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We’re joined by Paul Pender, an ophthalmologist and author of Standing Up & Speaking Out for Patients & Doctors. Together, we explore the study’s revelations about physician age, patient outcomes, and the critical role of experience and skill in health care.

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.

He discusses the KevinMD article, “Youth vs. experience: Who wins in medicine?”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast and get CME for this episode by clicking on the CME link in the show notes. Today we welcome back Paul Pender. He’s an ophthalmologist and the author of the book Standing Up & Speaking Out for Patients & Doctors. Today’s KevinMD article is titled “Youth vs. experience: Who wins in medicine?” Paul, welcome back to the show.

Paul Pender: Hey, thanks so much, Kevin. It’s great to be here again.

Kevin Pho: All right, so I think it’s been a few months since we last spoke. How have you been doing?

Paul Pender: Thanks. It’s been a hot summer, as you know, in New Hampshire, and it’s been good to get away on occasion.

Kevin Pho: All right, so for those who are interested in reading more or listening to you more, go to KevinMD.com/podcast. In the upper right-hand corner there is a search button, and you can search for Paul’s previous podcasts to hear his story in prior episodes. So today we’re going to talk about the youth versus experience conundrum. Your KevinMD article talks about that. How did it come together?

Paul Pender: Well, it started with reading an article posted in the Wall Street Journal about Harvard researchers who looked at Medicare patients’ results. The study dealt with inpatients who were served by internal medicine specialists, hospitalists, and also by surgeons, and the physicians were categorized by age. The conclusion of the authors and their research was that the outcomes favored the younger internists, the hospitalists, while the older surgeons had better outcomes compared to their younger peers. I found that somewhat curious, so I wrote an article trying to break it down.

Kevin Pho: All right, so as you reflected on that article, what did you find out? What were some of the causes behind those results?

Paul Pender: Well, I would say there were theories, maybe not so much causes. One theory from the authors was that perhaps the internists were more likely to keep up with newer drug developments and some treatments, while the older surgeons had perfected their muscle memory and learned how to look for problems before they occurred. It was a breakdown that was kind of skewed by the fact that these were all inpatients, and they were all cases that did not include elective admissions. We all know it’s also important to get patients in the best shape possible before their surgery, so it would have been good to have some other evidence that these were patients who had been through a complex preoperative evaluation.

So anyway, I concluded that perhaps performance is dependent on the frequency of doing the procedure, but there may come a point of diminishing returns. I claim that there’s a kind of inverted U-shaped curve, where, as a function of outcome, the frequency you have may reach a point beyond which it doesn’t really help. In other words, you get to the point where you may be doing so many cases, so fast, that you wind up cutting corners and thereby reducing quality.

Kevin Pho: Now, you’ve been an ophthalmologist for decades. As you reflect back on your career, can you contrast your technical skill as a surgeon, and your patient care, from when you first started out through the decades? How have those skills changed?

Paul Pender: OK, so I think when we are all residents, we are learning every day, from both peers and attendings, who really are kind of the shining lights, and we try to adopt some of those same characteristics. I went to a great training program at Wills Eye Hospital, and I felt I was ready to hang my shingle and do great work. And yet when you’re new, you are assuming a certain level of competence and taking on more complicated cases, and you learn from experience. Bad outcomes can sometimes give you a real good experience. But I think we wind up finding over time that, between discussing results with our peers, reading articles and actually attending meetings with practical labs, we develop additional skills.

In the article I quoted, there were observations that the peak performance of surgeons was somewhere in the age group between 40 and 60, and the peak performance of the internists who were hospitalists was somewhat under 50. I think surgeons, and I would say in ophthalmology in particular, realize that every step of a procedure, let’s say cataract surgery, is very critical, and if something happens in the early steps, it can actually complicate things down the road. So you wind up developing, I would say, a skill set where you’re moving along, but you’re looking for signs of trouble, and some of those signs of trouble can be very subtle. They don’t come right away; they take some experience.

Finally, I would say that this whole process of continued learning for physicians is something I think every physician will acknowledge, but the public doesn’t always understand. So what I concluded in the essay you kindly published is that it probably doesn’t matter what the age is of whoever is taking care of you, but it does matter how often they encounter problems similar to yours.

Kevin Pho: How many years out of residency was it before you really felt you were at the peak of your surgical powers?

Paul Pender: I think it took a few years to really gain that confidence. I built my own surgery center approximately four years after I started practice, and I felt at that point that I could actually hire the people I wanted and form a team. It’s kind of like having a dance partner. I’m sorry, I mean, when you have a really good assistant in surgery, that person knows your moves and hands you instruments almost before you have to ask. So I really felt I was providing patients with a better atmosphere for their surgery and more personalized service. And as a control freak, I could actually hire the people I wanted and schedule the surgery the way I wanted.

Kevin Pho: I don’t know how closely you keep up with current surgical training trends, but in some of the doctor groups I frequent, they talk about how the limits on work hours sometimes affect surgical training, meaning residents do fewer cases, and sometimes that affects their technical skill when they come out. So I just wanted to hear what you thought about that. Have the work-hour limitations affected surgical training?

