An interesting editorial appeared in ACP Journal CLub ( May/June 2005/volume 142 no. 3 p A-8) entitled " Does clinical experience make up for failure to keep up to date?" by GR Norman and KW Eva , both PhDs from McMaster University.(this publication requires a subscription).
They suggest the following thesis:Physicians in practice tend to not keep up but this seems to have little impact in patient outcomes.(Interestingly, they quote articles claiming that board certification and subspecialization both are associated with an absolute mortality difference (Norcini JJ, et al Med Educ 2002: 36;853-859)) As I have blogged about before,I am not convinced how prevalent the tendency is to not "keep up" or how valid the data is demonstrating that but the authors present some interesting ideas, at least some which is back up with some data and make several comments worthy of repeating.
They say experience makes docs make decisions rapidly. It is as if a vast medical storehouse of clinical cases is stored and a pattern-recognition process is triggered and a diagnosis is reached without conscious reflection. The authors also make the point that adherence to practice guidelines may be optimal-in some sense-at the population level but when an experienced physician considers a given cases, he may deliberately deviate from the guideline to more appropriately take care of the individual patient's needs.Less experienced docs tend more to adhere to the prescibed practice approach. So if we equate "quality" with adherence to guidelines are we really getting it right or is that just the easy way to claim we are evaluating physician's care?
It is probably too simple to say that young docs go by guidelines more and older docs have more experience based context into which to put things but there may be a trend in that direction.
Older docs can improve the degree to which they are current on guidelines-even if they decide if they are applicable or not on a case by case basis-but the only way young docs get the experience is to get to be old docs.