Physician Age Linked to Clinically Significant Patient Mortality Risk

The difference in mortality rates translates into one additional patient death for every 77 patients treated by physicians 60 and older, compared with those treated by doctors 40 and younger.

Patients treated by older hospitalists are somewhat more likely to die within a month of admission than patients treated by younger physicians, suggests research published this week in the BJM.

Researchers at Harvard note that the difference in mortality rates was modest yet clinically significant—10.8% among patients treated by physicians 40 and younger, compared with 12.1% among those treated by physicians 60 and older.

That translates into one additional patient death for every 77 patients treated by physicians 60 and older, compared with those treated by doctors 40 and younger.

Study lead author Anupam B. Jena, MD, a hospitalist, and associate professor of medicine at Harvard Medical School, spoke with HealthLeaders about the findings. The following is a lightly edited transcript.

HLM: Why did you study physician age and clinical outcomes?

Jena: Two reasons. First, we are broadly interested in understanding how care provided by individual physicians influences patient outcomes, and the particular understanding of how individual physician characteristics such as sex, where the physician trained, and their age relate to patient outcomes and cost of care.

Second, there is ongoing debate about what should be required of physicians in terms of continuing medical education as they age and go further out from residency. There are two competing ideas.

The first is that as physicians age and accumulate experience, their outcomes can improve because they see more and more patients and they have a better idea of how to diagnose and treat disease.

The competing idea is that as physicians go further out from their residency training, they may be less familiar with the latest treatment and diagnoses guidelines. That effect, if it is large enough, could outweigh the former effect and could lead to worse outcomes.

There is active debate about how to ensure that physicians provide high-quality care over the course of their careers and what is needed to ensure that occurs.

HLM: Why did you focus on hospitalists?

Jena: Because we were concerned about the possibility that older doctors might treat sicker patients and as a result their outcomes might be worse, not because of the care that was provided by the doctors, but because of the effect that these patients were sicker and at a higher risk of mortality.

The nice thing about focusing on hospitalists is that patients in this setting don't choose their doctors and doctors don't choose their patients. That allows for a degree of randomization of patients to doctors of varying age, which allows us to better elucidate what is the potential impact of a doctor's age on patient outcomes.

HLM: Could other factors besides age be in play?

Jena: Absolutely. We recognize that care in a hospital and outpatient setting is often team-based. That said, it doesn't explain why it is that the patients whose attending physicians are older would have worse outcomes.

We definitely recognize that the outcomes of a patient relate not only to a physician but to the team members. That could also be an explanation of our findings, aside from the possibility that there may be knowledge or skill differences.

HLM: Why is there no difference in 30-day readmissions?

Jena: It's entirely possible that you would see differences in 30-day readmissions and mortality because in general they are not well correlated.

HLM: You talk about “age effects" versus “cohort effects." Please elaborate.

Jena: “Age effect" means that, as a physician ages and gets further out from residency, is there a depreciation in their skills from time, or is there an inability to keep up with the most up-to-date diagnostic and treatment guidelines?

A “cohort effect" simply means that when you trained influences what your outcomes would be. Doctors who trained in the 1970s versus the 1990s have been trained in a different way, and that influences the kind of care they will provide throughout their careers.

One example might be that older hospitalists in early practice were primary care doctors who saw inpatients occasionally. Whereas, the newer cohort of hospitalists was more ingrained in inpatient care in their residencies and they practiced as hospitalists right out of residency.

That could explain the findings, as opposed to changes in the individual physicians as they get older.

HLM: How would these age or cohort differences manifest themselves at the bedside?

Jena: That is hard to answer. I can speculate that doctors who are in residency training now are more formally educated in team-based care, and that is a larger component of care now than it was 30 years ago. Familiarity with how to work in teams could be an explanation of a cohort-based mechanism for why we see our results.

An age-based mechanism might be that over time newer medications are used to treat certain conditions, but because you are not actively engaged in the literature and reviewing guidelines, you are less likely to use these medications as you get older.

These distinctions are important because if you repeat this study in 10 years you might not find any difference because now all the cohorts are being trained in team-based care.

HLM: Could these findings be applicable to other specialists?

Jena: They could be, but I'd hesitate to go too far.

Internal medicine and hospital care is a cognitively based specialty, where the decisions are almost exclusively about diagnoses and medical treatment of a condition, or referrals to an appropriate proceduralist.

That is very different from surgery, which also has a technical skill-based component. It's possible that the technical skill of a surgeon could improve over time as they do more and more cases, and dexterity and muscle memory evolve. Those features could potentially make these findings different if you look at other procedural fields.

HLM: What should be done with your findings?

Jena: The first thing is replicate it. I would say that about any controversial findings. It needs to be replicated in the same setting and in other settings that are more procedural- or primary care-based.

Once you have a body of evidence that points in a certain direction, then that would imply that we should do two things. One, we should measure outcomes of physicians whenever we are interested in setting policy, in this case whether or not we should be training physicians more as they age.

The second thing is to design policies and evaluate them.

I wouldn't stop there. I would ask what is the effect of that policy on outcomes? Look at when it was implemented. Measure patient outcomes among the physicians who were exposed to that intervention versus a controlled group of physicians who weren't.

Let's make sure that whatever we ask physicians to do, which is very time consuming, results in better outcomes.

HLM: How old are you?

Jena: 38

HLM: Could you be accused of ageism?

Jena: I recognize the implications of the findings, but I would say this is not an attack on older physicians. It is certainly not a fact that we can generalize upon, especially as it may be different outside of hospital medicine.

At the end of the day, what every physician should be concerned with is patient outcomes. That is our business. To the extent that we can use large databases and unique analytical methods to better understand the factors that relate to patient outcomes, we should welcome this kind of analysis.

I'm a low-volume physician as we define it in the study because I only see patients about six weeks out of the year, so I would fall into the category of doctors who could be in trouble. I'm not immune from our analysis.

HLM: Are you concerned that your findings could be distorted in the media?

Jena: That is always a concern. It's a risk/benefit tradeoff. Whenever you write a paper that you hope will get attention and influence how people think about the issue, you run the risk of it being over-exaggerated and scandalized.

I recognize the possibility. But if we are in the business of worrying about quality of care and specialty societies are thinking about how quality of care evolves over a physician's career, then we should look at outcomes. A failure to do that is more of an indictment of the research enterprise than anything else.