The worldwide population is getting older,1 and with it also the anaesthesia community, as renewal of senior staff is held back by limited input of fresh young talent.2. These two factors have a double, simultaneous impact on patients’ healthcare. First, because those appearing for surgery are becoming older and frailer, with multiple and more complex comorbidities that require a higher standard of care and vigilance.3 Second, because as their attending anaesthetist get older, they also are subject to cognitive, motor and sensorial decline,4 with potential for impaired decision-making, slow detection of critical events and a general erosion of technical competence.5 The combined impact of failing technical and slowing of nontechnical skills could have a synergistic effect leading to unfavourable patient outcome. To guarantee patients a high level of healthcare, establishing a competency evaluation programme for ageing anaesthetists could be of value. Simulation has been proven to be effective in the training of young anaesthetists and residents.6 For a more senior group, simulation could be even more valuable because it not only allows an evaluation of physician competence, but at the same time it offers an opportunity for further training and re-honing of practical skills.
The first objective of the present review is to give an overview of the current demographic trends within the anaesthesia community. The second objective is to discuss and define the criteria necessary to evaluate anaesthetists’ clinical work objectively. In turn, we will examine the impact of ageing on anaesthetists’ clinical activities, and then review methods to test its extent. Finally, we will go through the strategies that might offer the guarantee of a high level of competence within ageing anaesthesia practitioners.
Worldwide physicians’ age distribution has changed significantly over the last 30 years. In France, the percentage of anaesthetists older than 50 years in 1989 had increased from 20 to 52.5% by 2005 (Fig. 1).7 This same report predicts that if the current legislation on retirement is enacted, before 2020, more than half of the total anaesthetists in employment at 2005 will retire, and concurrently, the recruitment of younger anaesthetists will become inadequate.7 The combination of failing recruitment of trainees with a concomitant increase in anaesthetic workload is a reality of most European countries.2 The French government is planning to postpone the date of retirement to 72 years of age to compensate for this proposed shortage.8 In the United Kingdom, the age of retirement in the public sector is also going up. According to the new National Health Service pension scheme, currently up to 70% of the active members will have a pension age between 65 and 68.9 In the United States, the trend is similar; the mean age of retirement has changed with time, from 57 years in 1985 to 64 years at present.10 In recent years, several factors have contributed to the longer working lives of anaesthetists, including longer life expectancy, insufficient financial resources for retirement, career satisfaction, and the ability to work part-time and in teaching and administration.10 Conversely, retirement of anaesthetists at an earlier stage, 55 years old or less, is rare in the United States, and is mainly associated with sound financial status, health issues or career dissatisfaction.10 Currently, medicine as a profession seems less attractive to the younger generation, something that offers an explanation for problems of recruitment and renewal.11 If this trend continues, the United-States will be short of anaesthetists by the year 2020.11
Whether anaesthetists retire at a later stage in life, or opt to return to work from retirement to shore up the skill shortages, it is going to be necessary to assess their level of competence and determine whether they can offer an adequate standard of care.
Ageing and its impact: physiological age-related changes
Ageing is a global process that leads to gradual irreversible deterioration of multiple physiological systems.12,13 The functions subject to the decay of ageing that feature strongly in the performance of anaesthesia are fine movements, tactile perception, movement planning, musculoskeletal function, cognitive function and the nonrestorative sleep cycle.14 Each will be discussed below (Table 1).
‘Fine movements’ are affected in line with physiological ageing. With age, individuals show a deterioration of fine motor movements and a reduction of movement plan fluidity.15 This decline manifests itself as progressive impairment with difficulties starting, performing and controlling movement. However, because of interindividual differences, there is a wide variability in its onset.15 ‘Tactile perception’ is the feature most affected by age. It has been shown that changes start to occur after 45 years of life,16 and they become significantly more accentuated in the over 60s because the associated decline of fine movement is no longer able to counterbalance the deterioration in tactile perception.17 ‘Movement planning’ is the process of structuring an action, taking into account temporal and spatial aspects. This feature could be impaired by the ageing process, making corrections to movement planning necessary with reorganisation of the actions involved to complete the movement desired.17 The ‘musculoskeletal system’ is defined as the structure that allows and controls movement. This deteriorates gradually from the age of 50 to 75 years, with a sharper decline after 75 years.18 However, factors such as training, motivation and lifestyle influence the preservation of musculoskeletal functions over time.18 ‘Cognitive function’ is a term that encompasses a vast variety of entities such as memory, vigilance and reasoning, all essential in appropriate decision-making.19 ‘Mild cognitive impairment’ refers to cognitive deficits that exceed age-related cognitive decline.20 This condition affects the not-so-old working population and affects short and long-term memory. Schönknecht et al.21 recently studied a cohort of 500 to determine how many not-so-old study participants were affected by ageing-associated cognitive decline. They found that early mild cognitive decline was frequent among 15% of the 60 to 64 year olds and rose to nearly 25% after 4 years of follow-up.
