Key Points

Question Is physician age associated with an increased likelihood of receiving unsolicited patient complaints among ophthalmologists?

Findings This cohort study of 1342 ophthalmologists found that increasing physician age was associated with a decreased risk of receiving an unsolicited patient complaint. Younger ophthalmologists had a significantly shorter time to first complaint and were significantly more likely to receive a patient complaint than were older physicians.

Meaning Ophthalmologists’ patient complaints provide information that may have practical applications for patient safety, clinical education, and clinical practice management.

Abstract

Importance Understanding the distribution of patient complaints by physician age may provide insight into common patient concerns characteristic of early, middle, and late stages of careers in ophthalmology. Most previous studies of patient dissatisfaction have not addressed the association with physician age or controlled for other characteristics (eg, practice setting, subspecialty) that may contribute to the likelihood of patient complaints, unsafe care, and lawsuits.

Objective To assess the association between ophthalmologist age and the likelihood of generating unsolicited patient complaints (UPCs) among a cohort of ophthalmologists.

Design, Setting, and Participants Retrospective cohort study with variable duration of follow-up. The study assessed time to first complaint between 2002 and 2015 in 1342 attending ophthalmologists or neuro-ophthalmologists who had graduated from medical school before 2010 and were affiliated with an organization that participates in Vanderbilt University Medical Center’s Patient Advocacy Reporting System. Participants were stratified into 5 age bands and were followed up from the time of their employment to receipt of their first complaint. Trained coders categorized UPCs into 34 specific types under 6 major categories.

Main Outcomes and Measures Time to first recorded complaint. Multivariable Cox proportional hazards model was used to measure the association between time to first complaint and ophthalmologist age after adjustment for predetermined covariates.

Results The median physician age was 47 years, with 9% who were 71 years or older. The cohort was 74% male, 90% held MD degrees, and 73% practiced in academic medical centers. The mean follow-up period was 9.8 years. Ophthalmologists older than 70 years had the lowest complaint rate (0.71 per 1000 follow-up days vs 1.41, 1.84, 2.02, and 1.88 in descending order of age band). By 2000 days of follow-up (or within 5.5 years), the youngest group had an estimated UPC risk of 0.523. By 4000 days (>10 years), participants in the older than 70 years age band had an estimated risk of UPC of only 0.364. The 2 youngest age bands were associated with a statistically significant shorter time to first complaint. Compared with those aged 71 years or older, the risk of incurring a UPC for those aged 41 to 50 years was 1.73-fold higher (hazard ratio [HR], 1.73; 95% CI, 1.21-2.46; P = .002). Similarly, participants aged 31 to 40 years had a 2.36 times higher risk of incurring a UPC (HR, 2.36; 95% CI, 1.64-3.40; P < .001).

Conclusions and Relevance This study suggests that older ophthalmologists are less likely to receive UPCs than younger ones. Although limitations in the study design could affect the interpretation of these conclusions, the findings may have practical implications for patient safety, clinical education, and clinical practice management.

Introduction

Patients are uniquely positioned to observe and comment on their care, and their observations, in the form of unsolicited patient complaints (UPCs), can identify improvement opportunities.1-3 For example, one patient complains that the ophthalmologist rudely “…told me that if I didn’t have surgery I would go blind…put hands over my eyes saying, ‘Picture this: blackness, blackness, blackness.’” Another patient reports that the physician “started arguing…pointed to the computer and said, ‘I don’t care what your pharmacist told you. This is the right way! It’s your money if you want to waste it.’”

Unsolicited patient complaints give physicians and their health care system, hospital or medical group leaders opportunities to provide “service recovery” to address what patients perceive to be wrong in their health care encounter.4 In addition, aggregated UPCs are proxies for risk of malpractice claims1,5-8 and surgical complications.9-12 Once identified, systematic interventions with physicians designated as high risk have reduced their number of UPCs and lawsuit risk, demonstrating the value of addressing unnecessary variations in physician performance.13-15

The associations between performance or competence and physician age have received national attention because age also appears to be related to lawsuit risk and discipline-specific skills. Lawsuit risk appears to be highest during the first 10 years of practice.16,17 At the other end of the career trajectory, age-related declines in cognitive and motor skills have led to questions about late-career physicians’ patient-related skills and quality of medical care.18-24

Understanding the distribution of UPCs by physician age may provide insight into common patient concerns associated with ophthalmologists in the early, middle, and late stages of their careers. Most previous studies of patient dissatisfaction have not addressed the factor of physician age and were unable to control for other characteristics (eg, practice setting, subspecialty) that may affect the risk for patient complaints, unsafe care, and lawsuits.

