevitable,it is just the opposite.
It's being aware of the possibilityand then taking steps
to improve your psychomotorand cognitive function.
(14:56):
And that comes from thingsas simple as, doing, you know,
word games or number gamesor things like that to, you know, more,
more elaborate programsthat you can actually enroll in.
Well, I appreciateyou brought up physical fitness,
and I wanted to touch on that piecebecause I think there's some that's
(15:17):
on the individual, some that'smaybe on the, the culture, which is,
you know, I when I was a resident,I couldn't schedule a medical appointment.
I didn't get my call schedulewith enough notice.
I would call the dentist's officeand they would say,
yeah, six months from now,we'd be happy to get you in.
And I would say, well, I don't know whatI'm going to be doing six months from now.
(15:37):
And so I my personal experiencewas it felt impossible
to focus on my own sort of routinehealth maintenance.
And I hope we're getting better at that,not just at the resident level,
but at the practicingphysician level as well.
and then within the hospitals,you know, more focus on ergonomics.
I have a colleague, Dr Geeta Lal,who's focused on this.
(15:59):
There's a society
for surgical ergonomics, but, you know,we run up against all of these challenges.
We got the wellness mats in our operatingroom, and, that was great.
If you could get them to be brought inand, you know, stop
having people refer to them as,as princess mats,
as though they were an exceptionand really make it part of the expectation
(16:21):
that we're making ourselves
as well as we can be while doing thesechronic, repetitive motions.
and the last
thing that I learned was thatI needed to have massages regularly.
Once I hit about 40 that, you know,it took a different toll on my body.
I wonder if you can commenton the efforts, you know, among hospitals,
(16:41):
to bring more awareness tohow do we maintain that physical fitness
and decrease the,the workplace harms of our job?
Yeah,I think it is coming into the workplace.
And we certainly at, at our,my institution
are increasingly focused on that.
I know this is slightly off topic, but,you know, it's
(17:01):
been, a real, wakeup call to me.
Some of our,
female surgeons are dealing with issuesabout,
working during pregnancy in some,
some probably, extremely egregious ways.
And I think that's an areawe really need to focus on.
But, you know, physical healthequates to mental health and vice versa.
(17:24):
And I certainly thinkthat to go to go hand in hand,
you know, some of the,some of the challenges
that senior surgeonsface, of course, are not
cognitive, but they are motor.
and the more that we can keep ourselveshealthy, the more
we can continue to help contribute,support or support our patients.
So, in many ways,this is all rolled up into one,
(17:46):
and I think it's partof an ongoing effort to,
for force protection,borrowing a term from the military.
But, we can't contributeif we're not taking care of ourselves.
Yeah.
Thank you for that.
And I think hearing someone who is,
at your,
(18:07):
you know, position of power in surgery saythese things is really important to me,
because, again,I think that, we can believe it
and our leaders can believe it,but until everyone hears it
and until we give them the space to ask
for the things they need to be welland go out and ask and say what?
What is it that you need?
(18:29):
How can we maintain your well-being
and encourage that while you are workinghard to take care of patients?
You know, until we hear itfrom our leaders and see it in action,
it's not going to happenin the operating room and at the bedside.
You mentioned in the paper,
you know, that this empowerment strategyand the career long assessments,
(18:52):
and one of the things that comes upis sort of
when to intervene, you know,what is the model for intervention?
What are those look like when you doidentify that a surgeon's having an issue?
Yeah.
And, really the key to this initiativeor one of the cases
is not to make this ad hoc.
And that's where we all struggle. It, it,
(19:14):
when, when we do
not have an organized,systematized process for ongoing
competency review, then you get into,
concern, legitimate concerns,potentially about ageism.
So, you know, well, you're singling me outbecause I'm
a certain ageor you don't like what I'm doing anymore.
I'm not contributing as much.
And there are value assessments.
(19:35):
And we the a significant portion of thiseffort is to move away from that.
so at least in theory,in our initial thinking,
it should be part of in repeatedongoing feedback.
We all talk about feedback nowto surgeons on saying,
you know, yes, you are on par.
Your scoring or whateveris the same as it was 5 or 10 years ago.
(19:59):
Or perhaps no, we're seeing some evidence,maybe, of decline.
Let's keep an eye on that.
And again,that could be on your cognitive test.
It could be on your clinical performance.
It could be on other things.
