Teaching old docs some new tricks
Teaching old docs some new tricks
New approach needed to keep MDs up to date
A report published in the February Annals of Internal Medicine has received lots of attention as "the study that says older doctors don’t keep up," but the findings of the Harvard Medical School study apply to any physician who has been out of residency for five years or more, its author says.
"What we found is that we need to reevaluate how physicians keep up to date, and that our standards and practices of keeping up our certification, recertification, and continuing medical education [CME] are not as effective as they could be," says Niteesh Choudhry, MD, a Harvard instructor in medicine.
Choudhry and his fellow researchers reported findings that older physicians may be less likely to deliver currently accepted standards of care, and that the number of years a doctor has been in practice may decrease the likelihood of that physician providing technically appropriate care.
After the report was published, Choudhry and his team received a slew of letters from seasoned physicians who disagreed with him, insisting that their years of experience gave them richer abilities than they had when they were younger.
Choudhry says his reports’ use of the term "older" has less to do with age than with a physicians distance from his or her residency.
"The longer you’ve been out of residency — and age is just a proxy for that — seemed to be a predictor of providing lower-quality care," says Choudhry. "And by that I mean people who are 15 years out of residency. They’re far from old, but just during that time, lots of things have changed."
Years in practice showed differences in care
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%, found that older physicians were less likely to adhere to therapeutic standards. One study examined the prescribing behavior of physicians caring for patients with stable angina. Older physicians were significantly less likely to prescribe aspirin — a widely accepted standard treatment.
Older physicians seem less likely to adopt newly proven therapies and may be less receptive to new standards of care, Choudhry and his team wrote. 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 trained many years ago.
In one large study reviewed by Choudhry’s team, 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, the Harvard team reported; those doctors had 38%-48% lower odds of adhering than younger doctors.
The Harvard study did not examine patient satisfaction with physicians, and Choudhry stresses that younger doctors have much to learn from their older, more experienced colleagues.
Keeping up with changes difficult, variable
Young or older, physicians sometimes struggle just to meet their states’ and institutions’ CME requirements, and delivery of those educational requirements doesn’t always mean the physician has acquired up to date, useful knowledge, says Choudhry.
"Most [CME] processes rely on tacit techniques. That is, you read a journal article, go to a lecture, go to a conference; it’s not very effective and not changing behavior or keeping you up to date," he insists.
The study included a review of 59 previously published papers of 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 physicians’ medical school graduation or the physicians’ age. The researchers found that 73% of the studies showed a doctor’s performance declined with time. More than half of the studies showed performance declines for all of the outcomes measured, and 13 studies (21%) showed some, but not all, aspects of a doctor’s performance decline with time.
Keeping abreast of the rapid, widespread changes in medicine would be difficult even if a physician could devote a large part of every day to study, says Choudhry. Some specialties have a more difficult time because of variables in certification requirements, he adds.
"Some physicians in internal medicine, for example, who were certified before 1990, are exempt from recertification [by the American Board of Internal Medicine]," he says. "Their institutions, like hospitals or insurers, or their state licensing boards might require recertification, but they are variable in their requirements."
The two issues his study points out as in need of scrutiny are who gets recertified, and how recertification is earned, he says.
"The reason this is relevant is [that you often hear physicians say], I am relatively young, five years from my boards, and I find it difficult to keep up to date,’" says Choudhry. "That is precisely the challenge before us — there’s an explosion of information, thousands and thousands of relevant journal articles every year, and we barely scratch the minimal surface of them. We need better ways of keeping physicians up to date — [methods] that are more time-intensive seem more effective, but finding that time is a problem.
"The most effective methods involve interactions with other clinicians and people trained in certain aspects of medicine," he continues. "Interactive resources that prompt the physician to learn things pertinent to that particular physician’s clinical education is another example."
The problem lies not with individual doctors, who he says are conscientious and want to provide high quality care while keeping their own skills honed.
"It’s really an institutional problem, and a subtle problem," he says. "It impacts on patients, and it’s [individual physicians’] responsibility to take the leadership in this issue."
Choudhry says "academic detailing" is one example of an effective way to update physicians’ skills on a continuing basis. Academic detailing occurs when physicians or other health care personnel who are experts in a particular field or advance in treatment go into a physician’s practice and to teach them about that particular subject. He says the practice is recognized as an effective one, but has not been widely adopted into practice.
Source
- Niteesh K. Choudhry, MD, Instructor, Ambulatory Care and Prevention, Brigham and Women’s Hospital, 75 Francis St., Boston, MA 02115. Phone: (617) 732-8003; E-mail: [email protected].
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