Finally, another significant feature affected by age is ‘sleep’. With age, sleep interruptions are more frequent, and restorative sleep phases decrease.22,23 This results in a chronic state of fatigue, which in turn can lead to cognitive function impairment mainly perceived through lapses in attention.24 The amount of sleep recommended for a healthy adult is 7 h on a regular basis.25 When getting older, anaesthetists are likely to present with one or more of these conditions to a different extent, with a negative impact on their performances, competence and, above all, their patients’ outcomes.
Performance and competence: criteria of definition
The first step in the determination of whether anaesthetists are able to deliver a satisfactory standard of care would be to define precisely the criteria necessary to efficiently assess performance and competence. Performance can be defined as the standard to which a physician performs a task.26 It should be possible to measure the composite elements, namely procedural knowledge, professional behaviour, psychomotor skills and decision-making skills.27 However, different standards of evaluation lead to the lack of an objective measure of ‘how’ and ‘how well’ the care is delivered. For this reason, the term competence is more appropriate and indicates ‘the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served’.28 Competence has three main features. The first is developmental, which is a characteristic that changes according to the level of experience and knowledge. The second is dynamic impairment, a natural decline over time because of progressive physiological decay. Finally, the third is context-dependent, which is a feature that includes the relationship between skill, a task and the clinical context in which these elements are needed.28
In anaesthesia, competence requires the integration of many items of varying nature. They include technical skills (procedural skills), based on sensory-motor abilities; behavioural and social skills (communication skills, team working: ‘nontechnical skills’); mindset and efficient cognitive skills (scientific knowledge, problem-solving skills, decision-making skills).28 With time these functions may change, influencing professional competence. With regard to anaesthesia, for too long evaluation of competence has been limited to technical skills only. However, nowadays anaesthetists are regarded as ‘pilots of the human biosphere’, and the importance of ‘nontechnical skills’ is now understood.29 The latter skills are divided into two subgroups. The first one is cognitive skills, necessary for task management, situation awareness, decision-making and social interactions. The second one is interpersonal skills, which are essential for team communication.30 This has created the concept of ‘meta-competence’, a structured combination of the technical and nontechnical abilities required for successful anaesthesia.31
Consequently, anaesthetists’ ‘meta-competence’ should be the necessary component to assess to determine whether or not they are capable of delivering an appropriate standard of care.
Impact of ageing on anaesthetists’ competence
Because it degrades the quality of sleep, ageing is one of the main factors causing fatigue.32 Other age-related conditions affecting the quality of sleep are the menopause, prostatic hypertrophy and obstructive sleep apnoea syndrome. These conditions may exacerbate the disruption of the circadian cycle and consequently decrease vigilance.32,33 Also, the time to recover from on-call shifts is longer in older anaesthetists.32 Fatigue impairs all aspects of anaesthetists’ competence as it induces sensory, motor and cognitive changes,33 and the faculty most affected by acute and chronic sleep deficit is vigilance.32,34,35 Because anaesthetists are exposed to systematic acute sleep deficit through call duties,35 we are prone to acute and chronic sleep-deprivation.32 Not-so-old anaesthetists are more vulnerable to the consequences of inadequate sleep restoration, potentially leading to inadequate and delayed responses to critical clinical events, and also inadequate staff communication.24
The decline in fine motor movements, haptic perception and movement planning may impair senior anaesthetists’ ability to perform clinical manoeuvres such as placement of an epidural catheter or a central intravenous line. However, the effect of repeatedly performing clinical procedures over the course of a career could attenuate this process.36 The use of new technology such as automated anaesthesia devices may lighten the repetitive workload and compensate for the degree of physical impairment.37 Impaired vision, whether because of presbyopia or cataract, can easily be compensated for by spectacles or eye surgery.36 Similarly, the possible loss of hearing can be corrected by specific, discreet devices and optimised through new systems of decision support37,38 and smart monitoring.39 Technology and health science advancement could help senior anaesthetists in their practice, but to what degree?
