Bioethics Discussion Blog: Choosing Doctors: Older vs Younger: Who Will Treat You Better?

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Monday, October 27, 2008

Choosing Doctors: Older vs Younger: Who Will Treat You Better?


If you have the chance to pick your own doctor and not many of us have such a chance in this HMO world, who would you pick to manage your health? Who would treat you better, an older doctor or the younger one who is a few years out from final training? And what does “treat” mean? Does that mean more humanistic and sensitive to your concerns or does that mean able to make the diagnosis and begin the treatment more promptly and effectively---or both? Does the additional years of experience which the older doctor includes in his or her medical armamentarium make up for any of the more recent formal medical education which the younger doctor carries?

Researchers have studied this issue and a summary review of the studies was published in the Annals of Internal Medicine 15 February 2005 Volume 142 Issue 4 Pages 260-273. The article titled “Systematic Review: The Relationship between Clinical Experience and Quality of Health Care” by Niteesh K. Choudhry, MD; Robert H. Fletcher, MD, MSc; and Stephen B. Soumerai, ScD. Go to the above link to read the full article, however here is the abstract:



Background: Physicians with more experience are generally believed to have accumulated knowledge and skills during years in practice and therefore to deliver high-quality care. However, evidence suggests that there is an inverse relationship between the number of years that a physician has been in practice and the quality of care that the physician provides.
Purpose: To systematically review studies relating medical knowledge and health care quality to years in practice and physician age.
Data Sources: English-language articles in MEDLINE from 1966 to June 2004 and reference lists of retrieved articles.
Study Selection: Studies that provided empirical results about knowledge or a quality-of-care outcome and included years since graduation or physician age as explanatory variables.
Data Extraction: We categorized studies on the basis of the nature of the association between years in practice or age and performance.
Data Synthesis: Overall, 32 of the 62 (52%) evaluations reported decreasing performance with increasing years in practice for all outcomes assessed; 13 (21%) reported decreasing performance with increasing experience for some outcomes but no association for others; 2 (3%) reported that performance initially increased with increasing experience, peaked, and then decreased (concave relationship); 13 (21%) reported no association; 1 (2%) reported increasing performance with increasing years in practice for some outcomes but no association for others; and 1 (2%) reported increasing performance with increasing years in practice for all outcomes. Results did not change substantially when the analysis was restricted to studies that used the most objective outcome measures.
Limitations: Because of the lack of reliable search terms for physician experience, reports that provided relevant data may have been missed.
Conclusions: Physicians who have been in practice longer may be at risk for providing lower-quality care. Therefore, this subgroup of physicians may need quality improvement interventions.


Worrisome is the following extract from the full article:

Seven studies present data on the relationship between number of years in practice and actual health outcomes. The strongest of these was conducted by Norcini and colleagues, who analyzed mortality for 39 007 hospitalized patients with acute myocardial infarction managed by 4546 cardiologists, internists, and family practitioners. After controlling for a patient's probability of death, hospital location and practice environment, physician specialty, board certification, and the volume of patients seen, these researchers observed a 0.5% (SE, 0.27%) increase in mortality for every year since the treating physician had graduated from medical school.


So there you are with either taking what you get or having a chance to choose. And if you had that chance to choose, what criteria, to you, would be most important? Would the doctor’s age be most important or if not, what? Write about your own experiences in this regard but please don’t name names. ..Maurice.

Graphic: Classic illustrations of physicians, cropped by me for this thread.

7 Comments:

At Monday, October 27, 2008 3:22:00 PM, Anonymous Anonymous said...

My personal experience has been at both ends of the spectrum. I had an oncologist who surely had skills and years of practice, but he dropped the ball on a serious complication and quite frankly he often seemed cynical and burned out.

I had to switch to a new primary care doctor after finishing cancer tx, and chose a whippersnapper less than one year out of training. I thought he would be more up to date and enthusiastic... and he was, except he did not have the judgment or people skills that (hopefully) physicians acquire as they gain experience, and ultimately I left his practice.

I personally think it's not a question of age but of individual qualities. Intellectual curiosity and motivation to be knowledgeable and up to date on best practices are something doctors can possess at any age, yes? I think this is what I would value most. Just because you get older does not mean that you are less effective; just because you are young does not mean you know it all. I would suspect that somewhere within all the studies, there were individual older physicians who consistently maintained high standards of practice, and young physicians who made grievous errors of judgment.

On the whole, I would lean towards a doctor who has some experience but is still young, probably someone within his/her first decade of completing training. The best of both worlds, in other words. :)

 
At Monday, October 27, 2008 7:28:00 PM, Blogger FridaWrites said...

It completely depends on the individual person. I've seen residents with more people skills than their highly experienced mentors. Conversely, I've had an older doctor who is better at diagnosis (through needed labs) than a much younger one. Younger doctors can vacillate between insecurity and overconfidence while some older ones can be too determined on particular courses of action. But a combination of compassion and medical skills are far more important to me and I don't think I'd make age a primary factor in my decision. Both compassion and sharp diagnostic capabilities with appropriate treatment are necessary.

 
At Monday, October 27, 2008 8:41:00 PM, Blogger Alex Tang said...

Hi Maurice,

Did the study shows at what length of time post graduation or age did performance peak and when performance starts to decline?

 
At Monday, October 27, 2008 9:08:00 PM, Blogger Maurice Bernstein, M.D. said...

Alex, first it would depend on what behaviors or actions you define as "performance". But beyond that, I am not sure this review of multiple studies by different investigators under various protocols and covering various performances would provide a reliable answer to your general, but worthy, question. Alex, go to the journal article using the link above, and see if you can find the answer to your question. I can't. ..Maurice.

 
At Tuesday, October 28, 2008 2:19:00 PM, Anonymous james gaulte said...

In the interest of a "fair and balanced" presentation, you might consider mentioning, or summarizing or actually quoting some of the many letters to the editor of the annals that appeared after that article was published.Particularly compelling ( at least to me and several older docs) was the rebuttal and critique by Dr. Martin Samuels which, as did other letters,pointed out the poor methodology of the authors.One other aspect of this issue should be of interest in a ethics blog as the matter of possible conflict of interest of one of the authors.I discussed that in my blog.http://mdredux.blogspot.com/2005/07/harvard-professors-critical-of-fellow.html as did Dr. Roy Poses in Health Care Renewal.

That issue aside, I suggest that your publishing the conclusion of what I and others believe to be a very flawed article without at least referencing an alternative view might mislead some of your readers into believing that the review article is a valid indication of serious deficiencies in older physicians in general.

 
At Tuesday, October 28, 2008 5:53:00 PM, Blogger Maurice Bernstein, M.D. said...

James, I was unaware of the rebuttal and critique of the Annals article. I will see if I can find a link to the archive of those comments. In the meantime, I suggest my visitors take a look at your comment on your blog for which here is the link.

On the other hand, the topic is still worthy and it will be interesting to receive more visitor comments here about how they judge their selection of a physician either young or old. ..Maurice.

 
At Tuesday, October 28, 2008 7:04:00 PM, Blogger Maurice Bernstein, M.D. said...

To read the critiques of the review article which formed the basis of this thread, go to the following link to the July 5 2005 issue of the Annals of Internal Medicine and then scroll down to Letters where the PDF formatted letters can be downloaded free. I haven't read all of them as yet but obviously I also want to read the other side of the story. Well, I do have self-interest since I am one of the "older" physicians. ..Maurice.

 

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