Paul Pender: I think, unfortunately, the work limitations that were established by law have not always been observed, and students, interns and residents have all been putting in incredibly long hours, as they traditionally have. So I don’t know if the limitation that was imposed is actually being observed. I also think that in residency, we are clearly under supervision. When you’re out in private practice and you don’t have someone scrubbing in on your cases, you are learning what maneuvers you have to go through, and you have to gain some of that on your own. I think all residents who finish from approved programs are going to have the basic core of skills they need to practice, but then it is also incumbent upon them to see what new techniques develop.

In ophthalmology, a lot of new things have come about, including all the new biologics, which were just coming into clinical practice while I was finishing my years in clinical practice. There’s the whole idea of treating something like macular degeneration of the wet form by injecting something into the eye that stops the growth of new blood vessels. That all came about during the time I was in clinical practice, and now multiple agents are out there to provide these patients with a medical, if you will, or drug delivery system that helps preserve their vision. So I think all physicians have to keep learning, and whether it’s how to care for patients in the hospital, as that article talked about, or your surgical skill set, you still have to be willing to continue to learn about the new stuff.

Kevin Pho: Now, you’ve worked with new ophthalmologists over the decades. Have you noticed any difference in the training they receive, just coming out of residency or fellowship?

Paul Pender: Yeah, and it’s interesting that you raise that. One of the alumni magazines I got showed a laboratory that helps residents develop surgical skills, microsurgical skills, and this is now a formal part of their training. Before, we would have eyes that had been donated through the Lions Club or others and were not suitable for corneal transplant, and we would practice on those. We had animal labs; we had other ways of gaining some technical expertise. But now there are really formal labs with multiple microscopes, to be able to study a resident’s suturing technique or what have you. So yes, now it’s more formalized, and I think that’s probably a good thing.

Kevin Pho: Now, if I’m a patient listening to you, and I read this study, when choosing an ophthalmologist for cataract surgery, for instance, should age be part of the decision-making process from the patient’s standpoint?

Paul Pender: As long as they don’t have a tremor, I think they’re OK. But clearly, I think age is only one factor, and really the most important element for a good outcome, I think, is people who do the same kind of work all the time. If you are a really skilled surgeon and you’re doing a fair number of cases every week, you’re going to feel, “Yes, I can bring this patient my best efforts to get the best outcomes.” Also, having seen some complications earlier, you learn how to avoid them as you grow in your field. So I think it’s the frequency of procedures, or, from the internist’s point of view, of having to see someone with difficult kidney disease or whatever in the hospital. You develop certain algorithms that seem to work, and this is independent of age.

Kevin Pho: Now, sometimes you hear these stories on the news about doctors practicing into their 90s, even into their 100s in some cases. What are some signs physicians should look for to realize that maybe they should slow down a little, maybe they should hang it up, that maybe they’re not as good as they once were and may in fact be endangering patients? What kinds of questions should they be asking themselves to make sure they’re not practicing beyond their current capability?

Paul Pender: How about starting with, “Do you remember where you parked your car today?” I think there are going to be cognitive and physical limitations that come with age; there’s no doubt about that. One of the other comments I made at the end of the essay you were kind enough to publish is that it also helps to gain some perspective from the nursing staff who work with these doctors. You can’t hide. There are people who are going to be fair and honest about whether this doctor still seems to have the goods. And I think maybe around the late 60s or early 70s, kind of like what you see in the airline industry, where pilots are restricted after 65, at least on commercial airlines, though maybe they can get private gigs, there’s a kind of spread where physicians, or their partners, would probably take them aside and say, “You know what? I think it’d be better if you just did office-based work and didn’t do surgery anymore.” And I think that does occur fairly commonly.

Kevin Pho: We’re talking to Paul Pender. He’s an ophthalmologist, a regular guest on The Podcast by KevinMD and the author of the book Standing Up & Speaking Out for Patients & Doctors. Today we’ve been talking about “Youth vs. experience: Who wins in medicine?” Paul, as always, tell us some of the take-home messages that you want to leave with the KevinMD audience.

Paul Pender: Well, first of all, Kevin, this has been a pleasure for me. This has been going on for the last several years, and I really appreciate the opportunity to talk with you. I always find it a stimulating conversation. My take-home message is that if you’re doing your research, the doctor ratings are really survey stuff. Anyone can complete a survey, and they may be upset by what they got from the receptionist and not from the doctor. So I think the rating services are kind of overrated. If you do your homework and talk to physicians, your primary care physician, and you talk to people who’ve had work done by the doctor you’re hoping to engage, then I think you’ve done the best you can. And I think the question to ask that doctor is, “You’re recommending this treatment. How comfortable are you with this treatment, and how often do you do this kind of work?” That’s going to go a long way toward satisfying the patient’s concerns.

Kevin Pho: Paul, as always, thank you so much for coming on the show and sharing your time and insight.

Paul Pender: Kevin, thanks again for having me.