Ageing anaesthetists and patient outcome
Behind consideration of a performance that is negatively affected by ageing is the concern that this might lead to more patient casualties. Another possibility is that age and experience could be expected to be associated with better patient outcome and a higher standard of care. A review on the physician workforce in the United States reported a negative association between long clinical experience and competence, factual knowledge and compliance with the standard of practice.40 Unfortunately, these findings could not be extrapolated to the anaesthesia workforce. However, Tessler and colleagues have conducted an investigation using surrogate information. They have taken the rate of litigation as a marker of under-competence, hypothesising that older anaesthetists would have a higher rate of litigation because of poorer patients’ outcome. They found a 1.5 times increase in the risk of culpability arising from litigation along with a greater degree of injury compared with the practitioners younger than 51.41 In interpreting this study, it must be understood that as the legal process varies from country to country, and as there are differences in anaesthesia delivery and care, the findings are not more widely applicable.42
If senior anaesthetists are liable to have cognitive deficits then the influence of this on their performance should be evident. Fixation mistakes, environmental distractions, reduced attention and situation assessment were significantly more frequent in this group.43 Siu and others, in a high-fidelity simulation centre, have evaluated the procedural time and the technical and nontechnical competence of the ability to perform cricothyroidotomy44; they noted an age-related decline in the competence to perform this life-saving technical skill. We cannot be sure that deterioration of fine motor skills was responsible for these findings; another explanation might be that in the absence of frequent practice, the expertise required to perform cricothyroidotomy was lost. Siu and others pointed out in their publication, the crucial necessity of training to maintain the technical skills of ageing anaesthetists.
Ageing anaesthetists and adaptive measures
Ageing is only one of the various factors which influence competence and patient outcomes. Individual proficiency will vary according to intelligence, personality, motivation, curiosity and physical well-being. According to a recent survey, working and comparing with peers, learning new technologies from younger colleagues, meeting new standards, looking for feedback from colleagues and patients as part of competency evaluation, having extra-professional interests and mentoring have emerged as adaptive professional ageing features.45 The span of active healthy life is increasing in line with life expectancy.46 Where a healthy lifestyle is composed of sound diet, regular physical activity and absence of smoking, the impact of age on the ‘biological clock’ is significantly less.47 No matter how healthy a lifestyle might be, it cannot stop psychophysical decline, but it may help to attenuate its repercussions.48
In conclusion, decay may affect many human functions after 50 years of life. However, the ‘meta-competence’ decline may not necessarily affect senior anaesthetists at the same time and to the same extent. Therefore, it is of paramount importance to detect whether psychophysical decline among senior anaesthetists has reached a threshold that could affect significantly their ‘meta-competence’ and consequently patients’ care.
Methods of testing competence
Ideally the means to evaluate anaesthetists’ ‘meta-competence’ for recertification should be objective and self-adjusting, without the need for comparison with preexisting standards. For this purpose, three factors have emerged: validity, reliability and feasibility.49 ‘Validity’ reflects the degree of objectivity, of being based on facts or principles, and is divided into content validity and construct validity.50 Content validity refers to the degree of compliance between what should be measured and what is measured (facts). Construct validity indicates the level of agreement between a possible measure and an empirical measure (principle).49 ‘Reliability’ is the ability to produce a result consistently.51 ‘Feasibility’ is the capability to reach a goal.52 Traditionally, these features are assessed through the Miller pyramid. The latter is divided into four levels according to the quantities of tasks the physician can perform autonomously (Fig. 2).53 Although the first three levels (knows, knows how and shows how) are easily measurable, the fourth one implies a direct observation during clinical activity.49 With this method, the inability to simultaneously evaluate technical and nontechnical skills makes it incomplete as a tool for the evaluations of competence.54 Also, with this approach, an objective analysis is impossible.55 Not even self-evaluation is suitable for this purpose because there is weak or no association between self-assessment and external assessment regardless of the level of training, speciality, domain of self-assessment and method of comparison.56 There is a need for surrogate quantification.
To overcome these deficiencies, an active interest in simulation has grown exponentially over the last 20 years. It is now evident that high-fidelity simulation is an appropriate method for the exhaustive and objective assessment of clinicians’ ‘meta-competences’.6,27,57–61 In addition, if a substantial decline in competence is detected a dedicated remedial training programme could also be offered via simulation.