All are to be probably evaluatedfrom a slate of recommendations
that our task force will hopefully create,that institutions, perhaps
(20:21):
the American Board of Surgeons, perhapsthe Joint Commission, perhaps individual,
hospital, medical,
staff committeeswill help develop, for themselves.
So this is notthis is always hopefully going to be
recommendations, guideline suggestionsthat individual
regulatory bodiesthat are professionally led like
(20:44):
our medical staffs, our American Boardof Surgery, for example,
and specialty boardslikewise will help craft together.
And then the outcome of thatwill be, again, an ongoing feedback
to, physicians and surgeonsabout where their performance is at
an early, really an early warning about,
opportunities for improvement
(21:07):
or stabilization or early conversationsabout
what does life look likeoutside the operating room.
I love that we talk about succession
planning for different roles,
as well as careerplanning and development.
What is your next level?
And, and we so often focus on thatin sort of a progressive career ladder
(21:30):
way, you know,
how do you get from where you arenow to the next higher rung on the ladder?
And so I like this idea of looking aroundand saying, you know, it's
not a ladder to climb.
and where are you transitioning tofrom wherever you are, whether
that's to a higher rung or, you know,I have a lot of colleagues who take,
(21:51):
maybe a, slower careerpath at a time in their life
when they have more going onoutside of the operating room or outside
of their clinical work, maybe an aging,ailing parent, you know, maybe,
for their children, maybe they're doingsomething like running a marathon.
I mean, a lot of different
reasons that the focus comes outa little bit outside of the work.
(22:12):
I would love to hearif you have stories of things
that colleagues have done to transitionfrom their sort of aggressive,
focus on physical, clinical surgeryto other career paths.
That we do and,there are probably not enough
of those stories yet, and that'spart of the theme of what we're doing.
(22:33):
But, just, as we speak,we're in conversations with a surgeon
who is likely going to be steppingout of the operating room, and this person
had been facing the prospect of, well,what do I do now?
And I'm a little bit unhappythat I'm making this transition
because he had notthought about alternatives.
(22:54):
Oh, well, what a wonderful opportunityto take your experience,
your tremendous leadership skills
that have been developedover decades of practice
and, apply them towardssupporting the institution as a, a leader
of our growth initiative and qualityimprovement initiative.
And what a shame it would be to not
(23:15):
take advantageof those decades of experience
that are really invaluableand irreplaceable in many ways.
So, it's fascinating that even, thoughI've been immersed in this,
concept for many years,it was not instantaneous that I thought
of this person in this alternative role,which once we thought about it
(23:39):
was, a completely obvious choice,to move in this way.
But even for us in this area,
it did not occur automatically.
And we want to change that.
We want to make this almost a hard-wiredopportunity or pathway,
for life after the operating room.
(24:01):
Yeah.
I wanted to share a story too,because I've,
I've watched one of my colleaguesrecently,
chooseto move into an area of more passion, not,
you know, because of, of any decline,but because she really found a passion in
executive coaching and the way she didit was over sort of a year and a half.
So she slowly decreased herclinical practice
(24:22):
and transitioned to this now full timeexecutive coaching career.
And just to see her joyin finding a new passion,
was really inspiring to witness.
And and the attention to making ita smoother transition, I think for her,
for the patients and for usrather than an abrupt departure.
(24:44):
And that was one of the thingsthat resonated
when I read your paper is,you know, let's plan ahead for this.
Let's not make it,
you know, difficult or disruptive.
But it's expected that at some pointyou'll move on to the next
amazing phase of your career.
Absolutely.And you've captured it exactly right.
And by the way,we did what we didn't touch upon
(25:04):
is sometimes, you know, the thingthat's never spoken is sometimes there
are financial challenges and, you know,you need to plan ahead financially.
Of course, I know the College hasa number of initiatives in, in this field.
But, again, I think is, is, surgeons,
like many people,we don't necessarily plan ahead.
and we think the future is not inevitable.
(25:26):
and at some level,we need to include our paper
to make sure that we're helpingsurgeons in particular, think about,
their financial well-being,when their source of,
primary source of income, at some point,you know, is, is going to stop.
Yeah.
And as you say, talking about it early,that's something that
(25:47):
we try to dowith our actually our medical students,
we have a seminar for the fourth-yearmedical students at the University of Iowa
where they can learnabout financial planning
because it is importantand you don't know the future.
