Systematic Reviews
Copyright ©The Author(s) 2021.
World J Orthop. Apr 18, 2021; 12(4): 234-245
Published online Apr 18, 2021. doi: 10.5312/wjo.v12.i4.234
Table 1 Surgeon certification compared to non-medical professions
Mandatory retirement age (yr)
Certification based on cognitive and/or physical requirements
Surgeon[33] NoneComplete residency and board examination. Continuous self-learning or medical education (CME) for credit with periodic examination for certification. May have case list peer-reviewed and be evaluated by in-hospital staff. No physical exam or performance-based skills currently defined
Airline pilot[34,35]65Every 24 mo, complete flight review with instructor: Ground/flight training. Must demonstrate proficiency, competency, and sound judgement within approved standards during training. Medical certificate every 12 mo or every 6 mo if age > 40 yr
Air traffic controller[36-38]56, 61 with exceptionApply at < 31 yr. Medical exam. Pass biographical assessment, pass the ATSA, and pass training course at FAA academy. The ATSA is designed to measure the cognitive, visuospatial reasoning, and psychomotor abilities of candidates. Must submit to yearly physical exam, and job performance twice a year, with periodic drug screenings. Certificate valid until surrendered, suspended, or revoked
Firefighter[39,40]57Complete CPAT. Complete annual medical exam and physical testing, depending on department discretion. Physical testing consists of exercises related to firefighting such as step tests, and leg lifts
United States State Judge[41,42]70-75Obtained law degree and passed Bar examination. State court often requires mandatory retirement for state court judges
Table 2 Late career practitioner policies adopted at health institutions
Medical exam
Performance testing
Modification of privileges
Stanford Health Care[16,17]To ensure high quality care for patients and protect them harm and identify health concerns of practitioners74.5 years old and every 2 yr thereafter Comprehensive history and physical examination including vision, hearing, neurological, and cognitive testingPeer assessment by hospital staff of technical and procedural competencies, relative to Stanford expectations Yes, if non-compliant or unsafe practice patterns
Aging Surgeon Program at Sinai Hospital, Baltimore, MD[43]Designed to protect patients from unsafe surgeons and guard surgeons from arbitrary or unreliable methods of assessing competence or cognitive capacity. The program can identify potentially treatable or reversible disorders that, if properly treated, could restore or improve functional capacityNo mandatory age. Requested from surgeons, hospitals or licensing bodies of all surgical sub-specialtiesEvaluation of general health, vision, hearing, neurocognition, visual-spatial and fine motor capabilityNoneNo
Hartford Health Care[44]To ensure patient safety and high-quality medical care70 years old and above, and annually thereafterAnnual physical exam, vision, neurological testing and neuropsychological screeningOPPE. FPPE if needed, to identify patterns that may negatively impact quality and safety of careYes, discussion with department Chief ± Credentials Committee if deemed unable to safely exercise privileges
YNHH[21,45]To protect patients from harm and safeguard fair physician assessment70 years old and aboveOphthalmologic exam and 16 test neuropsychologic screening batteryNoneYes, MSRC suggestions based on screening results
Legacy Health, OR[46]To assess physicians to ensure patient safety and physician wellness70 years old and above, and every 2 yr thereafterPhysical capacity by occupational therapy and neuropsychological testingPeer review assessmentYes, determined by Credentials Committee, if health problems interfere with safe practice
Driscoll’s Children’s Hospital, Corpus Christi, TX[17]To assure that patient safety and quality are adequately supported by carefully assessing the capabilities, competencies and health status of each practitioner70 years old and aboveComprehensive examination addressing physical and mental capacity by a physicianPeer review assessment may be required. Must meet technical and procedural competenciesYes, determined by Credentials committee, if practice unsafe or incompetent
University of Virginia Health System[17]To assess each physician’s capacity to perform requested privilegesFirst assessment at age 70. Annual assessment after 75 years of ageComprehensive examination addressing physical and mental capacity under the Physician Wellness ProgramNoneYes, as determined by Department Chair
UC San Diego LCHS[47,48]To detect any physical or mental health problems that may affect a physician’s ability to practice70 years old and above. At request of hospital or medical groupHistory and physical exam. Cognitive and mental health screenDexterity tests for proceduralists/surgeonsNo
Tahoe Forest Health System, CA[49]To fairly and accurately evaluate physician performance and capabilities70 years old and above. Required to partake in LCHS See LCHSSee LCHSYes, after consultation with department Chair if adjustment is required
Table 3 Existing methods for determining surgical competency
MethodBasic structureAssessmentProcedure examplesValidated1 for

Practicing surgeons
Surgical trainees
Licensing bodies assessments
State Medical Boards[50-52]Mandatory to practice. Required to demonstrate competency through CME. However, states individually may evaluate professional conduct when a physician fails to provide appropriate quality of careMust regularly participate in CME activities and may require board certification. May have competency evaluation by independent evaluator or approved assessment program if signs of dyscompetence-Unclear-
ABMS[18,19]Voluntary certification to show knowledge of standards of practice. Rigorous process of evaluation every 10 yr with MOCMOC consists of 4-part assessment: Licensure/professional standing, participation in CME programs, cognitive expertise through examination, and documentation of quality of care and/or audits or peer review-Unclear-
Provincial Licensing Bodies in Canada[53-55]Mandatory to practice. Required to demonstrate competency through CME. Provincial licencing bodies identify those with deficiencies in competence, requiring peer reviewMust regularly participate in CME activities. If evidence of dyscompetence, rigorous individualized assessment of the surgeon’s practice is performed, with emphasis on quality of care-Unclear-
Fellows of the RCPSC[56,57] Voluntary certification to show commitment to competent practice. Evaluation and successful completion of MOC program every 5 yrMust participate in CPD activities. MOC based on 3 section framework: Group learning, self-learning, and assessment-Unclear-
Non-licensing bodies assessments
OSATS[58-61]Multi-station and timed with bench and live model simulations or surgical procedures. Peer evaluated with rating scaleChecklist and global rating scale by expert examiner to evaluate technical skill. Does not assess decision making or concrete surgical aspectsLaparoscopic Gastric Bypass Saphenofemoral dissection. Meniscectomy transtibial or anteromedial femoral tunnelYesYes
C-SATS[26,31]Video recorded surgical performance and evaluated with validated with rating scaleCrowds of anonymous and independent reviewers, including those nonmedically trained, evaluate surgical skill with validated performance tools such as OSATSUrinary bladder closure. Robotic surgery skillsNoYes
O-SCORE[27,62]Surgical procedure peer evaluated with rating scaleSurgical experts rate performance with 9 item tool and scaling system to assess competence to perform procedure independentlyOpen reduction internal fixation of hip, wrist, or ankle. Arthroplasty (total hip or hemi). Knee arthroscopyNoYes
GOALS[63,64] Laparoscopic procedure peer evaluated with rating scaleSurgical experts evaluate performance with 5-point rating scale of 5 items unique to laparoscopyLaparoscopic cholecystectomyNoYes
GEARS[65,66]Robotic procedures peer evaluated with rating scaleSurgical experts evaluate performance with 5-point rating scale of 6 items unique to robotic surgeryInanimate simulators–continuous suturing. Prostatectomy NoYes
Direct Objective Metric Measures[67,68] Skill/surgical procedure measured with concrete aspectsMeasurement of stiffness and failure load for each repair construct, with comparison to expected rehabilitation loadsTibial plafond fracture reduction. Distal radius fracture reductionNoYes