Harvard researchers who recently wrote an essay analyzed data from Medicare to draw conclusions about hospitalists and surgeons who treat hospital in-patients for non-elective admissions. The researchers grouped the physicians by age to determine which groups performed better. The yardstick by which they were measured was mortality within 30 days of admission. The sample size was significant—over 700,000 Medicare patients, all over 65 years of age. What they found were trends that favored younger internists (age 40 and younger compared to older internists aged 60 and above), while the trends were reversed for surgeons, with the older group performing better than the younger group. The sidebar quote in the article is important to note for the consideration of mortality statistics: “A doctor’s clinical judgment, decision-making, and technical skill could be the difference between life and death.” Agreed. Now, how do we interpret the findings?
The authors state that the younger internists may keep up with the latest research and drug development compared to their older peers, while older surgeons have developed the muscle memory for surgical techniques and the experience to anticipate problems before they occur. Interesting theories, but the most important common element to better performance is also the most logical: practicing your craft, time after time, with an eye for improvement. The best doctors hone their skills, not in a static fashion, but in a dynamic way, incorporating new concepts learned from medical journals, meetings, and conversations with peers. The volume of patients treated in the hospital is a proxy for honing those skills for both internists and surgeons. I would submit that clinical results as a function of volume are an inverted U-shaped curve, whereby there comes a point where the volume is just too high to maintain peak performance. In other words, if the volume is too high, corners may be cut, and outcomes may not be ideal. Furthermore, the article deals with the elderly population where patients were randomly assigned to physicians. One limitation of the article is that elective admissions were not considered. These types of admissions also challenge the physician to get the patient in the best shape possible prior to any procedure. For the elderly population undergoing surgery, time is truly of the essence. I can recall my surgical resident saying to me as a medical student, “The only thing better than being good is to be fast and good.” The longer the surgery and the attendant anesthesia last, the greater the risk for complications, including infection.
The authors conclude that questions directed to physicians should deal with their experience in treating problems similar to those the patient is experiencing, without regard to the age of the physician. Good advice. So is candidly asking the nurses about those doctors with whom they work routinely.
Paul Pender is an ophthalmologist and author of Standing Up & Speaking Out for Patients & Doctors and Rebuilding Trust in Healthcare: A Doctor’s Prescription for a Post-Pandemic America.