You might expectto work for 30 years in a career,
and it might not work out or it might notwork out at that same level,
salary.
(26:07):
So I appreciate that attention to, again,preparing for all of the aspects
that are going to make sure people are,well, set up for that transition.
I agree. Well, thank you for your time,
Dr Rosengart,and for this really important work.
I hope that people willlook at the Physician Competency
and Health Workgroupof the American College of Surgeons
(26:29):
because I knowthere will be more coming out of it,
beyond this effortand to guide us into the future.
Well, I really appreciate it.
Thank you for your interest.
Thank you for listening
to the Journal of the American Collegeof Surgeons Operative Word Podcast.
If you enjoyed today's episode,spread the word on social media
by using the hashtag #JACSOperativeWord.
(26:52):
Subscribe to The Operative Wordwherever podcasts are available
or listen on the American Collegeof Surgeons website at FACS.org/podcast.
You are listening to The Operative Word,
a podcast brought to you by the Journalof the American College of Surgeons.
I'm Dr Lillian Erdahl,and throughout this series, Dr Tom
Varghese and I will speak with recently
published authors about the motivationbehind their latest research
and the clinical implicationsit has for the practicing surgeon.
The opinions expressed in this podcastare those of the participants,
(00:26):
and not necessarilythat of the American College of Surgeons.
Hello, and welcome to the Operative Word,
a podcast of the Journalof the American College of Surgeons.
I'm Lillian Erdahl, and todayI'm joined by Dr Todd Rosengart,
who is the chair of the Baylor Collegeof Medicine Department of Surgery
and also serves as a governorfor the American College of Surgeons.
(00:49):
Welcome, Dr Rosengart. Glad to be here.
Thank you.
We're here to talk
about your paper, SustainingLifelong Competency of Surgeons:
Multi-Modality Empowerment,Personal and Institutional Strategies.
And first, I'll just ask you, do you haveany disclosures that we need to share?
I do not.
Okay, great.
Well,I, as I told you, when we set this up,
(01:12):
I'm so excited to talk about this work.
It's important for our workforce,our surgeons,
and it's important for our patients,which is the reason that we're all here,
is really to serve our patientsand ensuring that we're doing that while
also considering the health and well-being
and the career longevity of surgeonsis really exciting to me.
(01:33):
And I love that word empowerment, as well,both on the individual
and the professional levelfor all of our profession.
So tell me a little bitabout the background of how this work came
about for you.
Yeah, this actually startedthrough my personal experience
as a chair of surgery,and I really came to see
(01:54):
fairly quickly that there really isno comprehensive, well,
well thought through mechanismto evaluating and supporting,
the competency of surgeonsthrough their career.
And as,
as many of us know, that sometimescomes, comes to a head
when we're dealing with someonewho is at end of career and
there's not much of a mechanism in place,at least currently,
(02:17):
to properly evaluateand support, that clinician of any sort.
And especially, surgeons,so around 2018, 2019,
the society of surgical chairstook this on, in an exploratory way.
And we found that, the vastmajority of chairs felt likewise.
And our initial paper came out that,there was no mechanism.
(02:40):
This was a significant problem.
And it was an opportunity, potentially,for the American College of Surgeons
to help develop a strategy
for dealing with the lifelong competencyof surgeons, in particular.
So, the Society of Surgical Chairs,
came out with a paper on the topic.
and when I became a member of the boardof governors, and joined the task force
(03:04):
on physician competency with the supportof my colleague Adam Kopelan.
We took this on,
and we developed a verycomprehensive review of the literature
of the state, state of the art,and then recommendations, which the
as you know, the American Collegeof Surgeons eventually adapted.
As their statement on this issue,
to really chart a path forward.
(03:26):
So, yeah. I'm sorry.
Go ahead. Oh, no. You're fine.
I was just going to ask, you know, it's,there's so many,
pieces to just the background,you know, who is monitoring the competence
of the physician and particularlythe surgeon and, who owns it, right.
How is it regulated?
So can you talk a little bit about,you know, what things maybe do exist
(03:48):
on the institutionalor the national level for monitoring this?
Yeah.
And so of course everyone is interestedat some level in making
sure that surgeons are competentand overviewed
to make sure they're competent,that largely resides, our investigation
showed, at the level of medical staffsof hospital medical staff
(04:10):
committees, and a processthat's called ongoing
professional performanceevaluations or OPPEs,
however
that, really, once you get belowthe surface
that is a fairly informaland not well described process.
it typically includesreview of a physician
(04:33):
or a surgeon's clinical record,but in no, no specific ways.
