Quality Rounds
Practice Doesn’t Make Perfect
A study finding that physicians’ quality of care declines with experience calls into question the current system of continuing medical education.
By Scott D. Smith
It turns out that experience isn’t always the best teacher. That’s according to a study by Harvard researchers who found that rookie doctors fresh out of residency may have an edge over their more senior colleagues when it comes to delivering high-quality care.
After reviewing 59 previously published papers (comprising 62 studies done since 1966) that compared age or experience with quality of care, the authors concluded that physicians who have been in practice for more years have less factual knowledge, are less likely to adhere to appropriate standards of care, and may have poorer patient outcomes than physicians newer to practice. Results of the study were published in the February 2005 issue of the Annals of Internal Medicine.
Lead author Niteesh Choudhry, M.D., Ph.D., and colleagues discovered that about 73 percent of the studies found a negative association between years in practice and some or all of the outcome measures, 21 percent found no correlation, and about 6 percent found performance increased at least on some measures as experience increased. The measures included physician knowledge; adherence to standards of practice for diagnosis, screening, and treatment; and actual health outcomes such as mortality rates. For example, one study found physicians younger than 40 years had a better grasp of which therapies for treating acute myocardial infarction, such as thrombolytic agents, aspirin, or beta-blockers, were more likely to improve survival. Another found that physicians who had been out of medical school for at least 20 years were less likely to follow cancer screening guidelines. And a study of 39,007 patients hospitalized with acute myocardial infarction found a relative increase in mortality of 0.5 percent for every year since the treating physician had graduated from medical school.
Why the disheartening news that being in practice longer doesn’t make you a better doctor?
“We are quite sure it is not age itself,” Choudhry says, as many of the doctors in the underlying studies were in their 40s and 50s. “It’s the distance from their [medical school] studies.” Choudhry’s study could not determine an exact age or point at which performance started to decline because the studies used different methods to define experience. However, his intuition tells him that physicians’ performance peaks five to seven years after medical school.
Choudhry, who is also an internist, believes the performance decline is the result of failure to keep up with the latest knowledge and advances.
Information Overload
In medical school, learning is on the “front burner,” says David Carlson, M.D., an internist who retired from the Allina Medical Group in 2005. “But when you’re in practice, the time demands are so different.” Physicians get inundated with paperwork and phone calls, leaving only a few hours a week for ongoing education. And unlike when they’re in medical school and residency, practicing physicians don’t have daily contact with teachers and experts.
In addition, physicians who trained more than 20 years ago are less steeped in the ideology of evidence-based medicine, which can make accepting the use of evidence-based guidelines more difficult, especially if the recommendations of a guideline run contrary to one’s personal experience, he says.
But that’s not all. “There is a lot of concern about the explosion of medical information and how physicians can deal with this,” says University of Minnesota Medical School Dean Deborah Powell, M.D. Continuing education relies too much on lectures and conferences that don’t require physicians to participate or prove they’ve learned the material, Powell and other medical educators say. (Think passively listening to a lecture in Hawaii.)
“Adult learning theory has shown that most adults don’t retain information well that is just presented in a lecture format,” says Carl Patow, M.D., M.P.H., executive director of HealthPartners Institute of Medical Education. One way HealthPartners is trying to engage learners is by holding interactive sessions using computerized manikins at its medical simulation center. In one exercise, instructors left an unresponsive manikin with a blocked airway in a waiting room, evaluated how staff responded, and provided a follow-up debriefing. Patow says this type of training has received “incredible reviews” and that one clinic later reported that resuscitating a real patient went much more smoothly because of the training.
Medical educators also want to see more courses that are tailored to learners’ needs. They believe instructors should test learners’ knowledge, identify gaps between what they already know versus what they need to know, and build individualized courses to close those gaps.
Research also supports the effectiveness of problem-based learning, says Thomas Elliott, M.D., chief of education and research at St. Mary’s/Duluth Clinic (SMDC) Health System in Duluth. In a problem-based course, a small group of learners spends about 45 minutes working on a case with a trained facilitator before the content expert presents them with the solution. This type of training is effective because it simulates what it is like to confront a real medical case and exposes what the physicians do or do not know. Elliott says SMDC uses the technique in about 10 percent of its continuing education courses.
SMDC is also allowing physicians to earn continuing education credit by taking part in quality- or performance- improvement initiatives. SMDC has collaborative practice teams that identify a problem, implement an action plan, and then measure the results. Physicians earn five CME credits for taking part in each stage of the project.
Coupling quality initiatives with education results in meaningful learning because the material concretely influences a physician’s practice, medical educators say. Elliott explains that the real-world information about physicians’ behavior and performance—and about patient outcomes— motivates practitioners to learn the material and change.
Computers in exam rooms are also creating new learning opportunities, says Carole Warnes, M.D., a cardiologist and dean of the Mayo Clinic School of Continuing Medical Education.
Mayo is developing ways to help its doctors do “just-in-time learning,” which involves teaching new knowledge or skills just when a physician needs them. “The idea is to provide learning for physicians while they’re in the room with the patients,” Warnes says. The clinic is developing a database and a network of in-house subspecialists that physicians could access electronically if they’re struggling with questions related to patient care.
The American Medical Association has endorsed just-in-time learning by allowing CME credit for what it calls “point-of-care” learning, where a doctor researches a topic on the Internet for a patient, then documents the sources he or she consulted and the clinical application of the information. The AMA also allows credit for quality-improvement work in which a physician measures and tries to improve on an outcome.
Don’t Take Certification for Granted
Some specialties recently adopted recertification requirements that encourage physicians to keep on top of new developments. Family medicine was the first specialty to require recertification after 10 years of practice; others have followed suit. “The idea that you graduate and finish your fellowship and your learning is a thing of the past,” Warnes says.
Specialty societies are offering more interactive courses in order to help physicians achieve recertification—and make sure the learning sticks. For example, through the American Board of Internal Medicine, physicians can earn 20 CME credits by completing practice-improvement modules. Physicians use a Web-based program to evaluate how their practice is doing in terms of controlling patients’ diabetes and performing colonoscopy screenings on patients age 50 and older. Next, they implement a plan for improvement in the clinic and submit the results to the board.
Physicians say that added pressure to keep current is a good thing, and some even go further and question whether specialties should continue to grandfather in older physicians.
“I frankly think a lot of physicians, knowing they have that requirement, do a lot better job keeping up than if they knew they had certification for life,” Patow says. MM
Scott Smith is a staff writer for Minnesota Medicine.