Our study was designed to learn whether age is associated with increased likelihood of generating UPCs in a cohort of ophthalmologists from 20 US health care organizations that participate in Vanderbilt University Medical Center’s proprietary Patient Advocacy Reporting System (PARS) program.

Methods

Study Design

To examine the association between physician age and likelihood of generating UPCs, we performed a retrospective cohort study with variable follow-up of 1342 attending ophthalmologists and neuro-ophthalmologists practicing in 20 different US organizations (13 academic and 7 private, community, or regional medical centers) that participated in PARS. The study reviewed UPCs recorded about ophthalmologists from January 1, 2002, to December 31, 2015. The Vanderbilt University institutional review board approved the study as nonhuman subjects research and waived consent. Data were confidential and physicians and patients were deidentified.

Patient Advocacy Reporting System

The Vanderbilt Center for Patient and Professional Advocacy (CPPA) developed the PARS database, which contains patient complaint and specialty data for more than 60 000 physicians in active practice during the study period. Trained CPPA coders reliably assigned UPCs to 1 of 34 specific complaint types under 6 major categories: care and treatment, communication, access and availability, concern for patient and family, safety of environment, and billing (included only if complaints allege concerns about physician-related care and treatment).2 The CPPA also generated for each physician a complaint-type profile, which demonstrated the distribution of complaints across the major categories and permitted comparisons to all physicians in the local group and with other attending ophthalmologists affiliated with PARS partners.

Study Population

Physicians studied included confirmed attending ophthalmologists or neuro-ophthalmologists who had active credentials at a PARS partner site and had graduated from medical school before 2010, thereby excluding physicians in training (residents). Institutional websites and third-party physician review websites were used to ascertain medical school graduation years.

The primary exposure variable was physician age ascertained at the start of each ophthalmologist’s follow-up date. Age was approximated by assuming the typical medical student graduates at age 25 years, then determining the number of years from graduation to the start of each physician’s follow-up date. For example, for a physician who graduated in 1990 and started at a PARS site in 2010, age was calculated as follows: [25 + (difference between 1990 and 2010)], making that physician 45 years old. Ophthalmologists were then divided into five 10-year age bands: beginning with those who graduated before 1970, who were assigned ages greater than 70 years, through 2000-2009 graduates, who were assigned ages 31 through 40 years.

We randomly selected 162 attending ophthalmologists from the cohort (12.1% of the total) to verify age approximations against data from the National Provider Identification database (http://www.topnpi.com), which often includes the physician’s year of birth, and from internet searches. Use of the date of medical school graduation to approximate age resulted in a mean discrepancy of −0.40 years; 95.7% of estimated ages were within 5 years, with an overall range of –11 to 17 years.

Follow-up

The PARS program’s database includes UPCs recorded from January 1, 2002, through the present. Follow-up for each attending ophthalmologist began the first day of employment or affiliation with an institution that participated in PARS and when the attending ophthalmologist met study requirements. The end of follow-up was defined as the first of the following dates: study end date (December 31, 2015), resignation, retirement, death, end of an institution’s PARS contract, or receipt of a UPC. We did not censor study participants who may have had complaints before the beginning of study follow-up.

Database

The study required 2 distinct data sets. The first included ophthalmologists’ demographic information. A CPPA database analyst created the second data set, which included the date of each UPC, number of days between study entry and complaint date, identification numbers for each UPC report and specific embedded complaints, and identification numbers for the 6 complaint-specific categories and 34 complaint types. The database analyst merged the demographic data with the complaint information, and physicians were assigned unique, randomly generated identification numbers. The database analyst deidentified all physician data before study investigators were granted access to the complaint data (ie, number of UPCs, complaint-type profile). The resulting research database contained no physician names, patient identifiers, or organization names.

Covariates

Predefined covariates considered potential confounders were ascertained and cross-checked using the PARS database, institutional websites, and online third-party physician review sites (eg, Healthgrades, Vitals.com, and Topnpi.com). Covariates included practice setting (academic vs regional, community, or private medical center, the latter defined as an organization sharing neither the name nor physical location of a medical school), type of medical school attended (non-US or US medical school), degree(s) obtained (MD, MD and PhD, or DO), sex, institutional affiliation, and ophthalmic subspecialty (general or comprehensive, cornea, refractive surgery, glaucoma, medical retina, surgical retina, uveitis, oncology, pathology, neuro-ophthalmology, pediatrics and strabismus, and oculoplastics).

Measures

The primary end point was the time to first recorded UPC. The secondary end point was frequency of the most common complaint subtypes for each age group.

