Matters of experience

It was a bittersweet moment for Liz O’Brien. Dr. Wilson, her longtime dentist, was retiring and turning over his practice to his young associate.

Dr. Riley “looked younger than my own kids,” O’Brien blogged recently at MedPage Today. “I could feel my skepticism rising and my initial smile of welcome turning into a wooden grin. I hoped she didn’t notice. How much experience could this new dentist have?”

It’s an age-old question: Do patients benefit when their doctor is young, fresh out of training and up to date on the latest skills and knowledge, or are they better off with someone whose wisdom has been honed by years of experience?

As it turns out, the answer isn’t clear. Various studies have attempted to identify the effect of age on physician skills and produced conflicting results. Some found that as the physician’s experience increased, so did the quality of care on some outcomes – but not on others. A couple of studies found that physician performance peaked after a certain number of years in practice and then declined.

The study that perhaps has been cited most often appeared in 2005 in the Annals of Internal Medicine, where it generated considerable stir. The authors reviewed 62 previously published studies and found that in more than half, the results suggested that the longer physicians were out of medical school, the more likely they were to provide lower-quality care.

For example, in 15 of the studies that were reviewed, physicians who were in practice longer were less likely to follow guidelines on the appropriate use of diagnostic and screening tests. In the largest of these studies, physicians who had graduated from medical school more than 20 years previously were “consistently less likely” to follow recommended cancer screening guidelines, the authors of the Annals study wrote.

Perhaps even more significantly, a handful of the studies reported longer hospital stays and worse outcomes for patients whose doctors were farther along in their careers.

Taken together, these findings fly in the face of the usual assumption that the longer physicians are in practice, the more skilled and astute they become.

The authors of the study suggested several possible explanations:

Perhaps most plausible is that physicians’ “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. In addition, practice innovations that involve theoretical shifts, such as the use of less aggressive surgical therapy for early-stage breast cancer or protocols for reducing length of stay, may be harder to incorporate into the practice of physicians who have trained long ago than innovations that add a procedure or technique consistent with a physician’s pre-existing knowledge.

Another factor might be the cultural shift that has been taking place in medicine, ushering in concepts such as evidence-based care and performance evaluation. What we might be seeing is the “cohort effect,” the study’s authors wrote. “That is, when the current generation of more recently trained physicians has been in practice for a longer time, there may be smaller differences between their practice and those of their younger colleagues than our data would suggest.”

And yet this doesn’t seem to be the whole story.

Many competencies can only be developed by years of experience, one physician wrote in response to the Annals study. “I certainly thought I knew more when I finished my residency than I think I know now. However, like the teenager who knows everything, I could not always decide when best to use the information. Use of that knowledge comes with experience.”

If older doctors can become set in their ways, younger and more inexperienced physicians might be overconfident in their skills and possibly more aggressive in their use of prescription drugs and other therapeutic interventions that don’t necessarily benefit the patient.

What does it all mean for patients trying to decide between an older physician vs. a younger one? Sometimes the considerations are practical. A relative of mine who was looking for a new physician decided to steer clear of older doctors because he wanted a longer-term partnership, not one that would likely end in a few years when the doctor retired. It can also be easier to get an appointment with younger doctors who are building a practice and will take new patients. Often, however, it comes down to personal preference and what patients are looking for in the relationship.

What seems to matter most – and what the Annals study didn’t really address – are the individual qualities that separate an OK physician from a great one: conscientious, willing to listen, open to new ideas, intellectually curious, able to work well with a team, and humble enough to recognize what they know and what they don’t know. This can describe older physicians just as easily as younger ones.

Aside from several weaknesses with the methodology, the real message of the Annals study may be the importance of lifelong learning to ensure doctors stay on top of their game as they progress through their career.

There also seems to be a lesson here about not judging a book by its cover. O’Brien reflects on her first meeting with her longtime dentist: “Dr. Wilson was a young guy, but he had a bunch of diplomas on his office wall. He had been referred by someone I knew, seemed capable, calm, and nice, and I had trusted him.”

He might have been inexperienced but he was determined to be a good dentist, she wrote. “In his case, things worked out fine – very fine indeed. I hope it will work out for Dr. Riley too. I intend to give her a chance.”

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  1. Pingback: Is the doctor too old? | HealthBeat

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