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A snapshot survey of perceptions of healthcare professionals on ageing surgeons
  1. Vaikunthan Rajaratnam1,
  2. Chandra M Kumar2,
  3. Anupama Roy Chowdhury3,
  4. Chang Su4
  1. 1Department of Orthopaedic Surgery 90 Yishun Central, Khoo Teck Puat Hospital, Singapore, Singapore
  2. 2Department of Anaesthesiology, Khoo Teck Puat Hospital, Yishun, Singapore
  3. 3Department of Geriatric Medicine, Khoo Teck Puat Hospital, Yishun, Singapore
  4. 4Department of Clinical Research, Khoo Teck Puat Hospital, Yishun, Singapore
  1. Correspondence to Dr Vaikunthan Rajaratnam, Department of Orthopaedic Surgery 90 Yishun Central, Khoo Teck Puat Hospital, Singapore 768828, Singapore; vaikunthan{at}gmail.com

Abstract

Objective The aim of this research was to understand healthcare professionals’ perception of the continued practice of ageing surgeons in Singapore.

Methodology A quantitative method was chosen for this research to determine healthcare professionals’ perception of the practice of ageing surgeons. Ethical approval was obtained from the local ethical review board. A cross-sectional method using a population survey was performed among healthcare professionals in two tertiary institutions and the study was confined to stakeholders in practices of ageing surgeons. The population sampled was limited to nurses in the theatre, anaesthetists, surgeons and geriatricians (physicians). An online questionnaire was designed for the survey that took into consideration the various conceptual frameworks of ageing surgeons' practice that was obtained from a literature review.

Results There were 104 respondents of a population of 350 sampled (theatre nurses, anaesthetists, physicians and surgeons) giving a respondent rate of 30%. The mean age of the participants was 39.7; 72% were doctors (surgeons 34%, physicians 20% and anaesthetists 18%) and 28% nurses. Only 35% agreed with the statement that older surgeons face deterioration in cognitive faculties and 29% remained neutral. A similar trend was seen with the perception that older surgeons face a decline in memory. However, 44% agreed with the statement that older surgeons face a decline in visuospatial ability and another 40% agreed that they had a decline in psychomotor skills and reaction time. Fifty per cent agreed with the statement that they face deterioration in physical abilities. Sixty-three per cent did not think that older surgeons face a decline in reasoning and judgement. Forty-eight per cent believed that older surgeons’ vast fund of knowledge and experience could compensate for physical and cognitive changes. Only 13% agreed with the statement that older surgeons have higher surgical mortality. Forty-five per cent agreed that the retirement age should be 65 while 22% believed it should be over 65. Forty-four per cent agreed that a regular multidisciplinary, objective and comprehensive evaluation of an older surgeon's physical and cognitive function would help to identify and treat reversible problems which when corrected would aid in restoring the surgeon's function. Seventy-four per cent felt that it was the responsibility of all stakeholders to decide or report on when an ageing surgeon is unsafe to continue practicing. Fifty-five per cent disagreed with a mandatory retirement age for surgeons.

Conclusions This study showed that, in Singapore, stakeholders agreed there are changes in physical and cognitive abilities of ageing surgeons but they thought that these can be overcome with selective strategies to optimise their role in the workforce. They also disagreed on a mandatory retirement age.

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Ageing is known to be associated with sensory changes such as hearing and visual impairment, and a change in the motor skills of a person. In the USA, 22.2% of the population above 71 years of age had cognitive impairment without dementia.1 Singapore is one of Asia’s fastest ageing populations and it is estimated that one in six residents will be at least 65 years of age by 2020.2 In an analysis of the current practices and future trends faced by organisations in Singapore, the ageing workforce remains high on the list of national challenges.3 Singapore encourages older employees to continue working and this as an essential component of maintaining its economic vitality, resulting in the government putting in place the Retirement and Re-employment Act in 2012. This act enabled older employees to work beyond the current statutory retirement age of 62.

Practising surgeons are not immune from the ageing process. They are required to maintain adequate sensory, motor and cognitive skills for optimum and safe practice. Age-related neurocognitive changes, including a decline in processing speed, problem solving and fluid intelligence (the capacity to think adaptively and apply critical or analytical reasoning), affect surgical performance.4

Published literature on performance and ageing surgeons

According to research in the USA, ageing has been associated with a change in the performance of surgeons.5 ,6 Nearly one-third of currently active surgeons are 55 years and above and it is forecast that the population of ageing surgeons will increase as the population ages. Although greater clinical experience may benefit patients, these age-related physiologic changes may also paradoxically result in poor patient outcomes. Because ageing surgeons are reluctant to abandon their career, alternative areas to which they can contribute need to be considered.7

Collier suggested differentiating between strong and poorly performing ageing doctors when eliminating unfit ageing doctors. Generalisation and elimination will lead to a shortage of healthcare workers.8 However, in a study from the USA, a cohort of doctors (around 15% of medical practitioners aged 75 years and over) were found performing in the average range of those aged <35 years on neuropsychological testing.9