Statistical Analysis

Physician-level covariates were stratified by age band and compared using a Kruskall-Wallis test or χ2 test without continuity correction where appropriate. Hazard ratios for the different age bands were calculated using a multivariable Cox proportional hazards regression model, which permitted assessment of the association between a physician’s time to first complaint and age, adjusting for sex, medical degree, medical school setting, practice setting, and subspecialty. This model was selected because of the variable study follow-up, the rarity of the outcome, and the fact that UPC-related risk is not constant per unit of time. Furthermore, this was a binary outcome measure, the proportional hazards assumption was met, and each ophthalmologist’s follow-up beginning and end dates were known.25

Rates of complaints per 1000 follow-up days were compared across age bands using a 2-sided z test for differences and P < .05 for significance. Descriptive statistics were used to identify each age band’s complaint subtypes. We performed a sensitivity analysis in which we restricted the cohort to individuals who joined a PARS organization on or after the first date that complaints were included in the PARS database, thus ensuring that we were capturing all complaints during the physician’s exposure to PARS. All analyses were performed using R, version 3.3.0 (R Foundation for Statistical Computing) and STATA, version 13 (StataCorp, LLC).

Results

Characteristics of the Study Participants

Median age of the 1342 cohort ophthalmologists was 47 years (interquartile range, 38-60 years); 125 (9.3%) were at least 71 years old. Table 1 summarizes the prevalence of covariates by age bands. The cohort included 987 men (73.6%); younger bands included up to 40% women. Most (1214 [90.5%]) held MD degrees, and 978 (72.9%) practiced in academic medical centers. The mean (SD) follow-up period was 9.8 (4.7) years.

Physician Age and Time to First Complaint

The cumulative incidence of complaints by age bands is displayed in Figure 1. The oldest age band (>70 years) had the longest mean time to first complaint and the lowest complaint rate (0.71 complaints per 1000 follow-up days vs 1.41 for age 61 to 70 years, 1.84 for 51 to 60 years, 2.02 for 41 to 50 years, and 1.88 for 31 to 40 years). The youngest band (aged 31-40 years) had the shortest time to first complaint. According to a Kaplan-Meier survival curve, by 2000 days of follow-up (or within 5.5 years), the youngest group had an estimated UPC risk of 0.523 (number at risk, 71 individuals). By 4000 days (>10 years), participants in the older than 70 years age band had an estimated risk of UPC of only 0.364 (number at risk, 44) and those in the 61- to 70-year age band had an estimated risk of only 0.371 (number at risk, 68). The survival curves were statistically different (P < .001) according to a likelihood-ratio test for the overall effect of age band in the Cox proportional hazards regression model.

The 2 youngest age bands were associated with a statistically significant shorter time to first complaint. Compared with those aged 71 years or older, the risk of incurring a UPC for those aged 41 to 50 years was 1.73-fold higher (hazard ratio [HR], 1.73; 95% CI, 1.21-2.46; P = .002). Similarly, participants aged 31 to 40 years had a 2.36 times higher risk of incurring a UPC (HR, 2.36; 95% CI, 1.64-3.40; P < .001). Adjusted hazard ratios by age, selected demographics, and subspecialty appear in Table 2.

Physician-Level Covariates

Only neuro-ophthalmology was associated with a statistically significant higher adjusted HR for time to first complaint when compared with comprehensive ophthalmology (HR, 1.97; 95% CI, 1.29-3.01; P = .002) (Table 2). Ophthalmologists at regional medical centers had a lower hazard rate for time to first complaint than ophthalmologists at academic medical centers (HR, 0.79; 95% CI, 0.65-0.97; P = .02) (Table 2).

Most Common Complaint Subtypes

Complaints about care and treatment (eg, diagnosis, recommendations, and medications) were the most commonly reported, ranging from 29% of concerns for ophthalmologists older than 70 years to 44% among those aged 41 to 50 years (Figure 2). Second most common were concerns about accessibility and availability, ranging from 21% (oldest group) to 34% (age bands 41-50 and 51-60 years). Communication concerns were also commonly reported, ranging from 20% (age band 31-40 years) to 31% to 33% (combined age bands 41-60 years). Complaints about perceived lack of humanistic concern for patient or family were proportionately fewer, ranging from 14% and 15% in the youngest and oldest age bands to 26% and 27% in the 41- to 50-year and 51- to 60-year age bands. The proportion of ophthalmologists in each age band who received complaints specific to communication, care and treatment, humanistic concerns, access and availability, or billing did not differ significantly.

