Older Doctors Not Always the Best

Younger physicians more likely to keep up with current practices, study finds

MONDAY, Feb. 14, 2005 (HealthDay News) -- The older, more experienced physician may not necessarily be the better one, a new study suggests.

In fact, just the opposite may be true. According to new research appearing in the Feb. 15 issue of the Annals of Internal Medicine, older physicians appear less likely to be delivering accepted standards of care.

"I think this is a paradox. We revere our older colleagues. We have a lot to learn from them," said Dr. Niteesh Choudhry, lead author of the paper and a researcher at Harvard Medical School. "I anticipated that there might be declining performance for some things as time from graduation increased. I didn't expect these results would be quite so consistent as they seem to be."

As the article pointed out, these findings turn conventional wisdom on its head. Physicians with more experience, like people in many walks of life, are believed to have built up a reservoir of knowledge and skills that puts them at an advantage when delivering quality care.

There has also been some evidence, however, that the number of years in practice is inversely proportional to quality of care provided.

To investigate this relationship, Choudhry and his colleagues reviewed 59 previously published papers comprising 62 studies that had considered the issue of medical knowledge and health-care quality in relation to time in practice and physician age.

Almost three-quarters (73 percent) of the studies showed the average physician's performance declining over time. More than half (52 percent) showed performance declining for all outcomes measured, while 21 percent showed some aspects of performance deteriorating.

The current paper also looked at different categories of care. Of 24 studies that looked at a doctor's use of screening and diagnostic tests as well as preventive care, 63 percent found that older physicians were less likely than younger doctors to conform to current standards. The largest of these studies found that doctors who graduated from medical school more than 20 years ago had 38 percent to 48 percent lower odds of adhering to recommended practices than younger doctors.

All 12 studies looking at physicians' knowledge found an inverse relationship between knowledge and experience. And 14 of 19 studies (74 percent) looking at performance found that older physicians were less likely to adhere to therapeutic standards compared with younger doctors. For instance, older physicians were less likely to prescribe aspirin for stable angina, which is a widely accepted standard.

Seven of the studies looked at the effect of this performance on patients' well-being. Of those, three showed no association between length of time in practice and patient outcomes, while four showed some degree of decreasing outcome with increasing time in practice. One study found that patients were more likely to die of a heart attack if their physician had been in practice for more years.

Today's constantly changing medical business environment may have a lot to do with this.

"The pressure for productivity for physicians in practice as well as the increasing amount of paperwork that people have to do unfortunately has taken time away from both patient care as well as physician's ability to keep up with things," said Dr. Steven Weinberger, senior vice president for medical knowledge and education at the American College of Physicians, and co-author of an accompanying editorial in the journal. "It's very common for physicians, at the end of a very long day, to have several hours of work dictating charts and filling out paperwork."

"It's a struggle," confirmed Choudhry. "Being five years out of training, I attempt to read multiple journals every week. I see patients and I have lots of other responsibilities. There aren't enough hours in the day."

Science and medicine are constantly changing, Choudry added, but it's not always clear what these changes mean for day-to-day practice. "In any given disease, multiple organizations are putting out guidelines," Choudhry said. "Usually they match up pretty well but they don't always."

The solution to this issue lies in the ways physicians receive their continuing medical education, which remains a key part of every doctor's job.

"Assuming these results are right, we do know that some of the fundamental parts of passive knowledge translation -- I sit in a room and listen to a lecture -- don't work to change physician behavior," Choudhry said.

Choudhry and colleagues are presenting ideas that most schools would be wise to consider, including "active knowledge translation," involving interaction between the physician and another health-care professional.

Weinberger thinks smaller groups would work better. "There has to be a way that physicians can learn based on their own particular questions," he said. "We have to figure out ways of delivering [new knowledge] that are more relevant."

To that end, the next American College of Physicians session will include "practitioner reports," based on the "residents reports," one of the most popular educational experiences in medical school. Instead of having residents report on patients, the practitioner will come with his or her own problem cases to present and discuss in a group.

More information

The Accreditation Council for Continuing Medical Education has more information on continuing education for doctors.

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