"The results are paradoxical since it is generally assumed that clinical experience enhances knowledge and skill and therefore leads to better patient care," says lead author Niteesh Choudhry, HMS instructor in medicine. Choudhry performed the research as a pharmaceutical policy research fellow at the Department of Ambulatory Care and Prevention, a unique research and teaching collaboration between Harvard Pilgrim Health Care and Harvard Medical School.
The study included a review of 59 previously published papers (comprising 62 individual studies) with a large sample size of doctors. These studies included measures of physician knowledge or quality of care and also included the time since the physician's medical school graduation or the physician's age. The researchers found that 73 percent of these studies (45 of 62) showed that a doctor's performance declines with time. More than half of these studies (32 of 62, or 52 percent) showed that performance declines for all of the outcomes measured, and 13 studies (21 percent) showed that some but not all aspects of a doctor's performance decline with time.
"The findings also reflect the substantial environmental changes that have occurred in medicine over the past several decades. Evidence-based medicine has been widely adopted and quality assurance techniques, such as disease management and performance evaluation, are frequently used. More experienced doctors may have less familiarity with these strategies and may be less accepting of them," says co-author Stephen Soumerai, HMS professor of ambulatory care and prevention.
There are many possible explanations for these findings, and perhaps most plausible, write the researchers, is that doctors' "toolkits" are created during training and may not be updated regularly. Older physicians seem less likely to adopt newly proven therapies and may be less receptive to new standards of care. Additionally, practice innovations that involve theoretical shifts, such as the use of less aggressive surgical therapy for early-stage breast cancer, may be harder to incorporate into the practice of doctors who have trained long ago.
The study indicates that older doctors may need quality improvement interventions that are generally applicable to all physicians. The current requirements imposed on doctors to keep up to date and demonstrate continuing competence may need to be reconsidered, the authors suggest. Widely adopted techniques, such as distribution of printed materials and lectures, are largely ineffective, says Choudhry. In addition, many experienced doctors are exempt from the recertification requirements to which their more recently trained colleagues must adhere. For example, the American Board of Internal Medicine only requires physicians who received initial Board certification in or after 1990 to appear for periodic recertification exams.
"We need to start thinking about more effective ways to help doctors keep up to date," says Choudhry, also an internist at Brigham and Women's Hospital. "For example, 'academic detailing,' in which physicians or other health care personnel go and meet doctors in their practices to teach them about a specific drug or advances in treatment-similar to the way drug company representatives 'detail' physicians-is known to be a very effective way to improve the quality of care that doctors provide. What appears to be lacking is the widespread implementation of these and other knowledge translation strategies in to the practice of most physicians."
In the study, Choudhry and his colleagues categorized the 62 studies into four groups on the basis of whether they evaluated a doctor's knowledge; adherence to standards of care for diagnosis, screening, or prevention (for example, adherence to preventative care guidelines); adherence to standards of care for therapy, including appropriate prescribing; or health outcomes, such as mortality. The results indicate that doctors who have been in practice for more years (as well as older doctors) possess less factual knowledge, are less likely to adhere to appropriate standards of care, and may also have poor patient outcomes.
Twelve of the 62 studies assessed the knowledge of practicing physicians, and all studies reported a negative association between knowledge and experience. For example, one study found that doctors younger than 40 years of age were more likely to correctly believe in the value of therapies for heart attack that improve survival, such as aspirin and beta blockers, than their older peers.
Twenty-four of the 62 studies examined the appropriateness of a doctor's use of diagnostic and screening tests as well as preventative health care. Fifteen of these 24 studies, or 63 percent, demonstrated that physicians in practice for more years were less likely to adhere to the current standards of practice. In the largest of those studies, physicians were surveyed to measure their adherence to cancer screening guidelines endorsed by the American Cancer Society and the National Cancer Institute. Doctors who graduated more than 20 years ago were consistency less likely to adhere to recommended practices; those doctors had 38 to 48 percent lower odds of adhering than younger doctors.
The influence of a doctor's age or years in practice on performance was examined by 19 of the 62 studies. Of these, 14 studies, or 74 percent, found that older physicians were less likely to adhere to therapeutic standards. For example, one study examined the prescribing behavior of physicians caring for patients with stable angina. Older physicians were significantly less likely to prescribe aspirin, which is a widely accepted standard treatment.
The study was funded by the U.S. Agency for Healthcare Research and Quality, the Harvard Pilgrim Health Care Foundation, a Canadian Institutes of Health Research Postdoctoral Fellowship, a Harvard Medical School Fellowship in Pharmaceutical Policy Research, and a Frank Knox Scholarship from Harvard University.
DEPARTMENT OF AMBULATORY CARE AND PREVENTION
http://www.dacp.org/
The principal goals of the Department of Ambulatory Care and Prevention are to influence health policy, enhance collaborations between health care delivery systems and traditional public health agencies, train clinicians to manage care effectively, develop improved methods for delivery of health care, and develop new information about disease and therapeutics. DACP is a unique collaboration of Harvard Medical School and Harvard Pilgrim Health Care, one of the first departments of its kind in the nation.
HARVARD MEDICAL SCHOOL
http://hms.harvard.edu/
Harvard Medical School has more than 5,000 full-time faculty working in eight academic departments based at the School's Boston quadrangle or in one of 47 academic departments at 18 Harvard teaching hospitals and research institutes. Those Harvard hospitals and research institutions include Beth Israel Deaconess Medical Center, Brigham and Women's Hospital, Cambridge Hospital, The CBR Institute for Biomedical Research, Children's Hospital Boston, Dana-Farber Cancer Institute, Forsyth Institute, Harvard Pilgrim Health Care, Joslin Diabetes Center, Judge Baker Children's Center, Massachusetts Eye and Ear Infirmary, Massachusetts General Hospital, Massachusetts Mental Health Center, McLean Hospital, Mount Auburn Hospital, Schepens Eye Research Institute, Spaulding Rehabilitation Hospital, and VA Boston Healthcare System.
HARVARD PILGRIM HEALTH CARE
http://www.hphc.org
Harvard Pilgrim Health Care is a not-for-profit health care plan operating in Massachusetts, New Hampshire, and Maine with a network of more than 22,000 doctors, 130 hospitals, and more than 800,000 members. Harvard Pilgrim was the first New England health plan to establish a non-profit foundation with the sole purpose of serving the community at large. The efforts of the foundation reflect Harvard Pilgrim's mission, which is to improve the health of its members and the health of society.
Journal
Annals of Internal Medicine