Assessment and improvement of competence via high-fidelity simulation sessions
Simulation is defined as the technique of imitating the behaviour of situations and/or processes using suitably similar conditions or apparatus.62 Simulation is used not only in medicine but also in aviation, economics, engineering and in the military field.63 Simulation was introduced into anaesthesia at the end of the 1980s for training and assessment of competence without the risk of involving real patients.64,65 In the context of training in high-fidelity simulation, performance was significantly better in the management of crisis scenarios regarding response time, treatment score, deviation score and total performance score, than with conventional training methods.66 Training in emergency situations is intrinsically difficult because of their rarity.67 It has been demonstrated that a single high-fidelity simulation cricothyroidotomy training session can improve the procedural skills of attending anaesthetists, and that improvement was retained for at least 1 year.57 Simulation is extremely useful because it offers training for these uncommon life-threatening case scenarios, improving outcome without exposing real patients.68 Simulation has also been shown to be a useful tool for objectively assessing the level of anaesthetists’ performance.69,70 Recent reviews indicate that clinical experience and the related psychomotor skills acquired in the operating room can be objectively and reliably evaluated with high-fidelity simulation.69,71–73 Assessments are made via the responses of high-fidelity mannequins to specific interventions of the operator.72 The high-fidelity quality of the simulation reproduces psychological conditions related to the management of a complex and life-saving procedure. It can create states of positive stress which might contribute to enhanced performance and its maintenance over time. This environment and its associated mental state create cues which facilitate the retrieval of past experiences.44 The American Society of Anesthesiologists has reported that 95% of participants identified their gaps in knowledge and skills as a result of simulation.74 Participants put what they had learnt during the simulation session into practice productively, showing a significant improvement in technical and nontechnical performance.74 Most importantly, the competence acquired during simulation has been proven to be well tolerated when transferred to clinical practice in both ICUs75 and operating rooms.59
Although allowing senior anaesthetists to evaluate their practice, simulation has also been shown to be useful in detecting factors responsible for underperformance associated with ageing, and in correcting them.76 Baxter and colleagues77 have identified simulation as one of the tools that may prove useful in assessing and improving the competence of an ageing workforce. However, to the best of our knowledge, no studies have been conducted evaluating specifically the benefit of simulation either on the senior medical staff or senior anaesthetists.
By 1992, it was clear that simulation could be of great help in detecting and correcting those errors in anaesthetists’ performance that have an impact on patient outcome, such as wrong management of critical events, and fixation errors, that is, cognitive failure to revise a plan in the face of contradictory evidence.78 Today, there is an extensive body of research to show that high-fidelity simulation seems an effective tool in the assessment of both technical67,72,79 and nontechnical skills.43,80 For these reasons, it has acquired the status of a standard and is included in the Maintenance Of Certification in Anesthesiology examination.81 Interestingly, Steadman and colleagues81 observed that the variable ‘years of experience’ was not associated with an increased probability of passing the Maintenance Of Certification in Anesthesiology examination. Nevertheless, simulation for recertification is not mandatory.
The assessment, maintenance and improvement of competence of senior anaesthetists should not merely be a matter of personal motivation or satisfaction, but a moral obligation to maintain a high standard of care. These objectives could be easily achieved via high-fidelity simulation for the reasons described above. Through simulation, Miller's Pyramid fourth stage is easily measurable bearing no risk for the patient.78
Enthusiasm for simulation as a means to maintain skills is variable. Savoldelli and coworkers82 report that residents experienced simulation-based education more often than staff anaesthetists, with a ratio of 96 to 58%, respectively (P < 0.001). By way of explanation, the authors suggest that senior staff may not see a necessity in attending. They proposed a questionnaire to find out how simulation might become more popular among senior anaesthetists. The results indicate that the most popular answers were the provision of an individual evaluation profile with strengths and weaknesses, making the access to simulation easier, and the presentation of a certificate that would reduce malpractice insurance premium. Based on the above considerations, one could ask whether recertification should be left on a voluntary basis, or if a mandatory governmental prerequisite should be required.
If simulation shows promising results in assessing and improving the level of competence of senior anaesthetists, mandatory recertification to attest to an acceptable level of competence could be proposed to ensure the maintenance of high healthcare. In the long run, investigations should be performed determining the right age to start this recertification and the necessary frequency to repeat it.
The anaesthesia workforce is getting older because of delayed retirement, a low number of anaesthesia trainees and a low renewal rate of older anaesthetists by young physicians. Anaesthetists, like the rest of the working population, start to undergo a variable age-related psychophysiological decline once they pass 55 years of age. The latter may be responsible for impairment of competence which, in turn, could have a negative impact on patient outcomes. Technical and nontechnical skills characterise anaesthetists’ competencies. Age alone is not a predictive factor of changes in competence, and not all skills may evolve to the same extent and time. Impairment of ability needs to be detected at an early stage, and its impact on performance evaluated, before any correction is possible. Simulation is a reliable and valid way of achieving this without risk to patients.
If reluctance to accept simulation can be overcome, it might serve as a valuable asset in the face of the worldwide shortage of anaesthetists, ensuring that senior staff could continue working, guaranteeing the safety of their practice and preserving the highest standard of care.
Acknowledgements relating to this article
Assistance with the review: we would like to thank Dr G Lyons for his helpful editing of our text.
Financial assistance and sponsorship: none.
Conflicts of interest: none.
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