Old Doc, Young Doc: Studies Link Effectiveness to Patient Load and Knowledge of Medical Research, Not Age
Which physician is more effective – the younger one with fewer years of experience or the grey-haired Marcus Welby type? For those who select doctors based on age and who assume experience always equals skill, this recent Wall Street Journal article might come as a bit of a surprise.
The authors are two physicians who are also Harvard researchers – Doctors Anupam Jena and Christopher Worsham. The article describes how Jena and Worsham combed through records involving three-quarters of a million hospitalizations. Their surprising conclusion: a doctor’s age does not correlate with her or his effectiveness as measured by patient outcomes. However, there are some exceptions – so let’s dig a bit deeper.
Old Doc, Young Doc – Which Would You Choose?
“In a study published in 2017, one of us (Dr. Jena) and colleagues set out to shed some light on the role of age when it came to internists who treat patients in hospitals,” the article begins. “These physicians, called hospitalists, provide the majority of care for elderly patients hospitalized in the U.S. with some of the most common acute illnesses, such as serious infections, organ failure and cardiac problems.”
When choosing a primary care physician, it’s common for patients to choose their doctors based on bedside manner, expertise—whether real or perceived—responsiveness, and a certain “it” factor that’s impossible to measure.
But what about when patients don’t get to choose their doctor, such as in a hospitalization, where they have to accept the care of whatever doctor happens to be available? Those were the cases the Harvard duo sought to analyze.
Deep Dive Into Medicare Data
Writing in the Wall Street Journal, Jena and Worsham break down the study and the stats for us. “Using data from Medicare on patients over age 65 and a database containing doctors’ ages, we identified about 737,000 non-elective hospitalizations managed by about 19,000 different hospitalists from 2011-13. We divided patients into four different groups based on the age of the doctor who treated them: doctors aged less than 40, 40-49, 50-59, and 60 and above.”
They continue, “Older doctors obviously had more years of experience since completing residency, with doctors under 40 having an average of 4.9 post-residency years of experience, increasing to 28.6 years for doctors over 60. Older doctors were also more likely to be male: 61 percent of doctors under 40 were men, compared to 84 percent of doctors over 60, reflecting the shift in gender makeup that has occurred in our profession in recent decades.”
Clinical Judgment, Decision-Making Can Be Critical
How much does a particular doctor matter in the success rate of a person’s time in the hospital? Jena and Worsham admit that some percentage of hospitalized patients will either survive or die no matter who their doctor is. But in other cases, a unique doctor’s “clinical judgment, decision-making, and technical skill” may mean the difference between life and death. Surprisingly, by this measure, the data showed younger physicians with a slight but significant edge over their more senior counterparts.
“The next step, therefore, was to compare 30-day mortality rates between the four age different groups,” say the doctors. “Our statistical model found that as doctors got older, their patients had higher mortality rates. The rate for under-40 doctors was 10.8 percent, increasing to 11.1 percent in the 40-49 group, 11.3 percent in the 50-59 group, and 12.1 percent in the over-60 group,” the article states.
In the end, Jena and Worsham could only conclude, “We repeated the analysis using 60- and 90-day mortality rates, in case longer term outcomes might have been different, but again, the pattern persisted: Younger doctors had better outcomes than their more experienced peers.”
Why would this be?
Current Knowledge Seems to Be the Key Element
According to Jena and Worsham, there are two explanations for this seeming discrepancy.
The first is what they call a “true age effect”, where being older leads to changes in how a doctor practices. These ingrained habits can in turn lead to higher mortality rates. In the same way, included in this factor, an older doctor may have a higher level of overconfidence, and therefore might miss a tricky diagnosis or ignore other warning signs.
But the Harvard researchers also think that what is more likely is that the discrepancy in mortality rates could be due to the way doctors in different generations are trained. “Younger doctors possess clinical knowledge that is more current. If older doctors haven’t kept up with the latest advances in research and technology, or if they aren’t following the latest guidelines, their care may not be as good as that of their younger peers,” the article explains.
A Doctor’s Patient Load Plays a Part
Taking care of patients is the best way to stay up to date, according to Jena and Worsham. Seeing a breadth of diagnoses in a given practice may prompt doctors to check out the latest research, guidelines, or recommendations for various conditions they haven’t seen as often. And paying attention to medications can help with this, since newer and better drugs are being developed at a relatively rapid pace.
“To see if this might be the case, we repeated the analysis but this time divided doctors based on both age and case volume,” the article states. “We found that for ‘low volume’ doctors, older doctors had higher mortality. For ‘medium volume’ doctors, the pattern was less pronounced. And for ‘high-volume’ doctors, the pattern went away altogether. In practical terms, as long as a doctor is seeing a sufficiently large number of patients, the doctor’s age is irrelevant to the care they give.”
For Some Hospitalizations, Younger Appears to be Better
So, does this suggest that younger doctors are “better” than older doctors? “This study suggests that if ‘better’ is defined as a hospitalist having lower 30-day patient mortality, then we would have to say yes,” the article states.
But next, Jena and Worsham turn their attention to a different, more highly trained group of physicians: surgeons, “who in addition to their diagnostic skills require technical abilities that depend on experience and muscle memory.”
In a separate study, Dr. Jena and colleagues looked at 900,000 Medicare patients who had common, non-elective major surgeries, such as emergency hip fracture repair or gall bladder surgery. These surgeries represented a pool of about 46,000 surgeons of varying ages. As with the previous study, the patients were divided into four groups based on the age of their surgeon and the 30-day mortality rate was calculated with a statistical model.
One Category of Doctors Improves with Age
Perhaps surprisingly, and in contrast with the research on hospitalists, the study of surgeons showed that they do, in fact, get better with age.
“Their patient mortality rates had modest but significant declines as they got older: mortality was 6.6 percent for surgeons under 40, 6.5 percent for surgeons age 40-49, 6.4 percent for surgeons age 50-59, and 6.3 percent for surgeons over age 60,” the article explains.
Jena and Worsham chalk this up to a possible difference in the skillsets and how those skills are both gained and built over time. “It may be that for hospitalists, the benefit of steadily increasing experience starts to be outweighed by their waning knowledge of the most up-to-date care,” they write. “It’s different for surgeons, though, who hone many of their skills in the OR.”
For surgeons, muscle memory is built through repetition while working in confined spaces. “They learn to anticipate technical problems before they happen and plan around them based on prior experience,” the article states. “Over time, they build greater technical skills across a wider variety of scenarios, learn how to best avoid complications, and choose better surgical strategies.”
Choose Your Doctor with Care
Jena and Worsham end their article with a question: What does all of this mean for us, as patients, when meeting a new doctor? First, it’s clear that age cannot be dismissed as unimportant, but it’s one variable among many.
“If we’re concerned about the quality of care we’re receiving,” they conclude, “the questions worth asking aren’t ‘How old are you?’ or even ‘How many years of experience do you have?’ but rather ‘Do you have a lot of experience caring for patients in my situation?’ or ‘What do you do to stay current with the research?’”
We asked Rajiv Nagaich for the last word on this topic of choosing doctors. “This study is all well and good,” he responded, “especially if you find yourself in the hospital being treated by a doctor you didn’t choose. But for everyday care, I can’t over-emphasize enough the need to select a geriatrician as your primary care physician. You need someone trained in the unique physiology and psychology of senior patients – that’s the way to stay healthier longer!”
If you need a referral to a geriatrician near you, contact us – we’re glad to help.
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(originally reported at www.wsj.com)