Commentary: Aging, cognitive decline and performance: Will prevention provide the cure?

Central MessageMaintaining excellence should focus less on the adjudication of aging and more on establishing systematic protections for the patient.See Article page 1035. Maintaining excellence should focus less on the adjudication of aging and more on establishing systematic protections for the patient. See Article page 1035. In the current issue, Rosengart1Rosengart T.K. Assessing clinical competency: the long and the short of it.J Thorac Cardiovasc Surg. 2022; 164: 1035-1037Abstract Full Text Full Text PDF Scopus (3) Google Scholar explores the effect of cognition and age on human performance and the contribution of cognitive errors in deficiencies in performance are specifically examined. The adjudication of errors in the clinical environment represents a timely initiative in the quest for excellence and the establishment of quality standards in certification and credentialing realms. The author explicitly addresses the simultaneous contribution of aging to the spectrum of performance and deficits therein. This is pertinent as a growing proportion of cardiothoracic surgeons is approaching retirement in an era of intense scrutiny and sometimes relentless judgement.2Saver J.L. Best practices in assessing aging physicians for professional competency.JAMA. 2020; 323: 127-129https://doi.org/10.1001/jama.2019.20249Crossref PubMed Scopus (7) Google Scholar,3Katlic M.R. Coleman J. Russell M.M. Assessing the performance of aging surgeons.JAMA. 2019; 321: 449-450https://doi.org/10.1001/jama.2018.22216Crossref PubMed Scopus (22) Google Scholar The interface of age and experience is complex and not easily explained through the lens alone. Categorizing age in absolute terms, nevertheless, necessitates defining what is meant by “young,” “elderly,” “aging,” and “aged.”3Katlic M.R. Coleman J. Russell M.M. Assessing the performance of aging surgeons.JAMA. 2019; 321: 449-450https://doi.org/10.1001/jama.2018.22216Crossref PubMed Scopus (22) Google Scholar Age proffers experience and experience affords judgement and although age is accumulated in predictable increments, experience is not. Instead, experience is garnered in bursts and fits and starts. Discounting the wisdom borne from age might conjure conclusions on the basis of too narrow a lens of opinion. Age and outcome likely share an inverted V-shaped relationship rather than a linear one. Additionally, cognitive, and technical capabilities might wane at different rates.2Saver J.L. Best practices in assessing aging physicians for professional competency.JAMA. 2020; 323: 127-129https://doi.org/10.1001/jama.2019.20249Crossref PubMed Scopus (7) Google Scholar As such, one concept should not be adjudicated without permitting the other to provide contextual background. The contributory effect of the system in the construction of a durable surgical platform cannot be underscored. The system should seek to achieve reproducible results regardless of the individual surgeon. Indeed, the measurement of individual performance is confounded by the existence of a multitude of subjective and objective factors that exert alternating partial and impartial roles that might fluctuate with time, person, or agenda. Indeed, the very complexities surrounding the accurate evaluation of performance are the same ones that complicate the adjudication of culpability when that actual performance is impaired. Indeed, in adjudicating blame, we frequently highlight the importance of establishing systematic safeguards to identify and mitigate errors, deficiencies, and lapses in the quest for excellence. Perhaps then, in keeping with the author's aviation analogy and the spirit of retrospection and introspection, we might view performance as a function of more than just the capability of the individual surgeon. Instead, might we perhaps share the resources, scrutiny, and expectations with the system as a whole and establish a shared stakeholder alliance that makes each one accountable to the another and, of course, ultimately to the patient. As has often been expressed, a patient will suffer a bad surgeon in a great system far better than the converse. For example, the aviation industry has invested heavily in establishing built-in systems to protect air travel safety. Perhaps, in this vein, the quest for establishing and maintaining excellence should focus less on the adjudication of individual effects of aging in the surgeon and instead on proffering systematic protections for the patient against them. Assessing clinical competency: The long and the short of itThe Journal of Thoracic and Cardiovascular SurgeryVol. 164Issue 3PreviewHuman performance deficiencies are responsible for slightly more than half of all adverse surgical outcomes, according to a review of approximately 5000 cases conducted by our Department of Surgery in 2018.1 Cognitive errors were found in this study to account for half of these human performance deficiencies. Extrapolated to the nearly 17 million operative procedures performed in the United States annually, these findings suggest that each year cognitive error is the source of nearly 200,000 potentially preventable surgical adverse events. Full-Text PDF