You are listening to The Operative Word, a podcast brought to you by the Journal of 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 motivation behind their latest research and the clinical implications it has for the practicing surgeon. The opinions expressed in this podcast are those of the participants, and not necessarily that of the American College of Surgeons.
Hello, and welcome to the Operative Word, a podcast of the Journal of the American College of Surgeons. I'm Lillian Erdahl, and today I'm joined by Dr Todd Rosengart, who is the chair of the Baylor College of Medicine Department of Surgery and also serves as a governor for the American College of Surgeons. Welcome, Dr Rosengart. Glad to be here. Thank you.
We're here to talk about your paper, Sustaining Lifelong Competency of Surgeons: Multi-Modality Empowerment, Personal and Institutional Strategies. And first, I'll just ask you, do you have any disclosures that we need to share? I do not. Okay, great. Well, I, as I told you, when we set this up, 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 patients and ensuring that we're doing that while also considering the health and well-being and the career longevity of surgeons is really exciting to me. And I love that word empowerment, as well, both on the individual and the professional level for all of our profession.
So tell me a little bit about the background of how this work came about for you. Yeah, this actually started through my personal experience as a chair of surgery, and I really came to see fairly quickly that there really is no comprehensive, well, well thought through mechanism to evaluating and supporting, the competency of surgeons through their career.
And as, as many of us know, that sometimes comes, comes to a head when we're dealing with someone who is at end of career and there's not much of a mechanism in place, at least currently, to properly evaluate and support, that clinician of any sort. And especially, surgeons, so around 2018, 2019, the society of surgical chairs took this on, in an exploratory way. And we found that, the vast majority of chairs felt likewise. And our initial paper came out that, there was no mechanism.
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 competency of 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 board of governors, and joined the task force on physician competency with the support of my colleague Adam Kopelan.
We took this on, and we developed a very comprehensive review of the literature of the state, state of the art, and then recommendations, which the as you know, the American College of Surgeons eventually adapted. As their statement on this issue, to really chart a path forward. 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 particularly the 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 on the institutional or the national level for monitoring this?
Yeah. And so of course everyone is interested at some level in making sure that surgeons are competent and overviewed to make sure they're competent, that largely resides, our investigation showed, at the level of medical staffs of hospital medical staff committees, and a process that's called ongoing professional performance evaluations or OPPEs, however that, really, once you get below the surface that is a fairly informal and not well described process.
it typically includes review of a physician or a surgeon's clinical record, but in no, no specific ways. And the one thing that is not part of that in almost all circumstances is any evaluations of a physician or surgeons’ cognitive or psychomotor capabilities. This work originally began in, dealing with senior surgeons. The evidence, of course, across the board clearly shows that all of us get older, not surprisingly our cognitive and our psychomotor function begins to decline.
Interestingly, physicians and surgeons in particular, that decline tends to be less, abrupt and dramatic as the lay population. But it occurs nevertheless. And at least some of the data in the literature clearly shows that that can be correlated with 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 performance of younger surgeons. but that's not always the case. And interestingly, many surgeons and physicians are either unaware or unwilling or uncomfortable declaring that they've noticed a change.
So all of that really comes together to suggest that we needed to create a structure, not only for senior surgeons, but really surgeons throughout their career to support and maintain their competency. Yeah. The old adage, “physician, heal thyself” sort of comes to mind when you say that.
And, I think the culture that's mentioned as well of, you know, sort of being tough and being able to function, you know, after no sleep and after, you know, days and weeks and, and maybe months on call in, in certain circumstances, really has to change. It's not just the individual physician.
So I appreciate a strategy around providing the access to have your competency and your physical and, you know, cognitive health assessed, as opposed to kind of waiting for an individual to identify that they're struggling, especially when they may feel that people are depending on them. I mean, I think that so much of the experience, of, burnout is that people don't feel that 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 literature is, often again, not a surprise. Physicians and surgeons really define themselves 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 room doing 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.
And of course, one of the major emphases of, what will hopefully be an ongoing, development effort, supported by the American College of Surgeons is began at an early point to educate surgeons about the opp...and prepare surgeons for the opportunities that are outside the operating room. Of course, senior surgeons are surgeons, surgeons who bring a lot of experience, have lots to contribute, outside the operating leading hospitals, leading their programs, being mentors and teachers.
and it's important that we help develop those things, early on so that when the time does come, surgeons are prepared for that. Interestingly, one thing that we learned is, for example, airline pilots, commercial, FAA airline pilots know that they actually have a mandatory retirement, around 65. And they very early in their career begin to start thinking about, well, what am I going to do after I have faced this mandatory retirement?