And the one thing that is not part of thatin almost all circumstances
is any evaluations of a physicianor surgeons’
cognitive or psychomotor capabilities.
This work originally beganin, dealing with senior surgeons.
(04:53):
The evidence, of course, across the boardclearly shows that all of us get older,
not surprisingly our cognitive and ourpsychomotor function begins to decline.
Interestingly, physicians and surgeonsin particular, that decline tends
to be less, abrupt and dramaticas the lay population.
But it occurs nevertheless.
(05:14):
And at least some of the datain the literature clearly shows
that that can be correlatedwith declines in clinical performance.
Now, interestingly,
that's not always the case.
In many surgeons,because of their experience, judgment
that is developed over the years,actually retain, and in some cases
exceed the performanceof younger surgeons.
(05:36):
but that's not always the case.
And interestingly, many surgeonsand physicians are either unaware
or unwilling or uncomfortabledeclaring that they've noticed a change.
So all of that really comes together
to suggestthat we needed to create a structure,
not only for senior surgeons,but really surgeons
throughout their careerto support and maintain their competency.
(05:59):
Yeah.
The old adage, “physician, heal thyself”sort of comes to mind when you say that.
And, I think the culturethat's mentioned as well of,
you know, sort of being toughand being able to function,
you know, after no sleep and after,you know, days and weeks and,
and maybe months on call in, in certaincircumstances, really has to change.
(06:24):
It's not just the individual physician.
So I appreciate a strategy aroundproviding the access
to have your competencyand your physical and,
you know, cognitive health assessed,
as opposed to kind of waitingfor an individual
to identify that they're struggling,
especially when they may feelthat people are depending on them.
(06:45):
I mean,I think that so much of the experience,
of, burnout is that people don't feelthat there is an option
to work less or to ask for help.
so making it, you know,routine, makes a lot of sense to me.
Yeah.
And the other thing to that point,the other thing that we learned
as we went through the literatureis, often again, not a surprise.
(07:07):
Physicians and surgeons really definethemselves by their clinical work.
And surgeons
in particular, think of their mindset,and I've experienced this myself.
Or if I'm not in the operating roomdoing what I was trained to do,
then by definition,I am no longer contributing.
Yeah. What is my value?
What is my value? That's exactly right.
(07:27):
And of course, one of the major emphasesof, what will hopefully be an ongoing,
development effort, supportedby the American College of Surgeons
is began at an early pointto educate surgeons about the opp...and
prepare surgeons for the opportunitiesthat are outside the operating room.
Of course,senior surgeons are surgeons, surgeons
who bring a lot of experience, have lotsto contribute, outside the operating
(07:52):
leading hospitals, leading their programs,being mentors and teachers.
and it's important that we helpdevelop those things, early on
so that when the time doescome, surgeons are prepared for that.
Interestingly,one thing that we learned is, for example,
airline pilots, commercial, FAA airlinepilots know that they actually have
(08:15):
a mandatory retirement, around 65.
And they very early in their careerbegin to start thinking about, well,
what am I going to do afterI have faced this mandatory retirement?
We, of course, in surgery
don't have a mandatory retirementand we are not at all advocating for that.
In fact, just the opposite, becausesome of the things that we talked about,
(08:36):
however, we do have to startthinking about what do you do,
when that time does come,if you're interested in doing so?
And I like the idea of, you know,equitable practices, we're looking
not just at age and that number, buthow is someone performing and functioning.
And I think also if we can identify someof these trends, just like any other work,
(08:58):
we can empower peopleto look at their own practice.
One of the things that came up on the dataon aging surgeons is that there may be
a decrease inherentin adherence to evidence-based standards
of care, particularly over the age of 50.
And I think that makes sense to mepersonally.
You're a little bit farther awayfrom maybe your training.
And also, you know, we all get maybea little more set in our ways as we age.
(09:24):
And I think being aware of that tendencymay help people
to look for ways to stay up to dateand for feedback on their practice.
Yeah, absolutely.
And again, it's fascinatingthat there are surgeons who,
and the variability and changes in
cognitive functionactually increases as you get older.
(09:45):
There's a broad spectrum.
So, there are some who do maintainand there clearly are some who don't.
That number,of course, is relatively small. The,
the surgeons who actually do significantlyfall off, their performance curve.
