Abstract & Commentary
With Comment by Frank W. Ling, MD, an OB/GYN for Women’s Health Specialists, PLLC, Memphis, Tennessee.
Synopsis: Physicians who have been practicing longer may be at risk for providing less quality care.
Source: Choudhry NK, et al. Ann Intern Med. 2005;142: 260-273.
Choudhry and colleagues sought to establish the relationship between quality of care with clinical experience by reviewing 62 articles that measured physician knowledge or quality of care as well as time since medical school graduation or age. More than 50% of the studies suggested that physician performance actually declined while only 1 study showed improved performance. The areas measured in the various studies included: knowledge; adherence to standards of practice for diagnosis, screening, and prevention; adherence to standards of appropriate therapy; and outcomes.
Choudhry et al acknowledge that there are potential limitations to the study, each of which could explain aspects of the findings. For example, there may be other studies that were missed in the review of the literature showing the opposite findings, but there is no reason to believe that a significant number of those exist. Similarly, since the studies were not designed to specifically look at the relationship between experience and outcomes, these could be chance findings, but since the findings were very consistent, this explanation is unlikely. As a third explanation, Choudhry et al suggest that differences between practice guidelines could make standard of care a difficult measurement to establish. Analysis of the data did not support this view. Finally, the potential benefit of practice experience might be measured in parameters not covered here, such that its positive effects would not be apparent here. Since the measurements used seem to cover the gamut of how physician performance is usually assessed, this certainly cannot be disproven, but lacks credibility.
Comment
Before you skip past this review as irrelevant, consider its implications. Nobody (the authors, myself, or anyone else) is saying that you, specifically, are providing a lower quality of health care than your younger peers.
These data are all about large groups of physicians. Neither do the data tell us that younger physicians are better than their older, more seasoned peers. If you are wondering what specialties were involved in the studies reviewed, you should know that these were not just internists and, in fact, there were several studies which included obstetrician/gynecologists. The concern is both at the individual practitioner level as well as for medicine as a whole. Continuing medical education is under the gun here, as is the ongoing certification process. In order for the public to receive optimal healthcare, how do I individually, and we, collectively, address these findings?
Without question, I’ve got to look at my own practice patterns. Am I aware of current evidence-based recommendations and guidelines? Do I practice the way I was trained as a resident or based on what I heard from a single speaker at a meeting several years ago? Do I rely on more widely accepted recommendations offered by respected organizations that have done systematic reviews of the data? Do I keep up with current literature, whether by reading journals or through summaries in publications such as Internal Medicine Alert? Do I track my patient outcomes to look at problems that I need to address better?
Maybe these questions are answered more comfortably by someone who has recently completed training and has that little voice of their teachers asking nagging questions of them. Indeed, their database should be more current, albeit inexperienced. Certainly as my own hair whitens and thins, I am constantly reminded of the ever-changing technology and exploding knowledge base that I face. Having been in full-time private practice now for a full year, I am painfully aware of the challenges that I face trying to keep up. What I don’t ever want to do, however, is to only fall back on my years of experience at medical school and assume that is sufficient for the years ahead of me in practice. I would challenge the reader to do the same: keep this article in mind as you continue to provide your patients with the best care possible. Let’s maximize the effectiveness of our CME time, let's help the hospitals and insurance companies with their quality improvement plans, and let’s do the best we can for our patients, regardless of how long we’ve been out of training.
Physicians who have been practicing longer may be at risk for providing less quality care.
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