[Paleopsych] Experienced Physicians not better

[Lynn D. Johnson, Ph.D.]

Interesting piece from Medscape, since we sometimes discuss aging and 
functional loss.

http://www.medscape.com/viewarticle/499664


More Experienced Physicians May Provide Lower Quality of Care

Cathy Tokarski

Feb. 17, 2005 — Conventional wisdom about physician expertise generally 
holds that the longer a physician has been in practice, the better honed 
his or her clinical skills become. But a new study turns that adage on 
its head with its conclusion that physicians who have been in practice 
longer may, in fact, provide lower quality of care.

The problem is not that more experienced physicians are not intelligent, 
well-trained or competent, and the findings "should not be used to put 
the blame on older physicians," said study lead author Niteesh K. 
Choudhry, MD, an instructor of medicine at Harvard Medical School in 
Boston, Massachusetts. Instead, "the problem is that we've been relying 
on methods that may not be very effective in requiring that physicians 
keep up to date."

To address that gap, the traditional methods of keeping physicians' 
knowledge and clinical practice current need to be reexamined and 
altered, according to the study. "Over the past 15 or 20 years, there 
has been a body of literature generated that helps to identify what 
techniques work and don't work," Dr. Choudhry told Medscape in an 
interview. "We should refocus our efforts for recertification and 
relicensing on that."

The study linking physician years in practice to quality of care, 
published in the Feb. 15 issue of the Annals of Internal Medicine, was 
based on a Medline review of 59 articles from 1996 through 2004 that 
reported data on 62 groups of outcomes. Studies were included if they 
were original reports that provided empirical results; measured 
knowledge, guideline adherence, mortality, or some other type of 
quality-of-care process; and included years since graduation from 
medical school, years since certification, or physician age as a 
potential variable influencing results.

The studies were then categorized into four groups on the basis of 
whether they evaluated knowledge (such as knowledge of indications for 
blood transfusions); adherence to standards of care for diagnosis, 
screening, or prevention (for example, following preventive care 
guidelines); adherence to standards of care for therapy (such as 
appropriate prescribing); or health outcomes (mortality, for example).

Results were then classified into six groups on the basis of the 
association between the length of time a physician had been in practice 
and his or her performance: consistently negative, partially negative, 
no effect, mixed effect, partially positive, and consistently positive.

Overall, more than half (52%) of the 62 evaluations captured in the 
studies showed a negative association between increasing experience and 
performance for all outcomes assessed, and an additional 21% showed a 
negative association for some outcomes and none for others.

The study also found that only two evaluations (3%) reported that 
performance initially increased with longer experience, peaked, then 
decreased, while 21% found no association. One evaluation (2%) reported 
increased performance with longer experience in practice for some 
outcomes, but no association for others, and only one evaluation (2%) 
found increased performance with more years in practice for all outcomes.

In the area of assessing the knowledge of practicing physicians, for 
example, all of the 12 studies used reported a negative association 
between knowledge and increased experience, the study found. For 
example, after adjusting for specialty and other variables, physicians 
younger than 40 years were more likely to believe in the value of 
established therapies that improve survival rates for acute myocardial 
infarction (AMI), such as thrombolytic agents, aspirin, and 
beta-blockers, and less likely to believe in the value of therapies that 
have been disproved, such as prophylactic lidocaine, the study found.

The methodology used in the AMI study was "particularly well done," said 
Dr. Choudhry, controlling for variables that often can skew a theory 
about experience and competence. "What this study did was it controlled 
for a series of patient and physician factors that would have confounded 
the relationship," he said. "It's hard to dismiss the results out of hand."

The study results call into question the benefit of relying exclusively 
on continuing medical activities, such as attending lectures or reading 
journal articles, as a way to remain current in knowledge and practice, 
Dr. Choudry said. Such methods require only a "passive participation in 
acquiring knowledge." What is needed instead are activities in which 
"physicians are interacting with other physicians or using information 
technology" to measure or build on their clinical skills, he said.

So-called "academic detailing," in which physicians or pharmacists visit 
physicians' offices to discuss appropriate treatments has proven 
successful in areas where it has been tested in Canada, Dr. Choudhry 
said. "One of the big messages of the literature about behavior change 
is that we need to use more than one thing."

An accompanying editorial cautions, "The profession cannot ignore this 
striking finding and its implications: Practice does not make perfect, 
but it must be accompanied by an ongoing effort to maintain competence 
and quality of care."

To that end, the editorialists representing the American College of 
Physicians and the American Board of Internal Medicine recommend that 
professional development apply to a physician's entire career, not just 
to those in the early professional years.

In addition, the editorial called on physicians to support the concept 
behind the American Board of Medical Specialties' "maintenance of 
certification," which replaces one-time certification for life with 
ongoing performance measurement. "This model of professional development 
provides a way to identify gaps between current and ideal practice, 
which is the first step toward acquiring needed new knowledge, skills, 
and processes of care," the editorialists write.

Ann Intern Med. 2005:142:260-273, 302-303

Reviewed by Gary D. Vogin, MD