I am now what might be described as a more ‘senior’ doctor in the emergency medicine world. I think that gives me lots of experience and that’s surely a good thing right? Well perhaps not. In previous talks and blogs I’ve talked about the importance of peer review as a way to prevent senior clinicians becoming out of date. This view is supported by several studies that show that patient outcomes may fall as their treating clinician advances in age. However, to date there has been very little information about whether this is an issue in emergency medicine, that is until now. This month a paper in the addresses exactly try is question. The abstract is below, but as always please do read the full paper.
What kind of paper is this?
This is a database analysis, so effectively a retrospective cohort study using routinely collected data.
What did they do.
In the US Medicare system it is possible to identify the treating clinician, their age and the 7-day mortality of the patients seen. In simple terms the authors took this data and compared the age of the senior treating physician against the 7-day mortality. They focused on patients aged 65-89 as this group have a significant event rate owing to their age and likely presenting condition and co-morbidities. They divided the age of the clinicians into decades from the age of 40 upwards. Clinicians over 60 were grouped together into a single group.
What did they find.
Amongst 2,629,464 records and involving 32570 clinicians they found that mortality increased in a linear fashion across the different age bands. Although the differences are small they are statistically significant and there does appear to be a dose response effect, making it all the more believable.
Interesting! Here is a graph of the adjusted 7-day mortality difference. A "dose-response" effect. But very small (microscopic) differences. Is there leftover confounding? Maybe. Are these differences real? I hope not! pic.twitter.com/qAjChezNrD— Pieter Francsois Fouche (@PFFouche) September 5, 2023
What does this mean?
That’s a great question as the age of the physician is not something that is adjustable unless we can find a fountain of youth or a time-machine. Perhaps it is more interesting to suppose why these effects might be there. We can’t really know from this study as it’s always unwise to try and find causation from what is just a correlation on the basis of the evidence here. That said, a number of commentators have suggested possible explanations.
- More senior docs see sicker patients (not in my UK experience)
- More senior docs see fewer patients through portfolio careers and therefore are actually less experienced than their younger colleagues (in recent times)
- More senior docs are out of date because they did not keep up to date with more recent and more effective interventions
- More senior docs work disproportionately in different areas of the department where mortality is higher.
- Cognitive decline
- Psychomotor skill decline
- More senior docs are less reflective in their practice, less enthusiastic, more burnt out and generally more distracted.
I don’t really know if any of the above are true, but only points 3 and 7 seem to be areas for personal development and intervention (which is a bit depressing). That said, these are general effects across a very large range of clinicians and I have no doubt that there will be significant variability between clinicians, and I’m confident that some clinicians age very well indeed.
That said, the effect appears to be present, and is certainly interesting. In the UK the retirement age is now 67 years and it is likely that many clinicians will work well into their 60s. How then will we support them to be as good as they can be? I’m not sure but I’m really interested to know what you think. For myself I’ll try and stay fit, up to date, interested and excited about our speciality and help others to do the same. As long as I remain curious and reflective about our job I hope it will help.
Otherwise I will spend the next few months looking for the fountain of youth and some better face cream.
References and further reading
- Miyawaki A, Jena AB, Burke LG, Figueroa JF, Tsugawa Y. Association Between Emergency Physician’s Age and Mortality of Medicare Patients Aged 65 to 89 Years After Emergency Department Visit. Ann Emerg Med. 2023 Sep;82(3):301-312. doi: 10.1016/j.annemergmed.2023.02.010. Epub 2023 Mar 23. PMID: 36964007.
- Simon Carley, “SMACC2019: The Power of Peer Review,” in St.Emlyn’s, May 30, 2019, https://www.stemlynsblog.org/smacc2019-the-power-of-peer-review/.