A shortage of surgeons has been reported by the American Board of Surgery. There were 1047 surgeons who were certified in 1981 and this dropped to 909 in 2008.10 In contrast to the USA, the average age of surgeons in Australia is 52 years: 19% of those still practising are 65 years and older. In those over the age of 70, 45% practised in general surgery and 28% in orthopaedic surgery.4 In another study, Drag et al11 concluded: ‘The majority of practicing senior surgeons performed at or near the level of their younger peers on all cognitive tasks, as did almost half of the retired senior surgeons. This suggests that older age does not inevitably preclude cognitive proficiency’. However, the ageing surgeon's depth of knowledge and experience is not always sufficient to mitigate sometimes inevitable change in cognition and psychomotor skills.12 Habitual memory is better preserved than controlled analytic memory, however the surgeon requires both for safe practice, and surgeons' competency must be assessed and managed fairly and ethically.

Establishing a mandatory retirement age for surgeons may appear to be a straightforward solution to the ageing surgeons' problem in clinical practice. In the USA, fixed retirement ages for a number of professions that impact public safety have been implemented: commercial airline pilot (65 years), Federal Bureau of Investigation agent (57 years), National Park Ranger (57 years), air traffic controller (56 years), lighthouse operator (55 years). Mandatory retirement for surgeons does exist in many countries, but not in the USA.5 The use of a mandatory retirement age is archaic and there is a need for an objective evaluation of functional age.13 There is a need for a comprehensive, multidisciplinary, objective and confidential evaluation of the fitness to practice for the ageing surgeon.5 The variability in cognitive performance across age groups and retirement status suggests the need for formal measures of objective cognitive functioning to help surgeons detect changes in cognitive performance and aid in their decision to retire.11

The Singapore context

As far as we are aware, there has been no research conducted in Singapore to evaluate the perception of the practice of ageing surgeons by relevant stakeholders. The National Population and Talent Division in Singapore estimates the need for an additional 70% increase from present healthcare professional workforce numbers by 2030 to cater to the growing demands of the population.14 An understanding of the perception of the practice of ageing surgeons among healthcare professionals will help to develop strategies to maintain a pool of experienced and mature surgeons without imposing unnecessary risks to patients. Mandatory retirement of surgeons may further aggravate the manpower shortage in Singapore, in addition to the risk of losing a wealth of valuable experience in the teaching and mentoring of junior surgeons.

Aim of study

The aim of this research was to identify and understand healthcare professionals’ perception of the continued practice of ageing surgeons.

Methodology

A cross-sectional method was chosen for this research using a population survey performed among healthcare professionals in two tertiary institutions in Singapore (Khoo Teck Puat Hospital and Changi General Hospital). As the study was confined to stakeholders in ageing surgeons’ practices, the population sampled was limited to nurses in the theatre, anaesthetists, surgeons and geriatricians (physicians). Due to the cultural constraints of local staff being reluctant to criticise senior clinicians and to ensure honest and valid opinions of the local population, an online survey was chosen to deliver the questionnaire.

The online questionnaire was designed using various conceptual frameworks on ageing surgeons' practice that were obtained from a literature review.5 ,12 ,13 This questionnaire was then piloted to various members of the survey population and face and content validity was obtained before its administration. The survey was then emailed to 350 participants (consisting of nurses, physicians and surgeons) using Google form as a platform. Ethical approval for this study was obtained from the Singapore Domain Specific Review Board (Number 2015/00550).

Data were analysed using χ2 tests (p value <0.05 was considered statistically significant) and detailed group difference was determined using multilevel logistic regressions (using STATA V.13; StataCorp, Texas, USA).

Results

The response rate was 30% (104 respondents out of a population of 350 sampled, consisting of 29 theatre nurses (28%), 19 anaesthetists (18%), 21 physicians (20%) and 35 surgeons (33%).

The mean age of the participants was 39.7 years and 72% were doctors (surgeons 34%, physician 20% and anaesthesia 18%) and 28% nurses.

Only 35% agreed with the statement that older surgeons face deterioration in cognitive faculties, with 29% remaining neutral. A similar trend was seen with the perception that older surgeons face a decline in memory. However, 44% agreed with the statement that older surgeons face a decline in visuospatial ability. Forty per cent agreed that they had a decline in psychomotor skills and reaction time. Fifty per cent agreed with the statement that they face deterioration in physical abilities. Sixty-three per cent did not think that older surgeons had a decline in reasoning and judgement. Forty-eight per cent believed that the older surgeon's extensive experience could compensate for changes in physical and cognitive function. Only 13% agreed with the statement that older surgeons have higher surgical mortality. Forty-five per cent agreed that the retirement age should be at 65 and 22% believed it should be beyond 65.

Forty-four per cent agreed that a regular multidisciplinary, objective and comprehensive evaluation of an older surgeon's physical and cognitive function would help in identifying and treating reversible problems, which when corrected would aid in restoring the surgeon's ability to function. Seventy-four per cent felt that it was the responsibility of all stakeholders to decide or report on when an ageing surgeon is unsafe to continue practising. Fifty-five per cent disagreed with a mandatory retirement age for surgeons.