Over the course of the study, 564 ophthalmologists, 42% of the study cohort, were associated with at least 1 UPC. The top 5% (n = 67) were associated with a mean (SD) of 19.2 (8.3) UPCs over their most recent 4 years in the study. In a sensitivity analysis restricted to ophthalmologists who started employment at a PARS site after the earliest date of complaint capture, age band remained a significant predictor of having a UPC (P = .01) according to a likelihood-ratio test for the overall effect of age band in a Cox proportional hazards regression model, and the 2 oldest bands still had the lowest risk of having a UPC. Age band remained a significant predictor of risk of UPC.

Discussion

This retrospective study of 1342 ophthalmologists, designed to assess when UPCs are highest across an ophthalmologist’s career, found that increasing physician age was associated with a decreased risk of receiving a UPC. Overall, 42% of the physicians had at least 1 UPC. The cohort’s youngest physicians had the shortest time to first complaint and were significantly more likely to receive a UPC than older physicians. Practicing outside an academic medical center was associated with a longer time to first complaint (HR, 0.79; 95% CI, 0.65-0.97). Among ophthalmology subspecialties, only neuro-ophthalmologists were associated with a statistically significant shorter time to first complaint than comprehensive ophthalmologists (HR, 1.97; 95% CI, 1.29-3.01), which is consistent with previous findings that neuro-ophthalmic disorders are associated with more risk management activity than other ophthalmic conditions and that neuro-ophthalmologists are associated with greater numbers of UPCs.12,26

Early-career physicians may be associated with less time to first complaint and overall more UPCs owing to the challenges of mastering new clinical systems and how best to provide excellent attending-level care largely on their own (eg, managing patient treatment, identifying patient care resources).27 Moreover, because younger physicians may be more up-to-date with best practices, their UPCs may derive less from cognitive or technical deficits than from behavioral and confidence issues.27 Younger physicians may also have novice support staff and nurses, larger shares of “difficult” patients referred by late- and mid-career ophthalmologists, and insufficient training and experience to handle unsolvable medical situations or emotionally difficult conversations (eg, delivering a diagnosis of permanent blindness).27 Deidentified examples of complaints associated with early-career physicians can be found in the Box.

Box Section Ref ID

Box. Examples of Patient Complaintsa Unsolicited Patient Complaints About Ophthalmologists “After 72 minutes in the PACU, the patient and his family were all very upset because neither Dr ___ nor Dr ___ spoke to anyone regarding the patient’s surgical procedure. PACU RN paged and called both Dr ___ and Dr ___ several times for over an hour, with no response from either doctor.” (communication; access and availability)

“Our office received a phone call/complaint from Mr ___ because this patient feels Dr ___ did not see him and review the results of his lab work and MRI.” (communication) Unsolicited Patient Complaints About Older Ophthalmologists “Dr ___ was in someone else’s chart during my appointment. He kept calling me by another name.” (care and treatment; communication)

“Throughout the examination, Dr ___…had difficulty maneuvering in the examination room. [Patient] expressed her concerns with Dr __’s age.”

“Dr ___ put the wrong medication on my prescription. The pharmacist caught it, but…” (care and treatment) Abbreviations: MRI, magnetic resonance imaging; PACU, postanesthesia care unit; RN, registered nurse. a Complaints were categorized into 34 specific types under 6 major categories: care and treatment, communication, access and availability, concern for patient and family, safety of environment, and billing. Billing was included only if complaints alleged concerns about physician-related care and treatment. No complaints about safety of environment were attributed to ophthalmologists, so that category is not included.

Our finding that younger physicians had less time to first complaint and a greater risk for UPCs is consistent with findings that malpractice claim rates are highest in the first 10 years of practice and peak when physicians are in their 40s.16,17 Early-career physicians may provide insight on challenges they face and how institutions may support their transition from education to practice, especially through onboarding and ongoing professional development.

Mid-career attending ophthalmologists were associated with longer times to first complaint than early-career colleagues but shorter times to first complaint than late-career attending physicians. This finding appears consistent with research that mid-career physicians are overrepresented among those who lose their malpractice insurance.28 This finding may, however, reflect the time it takes before a physician’s malpractice claims demonstrate a pattern sufficient to result in termination of professional liability coverage, which is estimated at 10 to 15 years.28 In either case, physicians in the middle-aged cohort with multiple claims who purchase their own professional liability insurance might find some insurers unwilling to continue their coverage. This could drive some physicians with the worst exposure out of practice, potentially eliminating some in the middle cohorts from the data set and introducing survival bias. The overall departure rate of PARS program physicians with persistent disproportionate numbers of UPCs is 8% (0.35% of all physicians in the PARS database),13 suggesting that the magnitude of this type of bias is likely low.

