Standard of care by doctors may drop with years spent in practice
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《英国医生杂志》
Doctors may be less likely to deliver currently accepted standards of care and to provide technically appropriate care as the number of years they have spent in practice increases. These are the findings of a study that reviewed 59 previously published studies with a large sample size of doctors ( Annals of Internal Medicine 2005;142: 260-73).
The studies included measures of doctors' knowledge or quality of care and the age of the doctor or the length of time since graduation from medical school. Just over three quarters (45) of the studies showed that a doctor's performance declined with time. More than half (32) showed that performance declined for all outcomes measured, while a fifth (13) showed that some but not all aspects of a doctor's performance declined with time.
Lead author Niteesh Choudhry, a medicine instructor at Harvard Medical School, called the results "paradoxical, since it is generally assumed that clinical experience enhances knowledge and skill and therefore leads to better patient care."
Stephen Soumerai, professor of ambulatory care and prevention at Harvard Medical School and a co-author, says the findings reflect substantial cultural 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."
The researchers suggest that doctors' "toolkits" created during training may not be updated regularly. Doctors who have been practising for longer seem less likely to adopt newly proved treatments and may be less receptive to new care standards, such as the use of less aggressive surgery for early stage breast cancer.
One study found that doctors aged under 40 were more likely than their older peers to believe correctly in the value of treatments for heart attack that improve survival, such as aspirin and blockers. The largest of the studies found that doctors who graduated more than 20 years ago were consistently less likely to adhere to cancer screening guidelines endorsed by the American Cancer Society and the National Cancer Institute.
Doctors' performance seems to decline over time
Credit: HULTON/GETTY
Dr Choudhry, who is also an internist at Brigham and Women's Hospital, says more effective ways to help doctors keep up to date must be found. Widely used lectures and printed materials are largely ineffective. And many experienced doctors are exempt from the re-certification requirements to which their more recently trained colleagues must adhere.
Visits of physicians and other healthcare personnel to older doctors in their places of practice, to teach them about a specific drug or advances in treatment—in the way that drug company representatives "detail" doctors—is known to be an effective way to improve the quality of care that doctors provide, but such methods are not in widespread use.
An accompanying editorial by Dr Steven Weinberger of the American College of Physicians and Dr F Daniel Duffy and Dr Christine Cassel of the American Board of Internal Medicine says that the article sends a "wake up" call to the medical profession that cannot be ignored ( Annals of Internal Medicine 2005;142: 302-3). The editorial says that the study "informs us that we cannot maintain competence passively through accumulating experience" and that "we must actively cultivate competence throughout a professional career."(David Spurgeon)
The studies included measures of doctors' knowledge or quality of care and the age of the doctor or the length of time since graduation from medical school. Just over three quarters (45) of the studies showed that a doctor's performance declined with time. More than half (32) showed that performance declined for all outcomes measured, while a fifth (13) showed that some but not all aspects of a doctor's performance declined with time.
Lead author Niteesh Choudhry, a medicine instructor at Harvard Medical School, called the results "paradoxical, since it is generally assumed that clinical experience enhances knowledge and skill and therefore leads to better patient care."
Stephen Soumerai, professor of ambulatory care and prevention at Harvard Medical School and a co-author, says the findings reflect substantial cultural 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."
The researchers suggest that doctors' "toolkits" created during training may not be updated regularly. Doctors who have been practising for longer seem less likely to adopt newly proved treatments and may be less receptive to new care standards, such as the use of less aggressive surgery for early stage breast cancer.
One study found that doctors aged under 40 were more likely than their older peers to believe correctly in the value of treatments for heart attack that improve survival, such as aspirin and blockers. The largest of the studies found that doctors who graduated more than 20 years ago were consistently less likely to adhere to cancer screening guidelines endorsed by the American Cancer Society and the National Cancer Institute.
Doctors' performance seems to decline over time
Credit: HULTON/GETTY
Dr Choudhry, who is also an internist at Brigham and Women's Hospital, says more effective ways to help doctors keep up to date must be found. Widely used lectures and printed materials are largely ineffective. And many experienced doctors are exempt from the re-certification requirements to which their more recently trained colleagues must adhere.
Visits of physicians and other healthcare personnel to older doctors in their places of practice, to teach them about a specific drug or advances in treatment—in the way that drug company representatives "detail" doctors—is known to be an effective way to improve the quality of care that doctors provide, but such methods are not in widespread use.
An accompanying editorial by Dr Steven Weinberger of the American College of Physicians and Dr F Daniel Duffy and Dr Christine Cassel of the American Board of Internal Medicine says that the article sends a "wake up" call to the medical profession that cannot be ignored ( Annals of Internal Medicine 2005;142: 302-3). The editorial says that the study "informs us that we cannot maintain competence passively through accumulating experience" and that "we must actively cultivate competence throughout a professional career."(David Spurgeon)