Detailed group difference using χ2 tests showed that doctors in surgical specialties are more likely to disagree on the statements in table 1. In comparing opinions between nurses and doctors, the latter were more likely to agree on the statements in table 2.

Table 1

Disagreement of statements by surgeons

Table 2

Agreement of statements by doctors

However, doctors are more likely to disagree on the statement ‘A mandatory retirement age for surgeons must be imposed’ (p=0.001). Interestingly, Chinese participants are likely to agree with the statement ‘Older surgeons face a decline in memory’ and ‘Older surgeons face deterioration in physical faculties’ compared with Indian participants (p=0.047 and 0.008).

Surgeons were more likely to disagree on specific statements compared with other participants as highlighted in table 3.

Table 3

Surgeons’ opinions on statements compared with others

Doctors were more likely to agree on specific statements compared with nurses as highlighted in table 4, except for a mandatory retirement age for surgeons on which they disagreed.

Table 4

Doctors’ opinions on statements compared with nurses

Surgeons were more likely to disagree on specific statements compared with non-surgical doctors as highlighted in table 5.

Table 5

Surgeons’ opinions on statements compared with non-surgical doctors

Discussion

This study has shown that relevant stakeholders did not unanimously agree with the statement that the ageing surgeon had a decline in cognitive faculties, including memory. However, 44% perceived that there was a decline in visuospatial ability, psychomotor skills and reaction time. Fifty per cent agreed with the statement that ageing surgeons faced deterioration in physical abilities. When the surgeons' responses were analysed, they did not perceive a decline in their visuospatial ability, reasoning or judgement with ageing, or an increase in surgical mortality rates. The responding surgeons also did not believe that the multidisciplinary objective and comprehensive evaluation of ageing surgeons would help in protecting hospitals from liability risk and did not agree with a mandatory retirement age.

Surgeons were more likely to disagree compared with the other participants on the perception of a decline in visuospatial ability, reasoning, judgement and higher surgical mortality rates in their practice. They also were likely to disagree on a mandatory retirement age and regular multidisciplinary objective and comprehensive evaluation of the cognitive and physical function to protect hospitals from liability risk.

Doctors were more likely to agree than nurses on the perception of decline in visuospatial ability, reasoning and judgement, physical faculties, the importance of ageing surgeons in the workforce, the use of a regular multidisciplinary objective and comprehensive evaluation of a surgeon’s physical and cognitive function in aiding retirement and restoring the surgeon’s function. However, they disagreed on a mandatory retirement age for surgeons.

Non-surgical doctors were more likely to agree on the perception of decline in visuospatial ability and reasoning and judgement, higher surgical mortality and the use of a regular multidisciplinary objective and comprehensive evaluation of an older surgeon's physical and cognitive function in deciding on a surgeon's retirement and for the protection of hospitals from liability risk.

However, nurses perceived that surgeons face a decline in visuospatial ability, reasoning and judgement, and in physical faculties. They also perceived that the ageing surgeon's problem was an important issue to consider in the ageing workforce and believed that a regular multidisciplinary objective and comprehensive evaluation of the surgeon's abilities would help in deciding when they retire and in restoring surgical performance for those affected by changes associated with ageing.

The limitations of this study include a less than satisfactory response rate, a restricted sample population to two tertiary centres, a preponderance of doctors as respondents, static and time bound data and a snapshot of the situation without follow-up data.

Conclusion

This study in Singapore has identified that relevant stakeholders perceived that there are changes in physical and cognitive abilities of ageing surgeons. These stakeholders also perceived that these deficiencies can be overcome with selective strategies but disagreed on a mandatory retirement age for surgeons. Further qualitative research is advocated in the form of focus groups and a Delphi process to identify, design and develop strategies for managing the ageing surgeon. This process may facilitate consensus development for retirement policy on ageing surgeons in Singapore.

Main messages

  • Most respondents were in agreement that there should not be a mandatory retirement age.

  • Most respondents were in agreement that a regular multidisciplinary objective and comprehensive evaluation of the surgeons' abilities would help them in deciding when to retire, and in restoring surgical performance for those affected by changes associated with ageing.

  • Most respondents were in agreement on the importance of ageing surgeons in the workforce.

  • Most surgeons disagreed on the perception of a decline in visuospatial ability, reasoning, judgement and higher surgical mortality rates in their practice.

  • Most surgeons disagreed on the importance of ageing surgeons in the workforce.

Current research questions

  • What are the changes in cognitive and visuospatial ability of ageing surgeons in Singapore?

  • Is there a change in outcomes of surgery among ageing surgeons in Singapore?

  • How can the performance of ageing surgeons be managed to maximise their skills while maintaining patient safety?

References

View Abstract

Footnotes

  • Twitter Follow Vaikunthan Rajaratnam at @handsurgeryedu

  • Contributors Planning: VR and ARC; conducting survey: VR, CMK and ARC; reporting the work: VR, CMK, ARC and CS.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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