Tuesday, February 22, 2005

The Myth of the Battle-Tested Veteran Doctor?

An article (Choudry, et al.) has been circulated throughout my institution today that was fairly widely reported on by the popular press last week (for example). The article was published by the Annals of Internal Medicine and dealt with the issue of quality of care as a function of "clinical experience" (which may serve as a euphemism for age). The gist of the article was that the longer a physician is in practice, the more his quality of care declines.

This is a concept that may less evident to us "older" physicians than to the interns and residents that some of us teach. It may be even less evident to patients. So much for the benefit of experience.

We expect this in Olympic gymnasts but in physicians? Before patients fire their gray-haired doctors, perhaps a little perspective is in order.

The authors reviewed 59 articles in the academic literature that evaluated the benefit of clinical experience (generally estimated by length of practice) on 62 "outcome" measures. These measures were grouped as knowledge base (the ability to answer specific questions in their field), adherence to modern standards of practice for the diagnosis, screening and prevention of disease, adherence to standards of treatment of disease and most controversially, "outcomes".

A formal meta-analysis (a statistical conglomeration of different studies) was not done due to the heterogeneity of the study methods. The overall conclusion was that the further a physician gets from his or her training, the lower the overall quality of care.

The first three groups of measures are relatively easy to measure in the setting of a study. Measuring clinical outcome is notoriously difficult however and some of the studies cited gave conflicting results. In addition, some had methodological problems that perhaps attenuated their usefulness. I would therefore suspect that this final and most important group may or may not actually be inversely correlated to duration of practice.

I am however willing to accept that the first three more easily quantified groups have been satisfactorily demonstrated to be inversely correlated to time out of training. Clearly these measures must logically affect outcomes as there is a large amount of data that correlates the adoption of formal standards of care (sometimes referred to as clinical pathways) to outcomes.

The question is are there other qualities about a physician that may improve with time? In other words can there be some benefit of experience? I suspect that there must be. As physicians, don't we all give credence to the notion that an engaged, thoughtful, caring physician may just make that diagnosis or pick up a subtle finding just on the basis of his or her experience? And don't those occurances occasionally impact the patient's outcome? Aren't some of us occasionally amazed by the veteran doctor's intuition in knowing who's sick and who isn't?

I don't believe that to give credit for just being on the planet longer is misplaced. I also believe that these results need to be taken extremely serious by both the physicians and the patients among us. I'll have more to say this on another post.

3 Comments:

Anonymous Anonymous said...

I'm not a doctor but I have 2 chronically ill children (ages 12 and 17) who have seen doctors nationwide for most of their lives (including Mayo, Hopkins and NIH). I would choose an older, experienced doctor over a younger doctor any day, but with this limitation: The doctor must be a good listener and observer, not someone who has already made up his/her mind based on the medical records. I think this happens because practicing medicine today is subject to real time constraints. Also, younger doctors often don't have the experience to diagnose difficult cases, while some older doctors are so certain of their opinions and abilities that they don't listen and thus miss something important. The really good doctors - young and old, but usually the older ones - are focused observers and listeners.

February 24, 2005 10:20 AM  
Anonymous Anonymous said...

John,

It’s difficult to decipher from the abstract exactly what they are looking at, but at the risk of being anecdotal, the results don’t pass the common sense test. I’m in a procedure intensive specialty (anesthesiology) and am indeed a much better practitioner after years of experience. Years of doing cases, performing procedures and yes, dealing with complications, gives one a data base that you just don’t have fresh out of a training program.
A good point of comparison is the multiple studies showing that a surgeon doing an operation on a regular basis has a lower complication rate than one doing the surgery on an occasional basis. The hospital to go to for open-heart surgery is (statistically provable) the one doing the procedure frequently.

Les Hauge

February 24, 2005 2:05 PM  
Blogger JusPasenThru said...

I believe one of the things that the article said kept the older physicians up to snuff is their willingness to use technology. I think I get on my handheld and run a multicheck on everyone on more than two medications. If my Epocrates malfunctions, I'm calling off clinic.

March 16, 2005 6:43 PM  

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