Longer-Practicing Physicians Less Likely to Adhere to Standards of Care
A 2003 report by the National Committee for Quality Assurance stated that the US health care system is “riddled with quality gaps,” resulting in 57,000 deaths annually. To address this pressing issue many hospitals have formed interdepartmental quality improvement teams charged with improving the quality of care they deliver. Some health care organizations have also implemented best practice methods intended to help guide physicians when delivering their care.
Physicians play a central role in health care delivery and it is often assumed that the more experience a physician has, the better care he or she provides. At the same time, new medical information is constantly being generated, often leading to changes in standards of care. And although medical doctors are required to accrue a certain number of continuing education credits to maintain their license, there is no guarantee they will actually apply this new knowledge to the care of their patients.
A new study in the February 15, 2005 issue of the Annals of Internal Medicine set out to examine the relationship between clinical experience and quality of care by reviewing previously published studies in this area. Overall, 73% percent of these studies found that a physician’s performance declines with time in practice.
About the Study
The researchers analyzed findings from 59 previously published studies that measured physician knowledge or quality of care and also reported time since medical school or age. They categorized the studies into four groups based on whether they evaluated (1) medical knowledge, (2) adherence to standards of care for diagnosis, screening, or prevention, (3) adherence to standards of care for therapy, or (4) health outcomes (e.g., mortality).
After reviewing the results of each study, the researchers classified the outcomes as follows:
- Consistently negative – for studies where all reported outcomes showed a statistically significant decrease in performance with increasing years in practice or age
- Partially negative – for studies that demonstrated decreasing performance with increasing experience for some outcomes, but no association for others
- No effect
- Mixed effect
- Partially positive – for studies that showed increasing performance with increasing experience for some outcomes and no association for others
- Consistently positive – for studies where all reported outcomes showed a statistically significant increase in performance with increasing years in practice or age
- Concave – for studies that found performance to initially improve with years in practice or age, then peak, and thereafter decrease
Just over half of the outcomes (52%) were consistently negative; in other words, performance decreased as experience increased for all assessed outcomes. Out of the remaining studies: 13 (21%) showed a partially negative association, 13 (21%) found no effect, 1 (2%) showed a partially positive association, 1 (2%) showed a consistently positive association, and 2 (3%) found a concave relationship.
Additional findings included:
- All 12 of the studies that assessed the relationship between physician knowledge and years of practice reported a negative association.
- Out of 24 studies that assessed the appropriateness of physician use of diagnostic and screening tests, as well as preventive health care , 15 (63%) found that older or longer-practicing physicians were less likely to adhere to standards of practice in this area.
- Out of 19 studies that assessed the relationship between adherence to standards of therapy and years of practice, 14 (74%) found a partially or consistently negative association.
How Does This Affect You?
This study found that the physicians with the most experience are not necessarily the ones who deliver the best care. These results are intriguing and suggest that the current continuing education process for physicians may not be working.
The authors point out that this study did not look at qualities such as humanism and judgment, which may improve with experience and would factor into overall quality of care. Additionally, they note the current focus on evidence-based medicine has only recently been widely adopted; longer-practicing physicians who were not trained to practice medicine in this way may be less familiar with and less accepting of these strategies. The situation may improve as older physicians become comfortable with the new tools available to help them sort through the enormous quantity of constantly updated medical information.
It would be unreasonable and unfair to suggest avoiding older physicians based on this study. However, there are some actions you take to make sure you are getting the best care from your doctor: (1) Find out if your doctor is board-certified in their specialty; this means they have successfully completed a program that includes an examination designed to assess the knowledge, skills, and experience required to provide quality patient care in that specialty. (2) If you are having a procedure done, find out how often your doctor has performed it; contrary to these findings the more times a doctor has performed a procedure the more skilled he or she is likely to be. And (3), don’t hesitate to ask your doctor how he or she keeps up to date on the latest advances in the field.
Agency for Healthcare Research and Quality
Joint Commission on Accreditation of Health Care Organizations (JCAHO)
The National Committee for Quality Assurance (NCQA)
Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care. Annals of Internal Medicine . 2005; 142: 260-273.
Mission Statement. American Board of Medical Specialties website. Available at: http://www.abms.org/mission_statement.asp . Accessed February 17, 2005.
New report finds health care system’s “quality gaps” cause 57,000 deaths annually. National Committee for Quality Assurance website. Available at: http://www.ncqa.org/communications/news/sohc2003.htm . Accessed February 16, 2005.
Weinberger SE, Duffy FD, Cassel CK. “Practice makes perfect”…or does it? Annals of Internal Meidcine . 2005; 142: 302-303.
Last reviewed Feb 17, 2005 by ]]>Richard Glickman-Simon, MD]]>
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