Are patients worse off with more-experienced docs?



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11/07/28  NEW YORK: In a study that flies in the face of common sense, sicker patients turned out to fare worse under the care of seasoned doctors than when newcomers to medicine looked after them.

According to findings in the American Journal of Medicine, patients whose doctors had practiced for at least 20 years stayed longer in the hospital and were more likely to die compared to those whose doctors got their medical license in the past five years.

The results highlight “issues that we have as a medical profession in keeping up to date” with the latest medical knowledge, said Dr. Niteesh Choudhry of Harvard Medical School, who was not involved in the new study. It is “a quality of care problem that has been recognized for five to 10 years,” he told Reuters Health.

Dr. William Southern and colleagues looked at records of more than 6,500 patients who’d been hospitalized between 2002 and 2004 at New York City’s Montefiore Medical Center in the Bronx.

Montefiore is a teaching hospital where patients are first seen by a junior doctor who randomly assigns them to one of the hospital’s six medical teams. Each team has a medical student, recent medical school graduates, and at the top, a senior doctor known as the attending physician.

Over the course of the study, there were 59 different attending physicians. The researchers divided them up based on how long they were practicing: five years or less, six to 10 years, 11 to 20 years, or more than 20 years.

Because the researchers thought doctors might behave differently with their own long-time patients, they confined the study to cases in which patient and doctor had never met before.

In comparing the most and least experienced doctors, researchers saw the most-experienced group had more patients die in the hospital.

At first glance, compared to patients with the newest doctors, those with the most experienced physicians had more than a 70 percent increase in their odds of dying in the hospital and a 50 percent increase in their odds of dying within 30 days.

However, when the researchers took into account how sick the patients were, they found that only the sicker patients — those with complicated medical problems — were at higher risk in the hands of the more experienced doctors.

Southern’s group also found that while the doctor’s experience played a role in how long patients stayed in the hospital, it also mattered how many hospitalized patients he or she was taking care of.

When doctors weren’t very busy, they kept patients in the hospital for roughly the same average time no matter how many years of experience they had. But when they did have a lot of patients to see in the hospital, those with more than 20 years of experience kept patients there about half a day longer than their peers who’d been practicing for less than five years.

Previous research has found similar results across a variety of physician specialties. Earlier studies have also shown that physicians with more time in practice are less likely to adhere to practice guidelines.

“It’s not quite as simple to say that as you get further away from training, your quality gets worse,” cautioned Choudhry.

The problem, he said, is not with the capability of the more experienced doctors, but rather, their familiarity with more current guidelines and practices. The results suggest the need to rethink the way doctors are continually educated in the years after completing their certification, he added.

The authors suggest that physicians with more than 20 years in practice be required to recertify periodically. Most of the older doctors in the current study are presently exempt from having to take recertification tests, they say.

Most doctors do participate in “continuing medical education” programs after they finish their training. But much of it is passive, consisting mostly of attending lectures and reading articles by medical researchers. While these are important ways of learning new findings, said Choudhry, it would be better to develop educational programs that would actively engage the more experienced physicians.

Dr. Steven Weinberger, executive vice president and CEO of the American College of Physicians, cautioned that it is premature to make drastic changes based on the results of the study, which only looked at small numbers of attending physicians. He also came up with several alternative explanations for the findings.

For instance, the fact that patients were in a teaching hospital might have contributed to the different rates of death, since more experienced doctors might give the doctors-in-training more autonomy. And the different lengths of time patients stayed in the hospital could reflect a cultural difference in today’s younger physicians, who are taught to focus on reducing hospital stays.

Despite his concerns about the study, Weinberger agreed, “It is important for physicians to stay as current as possible.”