It's probably somewhere around 10% or so.
But of course, that's in absolute terms,that's a significant number.
(10:07):
And even if it were just a handful,I think as a profession, it's important.
You know, we are very
gratified to get the supportof our colleagues in this effort.
As a profession, we think we should bethe ones who are both monitoring this
and assuring our our patient populationthat that we do have this in hand and are
(10:28):
making sure that we are providing themwith the best possible care.
Well,and the other thing that came to my mind
was how we inform health systemsand how we think about practices.
If we have this limited resource,
this finite resource of surgeonsor workforce availability,
what are we doing to ensure that surgeonsare functioning at the top of their
(10:53):
license and utilizing the health system
to really maximize the use of surgeons
during their peak,during the time when they can do the work,
that's traditionally thought of andbefore they transition to something else.
Are there mechanisms such as
using more advanced practiceproviders, you know, looking at,
(11:18):
partnering with our colleaguesin other specialties,
how can we ensure that with an agingand perhaps,
a challenged resource in termsof being able to meet all of the needs
of the surgical population,how do we maximize the use of surgeons?
Yeah.
Well, first of all,
you touch on a very important point,which is, preserving our workforce.
(11:40):
And as you, you know,the surgical workforce is limited.
There are many, many countiesin the United States that have inadequate
numbers of surgeons available,and that is just going to get worse.
The physician shortfall,as you know, is going to be
in the tens of thousandsover the next decade or so.
So we don't want to be, either,arbitrary or,
(12:03):
or capricious about inappropriately
suggesting that a surgeon is not capableof continuing to contribute.
And that's one reason why we think that
the individual hospitaland the individual medical staff OPPE
is probably a very good placeto start in terms of creating this,
(12:23):
competency support and evaluation system,
so that it one rule does not fit all.
And the needs of one hospital
in a certain part of the countrymay be different than elsewhere.
that said, we think that there area lot of mechanisms
that that can continue to provide supportto surgeons.
It includes things, as you suggest,that of, greater APP involvement,
(12:47):
changing roles, perhaps being a firstassistant vs a primary surgeon
or again, start taking on activitiesthat are still clinical
but may not be doing the highest risk,highest complexity cases,
that one might have done when they were,you know, 20 or 30 years younger.
And again, I think most surgeons,make that adjustment.
(13:09):
But not all do.
And again, that that's part of whatwe're trying to tackle in this initiative.
You talked about some programs out
there, such as the Aging Surgeon program.
What are some of the modelsthat you think can help us
as we develop this more robust practiceacross the country?
Yeah.
(13:29):
Thanks for asking that question.
There are a number of programs out there.
because of course, thishas not been a highly focused, identity
or area for improvement.
They aren't there are not that manynor as many as I think there could be.
Hopefully this initiative will help growthose competency and wellness programs.
And I think they come in two forms,which are interesting.
(13:52):
One is evaluation.
And that could be, fairly simplistic,especially in a, in a screening manner.
But they can get very, sophisticatedand even multi-day evaluations.
Currently, there are also mechanisms.
And this is growing as we understandmore about,
neurocognitive health,
(14:13):
where you can train yourself to actually,at least retain
or slow the deterioration,but in some cases is evidence
that you can actually improveyour cognitive and psychomotor function.
I will tell you personally,
as I've gotten older and gotten much morefocused on my own health,
physical fitness and focusing on
(14:34):
how do I support my brain activity,and I think many of us do that.
But, as we learnmore about how to do that,
I think that this is not just about
avoiding the inevitable,it is just the opposite.
It's being aware of the possibilityand then taking steps
to improve your psychomotorand cognitive function.
(14:56):
And that comes from thingsas simple as, doing, you know,
word games or number gamesor things like that to, you know, more,
more elaborate programsthat you can actually enroll in.
Well, I appreciateyou brought up physical fitness,
and I wanted to touch on that piecebecause I think there's some that's
(15:17):
on the individual, some that'smaybe on the, the culture, which is,
you know, I when I was a resident,I couldn't schedule a medical appointment.
I didn't get my call schedulewith enough notice.
I would call the dentist's officeand they would say,
yeah, six months from now,we'd be happy to get you in.
And I would say, well, I don't know whatI'm going to be doing six months from now.
(15:37):
And so I my personal experiencewas it felt impossible
to focus on my own sort of routinehealth maintenance.
