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A patient calls a medical office, asking for an appointment with the most senior physician in the practice. No appointment is available for 4 months, but the staff member suggests the patient could get an appointment the following week with one of the junior associates. Does the patient agree?

Confusion races through the patient's mind.

Is access to the senior physician limited because the older practitioner is so skilled and in such high demand? Or is it because the older physician has limited their hours or gives preference to established patients?

Are young physicians more available because they are taking aggressive steps to build their practices? Or is it because the junior practitioner is not terribly experienced and has had suboptimal results -- and no one wants to see them?

Is the enhanced experience of older physicians a major advantage? Has the practice of medicine over decades honed their diagnostic and technical skills to an unmatched peak? Have they treated so many patients that they have defined their own calculus of risk-to-benefit that transcends anything in the medical literature?

Does the recent training of younger physicians mean they are more up-to-date and cognizant of the most recent advances in their chosen field? Are they more aware of newer drugs and procedures? Have they abandoned ineffective practices that still prevail among practitioners that trained decades earlier?

If older is better, is there an age that is too old? Patients would be understandably nervous if an elderly physician seemed disoriented and could not remember what was just said. If younger is better, is there an age that is too young? Physicians might not engender confidence if they look like they just graduated from high school, dress in a T-shirt and jeans, and spend the entire office visit looking at a computer screen.

You can scour the medical literature for an answer to the age-old question about age, but good studies are hard to find. Some reports suggest that older physicians are more likely to utilize outmoded procedures (e.g., routine episiotomy) and that younger physicians are more likely to prescribe drugs to (statins and antiplatelet drugs). But these observational analyses rarely adjust for the one variable that probably matters the most -- the busyness of the physician's practice. When properly adjusted, physician age is in patient outcomes, including mortality. A busy practice environment with constant communications and interactions between senior and junior physicians would seem to represent an ideal setting for optimizing patient care.

Haider Javed Warraich, MD, whose writings I admire, for an article in the New York Times in 2018. He argued the inexperience of younger physicians allowed them to be free of the "malignant relics from the past." He opined that younger physicians are more likely to place the patient on a pedestal rather than themselves. I understand his arguments, but I strongly disagree with him. And notably, at the time of the article's release, Warraich was 29 years old.

I would counter that older physicians entered the field of medicine when being a physician was a "calling" and a "career" rather than a "job." Therefore, they are more likely to spend the time needed to thoroughly pursue a difficult diagnosis or treatment strategy. Furthermore, their training focused on clinical assessments that are not strongly emphasized in current residency programs. But of course, at the time of this essay's publication, I am 70 years old.

Yet, I do remember what it was like to be a very young physician.

In 1973, I received my MD degree at the age of 22 years old, at least 3 years younger than most of my peers. In 1978, I became Director of the Coronary Care Unit at Mount Sinai Hospital in New York -- at the age of 27. By the age of 31, I had five first-authored original research articles in the New England Journal of Medicine. (I was working 16-hour days, 7 days a week.)

Based on my clinical rotations in medical school, I was acutely aware of perceptions about my youthful appearance. I really wanted physicians and patients to take me seriously and to trust me. I really wanted to look older than I was.

So, I grew a moustache. My 1973 medical school yearbook photo is reproduced below.

Readers may laugh. But studies have shown that growing a moustache adds to someone's perceived age. At the time, I thought: maybe that is all I need.

But it did not work as I planned. My research in heart failure led me to gain rapid prominence in the field, and in a short time, I was the go-to person for patients with heart failure in the New York metropolitan area. Patients would travel long distances to seek my opinion, invariably referred by cardiologists who were far older than I was.

In the days before the internet, patients typically did not know what their physicians looked like before an office visit. And so, when I entered the patient examining room for the first time, I could hear many patients (and their families) gasp.

"You are so young," they would say. Their discomfort was palpable. They seriously believed that any true expert should be someone who was old, at least much older than I was. Or at least older than the physicians who referred the patients to me. And so I responded: "Really? I am actually much younger than I look."

That single line made all the difference. The line delivered an emphatic and lighthearted sense of confidence, tinged with irony. Perhaps, the patients thought: "If he is willing to say something like that, he must believe in himself. And that is what really matters to me."

Self-confidence is what patients are looking for. If physicians are insecure about their own abilities, . If physicians do not trust themselves, how can they expect a stranger to trust them? Arguably, when compared with younger physicians, older physicians may have built a stronger sense of self-confidence, with some believing that , which is restored by years in practice. Or perhaps, older physicians have a better understanding of how to display their own self-confidence to patients.

Self-confidence cannot be faked. Those who pretend typically present themselves as arrogant. Self-confidence embodies a well-grounded sense of personal security that is ideally coupled with humility. It represents a keen self-awareness of what you know and can do, which should be linked to meaningful understanding of and comfort with one's personal limitations.

In contrast, a physician who is burned out, who is physically and mentally exhausted, and who is consumed (even if silently) about the difficulties of his/her own life, does not exude confidence. A patient is not looking for a practitioner who is distracted by their own sorrows or their own sense of insecurity. Patients who are ill are looking for a pillar of strength, not weakness.

One of the most successful military commanders in history was (Alexander III of Macedon). After ascending to the throne, he launched a lengthy military campaign that created one of the largest empires in history. He was undefeated in battle, not because of superiority in numbers, but because of strategic brilliance. Famous generals (who are not typically self-effacing) place Alexander above them in their ranking of the world's great military leaders. But apparently, the real secret of his success was the fact that he exuded a charismatic self-confidence, which led to him being revered both by his field commanders and troops. They fought valiantly for him because they trusted him completely. According to an apocryphal legend, troops were so loyal to Alexander that they would agree to to their death to show their obedience to him.

Alexander was 20 years old when he ascended to the throne, and he was 30 years old when his empire reached its peak.

The bottom line: patients judge physicians by their sense of self and their skills -- not their age.

Or to tweak a famous quote from Mark Twain: Age is an issue of mind over matter. If you are in the right frame of mind, it doesn't matter.

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