We, of course, in surgery don't have a mandatory retirement and we are not at all advocating for that. In fact, just the opposite, because some of the things that we talked about, however, we do have to start thinking 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, but how is someone performing and functioning.
And I think also if we can identify some of these trends, just like any other work, we can empower people to look at their own practice. One of the things that came up on the data on aging surgeons is that there may be a decrease inherent in adherence to evidence-based standards of care, particularly over the age of 50. And I think that makes sense to me personally. You're a little bit farther away from maybe your training.
And also, you know, we all get maybe a little more set in our ways as we age. And I think being aware of that tendency may help people to look for ways to stay up to date and for feedback on their practice. Yeah, absolutely. And again, it's fascinating that there are surgeons who, and the variability and changes in cognitive function actually increases as you get older. There's a broad spectrum. So, there are some who do maintain and there clearly are some who don't.
That number, of course, is relatively small. The, the surgeons who actually do significantly fall 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. 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 support of our colleagues in this effort.
As a profession, we think we should be the ones who are both monitoring this and assuring our our patient population that that we do have this in hand and are making sure that we are providing them with the best possible care. Well, and the other thing that came to my mind was how we inform health systems and how we think about practices.
If we have this limited resource, this finite resource of surgeons or workforce availability, what are we doing to ensure that surgeons are functioning at the top of their 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 and before they transition to something else.
Are there mechanisms such as using more advanced practice providers, you know, looking at, partnering with our colleagues in other specialties, how can we ensure that with an aging and perhaps, a challenged resource in terms of 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. And as you, you know, the surgical workforce is limited.
There are many, many counties in 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 thousands over the next decade or so. So we don't want to be, either, arbitrary or, or capricious about inappropriately suggesting that a surgeon is not capable of continuing to contribute.
And that's one reason why we think that the individual hospital and the individual medical staff OPPE is probably a very good place to start in terms of creating this, 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 country may be different than elsewhere. that said, we think that there are a lot of mechanisms that that can continue to provide support to surgeons.
It includes things, as you suggest, that of, greater APP involvement, changing roles, perhaps being a first assistant vs a primary surgeon or again, start taking on activities that 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. But not all do. And again, that that's part of what we'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 models that you think can help us as we develop this more robust practice across the country? Yeah. Thanks for asking that question. There are a number of programs out there. because of course, this has not been a highly focused, identity or area for improvement. They aren't there are not that many nor as many as I think there could be.
Hopefully this initiative will help grow those competency and wellness programs. And I think they come in two forms, which are interesting. One is evaluation. And that could be, fairly simplistic, especially in a, in a screening manner. But they can get very, sophisticated and even multi-day evaluations. Currently, there are also mechanisms.
And this is growing as we understand more about, neurocognitive health, where you can train yourself to actually, at least retain or slow the deterioration, but in some cases is evidence that you can actually improve your cognitive and psychomotor function. I will tell you personally, as I've gotten older and gotten much more focused on my own health, physical fitness and focusing on how do I support my brain activity, and I think many of us do that.
But, as we learn more 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 possibility and then taking steps to improve your psychomotor and cognitive function. And that comes from things as simple as, doing, you know, word games or number games or things like that to, you know, more, more elaborate programs that you can actually enroll in.
Well, I appreciate you brought up physical fitness, and I wanted to touch on that piece because I think there's some that's on the individual, some that's maybe 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 schedule with enough notice. I would call the dentist's office and 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 what I'm going to be doing six months from now. And so I my personal experience was it felt impossible to focus on my own sort of routine health maintenance. And I hope we're getting better at that, not just at the resident level, but at the practicing physician 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.
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 operating room, and, that was great. If you could get them to be brought in and, you know, stop having people refer to them as, as princess mats, as though they were an exception and really make it part of the expectation that we're making ourselves as well as we can be while doing these chronic, repetitive motions.
and the last thing that I learned was that I 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 comment on the efforts, you know, among hospitals, to bring more awareness to how 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 been, a real, wakeup call to me. Some of our, female surgeons are dealing with issues about, working during pregnancy in some, some probably, extremely egregious ways. And I think that's an area we really need to focus on. But, you know, physical health equates to mental health and vice versa.
