Physician age and outcomes in elderly patients in hospital in the US

The title should be "hospital patients treated by low volume physicians are more likely to die". But that would have been less likely to get published. The "high volume" group was also really NOT high volume: 200 patients per year is around 4 patients per week. So the study really tells us about very 'low volume' providers compared to slightly higher volume providers, it's interesting that that was enough to get rid of any age-related effect. That in turn suggests the effect was pretty small.

Similarly, I'm pretty sure that "code written by programmers who don't program often is more likely to have bugs", and "pilots who don't fly often are more likely to crash".

(Strictly speaking, you'd want to normalize the risk of bugs / crashes per some unit of output e.g. per hour flown for pilots.)

Could it be that older (more experienced) physicians are more likely to get assigned to patients with more complex or serious conditions?

(I don't mean to state the obvious but this wasn't made explicitly clear enough to me.)

Edit: My initial comment here is probably wrong based on the detailed section "Adjustment variables":

> Patient characteristics included age in five year increments, sex, race or ethnic group (non-Hispanic white, non-Hispanic black, Hispanic, other), primary diagnosis (diagnosis related group), 27 comorbidities (Elixhauser comorbidity index22), median household income of zip code (in 10ths), an indicator for dual Medicare-Medicaid coverage, day of the week of the admission date (to account for the possibility that severity of illness of patients could be higher on specific days of the week), and year indicators.

I always find it concerning when authors dichotomize a variable without an extremely solid basis for doing so. It reduces statistical power, and it hints of over-mining the data to dredge out an effect.

This group of authors is well respected and known for doing studies like this. However, if their chief interest is observing the effect of physician age on patient outcome, physician age should clearly be treated as a continuous or truncated variable here.

Edit: In the supplement [1. Table B], they do perform the calculation with physician age as a continuous variable, and the effect stands. Good on them for doing the math in this way.

1 = http://www.bmj.com/content/bmj/suppl/2017/05/15/bmj.j1797.DC...

I listened to a podcast on this, Freakenomics Radio Bad Medicine Part 3. The takeaway was that newer doctors had better outcomes than older doctors with the exceptions of surgeons.

"JENA: Exactly. So patients more or less end up getting quasi-randomized to physicians with different characteristics. So for example if you happen to get hospitalized in the first week of May, you may be treated by a group of doctors who on average have five years’ less experience than if you happen to get hospitalized in the second week of May. And we can basically see what happens if a patient happens to be treated by a doctor who is 20 years out of residency versus 5 years out of residency. And what we find is that if you happen to be treated by a doctor who is 10 years or 15 years out of residency, your mortality within thirty days of being hospitalized is higher."

The news here (Japan) was talking the other day about cases of TB slipping through diagnosis because younger physicians had no experience with it. Older doctors knew what it was right away.

The way I see it in the field, older doctors are less likely to try and keep terminal patients alive as long as possible and more likely provide just palliative care. You know, instead of intubating 90+ y/o elders that won't get extubated until death.

Sounds like a study with a lot of confounding factors. Example- patients treated in the ICU are more likely to die than those not in the ICU. The confounding factors being the critical condition of the patient. Patients in critical condition are brought to the ICU. The abstract of this paper says that it essentially compares doctors in the same hospital. Is it a stretch to think that senior doctors would see more complex cases.

In my experience, older doctors simply... get old.

They lose enthusiasm and energy. They are inclined to study less. They perform fewer procedures due to diminishing motor, visual-spatial and cognitive skills. They suffer the same ailments as their patients - hypertension, diabetes, arthritis, dementia; divorce, overwork, errant children (that's a whole category of grievance and burden !) as well as sundry personal issues.

There is the drudgery. Paperwork. After a few decades you have seen it all: the rare cases don't excite as much. They are just another presentation of the human condition.

Finally,medicine is a hierarchical discipline, younger practitioners are discouraged from questioning (dubious) decisions made by their seniors.

Older practitioners compensate for these deficits with an accumulated body of experience that a younger doctor simply does have.

The best age(s) to be a doctor is mid-thirties to early fifties. Just like most other professions.

The actual results are not quite as dire as the headline suggests:

"patients’ adjusted 30 day mortality rates were 10.8% for physicians aged <40 … and 12.1% for physicians aged ≥60 … Among physicians with a high volume of patients, however, there was no association between physician age and patient mortality."

All of the patients were 65 or older with a medical condition. Perhaps the oldest and sickest are regularly routed to older doctors? As ever, correlation does not imply causation:

http://www.tylervigen.com/spurious-correlations

https://xkcd.com/552/

Re: ". Among physicians with a high volume of patients, however, there was no association between physician age and patient mortality. Readmissions did not vary with physician age, while costs of care were slightly higher among older physicians."

So it's not just age per se, but age plus lack of case quantity.

Which now raises the questions:

1) How are patients assigned to doctors? Is there something else that effects outcomes?

2) Why are some docs carrying less patients? Is that the cause, and age the correlation?

It was an older vascular surgeon who found the ascending aortic dissection that the much younger ER attending and hospitalist had both missed. For hours.

It used to be a commented on phenomenon that the month after the twice yearly arrival of newly qualified housemen in hospitals were the worst periods, mortality wise.

I don't know if that is still the case or indeed was ever a 'real' thing.

From their conclusions, I wonder if there is some kind of "use-it-or-lose-it" effect going on in the sample of older physicians, which does not affect the sample of younger physicians as severely due to their age. That is, the high volume physicians are kept sharp by the high patient workload regardless of age.

Authors' conclusions reproduced below:

"Within the same hospital, patients treated by older physicians had higher mortality than patients cared for by younger physicians, except those physicians treating high volumes of patients."

A little off-topic, but I get the feeling that these studies won't be so important in the coming decades. AI is going to be better than both young and old doctors when it comes to diagnosis, or recommending drugs and treatments. I've tried to have some discussions about this on Quora and Reddit, but I quickly get shot down by people (sometimes doctors) who refuse to accept this. I think there are even a lot of skeptical people on Hacker News, which I don't understand. It just feels obvious and inevitable.

So... the patients with the most serious illnesses are assigned to the most experienced physicians? While the younger ones start out taking care of people with less serious conditions?

This does not relate to the physician population studied, but I've seen older attendings in certain specialties use political clout to score more exciting rotations in critical care units after rarely practicing while younger attendings who don't often practice generally are forced to maintain a clinic. I would be interested in seeing if that had any general impact in care.

For the people that keep saying this result is because older doctors get allocated sicker patients - this is definitely not the case. When you are rostered on, you see every patient that comes in the door no matter how simple or complex.

Paging Dr.House. Please report to Dr.Cuddy for a statistics consult.

A similar trend exists with practices which I read about in the book Peak by Anders Ericsson. Older doctors and specialists' performance grew worse over time. Older doctors knew less and did worse in terms of providing appropriate care than doctors with far fewer years of experience.

Or the more experienced doctors got the more serious cases