Despite greater experience and know-how, mid-career physicians’ UPCs may arise from greater external challenges, including personal, family, or financial problems that may drive them to undertake workloads for which they are not adequately trained and for which there is little institutional support. Furthermore, as mid-career physicians’ practices grow, they may feel personally or organizationally obliged to see ever more patients, who may then complain about shortened visits, poor availability, and lower quality of care.16 Busy practices may also limit the time physicians invest in continuing medical education and staying current with best practices.16

Late-career ophthalmologists had a longer time to first complaint than their younger counterparts had, and they were less likely to incur a UPC. We did not censor follow-up for individuals who had complaints before their organization adopted PARS. Thus, older cohort members may have “survived,” whereas those with more complaints may have left the organization before study follow-up began. Based on our earlier research by one of us (J.W.P.),13 we estimate that, similar to middle-aged physicians, 0.35% of the late-career cohort left while associated with large numbers of UPCs. Thus, the magnitude of survival bias is likely to be small. In addition, results of a sensitivity analysis that restricted the cohort to individuals who joined a PARS organization after the start of complaint capture for PARS were not materially different from the primary analysis, suggesting that the study findings are robust. Concerns have been raised about the potential for age-related declines in older physicians’ cognitive and motor skills,29,30 and our finding does not establish that older age is associated with retained competencies or safer technical practice. Why late-career physicians may be associated with fewer complaints remains to be explored.

Strengths and Limitations

Study strengths include the large sample size, which comprised physicians from across the United States at academic and regional (nonacademic) health care institutions and the unbiased measure of complaints captured by our exposure variable. Substantial covariate information was available for each participant, and all had long follow-up periods. Furthermore, the use of graduation year to approximate age accurately classified cohort members’ ages.

Study limitations include the potential for incomplete data collection at participating health care institutions, but the CPPA provides benchmarks and targets for institutions to minimize this possibility. Data on patient volume were not available for cohort ophthalmologists, but UPCs have been shown to be an independent risk factor for risk management activity after controlling for clinical volume. Physician ages increased during the 14-year study period; however, given the mean 9.8-year follow-up, the 10-year age bands still offer a straightforward means for following physicians through our study. Finally, physicians associated with UPCs before the study may have considered complaint causes and modified their practices accordingly, reducing their likelihood of receiving subsequent complaints.

For health care organizations, having information about UPCs can help reveal personal, systems, and interprofessional issues that increase patient dissatisfaction, adverse outcomes, and malpractice claims risk. These results have practical implications for patient safety, clinical education, and clinical practice management and can inform early-career ophthalmologists’ needs for support and debates about assessing competency in late-career ophthalmologists (and, perhaps, other physicians). Early-career ophthalmologists with disproportionate numbers of complaints may benefit from focused professional development and support. At the very least, those physicians should be made aware of their standing compared with peers because research has demonstrated that up to 80% of these physicians will self-correct when provided comparative feedback.13-15 Furthermore, UPCs may signal a need for physical, mental, and/or skills assessments, especially for older physicians who previously had few or no complaints and now manifest rapid increases. Such differences over time should prompt those physicians’ medical center or medical group leaders to consider evaluation and further action on behalf of and in support of these physicians, their clinical colleagues, and their patients.

Conclusions

Ophthalmologist age is significantly associated with receiving a patient complaint. These findings underscore the importance of including patients as health care team members because their observations can provide actionable information for individual physicians and leaders committed to providing the highest quality of care.

Back to top Article Information

Corresponding Author: William O. Cooper, MD, MPH, Center for Patient and Professional Advocacy, Vanderbilt University Medical Center, 2135 Blakemore Ave, Nashville, TN 37212-3505 (william.cooper@vanderbilt.edu).

Published Online: November 30, 2017. doi:10.1001/jamaophthalmol.2017.5154

Correction: This article was corrected on November 1, 2018, to correct a sentence in the Discussion section.

Accepted for Publication: September 28, 2017.

Author Contributions: Dr Cooper and Mr Domenico had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Fathy, Kohanim, Sternberg, Cooper.

Acquisition, analysis, or interpretation of data: Fathy, Pichert, Domenico, Sternberg, Cooper.

Drafting of the manuscript: Fathy, Pichert, Domenico, Sternberg, Cooper.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Fathy, Domenico, Cooper.

Obtained funding: Cooper.

Administrative, technical, or material support: Pichert, Sternberg, Cooper.

Study supervision: Pichert, Kohanim, Sternberg, Cooper.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Sternberg reported receiving personal fees as the chair of the data safety monitoring board of QLT, Inc and is a member of the DRCR.net External Protocol Review Committee. No other disclosures were reported.