And I certainly think that to go to go hand in hand, you know, some of the, some of the challenges that senior surgeons face, of course, are not cognitive, but they are motor. and the more that we can keep ourselves healthy, the more we can continue to help contribute, support or support our patients. So, in many ways, this is all rolled up into one, and I think it's part of an ongoing effort to, for force protection, borrowing a term from the military.
But, we can't contribute if we're not taking care of ourselves. Yeah. Thank you for that. And I think hearing someone who is, at your, you know, position of power in surgery say these 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 well and go out and ask and say what? What is it that you need?
How can we maintain your well-being and encourage that while you are working hard to take care of patients? You know, until we hear it from our leaders and see it in action, it's not going to happen in the operating room and at the bedside. You mentioned in the paper, you know, that this empowerment strategy and the career long assessments, and one of the things that comes up is sort of when to intervene, you know, what is the model for intervention?
What are those look like when you do identify that a surgeon's having an issue? Yeah. And, really the key to this initiative or one of the cases is not to make this ad hoc. And that's where we all struggle. It, it, 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 out because I'm a certain age or you don't like what I'm doing anymore.
I'm not contributing as much. And there are value assessments. And we the a significant portion of this effort is to move away from that. so at least in theory, in our initial thinking, it should be part of in repeated ongoing feedback. We all talk about feedback now to surgeons on saying, you know, yes, you are on par. Your scoring or whatever is the same as it was 5 or 10 years ago. 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 evaluated from a slate of recommendations that our task force will hopefully create, that institutions, perhaps the American Board of Surgeons, perhaps the Joint Commission, perhaps individual, hospital, medical, staff committees will help develop, for themselves.
So this is not this is always hopefully going to be recommendations, guideline suggestions that individual regulatory bodies that are professionally led like our medical staffs, our American Board of Surgery, for example, and specialty boards likewise will help craft together.
And then the outcome of that will be, again, an ongoing feedback to, physicians and surgeons about where their performance is at an early, really an early warning about, opportunities for improvement or stabilization or early conversations about what does life look like outside the operating room. I love that we talk about succession planning for different roles, as well as career planning and development. What is your next level?
And, and we so often focus on that in sort of a progressive career ladder way, you know, how do you get from where you are now to the next higher rung on the ladder? And so I like this idea of looking around and saying, you know, it's not a ladder to climb.
and where are you transitioning to from wherever you are, whether that's to a higher rung or, you know, I have a lot of colleagues who take, maybe a, slower career path at a time in their life when they have more going on outside of the operating room or outside of their clinical work, maybe an aging, ailing parent, you know, maybe, for their children, maybe they're doing something like running a marathon.
I mean, a lot of different reasons that the focus comes out a little bit outside of the work. I would love to hear if you have stories of things that colleagues have done to transition from their sort of aggressive, focus on physical, clinical surgery to other career paths. That we do and, there are probably not enough of those stories yet, and that's part of the theme of what we're doing.
But, just, as we speak, we're in conversations with a surgeon who is likely going to be stepping out 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 unhappy that I'm making this transition because he had not thought about alternatives.
Oh, well, what a wonderful opportunity to take your experience, your tremendous leadership skills that have been developed over decades of practice and, apply them towards supporting the institution as a, a leader of our growth initiative and quality improvement initiative. And what a shame it would be to not take advantage of those decades of experience that are really invaluable and irreplaceable in many ways.
So, it's fascinating that even, though I'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 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-wired opportunity or pathway, for life after the operating room.
Yeah. I wanted to share a story too, because I've, I've watched one of my colleagues recently, choose to 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 did it was over sort of a year and a half. So she slowly decreased her clinical practice and transitioned to this now full time executive coaching career. And just to see her joy in finding a new passion, was really inspiring to witness.
And and the attention to making it a smoother transition, I think for her, for the patients and for us rather than an abrupt departure. And that was one of the things that 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 point you'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 is sometimes, you know, the thing that's never spoken is sometimes there are financial challenges and, you know, you need to plan ahead financially. Of course, I know the College has a 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.
and at some level, we need to include our paper to make sure that we're helping surgeons 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 we try to do with our actually our medical students, we have a seminar for the fourth-year medical students at the University of Iowa where they can learn about financial planning because it is important and you don't know the future. You might expect to work for 30 years in a career, and it might not work out or it might not work out at that same level, salary.
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 will look at the Physician Competency and Health Workgroup of the American College of Surgeons because I know there will be more coming out of it, beyond this effort and to guide us into the future. Well, I really appreciate it.
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