Older doctors are not keeping up to date clinically, study says
■ Research shows that more experienced physicians are providing less effective care. But the study's authors say the problem is not about age.
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Robert H. Fletcher, MD, considers himself an "older physician." A professor emeritus at Harvard Medical School and the former editor of the Annals of Internal Medicine, he graduated from Harvard in 1966.
So it was with a sympathetic heart that he co-authored a study showing that doctors in practice for longer periods of time are more likely to possess less factual knowledge, are less likely to follow appropriate standards of care and more likely to have poorer patient outcomes.
The study, based on a review of 59 articles that appeared on Medline between 1996 and 2004, was published in the Feb. 15 Annals of Internal Medicine. Seventy percent of 62 evaluations in those articles found a negative association between years of practice and quality of performance.
The problem, as the study's authors see it, is not the aging of physicians. It's whether those physicians are able to keep up with the latest medical advances, particularly as evidence-based medicine takes a greater foothold.
"I think those in the trenches, with payment problems and malpractice problems, might feel this is just another thing someone is trying to criticize, but the more forward-thinking people will say this is information we ought to know for the sake of the patients," Dr. Fletcher said. "Some might say, 'Yup, I recognize me in that.' "
Dr. Fletcher, who practiced internal medicine in Massachusetts until a year ago, said he knows the challenges of staying on top of the latest treatments and drugs.
"It's really easy as an older physician to feel like you're doing the right thing," he said. "You're comfortable in your role. Patients like you because of your experience and confidence. That's all wonderful, and those are great assets, but it doesn't replace the need to know the best evidenced-based care."
Staying in touch
The study, titled "Systematic Review: The Relationship between Clinical Experience and Quality of Health Care," acknowledges that nonmeasurable skills such as humanism and judgment might improve with age. Niteesh K. Choudhry, MD, lead author of the study and an instructor at Harvard Medical School, cautioned against judging physicians of a certain age as second-rate.
"I do believe these results," Dr. Choudhry said, "but I don't want people to jump to conclusions and say, 'I have an older doctor, and I won't go anymore.' "
But the authors say those intangible skills can't replace the clinical skills that older physicians appear not to be getting.
Dr. Choudhry said there could be several explanations for the findings. Foremost is the fact that during training, physicians develop what is called a tool kit that they rely on, but that tool kit is time-intensive to update.
"I have an armament of skills to treat conditions that I learned in medical school and residency, when I was hearing all kind of opinions from different people and was reading a lot," Dr. Choudhry said.
"Now I have a bunch of things that I think work, and that's what I like to use when I treat my patients. Updating those things is a harder exercise, and we may not do it so often."
Steven E. Weinberger, MD, senior vice president of medical knowledge and education at the American College of Physicians, was initially skeptical when he saw the study.
"My first reaction was surprise," he said. "When I thought about it more, I could see in many ways, it's not that surprising. In many ways it is harder for physicians to keep up, the farther out they get from training.
Dr. Weinberger co-authored an editorial in the Feb 15 Annals of Internal Medicine supportive of the study.
What to do?
So how is a busy physician supposed to keep up?
Continuing medical education is supposed to keep physicians up to date on new standards of care. But, the study said, "widely adopted continuing medical education techniques, such as the distribution of printed materials and lectures, are largely ineffective, even in experimental conditions."
Dr. Weinberger, whose job focuses on professional development for physicians, said the study is a "wake-up call" for the profession, particularly in regard to speeding up the development of interactive CME.
"We need to provide the kind of educational resources that are the most useful for physicians, that help them change practice," he said. "A lot of CME offerings are still very much passive learning."
Dr. Weinberger would like to see CME developed that's more analogous to resident reports, but instead of residents, practicing physicians would gather to present and discuss cases with a seasoned expert.
Dr. Fletcher found that real-time learning tools were vital to staying up to date when he was practicing.
"The only answer I've found that works is to have the best evidence-based information available at the point of patient care," he said. "You must have the ability to look up the question right at that time of care."
Also, it's one thing to look up information on diseases you are unfamiliar with, he said. It's another to stop and double-check standards of care for conditions you think you know fairly well. You may discover the field has moved on, he said.
"Just saying 'I'll try hard to read the journals' is not enough these days," Dr. Fletcher said.
"The good side is that there are ways ordinary mortals can do this," he added. "If I didn't have help, I would be out of date, and I can't just stick it in my brain and carry it around."