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The other day, I was in clinic seeing patients with a few students. One particular patient was an 81 year-old, a very pleasant lady, who, among other issues, described a history of fibromyalgia. During my student’s initial contact with her, she instructed him that fibromyalgia was “arthritis all over my body.” When it was my turn to see the patient, she told me the same incorrect information and then relayed to my student that I would teach him about fibromyalgia being arthritis all over the body. This particular patient was firmly convinced about the “etiology” of fibromyalgia, so I didn’t feel it necessary or fruitful to her foot complaint to point out her ignorance.
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Most of us still equate
wisdom with age |
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I started thinking about age and wisdom after seeing the dichotomous reactions of my patient and student. Of the two individuals, my student — perhaps 50 years younger than our patient — demonstrated greater wisdom and understanding of the true situation (respect for an elder plus a sensitivity to the situation) while the patient, being older, seemed to think she was better educated about a medical issue, despite her ignorance.
As a podiatric physician who appears young for his age — I’m 39, but, as my father likes to say, I look like I’m 12 — the age/wisdom issue has cropped up many times over my career thus far. In fact, just about 2 weeks ago, I walked into another patient’s room who’s response when he saw me was an incredulous, “How old are you?” He was shocked when I told him my age. For the majority of my patients, my apparent young age doesn’t seem to be a problem, but I have had a few patients look for older alternatives. Of course, I don’t have any problem with this, for the simple reason that if a patient has reservations about me — for whatever reason — this is a poor start to a complex relationship which can make our later interactions problematic.
Several years ago, I wrote about a similar topic and proposed a personal experiment to add grey to my hair temporarily and see if this changes my patients’ reactions. However, I’ve noticed over the past couple of years increasing numbers of grey hairs and no longer want to rush the greying issue! So, I’ll throw my suggestion out to some other young-appearing-for-their-age doctors to give my experiment a try.
Despite my anecdote above, most of us still equate wisdom with age. However, is this really true in medicine? Some of you more “seasoned” doctors may get a little hot under the collar from this point forward, so I’ll disclaim at the onset that I personally have the greatest respect for my elders and have no intention to minimize the importance of experience. To answer this question, I looked at the research literature and found some interesting results.
The highest level of evidence to date is a systematic review published in 2005. These authors examined 59 empirical studies that looked at various indicators of physician performance. Overall, about 70% of the studies showed a negative association between experience and performance. That is, the majority of studies showed decreasing physician performance with increased level of experience. More specifically, 12 studies looked at knowledge of practicing physicians, and all 12 demonstrated decreased knowledge with years in practice. Fifteen of twenty-four studies (63%) that studied appropriate physician use of diagnostic and screening tests found this same relationship. Fourteen of nineteen studies (74%) that looked at adherence to standards of therapy found an inverse relationship between physician years in practice and adherence to standards. Similarly, the authors found this same relationship when they looked at studies that examined outcomes measures.1
Hartz and colleagues also found striking results after a study in which they looked at a 3 state database and calculated the mortality ratio from 275 surgeons who performed CABG surgery on 83,547 patients over a 3 year period. They found that patient mortality rates actually went up with increasing surgeon years out of training.2
Why the counterintuitive results of these studies? One might think that many years of practice would provide the experience necessary to achieve better outcomes. Overall clinical judgment may be improved as a result of more time in practice; however no empirical research has born this out yet.
Until then, I think I'm going to ask my partners to assist with my cases more often. It was a rare treat to say the least!
The authors of our first study argue the possibility that “physicians who have been in practice for more years and older physicians possess less factual knowledge, are less likely to adhere to appropriate standards of care, and also have poorer patient outcomes”.1 They go on to propose that the training obtained during residency may not be updated regularly, older physicians may not be as likely to adopt newly proven therapies, and may be “less receptive to new standards of care”.1
One might argue that the older surgeons may be slowing down and doing less surgery with a concomitant decrease in skills. However, the authors of our second study found no difference in the volumes of older versus younger surgeons in their study. The authors argued “the possibility that younger physicians are better trained in the newer and most effective surgical techniques, but it is also possible that clinical skill may diminish with age for some physicians”.2
My personal view is rather more simplistic (and by no means original). I think the issue is mostly about continuing medical education. Medicine is a knowledge pursuit, one that changes rapidly over very short periods of time but also has a very large required set of basic knowledge and skills. Physicians are caught between a rock (the difficulty maintaining current knowledge and new skills) and a hard place (the challenge of remembering the vast base of medical knowledge). Physicians in practice around 10 years or so sit in the “sweet spot,” balanced between relatively recent training and remembering the base of medical knowledge. It seems, then that age doesn’t equal wisdom, at least in the medical professions.
How do we prevent the disintegration of these all important knowledge and skills? Part of it is institutional. Our CME methods must continue to evolve and become more efficient with greater power to influence practice patterns. Additionally, though, and most importantly, each of us must maintain our knowledge and skills through continued self-study. Without the drive to stay current we stagnate. As Ray Kroc, the founder of McDonald’s said, “If you’re green you’re growing. If you’re ripe you rot.” I hope to stay green as long as possible, even if it means my patients think I’m a 12 year-old. Best wishes.
Keep writing in with your thoughts and comments. Better yet, post them in our eTalk forum.
Best wishes.
Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]
REFERENCE:
- Choudhry N, et al. Systematic Review: The Relationship between Clinical Experience and Quality of Health Care. Annals of Internal Medicine, Feb 2005; 142(4): 260-273.
- Hartz A, et al. Prestige of Training Programs and Experience of Bypass Surgeons As Factors in Adjusted Patient Mortality Rates. Med Care, 1999; 37: 93-103.
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