And I hope we're getting better at that,not just at the resident level,
but at the practicingphysician level as well.
and then within the hospitals,you know, more focus on ergonomics.
I have a colleague, Dr Geeta Lal,who's focused on this.
(15:59):
There's a society
for surgical ergonomics, but, you know,we run up against all of these challenges.
We got the wellness mats in our operatingroom, and, that was great.
If you could get them to be brought inand, you know, stop
having people refer to them as,as princess mats,
as though they were an exceptionand really make it part of the expectation
(16:21):
that we're making ourselves
as well as we can be while doing thesechronic, repetitive motions.
and the last
thing that I learned was thatI needed to have massages regularly.
Once I hit about 40 that, you know,it took a different toll on my body.
I wonder if you can commenton the efforts, you know, among hospitals,
(16:41):
to bring more awareness tohow do we maintain that physical fitness
and decrease the,the workplace harms of our job?
Yeah,I think it is coming into the workplace.
And we certainly at, at our,my institution
are increasingly focused on that.
I know this is slightly off topic, but,you know, it's
(17:01):
been, a real, wakeup call to me.
Some of our,
female surgeons are dealing with issuesabout,
working during pregnancy in some,
some probably, extremely egregious ways.
And I think that's an areawe really need to focus on.
But, you know, physical healthequates to mental health and vice versa.
(17:24):
And I certainly thinkthat to go to go hand in hand,
you know, some of the,some of the challenges
that senior surgeonsface, of course, are not
cognitive, but they are motor.
and the more that we can keep ourselveshealthy, the more
we can continue to help contribute,support or support our patients.
So, in many ways,this is all rolled up into one,
(17:46):
and I think it's partof an ongoing effort to,
for force protection,borrowing a term from the military.
But, we can't contributeif we're not taking care of ourselves.
Yeah.
Thank you for that.
And I think hearing someone who is,
at your,
(18:07):
you know, position of power in surgery saythese things is really important to me,
because, again,I think that, we can believe it
and our leaders can believe it,but until everyone hears it
and until we give them the space to ask
for the things they need to be welland go out and ask and say what?
What is it that you need?
(18:29):
How can we maintain your well-being
and encourage that while you are workinghard to take care of patients?
You know, until we hear itfrom our leaders and see it in action,
it's not going to happenin the operating room and at the bedside.
You mentioned in the paper,
you know, that this empowerment strategyand the career long assessments,
(18:52):
and one of the things that comes upis sort of
when to intervene, you know,what is the model for intervention?
What are those look like when you doidentify that a surgeon's having an issue?
Yeah.
And, really the key to this initiativeor one of the cases
is not to make this ad hoc.
And that's where we all struggle. It, it,
(19:14):
when, when we do
not have an organized,systematized process for ongoing
competency review, then you get into,
concern, legitimate concerns,potentially about ageism.
So, you know, well, you're singling me outbecause I'm
a certain ageor you don't like what I'm doing anymore.
I'm not contributing as much.
And there are value assessments.
(19:35):
And we the a significant portion of thiseffort is to move away from that.
so at least in theory,in our initial thinking,
it should be part of in repeatedongoing feedback.
We all talk about feedback nowto surgeons on saying,
you know, yes, you are on par.
Your scoring or whateveris the same as it was 5 or 10 years ago.
(19:59):
Or perhaps no, we're seeing some evidence,maybe, of decline.
Let's keep an eye on that.
And again,that could be on your cognitive test.
It could be on your clinical performance.
It could be on other things.
All are to be probably evaluatedfrom a slate of recommendations
that our task force will hopefully create,that institutions, perhaps
(20:21):
the American Board of Surgeons, perhapsthe Joint Commission, perhaps individual,
hospital, medical,
staff committeeswill help develop, for themselves.
So this is notthis is always hopefully going to be
recommendations, guideline suggestionsthat individual
regulatory bodiesthat are professionally led like
(20:44):
our medical staffs, our American Boardof Surgery, for example,
and specialty boardslikewise will help craft together.
And then the outcome of thatwill be, again, an ongoing feedback
to, physicians and surgeonsabout where their performance is at
an early, really an early warning about,
opportunities for improvement
(21:07):
or stabilization or early conversationsabout
what does life look likeoutside the operating room.
I love that we talk about succession
planning for different roles,
as well as careerplanning and development.
What is your next level?
And, and we so often focus on thatin sort of a progressive career ladder
(21:30):
way, you know,
how do you get from where you arenow to the next higher rung on the ladder?
And so I like this idea of looking aroundand saying, you know, it's
not a ladder to climb.
and where are you transitioning tofrom wherever you are, whether
that's to a higher rung or, you know,I have a lot of colleagues who take,
(21:51):
maybe a, slower careerpath at a time in their life
when they have more going onoutside of the operating room or outside
of their clinical work, maybe an aging,ailing parent, you know, maybe,
for their children, maybe they're doingsomething like running a marathon.
I mean, a lot of different
reasons that the focus comes outa little bit outside of the work.
(22:12):
I would love to hearif you have stories of things
that colleagues have done to transitionfrom their sort of aggressive,
focus on physical, clinical surgeryto other career paths.
That we do and,there are probably not enough
of those stories yet, and that'spart of the theme of what we're doing.
(22:33):
But, just, as we speak,we're in conversations with a surgeon
who is likely going to be steppingout of the operating room, and this person
had been facing the prospect of, well,what do I do now?
And I'm a little bit unhappythat I'm making this transition
because he had notthought about alternatives.
(22:54):
Oh, well, what a wonderful opportunityto take your experience,
your tremendous leadership skills
that have been developedover decades of practice
and, apply them towardssupporting the institution as a, a leader
of our growth initiative and qualityimprovement initiative.
And what a shame it would be to not
(23:15):
take advantageof those decades of experience
that are really invaluableand irreplaceable in many ways.
So, it's fascinating that even, thoughI've been immersed in this,
concept for many years,it was not instantaneous that I thought
of this person in this alternative role,which once we thought about it
(23:39):
was, a completely obvious choice,to move in this way.
But even for us in this area,
it did not occur automatically.
And we want to change that.
We want to make this almost a hard-wiredopportunity or pathway,
for life after the operating room.
(24:01):
Yeah.
I wanted to share a story too,because I've,
I've watched one of my colleaguesrecently,
chooseto move into an area of more passion, not,
you know, because of, of any decline,but because she really found a passion in
executive coaching and the way she didit was over sort of a year and a half.
So she slowly decreased herclinical practice
(24:22):
and transitioned to this now full timeexecutive coaching career.
And just to see her joyin finding a new passion,
was really inspiring to witness.
And and the attention to making ita smoother transition, I think for her,
for the patients and for usrather than an abrupt departure.
(24:44):
And that was one of the thingsthat resonated
when I read your paper is,you know, let's plan ahead for this.
Let's not make it,
you know, difficult or disruptive.
But it's expected that at some pointyou'll move on to the next
amazing phase of your career.
Absolutely.And you've captured it exactly right.
And by the way,we did what we didn't touch upon
(25:04):
is sometimes, you know, the thingthat's never spoken is sometimes there
are financial challenges and, you know,you need to plan ahead financially.
Of course, I know the College hasa number of initiatives in, in this field.
But, again, I think is, is, surgeons,
like many people,we don't necessarily plan ahead.
and we think the future is not inevitable.
(25:26):
and at some level,we need to include our paper
to make sure that we're helpingsurgeons in particular, think about,
their financial well-being,when their source of,
primary source of income, at some point,you know, is, is going to stop.
Yeah.
And as you say, talking about it early,that's something that
(25:47):
we try to dowith our actually our medical students,
we have a seminar for the fourth-yearmedical students at the University of Iowa
where they can learnabout financial planning
because it is importantand you don't know the future.
You might expectto work for 30 years in a career,
and it might not work out or it might notwork out at that same level,
salary.
(26:07):
So I appreciate that attention to, again,preparing for all of the aspects
that are going to make sure people are,well, set up for that transition.
I agree. Well, thank you for your time,
Dr Rosengart,and for this really important work.
I hope that people willlook at the Physician Competency
and Health Workgroupof the American College of Surgeons
(26:29):
because I knowthere will be more coming out of it,
beyond this effortand to guide us into the future.
Well, I really appreciate it.
Thank you for your interest.
Thank you for listening
to the Journal of the American Collegeof Surgeons Operative Word Podcast.
If you enjoyed today's episode,spread the word on social media
by using the hashtag #JACSOperativeWord.
(26:52):
Subscribe to The Operative Wordwherever podcasts are available
or listen on the American Collegeof Surgeons website at FACS.org/podcast.
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